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Prehospital Times
Date: 19.02.97 18:12
From: Enrique Montbrun [montbrun@ccs.internet.ve]

Hello everybody! The time critical nature of trauma care has been well established. What are acceptable prehospital times for delivery of the patient to a trauma center in the suburban or rural environment? What are your opinion about field stabilization for the trauma patient where travel times are longer than golden hour? "stay and stabilize" or "scoop and run". How do you do to manage trauma victims in place where medevac take a long time to response?

Dr. Enrique Montbrun
Assistant Professor of Surgery
Universidad Central of venezuela

Date: 20.02.97 17:22
From: Aviel Roy-Shapira

It makes sense, but the 'golden hour' has never been scientifically validated.

An unstable trauma patient belongs in the operating room. You cannot stablize such patients in the field, no matter how long it takes to drive.

Put another way, those patients whom you can stabilize in the field are patients who stopped bleeding. These patient can be resuscitated en-route, and it matters not if you stay and play or scoop and run. For the patients who cannot be resuscitated in the field, any delay in evacutation to a facility with operating capabilities is deadly.

The safest course is to roll them out and do everything en-route as advocated by the PHTLS course.

That said, I think that one should make sure about A and B, before moving the patient. That does not necessarily mean intubation, but at least be able to ventilate with a bag-valve mask. I also think that tension pneumothorax should be treated in the field. So it is not pure scoop and run - remember that the run in "S&R" is run as in run away. I believe the term originated in Vietnam, when it was impossible to do anything in the field because of danger to the evacuating team.

Avi
===========================================
Aviel Roy-Shapira, M.D. Ben-Gurion University Medical School
Dept. of Surgery A. POB 151, Beer Sheva, Israel

Date: 20.02.97 18:17
From: "John A. Aucar, M.D." [jaucar@bcm.tmc.edu]

Extrication and transport times are typically short (10-15 min) in Houston, but vary widely according to circumstances. I'm not that certain that the "golden hour" should be accepted as fact (fact: a term that marks the point at which we allow investigation to cease).

Some believe that the patients protective physiologic mechanisms will "stabilize" him better than we can. If he is not fatally wounded, he can survive significant transport times. If he is progressively deteriorating, you can probably not achieve "stabilization" in the field, unless you can control the injury. Except for securing an airway and pressure control of external bleeding, you should not "stay and play", but rather get to the nearest operating room or angiogram suite.

If a patient is unstable, say from a pelvic fracture or hepatic injury, his only hope is probably that the blood pressure will fall and vessels constrict enough to limit the bleeding and redirect blood flow to heart, brain and kidneys. His worst luck might be that a well meaning meddler may decide to "resuscitate" him with fluid and increase his BP, lower his body temp, dilute his clotting factors and aggravate the bleeding and it's subsequent complications. There is experimental support for this perspective in animal studies and penetrating human trauma. It's application to blunt trauma is purely extrapolated. No one to my knowledge has shown the feasibility or advantage to delivering definitive care in the field, except perhaps for limb amputations.

JAA
--
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
! John A. Aucar, M.D.,F.A.C.S. !
! Dept. of Surgery !
! One Baylor Plaza !
! Houston, TX 77030 !
! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
! Assistant Professor, Surgery, Baylor College of Medicine !
! Ben Taub Gen. Hospital; http://www.bcm.tmc.edu/surgery/ !

Date: 20.02.97 20:05
From: "Smith, J. Stanley, MD"

one hour maximum. Scoop and run is better with immobilization and splinting of fractures and spine. If too long for paramedics, try to rendezvous in between.

Date: 21.02.97 12:08
From: "J.K.Turner"

Re - fluid resuscitation in the field. You may be interested to know that the Medical Care Research Unit, University of Sheffield is at present conducting an RCT of pre-hospital IV fluids in trauma patients. 300+ paramedics have been randomised to two treatment protocols i.e. give fluids or withhold them. These are predominantly blunt trauma patients (penetrating trauma accounts for less than 5% of all trauma in the UK) so hopefully we will produce some evidence for the blunt injury group which will contribute to the debate.

