Golden hour (medicine)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


Overview

In emergency medicine the golden hour is the first sixty minutes after the occurrence of multi-system trauma. It is widely believed that the victim's chances of survival are greatest if he receives definitive care in the operating room within the first hour. Recent scrutiny, however, calls this assertion into question.

General concept

In cases of severe trauma, especially internal bleeding, nothing can replace surgery. Complications such as shock may occur if the patient is not managed appropriately and expeditiously. It is therefore necessary to transport victims as fast as possible to specialists who are most often found at a hospital trauma center. Because some injuries can cause a trauma victim to decompensate extremely rapidly, the lag time between injury and treatment should ideally be kept to a bare minimum; over time, this lag time was further clarified to a now-standard time frame of no more than 60 minutes, after which time the survival rate for traumatic patients is alleged to fall off dramatically.

Origins of the term

The late Dr. R Adams Cowley is credited with promoting this concept first as a military surgeon and later as head of the University of Maryland Shock Trauma Center.[1][2]

The concept of the "Golden Hour" may have been derived from French military World War I data.[3]

The R Adams Cowley Shock Trauma Center section of the University of Maryland Medical Center's website quotes Dr. R. Adams Cowley as saying, "There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -- but something has happened in your body that is irreparable."[2]

Controversy

While most medical professionals agree that delays in definitive care are undesirable, recent peer reviewed literature casts doubt on the validity of the 'golden hour' as it appears to lack a scientific basis. Dr. Bryan Bledsoe, an outspoken critic of the golden hour and other EMS "myths" like Critical Incident Stress Management, has indicated that the peer reviewed medical literature does not demonstrate any "magical time" for saving critical patients.[4]

Medical conditions with time-critical treatment considerations

On the other hand, two emergency medical conditions have well-documented time-critical treatment considerations: stroke and myocardial infarction (heart attack). In the case of stroke, there is a window of three hours within which the benefit of clot-busting drugs outweighs the risk of major bleeding. In the case of a heart attack, rapid stabilization of fatal arrhythmias can prevent sudden cardiac death. In addition, there is a direct relationship between time-to-treatment and the success of reperfusion (restoration of blood flow to the heart), including a time dependent reduction in the mortality.


References and notes

  1. Lerner, EB; Moscati (2001). "The Golden Hour: Scientific Fact or Medical "Urban Legend?"". Academic Emergency Medicine 8 (7): 758-760.
  2. 2.0 2.1 "Tribute to R Adams Cowley, M.D.," University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Accessed June 22, 2007.
  3. "Original data supporting the 'Golden Hour' concept produced from French World War I data," Trauma Resuscitation at Trauma.com, Accessed June 22, 2007.
  4. Bledsoe, Bryan E (2002). "The Golden Hour: Fact or Fiction". Emergency Medical Services 6 (31): 105.

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