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The Golden Hour

The Golden Hour. "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 may be three days or two weeks later -- but something has happened in your body that is irreparable." - R. Adams Cowley.

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The Golden Hour

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  1. The Golden Hour "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 may be three days or two weeks later -- but something has happened in your body that is irreparable." - R. Adams Cowley

  2. 1918
Original data supporting the 'Golden Hour' concept produced from French World War I data. 'In World War I, there was a real appreciation of the time factor between wounding and adequate shock treatment. If the patient was treated within one hour, the mortality was 10 percent. This increased markedly with time, so that after eight hours, the mortality rate was 75 percent.’ Time from injury Mortality 1 hr 10 % 2 hr 11 % 3 hr 12 % 4 hr 33 % 5 hr 36 % 6 hr 41 % 8 hr 75 % 10 hr 75 % Santy, P. Marquis Moulinier, Da Shock Tramatique dans les blessures de Guerre, Analysis d'observations. Bull. Med. Soc. Chir., 1918, 44:205

  3. First World War triage: prioritising patients Under this system the wounded are divided into three groups. Soldiers who are only slightly injured are treated quickly and returned to the battlefield. The next group are those who need to be transported to hospital. The third group are those deemed to be beyond help and, when resources are limited, this group receives the least attention. The system began to be developed by the French surgeon Dominique Larrey during the Napoleonic Wars (1803-15) and became standard practice in the First World War (1914-18). Medical officers were stationed with the soldiers to look after them. If the soldiers were badly injured they would be removed from the front line by field ambulance to a casualty clearing station on the medical officer’s orders and from there to a hospital further down the ‘line’.

  4. I guerra mondiale - shock circolatorio “...The United States was a late entrant to World War I, but there were 53,402 Americans killed in action and 63,114 dead from other causes. Durante la I guerra mondiale la principale causa di morte dei soldati feriti era considerata il “wound shock” (shock da ferite). Solo nella prima metà degli anni ’30 si chiarì che lo shock da trauma era dovuto ad una riduzione del volume ematico.

  5. II guerra mondiale - shock circolatorio By World War II, the Pentagon counted 291,557 deaths in action and 113,842 from other causes...” Durante la II guerra un soldato ferito aveva una possibilità di sopravvivenza, se trattato da un medico entro la prima ora, dal trauma 3 volte maggiore rispetto alle statistiche di sopravvivenza della I guerra.

  6. II guerra mondiale - shock circolatorio All’inizio della II guerra mondiale lo shock circolatorio continuò ad essere la principale causa di morte nei soldati con trauma. A guerra in corso si sviluppò il concetto di trattamento chirurgico precoce in ospedali da campo.

  7. The idea for MASH (Mobile Army Surgical Hospital) originated in World War II with a Boston chest surgeon, Col. Edward “Pete” Churchill, MD, who in 1943 moved his best surgeons forward into rudimentary, auxiliary field hospitals during the invasion of Italy.

  8. …ma i feriti che sopravvivevano dopo l’arresto dell’emorragia, morivano più tardi per anuria. Alla fine della guerra, il rene incominciò ad apparire come il successivo organo ad essere compromesso dopo un trauma.

  9. Guerra di Corea The Mobile Army Surgical Hospital (MASH) were fully deployed during the Korean War. Triage at the MASH units was modeled after the dictum: "life takes precedence over limb, function over anatomical defects.”

  10. Guerra di Corea - insufficienza renale The resuscitation of casualties with crystalloid was not practiced until the Vietnam War, therefore, as in World War II, unstable patients were often transfused whole blood. This was effective for resuscitation in some patients; however, acute renal failure was seen in 0.5% of casualties evacuated from the battlefield. Acute renal failure in this setting yielded high mortality despite supportive care (80-90%).

  11. Guerra di Vietnam - insufficienza respiratoria Nel corso della guerra del Vietnam il fulcro dell’assistenza medica consistette principalmente nel trattare ed evacuare i feriti verso gli ospedali da campo. Gli elicotteri del Medevac potevano trasportare anche medici, che erano così in grado di continuare il trattamento durante il trasporto. Vi fu una percentuale di sopravvivenza pari al 98% per i soldati feriti evacuati entro la prima ora dal trauma.

  12. Guerra di Vietnam - insufficienza respiratoria Il concetto di ritenzione di acqua e sodio dopo il trauma o chirurgia con conseguente necessità di restrizione dell’apporto idrico, fu progressivamente sostituito dalla acquisizione che il trauma causava una riduzione del liquido dello spazio extracellulare, con la necessità di somministrare maggiori volumi di acqua e sodio.

  13. Guerra di Vietnam - insufficienza respiratoria Si impose il concetto di fluidoterapia massiva per la rianimazione cardiocircolatoria dopo shock traumatico. L’insufficienza renale divenne meno frequente.

  14. Guerra di Vietnam - insufficienza respiratoria Sia come conseguenza di massiva fluidoterapia per sostenere il circolo ed il rene, sia come manifestazione di danno polmonare diretto che poteva ora manifestarsi per la mancata mortalità da shock circolatorio e renale, il polmone divenne il successivo organo a manifestare insufficienza dopo il trauma (ARDS).

