The Golden Hour
                        ===============

þ The Golden Hour concept was used quite effectively by Cowley, but the data
from which it is derived is a bit older - from 1918 - World War I !

To quote from a 1992 review (1): "In World War I, there was a real
appreciation of the time factor between wounding and adequate shock
treatment. If the patient was treated within one hour, the mortality was
10 percent. This increased markedly with time, so that after eight hours,
the mortality rate was 75 percent." (2)

   Time from injury     Mortality
      1 hr                        10 %
      2 hr                        11 %
      3 hr                        12 %
      4 hr                        33 %
      5 hr                        36 %
      6 hr                        41 %
      8 hr                        75 %
      9-10 hr                     75 %

I haven't yet found a copy of the original paper (and my french is very
rusty), but if anyone else does, please send one to me!

References:

1   Hardaway, R M. Care of the Wounded of the United States Army From 1775
to 1991
     SG&O, 1992; 175: 74-88 (quote from p 76) (data p 85)

2   Santy, P. Marquis Moulinier, Da Shock Tramatique dans les blessures de
Guerre, Analysis d'observactins.
     Bull. Med. Soc. Chir., 1918, 44:205

William P. Bozeman, MD, FAAEM
-------------
Trunkey wrote about the "Golden Hour" in 1983 when he published a study of
trauma deaths and found a trimodal distribution of the time-of-trauma to
time-of-death interval: IMMEDIATE which was defined as within one hour
(~50%), EARLY which was defined as 2-3 hrs after injury (~30%), and LATE
defined as days to weeks after injury (the remainder).  This series
included your standard American trauma mix before gangs and guns were in
vogue and therefore was heavy into blunt trauma. It was felt (and has been
taught since) that rapid transport to a trauma center could prevent some
of the IMMEDIATE deaths as defined in that report. However, if you look at
the Wound Data and Munitions Effectiveness Team (WDMET) analysis of U.S.
casualties from Vietnam inthe '67-'69 period the "Golden Hour" disappears.
 In this large (~8,000) cohort of penetrating injuries almost 70% of all
combat deaths (including Killed-in-Action and Died-of-Wounds) die in less
than 5 MINUTES, giving a different connotation to the word IMMEDIATE. In
fact, almost 90%!! die in what Trunkey defined as the immediate period.

Sauaia, Moore, Moore, et.al., published a reassessment of trauma deaths in
1993 (J Trauma, 1993;35:170) using a civilian population with a greater
percentage of penetrating trauma somewhat mirrors the WDMET results.  This
led Bellamy to suggest that if there is a golden period it is in the first
five minutes WHEN IT COMES TO MILITARY TYPE PENETRATING WOUNDS, not MVC's
or falling down the steps.

An analysis of 45 civilian mass shootings (ala Luby's Cafeteria, San
Ysidro McDonald's, Port Arthur Massacre, etc.) which is in the works,
shows little to no difference from the Vietnam experience.

How about the Platinum 10 minutes and Titanium 5 minutes?!

Special thanks to Ronald Bellamy, COL, MC, USA (Ret) who has been a mentor
in this particular area.

Tom Stein, MD, FACEP