The Golden Hour of Trauma

What happens when a trauma patient arrives to the emergency department

by Nikita Joshi MD  @njoshi8

“Trauma code team to the CCT, Trauma code team to the CCT” – These are the siren calls that echo throughout the halls of Kings County hospital in Brooklyn, one of thousands of trauma hospitals scattered throughout the United States that are dedicated to caring for victims of trauma and violence. This call instantly sends out the signal – a patient on the brink of death is coming, and very soon with the screaming lights of an ambulance.

Instantly, the pulse of doctors, nurses, technologists, and pharmacists quickens; their minds focus; and the meal they were about to enjoy gets tossed in the trash. The trauma team descends upon the emergency department trauma bay with brisk, familiar precision as each member of the team assumes their positions and prepares for their role in saving a life. They will begin the ritual of donning gowns, pulling on gloves, and scanning the room for necessary equipment – scalpel, check; intubation equipment, check; suction? on; bucket of blood? next to the nurse on the stand. A strained quiet falls on the room as the team awaits with anticipation the arrival of a critically ill gunshot victim.

This practiced ritual of mental and physical preparation is deeply ingrained in our culture of trauma medicine. Doctors and nurses are trained to act quickly in a highly ordered and structured team environment to manage and save the lives of injured people. This is a time when seconds and minutes can make the difference between life and death.

This emphasis on time and preparation is called “the Golden Hour” of trauma. Here, we will demystify what the Golden Hour is – and why it is so important for treating patients with gunshot wounds.

What is the Golden Hour?

The Golden Hour of trauma is a phrase emphasizing that critically injured patients will require medical and surgical intervention rapidly. While this time is not literally limited to one hour, it encapsulates the importance of getting the patient to a trauma hospital immediately and having both the necessary team and equipment ready to help the patient to survive. Read more here about the early history of trauma management and the Golden Hour.

The Trauma Team

There are many important members of the trauma team. Each person has a clearly-defined, essential role in responding to trauma alerts. The team members who gather may look exactly the same in their scrub uniforms, but they all play a different and vital role. Usually the important team members include emergency medicine doctors – they are skilled at resuscitation, intubations, and stabilizing critically ill patients. Also trauma surgery doctors – they are skilled at resuscitation, emergency surgery, and taking care of the patient throughout the hospital course. Other doctors that can assemble include neurosurgery doctors if there are injuries to the brain or spinal column, orthopedic doctors if there are injuries to bones, and vascular surgery doctors if there are injuries to arteries and blood flow to parts of the body. An equally important part of the team involves nurses who help with the initial assessment, place IVs, draw blood, and assist with procedures, respiratory technicians who help with intubations, x-ray technicians who help obtain important radiographs, and pharmacists who help to draw and give life sustaining medications. Of course the pre-hospital providers are critical for bringing patients to the emergency department quickly and safely in an ambulance, helping to start life saving things such as IVs, and relaying important information to the medical team about how they found the patient and the circumstances of what happened.

Trauma Centers

Because so many different types of doctors and medical professionals are required for the successful resuscitation of an injured person, it is impossible for all hospitals to be able to staff and have the necessary resources required for critical trauma care available at all times. There are hospitals known as Trauma Centers that are certified to provide critical trauma care. These facilities have the important resources and manpower to manage injured patients. This is why patients are sometimes taken to a more distant hospital with a high level of trauma expertise, rather than to the closest hospital . At times, a critically ill patient must be first stabilized at a nearby hospital and then later airlifted or flown to a hospital in which the specific expertise and resources are available to effectively treat the patient’s specific injuries. Learn more here.

This is a time when seconds and minutes can make the difference between life and death.

Pathophysiology

The Golden Hour is also important when thinking about what happens to the person who has suffered a gunshot wound. Depending upon what part of the body is affected, the injuries can be severe and either end a life in a few minutes from bleeding, or lead to something disastrous such as a patient having to amputate an arm or leg, or becoming paraplegic from a spinal cord injury. If there is internal bleeding from an artery, the person can bleed very fast, and often the only way to stop the bleeding is to rush the patient to the operating room. The person may also need to get a rapid supply of blood called Massive Transfusion in order to make up for the large quantity of blood that they are losing. Without fast interventions, the person can quickly become hypotensive where the blood pressure is dangerously low. If the blood pressure does not improve, the important organs in the body will not get the blood needed to function. The patient may develop a very fast heartbeat; she may breathe very rapidly; and she may become confused. She may ultimately stop talking or responding. The other dangerous part of not getting the necessary blood to the organs is that the body develops acidosis. Too much acid in the body will start to poison all of the cells in the whole body, which sets off a cascade of bad events. This leads the patient to get sicker and sicker, and the patient may ultimately die.

Procedures

Getting the person who is shot quickly to the hospital allows the trauma team to immediately initiate the necessary treatments to try to stop the cascade of systemic shock, to identify the injuries as fast as possible, and to provide medical treatment or emergent life-saving surgery. In order to accomplish all of this, the trauma team will rapidly cut off clothes in order to fully examine the patient, place IV catheters to give medications and blood, put stickers on the chest to record vitals like heart rate and blood pressure, perform bedside ultrasounds to see if there is blood in the chest or abdomen, obtain x-rays to look at the organs and bones, and initiate life saving procedures. Sometimes patients are rushed to the operating room, or get cat scans, or have emergency procedures performed in the emergency department if they are too sick to be transported to the operating room on a gurney.

Ultimately, all of this is performed seamlessly and rapidly to try to save the patient within this critical Golden Hour.

What You Need to Know

  • The Golden Hour of trauma means that people who are shot only have a short amount of time before it may be too late to save their lives
  • Getting a person who has suffered a gunshot wound to the hospital is critically important – call 911
  • Not every hospital is a Trauma center that is adequately equipped to handle victims of gun violence; calling 911 will mobilize the ambulances and get the person to the proper hospital facility that has the appropriate level of expertise and resources so that the patient will receive the proper life-saving help he will need.

Where We Need More Research

  • Exactly how long is the Golden Hour – the time a person who is shot has before they are too sick and cannot be saved?
  • How much time should the prehospital providers spend on the field to try to save someone before bringing them to the hospital?

Nikita Joshi MD  @njoshi8