title: Revisiting the "Golden Hour": An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury.
abstract: OBJECTIVE
  We evaluate patients with shock and traumatic brain injury who were previously enrolled in an out-of-hospital clinical trial to test the association between out-of-hospital time and outcome.
  
  
  METHODS
  This was a secondary analysis of patients with shock and traumatic brain injury who were aged 15 years or older and enrolled in a Resuscitation Outcomes Consortium out-of-hospital clinical trial by 81 emergency medical services agencies transporting to 46 Level I and II trauma centers in 11 sites (May 2006 through May 2009). Inclusion criteria were systolic blood pressure less than or equal to 70 mm Hg or systolic blood pressure 71 to 90 mm Hg with pulse rate greater than or equal to 108 beats/min (shock cohort) and Glasgow Coma Scale score less than or equal to 8 (traumatic brain injury cohort); patients meeting both criteria were placed in the shock cohort. Primary outcomes were 28-day mortality (shock cohort) and 6-month Glasgow Outcome Scale-Extended score less than or equal to 4 (traumatic brain injury cohort).
  
  
  RESULTS
  There were 778 patients in the shock cohort (26% 28-day mortality) and 1,239 patients in the traumatic brain injury cohort (53% 6-month Glasgow Outcome Scale-Extended score ≤4). Out-of-hospital time greater than 60 minutes was not associated with worse outcomes after accounting for important confounders in the shock cohort (adjusted odds ratio [aOR] 1.42; 95% confidence interval [CI] 0.77 to 2.62) or traumatic brain injury cohort (aOR 0.77; 95% CI 0.51 to 1.15). However, shock patients requiring early critical hospital resources and arriving after 60 minutes had higher 28-day mortality (aOR 2.37; 95% CI 1.05 to 5.37); this finding was not observed among a similar traumatic brain injury subgroup.
  
  
  CONCLUSIONS
  Among out-of-hospital trauma patients meeting physiologic criteria for shock and traumatic brain injury, there was no association between time and outcome. However, the subgroup of shock patients requiring early critical resources and arriving after 60 minutes had higher mortality.
authors.affiliation: Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR. Electronic address: newgardc@ohsu.edu.
authors.forename: Craig D
authors.initials: CD
authors.lastname: Newgard
authors.affiliation: Department of Biostatistics, University of Washington, Seattle, WA.
authors.forename: Eric N
authors.initials: EN
authors.lastname: Meier
authors.affiliation: Department of Surgery, University of Washington, Seattle, WA.
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
authors.affiliation: Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Jason
authors.initials: J
authors.lastname: Buick
authors.affiliation: Department of Biostatistics, University of Washington, Seattle, WA.
authors.forename: Kellie
authors.initials: K
authors.lastname: Sheehan
authors.affiliation: Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Steve
authors.initials: S
authors.lastname: Lin
authors.affiliation: Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Minei
authors.affiliation: Vancouver Fire Department, Vancouver, WA, and the Providence Medical Group, Happy Valley, OR.
authors.forename: Roxy A
authors.initials: RA
authors.lastname: Barnes-Mackey
authors.affiliation: Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
authors.forename: Karen
authors.initials: K
authors.lastname: Brasel
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000628:therapy*; D005260:Female; D015600:Glasgow Coma Scale / Q000706:statistics & numerical data; D023261:Glasgow Outcome Scale / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D012769:Shock / Q000401:mortality / Q000628:therapy*; D013997:Time Factors; D014193:Trauma Centers / Q000706:statistics & numerical data; D055815:Young Adult