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Early management of trauma: The golden hour

Article  in  Current Medical Issues · January 2020

DOI: 10.4103/cmi.cmi_61_19

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Review Article

Early Management of Trauma: The Golden Hour

Kundavaram Paul Prabhakar Abhilash, A. Sivanandan
Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Abstract
The first 60 minutes after traumatic injury which is the most crucial period that determines the patient’s outcome has been termed the “golden
hour.” The concept that definitive resuscitative trauma care must be initiated within this early window has been publicized, taught, and practiced
worldwide for more than four decades. The main steps in the early management of trauma are primary assessment; resuscitation: perform primary
assessment and resuscitation together; reassessment of airway, breathing, and circulation; and secondary assessment. The primary assessment
provides basic data essential for the patient’s survival when life or limb is threatened. Resuscitation should be initiated simultaneously with
the primary assessment. It is performed when any component of the primary assessment appears unstable. The secondary assessment is to be
performed after the completion of primary assessment and resuscitation. It provides comprehensive information about the various organ systems.

Key words: Early management, emergency department, golden hour, trauma

Address for correspondence: Dr. A. Sivanandan, Department of Emergency Medicine, Christian Medical College, Vellore ‑ 632 004, Tamil Nadu, India.
E‑Mail: [email protected]

Introduction
Trauma is a leading cause of death in the first four decades of life. There is a trimodal peak of death and the first peak occurs within
seconds to minutes. It is usually due to laceration of the brain stem, heart, aorta, and other large vessels. Salvage after injury in these
instances is difficult, and the victims most often succumb to the trauma. The second peak occurs within minutes to hours later and can
be due to diverse injuries such as subdural hematoma, hemopneumothorax, splenic laceration, life‑threatening long bone fractures,
and significant blood loss. This group is potentially at risk of death, which may be averted if aggressive and appropriate management
is instituted at the earliest. The concept of the golden hour (the 1st h after trauma) arose from the treatment of this group of patients.

Golden Hour
The first 60 minutes following trauma is a critical period for getting patients to a trauma center and has been called the “golden
hour.”[1,2] This concept is deeply entrenched in trauma systems, field triage guidelines, emergency medical services, and emergency
department management of trauma victims.[2,3] The concept that definitive resuscitative trauma care must be initiated within this
early window has been publicized, taught, and practiced worldwide for more than 4 decades.[4,5] Numerous studies have, in the
past, explored the relationship between out‑of‑hospital time and outcome following injury.[4‑14]

Early Management of Trauma

The focus of early management of trauma will essentially be on patients with a compromised airway, breathing, or circulation.
The third peak of death occurs several days to weeks after the initial injury and is most often due to sepsis and multiple organ

Date of Submission: 19-Nov-2019 Date of Review: 06-Dec-2019

Date of Acceptance: 20-Dec-2019 Date of Web Publication: 03-Feb-2020

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DOI:
10.4103/cmi.cmi_61_19 How to cite this article: Abhilash KP, Sivanandan A. Early management
of trauma: The golden hour. Curr Med Issues 2020;18:36-9.

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Abhilash and Sivanandan: Golden hour of trauma

