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The Golden Hour Trauma Care Published online: 2021-02-22 THIEME Guidelines 1 The Golden Hour Trauma Care Subbiah Venkatesh Babu1 Dr. S. Venkatesh Babu’s ORCID is 0000-0002-3488-8031. 1Department of Orthopaedic & Trauma, Sri Sakthi Hospital, Address for correspondence Dr. Subbiah Venkatesh Babu, MB BS, MCh Tirunelveli City, Tamil Nadu, India Orth., FRCS, Department of Orthopaedic & Trauma, Sri Sakthi Hospital, 48 F, St Xavier’s Colony, South Bypass Road, Tirunelveli 627 005, Tamil Nadu, India (e-mail: drsvbabu@hotmail).com). Indian J Neurotrauma Abstract Globally the road accidents had become a great burden and claiming lot of precious lives today. However, the initial treatment within the first hour of the injury indeed had Keywords proven the high chance of survival after the trauma. This article updates and signifies ► prehospital the systematic emergency approach and current principles in saving lives after injury. ► trauma ► injury ► golden hour Introduction promptly before reaching the hospital, then the possibility of their survival is good. Our world faces extensive amount of trauma-related morbid- ity and mortality every day. India adds more lives in the road Prehospital Trauma Care accidents. The care of injured in all scenarios like road traffic, The steps involved in prehospital trauma care are as assault, or in disaster situation is getting viewed sincerely follows: by the Indian Medical Association and by the Government today.1 • Clearing the airway. Every doctor irrespective of the specialty needs to have •S topping the bleeding. the knowledge in life support and skills in saving the trauma • Supporting the fractured limbs. victims. The honorable Supreme Court of India has directed • Shifting the victims safely to the nearest clinical all health establishments in our country to provide initial establishments. care for emergency and trauma victims and not to refuse When the trauma patients arrive at the clinical establish- treatment.2 The Central and State Governments are taking ments, every clinician while taking care of the trauma vic- significant initiatives in road safety and trauma care. The tims should comprehend following subjects well. “Platinum ten minutes” (immediate 10 minutes from the minute of injury) is the purview of first responders includ- ing fire rescue officers, police, paramedics, and knowledge- Systemic Response to Trauma able bystanders with initial stabilization and bringing the Any injured patient will have a local and a systemic response victims to the nearest clinical establishments irrespective of which is the real disease of trauma. Conventionally, this the dimension (scoop and run). Providing the golden hour response is described as an initial catabolic, hypermetabolic trauma care (very first hour after injury) and shifting them phase, followed by an anabolic phase of recovery, all largely to the higher center after stabilization is doctors’ responsi- due to the effect of the endocrine response to trauma which bility. However, the golden hour is individualized whether is far more complex. it is minutes or entire hour as per the injuries and needs of It consists of multiple linked responses or cascades with each patient.3,4 multiple alternative pathways so that intervention in one It is well proven that the initial timely care will increase response usually leads to bypass others. We should intervene the chance of survival of the trauma victims and of course to stop the process at source, i.e., stopping the hemorrhage, significantly reduce the morbidity after injury. Patients with correcting the hypoxia, and clearing the contamination as life threatening injuries are increasing today. When these crit- soon as possible after injury and support organ function till ically ill patients get the following initial life saving measures the recovery takes place. received DOI https://doi.org/ © 2021. Neurotrauma Society of India. May 8, 2020 10.1055/s-0040-1718479 This is an open access article published by Thieme under the terms of the Creative accepted after revision ISSN 0973-0508. Commons Attribution-NonDerivative-NonCommercial-License, permitting copying June 8, 2020 and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/). Thieme Medical and Scientific Publishers Pvt. Ltd. A-12, 2nd Floor, Sector 2, Noida-201301 UP, India 2 Prehospital and Initial Care of the Injured Babu. Trimodal Death Distribution in Trauma Airway and Spinal Immobilization It is well proven that the initial timely care will increase • The first peak of death occurs at the time of injury which the chance of survival of the trauma victims and of course happens in seconds to minutes of injury. The reasons significantly reduce the morbidity