  15. Figura a. ARDS in paziente con shock post-traumatico: si evidenzia un massivo pnx sinistro. Sono presenti estesi addensamenti di aspetto "fioccoso" del polmone destro, caratteristici del Quadro radiologico conclamato di ARDS. Figura b. ARDS in paziente con shock post-traumatico: stesso caso della figura precedente ad una settimana di distanza. Si noti il coinvolgimento diffuso e bilatera- le del parenchima polmonare.

  16. STABILILIZZAZIONE

  17. La Multiple Organ Failure Syndrome (MOFS) è una sindrome studiata in tempo di guerra, ma che si è pienamente espressa da un punto di vista clinico in tempo di pace e di sviluppo economico e sanitario. E’ una sindrome del “benessere”.

  18. Triage The sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors (from the French trier, to sort) (Merriam-Webster) Developed by Baron Dominique-Jean Larrey, Napoleon's Chief Surgeon, for use by the first ambulance corps—theambulances volantes—during the early 1800s

  19. Triage Unit Leader Incident Site Casualty Collection Point Triage: A rapid approach to prioritizing a large number of patients Simple Triage And Rapid Treatment JumpSTART

  20. Triage • Triage should be performed RAPIDLY • Utilize START/ JumpSTART Triage to determine priority • 30–60 seconds per patient • Affix tag on left upper arm or leg

  21. START/JumpSTART Now use START/JumpSTART to assess and categorize the remaining patients… USECOLOREDRIBBONS ONLY

  22. START/JumpSTART Categorize the patients by assessing each patient’s RPMs… • Respirations • Pulse/perfusion • Mental Status

  23. START/JumpSTART—RPM RESPIRATIONS Is the patient breathing? Yes Adult – respirations > 30 = Red/Immediate Pediatric – respirations < 15 or > 45 = Red/Immediate Adult – respirations < 30 = check perfusion Pediatric – respirations > 15 and < 45 = check perfusion

  24. START/JumpSTART—RPM RESPIRATIONS Is the patient breathing? No Reposition the airway… Respirations begin = IMMEDIATE/RED If patient isAPNEIC • Adult – deceased = BLACK • Pediatric: Pulse Present – give 5 rescue breaths • respirations begin =IMMEDIATE/RED • absent respirations – deceased = BLACK

  25. START/JumpSTART—RPM PULSE/PERFUSION Is the RADIAL pulse present? Is capillary refill (CR) LESS than < 2 seconds? Yes Check mental status No Adult: Pulse absent or CR > 2 seconds patient = IMMEDIATE/RED Pediatric: No palpable pulse patient =IMMEDIATE/RED

  26. START/JumpSTART—RPM MENTAL STATUS… Can the patient follow simple commands? No Adult = IMMEDIATE / RED Pediatric – “P” pain causes inappropriate posturing or “U” unresponsive to noxious stimuli = IMMEDIATE/ RED

  27. START/JumpSTART If the patient is IMMEDIATE/RED upon initial assessment…then, before moving the patient to the treatment area, attempt only life-saving interventions: Airway, Needle Decompression, Tourniquet, Antidote DO NOT ATTEMPT ANY OTHER TREATMENT AT THIS TIME

  28. Combined START/JumpSTART Triage Using the JS algorithm YES ** CAN YOU MINOR SECONDARY TRIAGE ** evaluate all children first WALK ? who did not walk under their own power. NO Evaluate infants first in BREATHING IMMEDIATE secondary triage using NO Position Upper Airway Breathing ? entire JS algorithm ! APNEIC ADULT PEDIATRIC HAS A NO PULSE PULSE PEDI Neurological Assessment APNEIC Expected / Deceased 5 Rescue Breaths YES A Alert BREATHING Respondsto V IMMEDIATE Verbal Stimuli Responds to 30 ADULT P > Respiratory IMMEDIATE Painful Stimuli Rate ? PEDI Unresponsive 45 > OR < 15 U 30 ADULT < To Noxious Stimuli - PEDI 15 45 ADULT CR >2 Sec or NO PALPABLE PULSE IMMEDIATE Perfusion ? PEDI - NO PALPABLE PULSE YES “P” INAPPROPRIATE POSTURING OR “U” ( PEDIATRIC ) DOESN’T OBEY COMMANDS Mental IMMEDIATE ? Status ADULT OBEY COMMANDS - ADULT DELAYED ) PEDIATRIC “A” , “V” , OR “P” ( APPROPRIATE - www . jumpstarttriage . com Http :// Http :// starttriage . com www .

  29. Adult Respirations > 30 BPM CR > 2 seconds or no palpable radial pulse Cannot follow simple commands Pneumothorax Hemorrhagic Shock Closed Head Injury Pediatric Respirations < 15 or > 45 CR > 2 seconds or no palpable radial or brachial pulse Inappropriate “Pain” (e.g., posturing) or “Unresponsive”

  30. Adult: respirations, capillary refill, and mentation are normal • Isolated burns • Extremity fractures • Stable other trauma • Most patients withmedical complaints Pediatric: “A,” “V,” or appropriate “P” (e.g., withdrawal from pain stimulus)

  31. “Walking wounded” • Psychological casualties • Always look for children being carried and assess them

  32. CODICI di GRAVITA’ o CRITICITA’ CODICI di INVIO: • BIANCO: intervento differibile • VERDE: intervento differibile, paziente non critico • GIALLO: urgenza, paziente mediamente critico • ROSSO: emergenza, paziente molto critico

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