system failures. Certain basic principles need to be clearly breathing may indicate a cervical cord lesion. Paradoxical
understood in the early management of trauma: chest wall motion may indicate the presence of a flail chest.
• Treat the greatest threat to life first The flail segment will move inward with inspiration and
• Lack of a definitive diagnosis should never impede the outward with expiration. Chest excursions and symmetry of
application of an indicated treatment breathing patterns should be observed. Injuries than can acutely
• A detailed history is not a prerequisite to begin the impair ventilation include tension pneumothorax, flail chest
evaluation of an acutely injured patient. with pulmonary contusion, massive hemothorax, and open
pneumothorax. A tension pneumothorax is a life‑threatening
To be able to focus on the priorities in an injured patient, a
condition and is treated immediately by performing a needle
definite system or drill needs to be implemented. The advantage
thoracostomy prior to further assessment of the patient.[19,20]
of such a system is that priorities are established and as every
member of the team follows the system; communication Circulation with hemorrhage control
between team members is easier and more meaningful. The Hemorrhage, a predominant cause of death in trauma, is
main steps in the early management of trauma are: amenable to the effective treatment. Clinical parameters that
1. Primary assessment provide information about the circulation status are pulse,
2. Resuscitation: Perfor m primar y assessment and neurological status, and blood pressure. A rapid and thready
resuscitation together pulse is an early sign of hypovolemia. A restless or an unusually
3. Reassessment of airway, breathing, and circulation (ABC) cooperative patient is usually because of decreased cerebral
4. Secondary assessment. perfusion. The assessment of circulation begins with the
insertion of two large‑bore cannulae so that rapid infusions
Primary Assessment of fluids may be administered if necessary.[21,22]
The purpose of the primary assessment is to identify life If obvious external bleeding is noted, external pressure is
and limb‑threatening injuries.[15] It should be conducted in a applied to the site. If hypotension is present, an initial fluid
sequential manner as follows: bolus of 1–2 l of Ringer’s lactate (RL) solution is infused and
circulatory status is reassessed. If hypotension persists, the
Airway with in‑line cervical spine immobilization patient may have an injury that continues to bleed. A search for
Patency of the airway should be assessed first. In a conscious the source of hemorrhage must be made and the hemorrhage
patient, clear speech is a good indicator of a clear airway. Noisy must be controlled before proceeding with the rest of the primary
breathing is an indication of airway obstruction. Suctioning of assessment. The search for internal hemorrhage may require
the mouth with a chin lift or jaw thrust maneuver will prevent imaging modalities like a focused assessment with sonography
the airway from being obstructed.[16] An oropharyngeal airway for trauma or computed tomography. It is prudent to remember
may be required to maintain a patent airway. If the above that the endpoints of volume resuscitation are unclear. There is
initial measures are inadequate to maintain an effective airway, some evidence that bringing up the blood pressure to normal
endotracheal intubation should be carried out.[17] Patients levels in the face of an ongoing hemorrhage may actually cause
who have lost airway protective reflexes and who have risk more damage than good. The relationship to normal parameters
aspiration of gastric contents where an endotracheal intubation of blood pressure, heart rate, and urine output may be inadequate.
is not possible, a surgical airway must be established without
delay.[18] Disability – neurological status, as expressed by the
patient
Measures to establish a patent airway should include the
A rapid neurological evaluation should be performed as a
protection of the cervical spine. Always assume that the patient
part of the primary assessment. The level of consciousness is
has a cervical spine injury. This is particularly in any patient
assessed using the Glasgow Coma Scale (GCS).[23]
with multisystem trauma, altered level of consciousness, or a
blunt injury above the clavicle. Unintentional movement of Exposure of the entire body, looking for occult injuries
the cervical spine during orotracheal intubation is minimized It cannot be overemphasized that complete disrobing of the
by manual in‑line stabilization of the neck, provided by an patient is mandatory if occult injuries are to be identified.
assistant. However, in view of sociocultural restraints, undergarments
of the patient may be retained, after the physical examination.
Breathing with oxygen supplementation
Examination of the external genitalia and rectal examination
Airway patency alone does not ensure adequate ventilation.
are part of the secondary assessment.
Adequate gas exchange is mandatory. Once the airway is
established, oxygen is administered using high flows or
reservoir bag to ensure a high fraction of inspired oxygen Resuscitation
concentration. This is followed by inspection, palpation, Resuscitation should follow the ABC pattern of the primary
and auscultation of the patient’s chest. The type of breathing assessment and should be performed simultaneously.
pattern can provide clues about the presence of a neurological • If the airway is compromised, the primary assessment
injury. For example, no chest wall movement with abdominal should be suspended till the airway is secured

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Abhilash and Sivanandan: Golden hour of trauma

• If breathing is compromised, then that should be dealt bogginess, or step deformities indicating the possibility
with appropriately. This may require decompression of a cervical spine injury
of a tension pneumothorax or a massive hemothorax. It • Scalp lacerations tend to bleed profusely because of
may also involve endotracheal intubation and mechanical abundant vascular supply. Apply direct pressure to control
ventilation in a patient who is not breathing adequately any bleeding. Check the continuity of the cranium with a
• Resuscitation of circulation includes insertion of two gloved hand, palpating gently with the fingertips. Beware
large‑bore cannulae and infusing 1–2 l of normal saline/RL of small puncture wounds of the scalp, which may indicate
solution. At the same time, blood is taken for the cross penetrating injury of the brain
match, electrolytes, and hemoglobin (Hb). • Assess the GCS
Reassessment of the ABC is an integral component to ensure • Examine the nose and ears for bleeding and leakage of
that there has been no decompensation. This should be done cerebrospinal fluid
as each step of the primary assessment is completed or if there • Inspect the mouth for lacerations, broken teeth, or vomitus
is a time lag between components. since they could jeopardize the airway.

