The Golden Hour between life and death

Dr Ramprasad J, HOD and Director of Trauma, MIOT Hospital, Chennai explains the significance of the golden hour and elaborates on ways to provide effective emergency care to victims. Trauma caused by Road Traffic Accidents has been a leading cause of mortality in India for a very long time. According to the India Spend report, nationwide, 467,044 road accidents were reported in 2018–or 53 every hour, on average–an increase of 0.46 per cent compared to 2017, according to the Road Accidents in India 2018 report released in September 2019. These crashes killed 151,417 people–or 17 every hour, on average—2.4 per cent higher than in 2017 and injured 469,418 people.

A third of the road-accident deaths reported were in urban areas, which accounted for 41 per cent of all reported accidents, while two-thirds were in rural areas, data show.

Moreover, the National Crime Records Bureau data states that a total of 4,21,104 people died in accidents due to various causes in the country in 2019. During the same year, a total of 4,37,396 cases of road accidents were reported which left 4,39,262 persons injured and caused 1,54,732 deaths. The highest death rates were noted in the states of Tamil Nadu, Madhya Pradesh, Uttar Pradesh, Karnataka and Kerala among young adult males in the age group of 15-39 years. Pedestrians, motorcyclists and cyclists are known to be more vulnerable to these injuries as they are less protected than the drivers or passengers of vehicles.

Impact of road accidents in India
Rapid urbanisation along with lack of infrastructure and road safety rules as compared to the growing population and vehicle density has led to a surge in high-velocity polytrauma and road traffic accidents.
Such accidents have a far-reaching economic impact that includes loss of primary breadwinners of families, huge treatment cost which can push families into poverty and also cause huge economic loss to the nation.
It is a well-established fact that chances of survival of the injured person are higher if they receive emergency medical care in the shortest period.
Significance of the Golden Hour
The first 60 minutes after a traumatic injury which is the most crucial period that determines the patient’s outcome is called the ‘golden hour’. As R Adams Cowley – Shock Trauma Center, Baltimore University, says, “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 maybe three days or two weeks later- but something has happened to your body that is irreparable.”
This means that definitive resuscitative trauma care must be initiated within this early window. This concept has been publicised, taught, and practiced worldwide for more than four decades.
But unfortunately, in India, victims are unable to reach the right hospital within the golden hour period due to lack of awareness and proper rescue facilities.
Ways by which effective trauma care can be initiated during the golden hour
• After reaching the hospital emergency, the main steps in the management of these multiple injured patients are:

  1. Primary Assessment – Diagnosis of life-threatening injuries.
  2. Damage Control Resuscitation – Treatment of shock and severe injuries.
    • Both are performed together which avoids loss of valuable moments of the golden hour essential for the patient’s survival.
    • Resuscitation should be initiated simultaneously as the primary assessment is done which includes replacement of the blood loss in the injury with blood, blood products or blood substitutes.
    • As the resuscitation process is done simultaneously the immediate life-threatening injuries are also identified which may be :
  3. Brain injury (50 per cent of mortality)
  4. Bleeding/shock (35 per cent of mortality)
  5. May have both
  6. Both are time-sensitive, minutes count!
    • In cases of abdominal / chest injuries especially with internal bleeding will require immediate surgical intervention to save the life and consequence of prolonged hypovolemic shock.
    • Complications from shock may occur if the person is not managed appropriately and expeditiously in this golden hour. It is therefore paramount to transport accident victims with severe trauma as fast as possible to a tertiary care hospital. These accident victims should reach the right hospital at the right time to get the right treatment for higher chances of survival and early recovery. The golden hour of multiple injured patients must be utilised properly to revive and give them back the life they expect to have.
    Saving the Golden hour concept
    As a progressive society, it is our collective social responsibility to be aware of this “golden hour concept” which includes field triage guidelines, emergency medical services and rescue and transportation of trauma victims to tertiary care centre within the golden hour. We as a community should partner and associate with trauma care providers to save as many lives of people in our country.
    References:
    https://www.indiaspend.com/road-accidents-killed-17-indians-every-hour-even-as-trauma-care-remains-ill-equipped/
    https://ncrb.gov.in/sites/default/files/ADSI-2019-FULL-REPORT.pdf

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