Janette Turner - Research Fellow & project leader

Medical Care Research Unit
University of Sheffield
Regent Court
30 Regent Street
SHEFFIELD, S1 4DA

Date: 22.02.97 18:36
From: "Smith, J. Stanley, MD" [JStanley.Smith@hmc.psu.edu]

The most recent annual report for the state of Pennsylvania's Trauma Centers was released this week showing an average prehospital time of 45 minutes from the time of injury to trauma center arrival for direct admissions from the scene of the accident.

We have a suburban/rural trauma center with a helicopter service. We also have an EMS service and receive most of our patients by ground ambulance. Our average prehospital time for the year 1996 was 48 minutes. Considering this represents time from the injury or first communication of the accident, response of the EMS system (scrambling, travel time to the scene), assessment at the scene, and travel to the hospital, 45-48 minutes seems about right for a suburban/rural system.

Date: 25.02.97 16:54
From: Frank Grosso [fgrosso@umabnet.ab.umd.edu]

I respectfully have to disagree with Dr Roy-Shapira with the above portion of his response. The theory of the "golden Hour" has been proved as much as many other medical theories have been "proved".I believe it was Dr R Adams Cowley who did research in the 1950s and 1960s, originally on dogs. He basically took the dogs and and phlebotomized them. They were all hooked up to blood pressure and cardiac monitors. THose whose blood was autotransfused within a 1 hour period would usually recover and hold thier blood pressure and would survive. Those who waited for greater than an hour for the auto transfusion did not. They would begin to rally and restore thier BP as thier bodies compensentary mechanisms took over. But thier vitals would eventually decline in spite of a later autotransfusion and die. Dr Cowley investigated this golden hour after working as an Army field surgeon with the US Army in Europe immediately post WW2. He found that soldiers who reached his field hospital within an hour after having thier accident( fairly common with the old jeeps that frequently rolled over) were more likely to survive than those with longer transport times. Well, he followed up with the above mentioned dog experiment. He convinced his fellow surgeons to let him care for thier traum patients that they considered to have no hope. Families eagerly agreed to this ray of hope. Well, the patient was put into one room, while the room next door was made into a lab. Serial studies were performed on every test they could perform, every hour I believe. He was able to save 50 % of these "totally hopeless" patients. More importantly, although not to those patients, was the information he found to support his theories. He eventually developed this 2 room suite in a corner of the University of Maryland into the R Adams Cowley Shock Trauma Center here in Baltimore, the first(I believe) Trauma Center in the world. It is now a 120+ bed hospital accepting only trauma patients.

Ok, sorry about the long winded answer1 :) I do tend to ramble on at times....Anyway, I do not have the specific cites of his articles and or texts that provide the concrete back up to support my statements . However, if you are interested in seeing the raw data, I live across from our regional Health sciences library. I would be able to give you the citations at the very least and would be able to scan in a journal article or excerpt and email it to you. I'm not sure about the legalities of sending that to multiple persons( ie the whole list).

Cheers!
Frank

Date: 27.02.97 07:43
From: "Aviel Roy-Shapira" [avir@bgumail.bgu.ac.il]

Thanks for the interesting details about Dr. Cowley's experimental work.

Perhaps I should have said that the concept of the golden hour was never validated in Humans.

Dr. Cowley's contributions to the care of trauma are an example to us all, and notwithstanding the above comment, we still use the golden hour as a goal in most trauma systems.

Please send the citations. It would be interesting to review the raw data.

Avi
Aviel Roy-Shapira, M.D.
Dept. of Surgery A, and the Critical Care Unit, Soroka University Hospital
POBox 151, Beer Sheva, Israel

Date: 01.03.97 02:37
From: Ken Mattox [KMATTOX@aol.com]

Dr. Avi Roy-Shapira is RIGHT. The Golden hour is merely a concept. It has NEVER been validated in people, animals, or a computer model. Population based studies from several centers have also demonstrated that it is not a fact but a concept. Marketing concept.

k


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