Joint Trauma System, United States Army Institute of Surgical Research, Joint Base San Antonio-Ft Sam Houston, Texas2Uniformed Services University of the Health Sciences, Bethesda, Maryland3Texas A&M Health Science Center College of Medicine, College Stat.
Joint Trauma System, United States Army Institute of Surgical Research, Joint Base San Antonio-Ft Sam Houston, Texas.
JAMA Surg. 2016 Jan;151(1):15-24. doi: 10.1001/jamasurg.2015.3104.
The term golden hour was coined to encourage urgency of trauma care. In 2009, Secretary of Defense Robert M. Gates mandated prehospital helicopter transport of critically injured combat casualties in 60 minutes or less.
To compare morbidity and mortality outcomes for casualties before vs after the mandate and for those who underwent prehospital helicopter transport in 60 minutes or less vs more than 60 minutes.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective descriptive analysis of battlefield data examined 21,089 US military casualties that occurred during the Afghanistan conflict from September 11, 2001, to March 31, 2014. Analysis was conducted from September 1, 2014, to January 21, 2015.
Data for all casualties were analyzed according to whether they occurred before or after the mandate. Detailed data for those who underwent prehospital helicopter transport were analyzed according to whether they occurred before or after the mandate and whether they occurred in 60 minutes or less vs more than 60 minutes. Casualties with minor wounds were excluded. Mortality and morbidity outcomes and treatment capability-related variables were compared.
For the total casualty population, the percentage killed in action (16.0% [386 of 2411] vs 9.9% [964 of 9755]; P < .001) and the case fatality rate ([CFR] 13.7 [469 of 3429] vs 7.6 [1344 of 17,660]; P < .001) were higher before vs after the mandate, while the percentage died of wounds (4.1% [83 of 2025] vs 4.3% [380 of 8791]; P = .71) remained unchanged. Decline in CFR after the mandate was associated with an increasing percentage of casualties transported in 60 minutes or less (regression coefficient, -0.141; P < .001), with projected vs actual CFR equating to 359 lives saved. Among 4542 casualties (mean injury severity score, 17.3; mortality, 10.1% [457 of 4542]) with detailed data, there was a decrease in median transport time after the mandate (90 min vs 43 min; P < .001) and an increase in missions achieving prehospital helicopter transport in 60 minutes or less (24.8% [181 of 731] vs 75.2% [2867 of 3811]; P < .001). When adjusted for injury severity score and time period, the percentage killed in action was lower for those critically injured who received a blood transfusion (6.8% [40 of 589] vs 51.0% [249 of 488]; P < .001) and were transported in 60 minutes or less (25.7% [205 of 799] vs 30.2% [84 of 278]; P < .01), while the percentage died of wounds was lower among those critically injured initially treated by combat support hospitals (9.1% [48 of 530] vs 15.7% [86 of 547]; P < .01). Acute morbidity was higher among those critically injured who were transported in 60 minutes or less (36.9% [295 of 799] vs 27.3% [76 of 278]; P < .01), those severely and critically injured initially treated at combat support hospitals (severely injured, 51.1% [161 of 315] vs 33.1% [104 of 314]; P < .001; and critically injured, 39.8% [211 of 530] vs 29.3% [160 of 547]; P < .001), and casualties who received a blood transfusion (50.2% [618 of 1231] vs 3.7% [121 of 3311]; P < .001), emphasizing the need for timely advanced treatment.
A mandate made in 2009 by Secretary of Defense Gates reduced the time between combat injury and receiving definitive care. Prehospital transport time and treatment capability are important factors for casualty survival on the battlefield.
重要性：“黄金时间”一词的提出是为了鼓励对创伤救治的重视。2009 年，国防部长罗伯特·盖茨下令将危重伤员的前接后送时间限制在 60 分钟以内。
目的：比较在该命令发布前后伤员的发病率和死亡率，以及在 60 分钟或更短时间内接受前接直升机转运和超过 60 分钟接受前接直升机转运的伤员的发病率和死亡率。
设计、地点和参与者：对 21089 名在阿富汗冲突期间（2001 年 9 月 11 日至 2014 年 3 月 31 日）发生的美国军事伤员的战场数据进行回顾性描述性分析。分析于 2015 年 1 月 21 日进行。
主要结果和措施：根据是否在该命令发布前后发生，对所有伤员的数据进行了分析。对接受前接直升机转运的伤员进行了详细分析，根据是否在该命令发布前后以及是否在 60 分钟或更短时间内发生进行了分析。排除了轻伤伤员。比较了发病率和死亡率结果以及与治疗能力相关的变量。
结果：对于总伤员人数，战场上死亡（16.0%[2411 名中的 386 名] vs 9.9%[9755 名中的 964 名]；P < .001）和病死率（CFR [3429 名中的 469 名] vs 17.660 名中的 1344 名；P < .001）在该命令发布前后较高，而因伤死亡（4.1%[2025 名中的 83 名] vs 4.3%[17891 名中的 830 名]；P = .71）保持不变。该命令发布后病死率下降与在 60 分钟或更短时间内接受转运的伤员比例增加有关（回归系数为-0.141；P < .001），预计与实际病死率相差 359 人。在有详细数据的 4542 名伤员（平均创伤严重程度评分 17.3；死亡率 10.1%[4542 名中的 457 名]）中，该命令发布后转运时间中位数减少（90 分钟 vs 43 分钟；P < .001），在 60 分钟或更短时间内完成前接直升机转运的任务增加（24.8%[731 名中的 181 名] vs 75.2%[3811 名中的 2867 名]；P < .001）。当根据创伤严重程度评分和时间调整后，接受输血的危重伤员死亡率较低（6.8%[589 名中的 40 名] vs 51.0%[488 名中的 249 名]；P < .001），且在 60 分钟或更短时间内转运的死亡率较低（25.7%[799 名中的 205 名] vs 30.2%[278 名中的 84 名]；P < .01），而最初在战斗支援医院接受治疗的危重伤员死亡率较低（9.1%[530 名中的 48 名] vs 15.7%[547 名中的 86 名]；P < .01）。在 60 分钟或更短时间内转运的危重伤员急性发病率较高（36.9%[799 名中的 295 名] vs 27.3%[278 名中的 76 名]；P < .01），最初在战斗支援医院接受治疗的严重和危重伤员发病率较高（严重受伤者，51.1%[315 名中的 161 名] vs 33.1%[314 名中的 104 名]；P < .001；危重伤员，39.8%[530 名中的 211 名] vs 29.3%[547 名中的 160 名]；P < .001），以及接受输血的伤员发病率较高（50.2%[1231 名中的 618 名] vs 3.7%[3311 名中的 121 名]；P < .001），强调了及时进行高级治疗的重要性。
结论和相关性：2009 年国防部长盖茨发布的命令缩短了伤员从受伤到接受确定性治疗的时间。前接转运时间和治疗能力是战场上伤员生存的重要因素。