By the end of the primary assessment and resuscitation, the Examination of the thorax
following should be achieved: Although assessed during the primary assessment, the thorax
• Airway established and maintained should again be reviewed for injuries. Check SpO2 to assess
• Supplemental oxygen initiated peripheral oxygen saturation.
• Cervical spine immobilized Examination of the abdomen
• Two large‑bore intravenous lines started • Abdominal assessment includes inspection for contusions,
• Blood drawn for baseline investigations and cross‑match abrasions, and distension. Discoloration of the flanks may
• External hemorrhage control achieved indicate retroperitoneal bleeding. Any wound above the
• Electrocardiography  (ECG), blood pressure, and SaO2 umbilicus may have penetrated the thorax
monitoring • Femoral pulse should be simultaneously palpated
• Brief neurological examination completed bilaterally and assessed for equality
• Full exposure and environmental control done. • The integrity of the pelvis should be evaluated by pushing
Adjuncts to primary assessment on the wings of the iliac bone to determine if this action
• ECG monitoring is essential for all trauma patients. elicits pain
Tachycardia indicates volume loss and arrhythmias • Examine the urinary meatus for the presence of blood,
indicate blunt trauma to the chest. The pulseless electrical which may indicate ruptured urethra
activity where there is an ECG trace but no palpable pulse • Perform a digital pelvic examination in females to look
is seen in tension pneumothorax or cardiac tamponade for the presence of vaginal bleeding
• Pulse oximetry is a useful adjunct to monitoring. The pulse • The patient should be logrolled with the head aligned to
oximeter measures the oxygen saturation of Hb and is an the body and the spine evaluated for asymmetry and the
indirect means of measuring the adequacy of ventilation. presence of tenderness
• During the logroll, perform a rectal examination to
evaluate the sphincter tone and presence of blood.
Secondary Assessment
The secondary assessment should be performed after the Examination of the extremities
completion of the primary assessment. It is a head‑to‑toe • Palpate the extremities for tenderness, crepitus, and
systematic and comprehensive evaluation of all organ systems. deformities
It is during this phase of management that the patient’s detailed • Evaluate for quality and integrity of pulses. Diminished
history should be elicited. A useful system for history elicitation pulses suggest disrupted blood vessels. Traction generally
is the AMPLE: restores blood flow
• A Allergies • If the patient is conscious, assess sensory and motor
• M Medications (especially anticoagulants, insulin, and functions
cardiovascular medications) • Suspected fractures and dislocations should be splinted
• P Previous medical/surgical history for further radiographic and diagnostic evaluation.
• L Last meal (time)
• E Event – details regarding the biomechanism of injury. Adjuncts to Secondary Assessment
Examination of the head and face 1. A urinary catheter is a vital adjunct for polytrauma
• Immobilize the neck with a hard cervical collar until the management. The urine output is an excellent way of
cervical spine X‑ray is done and cleared. With an assistant assessing perfusion in patients with an intact renal
immobilizing the head, remove the cervical collar function. Moreover, blood in the urine may indicate renal
and examine the neck for any lacerations, tenderness, trauma. The urinary catheter should be inserted only

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Abhilash and Sivanandan: Golden hour of trauma

