The Golden Hour of Casualty Care: Rapid Handoff to Surgical Team is Associated with Improved Survival in War-injured US Service Members.

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OBJECTIVE: Examine time from injury to initiation of surgical care and association with survival in US military casualties.

BACKGROUND: Although the advantage of trauma care within the "golden hour" after injury is generally accepted, evidence is scarce.

METHODS: This retrospective, population-based cohort study included US military casualties injured in Afghanistan and Iraq, January 2007-December 2015, alive at initial request for evacuation with abbreviated injury scale scores ≥2 and documented 30-day survival status after injury. Interventions (1) handoff alive to surgical team, and (2) initiation of 1st surgery were analyzed as time-dependent covariates (elapsed time from injury) using sequential Cox proportional hazards regression to assess how intervention timing might affect mortality. Covariates included age, injury year and injury severity.

RESULTS: Among 5,269 patients (median age 24 y, 97% male, 68% battle-injured), 728 died within 30 days of injury, 68% within 1 hour, 90% within 4 hours. Only handoffs within 1 hour of injury and the resultant timely initiation of emergency surgery (adjusted also for prior advanced resuscitative interventions) were significantly associated with reduced 24-hour mortality compared to more delayed surgical care (adjusted hazard ratios=0.34, 95% CI=0.14-0.82, P=.02; and 0.40, 95% CI=0.20-0.81, P=0.01, respectively). In-hospital waits for surgery (mean=1.1 hours, 95% CI=1.0-1.2) scarcely contributed (P=0.67).

CONCLUSION: Rapid handoff to surgical team within 1 hour of injury may reduce mortality by 66% in US military casualties. In the subgroup of casualties with indications for emergency surgery, rapid handoff with timely surgical intervention may reduce mortality by 60%. To inform future research and trauma system planning, findings are pivotal.




Medicine and Health Sciences




Department of Pathology and Laboratory Medicine

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