• Stacy A Shackelford, Deborah J Del Junco, Edward L Mazuchowski, Russ S Kotwal, Michael A Remley, Sean Keenan, and Jennifer M Gurney.
• Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX.
• Ann. Surg. 2024 Jan 1; 279 (1): 1101-10.

ObjectiveTo examine time from injury to initiation of surgical care and association with survival in US military casualties.BackgroundAlthough the advantage of trauma care within the "golden hour" after an injury is generally accepted, evidence is scarce.MethodsThis retrospective, population-based cohort study included US military casualties injured in Afghanistan and Iraq, January 2007 to December 2015, alive at initial request for evacuation with maximum abbreviated injury scale scores ≥2 and documented 30-day survival status after injury. Interventions: (1) handoff alive to the surgical team, and (2) initiation of first 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.ResultsAmong 5269 patients (median age, 24 years; 97% males; and 68% battle-injured), 728 died within 30 days of injury, 68% within 1 hour, and 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 with more delayed surgical care (adjusted hazard ratios: 0.34; 95% CI: 0.14-0.82; P = 0.02; 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).ConclusionsRapid handoff to the 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.Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

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