Severe head injury – and the importance of the ‘Golden Hour’

Trauma is predictable; it happened yesterday, it is happening today, and it will happen tomorrow. Road traffic accidents account for more than 60% of the cause of trauma with other causes being falls, assault, sports, and other accidents. India has the unenviable distinction of having the highest rate of head injuries in the world and with increasing urbanization and industrialization, this is going to get worse. And in fact, the WHO estimates that by 2020, the sharply accelerating number of vehicles in developing countries particularly India, would result in an ever increasing number of Head Trauma cases and crowding ill prepared Government Hospitals. WHO predicts that death by Traumatic accidents would increase by 92% in China, and 147% in India. Truly very worrisome stats!

 

The ‘Golden Hour’ refers to a time period lasting from a few minutes to several hours following a traumatic injury during which there is the highest likelihood that prompt medical treatment will prevent death. The late Dr. R. Adams Cowley, first in his capacity as a military surgeon and later as the Head of University of Maryland Shock Trauma Centre is credited for recordings and observation of Trauma cases from which he recognised that the sooner trauma patients reached definitive care – particularly if they arrived within 60 minutes of being injured – The better their chances of survival.

Over the years, it has been debated whether the ‘Golden Hour’ is actually 60 minutes. However, Dr. Cowley’s concepts unambiguously remain true. In this effort, people have gone from “load and go” to “stay and play” back again. Various studies, prospective and retrospective have shown a significant association with mortality with each incremental minute of patient arrival in hospital.  Although the first 60 minutes has not shown any survival benefit, in some studies, undue delay has certainly shown increased mortality.

Survival benefits exists in severe head injury but the benefit may extend beyond the Golden Hour; there is definite evidence of unproved functional outcomes in patients arriving within 60 minutes of injury time. While the debate on the true utility of the ‘Golden Hour’ may continue, there is no doubt that increasing delay of patients in reaching the hospitals would greatly increase the developments of secondary head injury in severe primary head injury. T

This happens due to unrecognized and untreated hypoxia, hypovolemia and raised intracranial tension to name the most important ones.

Although a rarity in the western world, delay in surgery in traumatic intracranial haematomas is a common occurrence in India. Outcome following surgical decompression in patients with acute SDH and epidural haematomas, although influenced by the preoperative state of consciousness and associated brain injury, it is also to a large extent dependent on the time interval between onset of coma and surgical decompresses.

Various studies have shown that in acute EDH, an interval under two hours had 5-15% mortality and 75% -85% good recovery compared to 65-80% mortality and 15-35% good recoveries after two hours. While in acute SDH, when this interval exceeded 2 hours, the mortality rose 40% to 80%.

Hence the need for early admission to a hospital with neurosurgical facilities in cases of severe traumatic brain injuries is a must. The biggest help one can render a patient with severe head injury is to take him/her to a good neurosurgical unit within hours of trauma.

 

 

Dr. J.P. Singh

Neurosurgeon

Shri Mata Vaishno Devi Narayana Superspeciality Hospital, Jammu

 

 

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