The Golden Hour

[Aussieaid]

Those who die in hours have done so due to the laziness of a doctor in properly assessing their patient & getting them to theatre.

Those who die in days usually die from sepsis and this is a failing of the hospital & their infection control measures.

Not quite sure how to start with this... Not every patient who dies as a result of trauma dies from not being operated on fast enough. In the prehospital area you see the patient in the first few hours of severe trauma. You don't get to see the sequelae from the massive insults to the body. And not every patient is a candidate for surgery. How does surgery help pulmonary contusions, MODS, DIC, cerebral edema, fat emboli ...just to name a few of the actual causes of death of those who die within a few hours, days or even years post injury. Add to that, one single blood transfusion has risks and some of these people who have massive transfusions end up with complications caused by the transfusions alone on top of the trauma that the body is trying to deal with. A single episode of hypotension or hypoxia can also be an insult to a critically injured person that can increase their risk of death by a large percentage. (I don't have any of the studies at my fingertips but it's well documented).

I'm too tired to really think of what I wanted to say here so I may come back to it tomorrow.

Cheers!

[Kiwiology]

I think AA has it right, trauma is increasingly a non surgical disease. Does that mean we should piss around on scene shaking our wang and playing Doctor, no, does it mean everybody needs to go into hospital on red lights because they might need to be operated on? No as well.

Yes there are some patients who are emergently time critical who require surgical intervention to stop internal bleeding or some other surgically correctable problem however that is not everybody. Some people need to go to Intensive Care and should have thier scene time minimised. partic those who are traumatically brain injured.

Then there are those people who are not emergently time critical. We spent an hour getting a little old nana with a NOF fx out of her house because that is how long it took to get her adequately packaged and pain under control. Should we have just dragged her out on the scoop in two minutes and raced her in lit up like a christmas tree?

[Dragoon]

I think for the most part that everyone agrees that scene time should be minimized.

I'm all for advancing the prehospital care that we provide but part of that is knowing where to stop and when to get the wheels turning for more definitive care as mentioned previously.

The "golden hour" is nothing more than a cookie cutter applied to kinematics of trauma. It's BS. Each patient is unique and your scene size-up combined with rapid patient assessment should be indicators of how long you can stay onscene.

Now what do we do with all the texts that mention the "golden hour": burn 'em, use them to build cabins like lincoln logs?

[HERBIE1]

I think for the most part that everyone agrees that scene time should be minimized.

I'm all for advancing the prehospital care that we provide but part of that is knowing where to stop and when to get the wheels turning for more definitive care as mentioned previously.

The "golden hour" is nothing more than a cookie cutter applied to kinematics of trauma. It's BS. Each patient is unique and your scene size-up combined with rapid patient assessment should be indicators of how long you can stay onscene.

Now what do we do with all the texts that mention the "golden hour": burn 'em, use them to build cabins like lincoln logs?

I think the concept of prehospital care in general- and specifically in this case, critical trauma patients- is still a work in progress. Great- with all the advancements in medicine and technology, many people are "saved" that used to either die on the scene, or be declared DOA at an ER. As was noted, "saving" people is just the first step- the complications that arise AFTER their vitals are stabilized and immediate life threats are treated are a whole different story. Days, weeks, and months in an ICU or extended care facility with devastating deficits might not be everyone's definition of a "positive" outcome. That's also a topic for another discussion.

The golden hour was a direct response to the advancement of prehospital care. Like you say, it was about understanding that someone with multisystem trauma needed a surgeon, not an ER doc and quick identification, notification, and transport was critical, vs running a mega code in the back of the ambulance. We CAN and DO make a difference with many medical and cardiac patients- we have enough toys and medications to at least mitigate the immediate life threat until we can get them to a hospital.