after injury. mainly are apnea after severe head injury, high spinal In severe trauma, resuscitation and assessment are per- cord injury, rupture of the heart, and major vessels. formed simultaneously to detect and treat conditions that Only prevention of trauma can reduce this peak of may be rapidly fatal. Diagnosing a threatened airway, clear- trauma-related deaths. ing it, and if necessary, providing a definitive airway is the • The second peak lasts from the end of this first peak to first priority, because an obstructed (threatened) airway several hours after the injury has taken place. Deaths can be fatal within 3 to 5 minutes. Common causes are head that occur during this period are usually due to subdu- injury-induced coma (Glasgow Coma Scale [GCS] <9), severe ral and epidural hematoma, hemopneumothorax, splenic shock (systolic blood pressure <70 mm Hg), unstable fracture rupture, liver injury, pelvic fracture, and other injuries maxilla, bilateral fracture mandible, inhalational burns, and which contribute to major blood loss. less commonly, tracheal or laryngeal injury. • The third peak of trauma death occurs several days or weeks after the initial injury. It is often due to sepsis and multiorgan failure. Airway Assessment The development of standardized trauma training, better • A talking patient has a clear airway. prehospital care, and the implementation of trauma care sys- • Apnoeic patients are dying hence immediate orotracheal tems with established protocols to care for injured patients intubation is warranted. will appreciably alter the said picture. The awareness of • Maintain the immobilization of spine until cleared. trauma care and all the facts related to trimodal distribution • Look: Air hunger, restlessness, coma (unresponsive to of mortality and their morbidity after injury, significance of painful stimuli), penetrating injury to the throat. Cyanosis medications, blood transfusion, longevity of hospital stay, is a late sign. and rehabilitation should be explained to the society well. • Listen: Stridor, gurgling in the throat, snoring. This strategy has to be applied by the medical profession- •F eel: Facial fractures, surgical emphysema of the neck. als in association with the government and nongovernment •D ecide: Threatened airway or not. If not threatened, organizations. provide oxygen by face mask. If threatened, provide a definitive airway. In-Hospital Golden Hour Trauma Care Every physician/doctor/specialist should be acquainted Breathing with the following important aspects of trauma care which Once the airway is defined as clear, or controlled (cuffed tube are the “MIST”—from the ambulance paramedical staff, in the trachea), one can assess and treat the seven threats primary survey, resuscitate and re-evaluate, secondary to life in the chest. Most are due to deficient breathing. survey, definitive care, tertiary survey, cardiopulmonary These are: resuscitation (CPR), and safe transportation of trauma victims. 1. Tracheal injury 2. Tension pneumothorax The “MIST” Handover 3. Sucking chest wound ____________________________________________ 4. Massive hemothorax 5. Flail chest + pulmonary contusion M Mechanism of injury 6. Cardiac tamponade I Injuries observed 7. Contained rupture of the aorta S Vital signs T Therapy established Management for the threats to life are performed by look- _______________________________________________ ing, feeling, listening, and immediately acting as mentioned below: At the Clinical Establishment • Look: For external injury to the neck or chest, cyanosis, Primary survey and initial trauma care: air hunger, sucking chest wounds, asymmetry of chest • Ascertaining a patent airway with cervical spine control. movement. • Sufficient ventilation. • Feel: Trachea centra, surgical emphysema, fractured ribs, • Maintaining circulation which includes cardiac function and flail segment. and intravascular volume. • Listen: Air entry left and right. •E valuating the overall neurological status. • Decide: Is there a threat to life? Indian Journal of Neurotrauma © 2021. Neurotrauma Society of India. Prehospital and Initial Care of the Injured Babu. 3 • t Ac : Needle thoracentesis or not, three-way dressing or transfusion. By this time, the patient should be on his way not, intercostals drain or not, intubate and ventilate or to theater. not, pericardiocentesis or not. Class 4: Blood loss >2,000 mL. Most serious injuries are • X-ray: The only other threat to life is a contained rupture possible and consider ER thoracotomy in penetrating of the aorta, which will be picked up on X-ray chest. trauma. Treatment The diagnosis of shock is based on clinical signs. Drop in BP is a late sign, indicating
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