after ensuring that there are no pelvic fractures that could 4. Sampalis JS, Denis R, Lavoie A, Fréchette P, Boukas S, Nikolis A, et al.
have injured the urethra. Blood in the meatus, perianal Trauma care regionalization: A process‑outcome evaluation. J Trauma
1999;46:565‑79.
hematoma, or a high‑riding prostate on rectal examination 5. Sampalis JS, Lavoie A, Williams JI, Mulder DS, Kalina M. Impact of
should raise suspicion of urethral injury. Under these on‑site care, prehospital time, and level of in‑hospital care on survival in
circumstances, urinary catheterization should only be severely injured patients. J Trauma 1993;34:252‑61.
attempted after an ascending urethrogram 6. McCoy CE, Menchine M, Sampson S, Anderson C, Kahn C. Emergency
medical services out‑of‑hospital scene and transport times and their
2. The nasogastric tube needs to be inserted to avoid association with mortality in trauma patients presenting to an urban
stomach distension and to reduce the risk of aspiration. Level I trauma center. Ann Emerg Med 2013;61:167‑74.
When a base of skull fracture is suspected, the gastric 7. Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, et al.
tube should be inserted orally to prevent the intracranial The OPALS major trauma study: Impact of advanced life‑support on
survival and morbidity. CMAJ 2008;178:1141‑52.
passage 8. Pepe  PE, Wyatt  CH, Bickell  WH, Bailey  ML, Mattox  KL. The
3. If available, obtain an ABG to assess the Haematocrit, relationship between total prehospital time and outcome in hypotensive
PaO2, and the degree of acidosis. victims of penetrating injuries. Ann Emerg Med 1987;16:293‑7.
9. Petri RW, Dyer A, Lumpkin J. The effect of prehospital transport time on
Mandatory radiology in trauma evaluation for all high‑velocity the mortality from traumatic injury. Prehosp Disaster Med 1995;10:24‑9.
accidents includes the chest, lateral cervical spine, and pelvis. 10. Lerner EB, Billittier AJ, Dorn JM, Wu YW. Is total out‑of‑hospital time
Focussed assessment with sonography for trauma (FAST) is a significant predictor of trauma patient mortality? Acad Emerg Med
2003;10:949‑54.
indicated if an intra‑abdominal injury is suspected.[24] 11. Pons PT, Markovchick VJ. Eight minutes or less: Does the ambulance
response time guideline impact trauma patient outcome? J Emerg Med
Conclusion 2002;23:43‑8.
12. Di Bartolomeo S, Valent F, Rosolen V, Sanson G, Nardi G, Cancellieri F,
• Early management of trauma is a well‑defined protocol, et al. Are pre‑hospital time and emergency department disposition time
which needs to be methodically followed useful process indicators for trauma care in Italy? Injury 2007;38:305‑11.
13. Osterwalder JJ. Can the “golden hour of shock” safely be extended in
• The primary assessment provides basic data essential for blunt polytrauma patients? Prospective cohort study at a level I hospital
the patient’s survival when life or limb is threatened in eastern Switzerland. Prehosp Disaster Med 2002;17:75‑80.
• The airway is of primary importance. No other therapeutic 14. Newgard  CD, Schmicker  RH, Hedges  JR, Trickett  JP, Davis  DP,
assessment or intervention should take place before the Bulger  EM, et al. Emergency medical services intervals and survival
in trauma: Assessment of the “golden hour” in a North American
airway is secured. The ABCs take priority in that order prospective cohort. Ann Emerg Med 2010;55:235‑46.
• Resuscitation goes hand in hand with the primary 15. Wyatt J, Beard D, Gray A, Busuttil A, Robertson C. The time of death
assessment. It is performed when any component of the after trauma. BMJ 1995;310:1502.
primary assessment appears unstable 16. Ollerton JE. NSW Institute of Trauma and Injury Management. Adult
trauma clinical Practice Guidelines: Emergency Airway Management in
• The secondary assessment is to be performed after the the Trauma Patients. North Ryde: NSW Institute of Trauma and Injury
completion of primary assessment and resuscitation. It Management; 2007.
provides comprehensive information about the various 17. Graham CA, Beard D, Oglesby AJ, Thakore SB, Beale JP, Brittliff J, et al.
organ systems Rapid sequence intubation in Scottish urban emergency departments.
Emerg Med J 2003;20:3‑5.
• Prehospital care plays a vital role in the early resuscitation
18. Hagberg  CA, editor. The traumatized airway: Principles of airway
of trauma victims. In India, prehospital care is almost management in the trauma patient. In: Benumof’s Airway Management.
nonexistent, and there is an urgent need to train paramedics 2nd ed. New York: Mosby Elsevier Inc.; 2008.
in trauma management to improve mortality and morbidity 19. Harrison  BP, Roberts  JA. Evaluating and managing pneumothorax.
Emerg Med 2005;37:18‑25.
associated with trauma.
20. Zhang  M, Liu  ZH, Yang  JX, Gan  JX, Xu  SW, You  XD, et al. Rapid
Financial support and sponsorship detection of pneumothorax by ultrasonography in patients with multiple
trauma. Crit Care 2006;10:R112.
Nil. 21. Lakstein  D, Blumenfeld  A, Sokolov  T, Lin  G, Bssorai  R, Lynn  M,
et al. Tourniquets for hemorrhage control on the battlefield: A  4‑year
Conflicts of interest accumulated experience. J Trauma 2003;54:S221‑5.
There are no conflicts of interest. 22. Dennis JW. Blood replacement massive transfusion and hemostasis in
hemorrhagic shock. Trauma Q 1992;8:62‑8.
23. Chou  R, Totten  AM, Pappas  M, Carney  N, Dandy  S, Grusing  S,
References et al. Glasgow Coma Scale for Field Triage of Trauma: A Systematic
1. Committee on Trauma. Resources for Optimal Care of the Injured Review. Comparative Effectiveness Review No. 182.  (Prepared by
Patient. Chicago, Ill; American College of Surgeons; 2006. the Pacific Northwest Evidence‑Based Practice Center under Contract
2. Mackersie  RC. History of trauma field triage development and No.  290‑2015‑00009‑I.) AHRQ Publication No. 16  (17)‑EHC041‑EF.
the American College of surgeons criteria. Prehosp Emerg Care Rockville, MD: Agency for Healthcare Research and Quality; 2017.
2006;10:287‑94. 24. Kleinman  J, Inaba  K, Pott  E, Matsushima  K, Demetriades  D,
3. Lerner  EB, Moscati  RM. The golden hour: Scientific fact or medical Strumwasser  A. Early FAST examinations during resuscitation may
“Urban legend”? Acad Emerg Med 2001;8:758‑60. compromise trauma outcomes. Am Surg 2018;84:1705‑9.

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