Not so for trauma patients. Unless we can surgically repair a transected aorta, remove a spleen, or repair the damage done by a projectile lodged in some internal organ, these folks are beyond our scope to "fix". So in the end, we still need to practice good assessment skills, understand that sometimes our best treatment is diesel therapy, and let someone else decide the ramifications of whether or not the system is doing more harm than good. The "golden hour" shouldn't be some iron clad barrier, but a general rule that dictates what course of action and/or the best facility is for our patient.

When I started in this business, the concept of trauma centers was nonexistant. Critically injured- but still salvageable patients- simply did not make it. Later, when I worked on the side in a busy Level 1 trauma center, I saw more thoracotomies than you could shake a stick at- sometimes one or 2 a day. Gradually the data showed that the survival rate of these folks was virtually zero, and the cost of such futile interventions was prohibitive. It was soon understood that top notch trauma care is incredibly expensive, and they sought ways to minimize costs whenever possible. Now, it is rare if you see a "cracked chest"- essentially it only happens if the trauma patient arrests in the ER, then MAYBE they decide to open their chests. Trauma(and prehospital) care IS still evolving, and in many cases, folks that used to be rushed to an ER in a futile attempt to save them, are simply declared dead on the scene(based on proper criteria, of course). Who knows what the next evolution of care will be, but you alluded to it- the concept of the "golden hour" should be a guideline, not something etched in stone.

[tniuqs]

I think AA has it right, trauma is increasingly a non surgical disease. Does that mean we should piss around on scene shaking our wang and playing Doctor.

I have personally witnessed many Doctors screwing around wasting time (when belly's are getting shiny) this in ER or ICU .. its not limited to Paramedics.I often wonder if there was "protocol allowed" to admin O neg in the field if this would make a difference in mortality morbidity, too bad the artificial O2 carrying blood substitutes have been less than promising.

Thing is that with the vast majority of "elemental medic educational programs" they leave a paint by numbers philosophy when its actually experience (in many cases) that one needs as a guide just when chillax and to "do no harm" and when to get to "get the hell out of Dodge".

cheers

cheers.

[aussiephil]

I have personally witnessed many Doctors screwing around wasting time (when belly's are getting shiny) this in ER or ICU .. its not limited to Paramedics.I often wonder if there was "protocol allowed" to admin O neg in the field if this would make a difference in mortality morbidity, too bad the artificial O2 carrying blood substitutes have been less than promising.

Thing is that with the vast majority of "elemental medic educational programs" they leave a paint by numbers philosophy when its actually experience (in many cases) that one needs as a guide just when chillax and to "do no harm" and when to get to "get the hell out of Dodge".

cheers

cheers.

The only problem with this is that you have not stemmed the source of the bleeding. You can pump in as much blood product, fluids, gel-o-fusion or whatever, it will not make any difference until the liver, spleen or other source of bleeding had been contained. Nice idea tho.

[HERBIE1]

The only problem with this is that you have not stemmed the source of the bleeding. You can pump in as much blood product, fluids, gel-o-fusion or whatever, it will not make any difference until the liver, spleen or other source of bleeding had been contained. Nice idea tho.

I think the point with the blood transfusion was that in some cases, trauma patients have lost so much blood that even though we may be able to keep a decent BP with massive fluids, the person has nothing left to carry oxygen. I agree- unless you fix what's bleeding, pumping more blood won't help, but it might buy us time prehospital. I can't tell you how many times we would have a massive bleed- multiple GSW's, multiple trauma, stab wounds, etc, and by the time we get to the ER, the person's bleeding pink fluids from their wounds- they are just circulating blood tinged saline- or LR in the old days. Never a good outcome from that.

[armymedic571]

I think the point with the blood transfusion was that in some cases, trauma patients have lost so much blood that even though we may be able to keep a decent BP with massive fluids, the person has nothing left to carry oxygen. I agree- unless you fix what's bleeding, pumping more blood won't help, but it might buy us time prehospital. I can't tell you how many times we would have a massive bleed- multiple GSW's, multiple trauma, stab wounds, etc, and by the time we get to the ER, the person's bleeding pink fluids from their wounds- they are just circulating blood tinged saline- or LR in the old days. Never a good outcome from that.

Begs the question of whether blood products are the solution, or something more along the lines of permissive hypotension?

but as you said that is another topic.......

AM 571

[HERBIE1]

Begs the question of whether blood products are the solution, or something more along the lines of permissive hypotension?

but as you said that is another topic.......

AM 571

It was alluded to here- for years they've been playing around with the idea of artificial blood, but cannot seem to get it to work. I'm not sure what the problems are, but isn't it amazing- with all our technology, we still cannot beat mother nature when it comes to something like blood?

[tniuqs]

Pssst: Hey HERBIE1 over here..

Anti-bleeding drug cheap way to save lives.

A cheap drug that can stop bleeding in recently injured accident victims could save tens of thousands of lives worldwide every year, researchers say.

They studied the effects of tranexamic acid, or TXA, in more than 10,000 adult trauma patients in 40 countries who received the drug within eight hours of being injured. They compared those patients' outcomes with more than 10,000 accident victims who received a placebo.

'We could probably use tranexamic acid on a daily basis.'—Dr. Karim Brohi, London ER

The research study was published online Tuesday in the medical journal Lancet.

Doctors found that patients who were given TXA had a 15 per cent lower chance of dying from a hemorrhage than those who didn't get it. They also had a 10 per cent lower chance of dying from any other cause, including organ failure and a head injury, versus patients who didn't receive TXA.

The drug is commonly used in wealthy countries during elective surgeries to stop bleeding, but isn't prescribed for accident victims.

TXA is off-patent and made generically by many companies. It costs about $4.50 US per gram, and a typical dose is two grams. It is usually given via an injection and would be easy to introduce, even in poor countries, experts said.

"This is one of the cheapest ways ever to save a life," said Ian Roberts, a professor of epidemiology at the London School of Hygiene and Tropical Medicine and one of the study's main investigators.

Previous tests of the drug regarded its use in elective surgeries, such as heart operations, but this was the first study to test the drug on accident victims.

Doctors were worried it might increase side-effects such as blood clots in the heart and lungs, strokes or heart attacks. There was no evidence of that in the Lancet study, though the authors said they might have missed some of these incidents.

For people between age five and 45, accidents are the second leading cause of death worldwide after AIDS, and about 600,000 injured patients bleed to death every year. Nearly six million people die of injuries every year, more than AIDS, malaria and tuberculosis combined.

For ERs in West too

Roberts and colleagues estimated that if TXA were readily available, between 70,000 and 100,000 lives a year could be saved.

Though the drug wasn't tested in children, he said it would almost certainly work in them as well.

Etienne Krug, director of violence and injury prevention and disability at the World Health Organization, said the drug would likely have the biggest impact in developing countries such as China and India, where 90 per cent of all injury-related deaths occur.

"People often have a fatalistic attitude about accidents and think nothing can be done to save people," he said. "But this study shows that isn't true."

Experts said rolling out TXA could save as many lives as other measures such as making seatbelts compulsory or strengthening drunk-driving laws.

The drug also could save thousands of people in the West.

"This is not just something for developing countries," said Dr. Karim Brohi, who works at one of London's busiest emergency rooms at Barts and the London School of Medicine and University of London-Queen Mary. "We could probably use tranexamic acid on a daily basis."

Last week, Roberts and colleagues submitted an application to the World Health Organization to include TXA on its list of essential medicines, which is used by many developing countries.

Once drugs are on WHO's list, other UN agencies such as UNICEF often buy the drug for poor countries.

"In many developing countries, emergency departments are like war zones, even when there's no war," Roberts said. "If [TXA] is available, a lot of those deaths could be avoided."

The study was financed by the British government.

Read more: http://www.cbc.ca/health/story/2010/06/14/bleeding-drug-txa.html#ixzz0w3UO3H1Y

I will look for the real EBM studies.

cheers