A Brief History of the “Golden Period”

The idea of the golden period is a pretty old one. It arises from (surprise surprise) cruel animal data. Way back in
1898, Professor Paul Leopold Friedrich lacerated the skin of guinea pigs, then inoculated the wounds with bacteria.
He then determined that if the surrounding skin was not excised within 6 hours, the animals died.

…and there you have it: the initial determination of the “golden period.” Already, you can see the problems in relating
this to your clinical practice. Artificially inoculating a wound with bacteria is not the same as the natural and (probably
less pathogenic) bacterial exposure that occurs with traumatic lacerations; and excision of surrounding skin is not
typically the standard practice for decontamination of wounds (though it is an option in certain situations–to be
featured in an upcoming post!).

Still, it’s become pretty well accepted that there exists some window of time in which it is safe to primarily close
traumatic lacerations. That window of opportunity is cited as anywhere between 3 to 24 hours, depending on what
textbook or source you read. If you believe in the germ theory of disease, it’s a little hard to argue with the notion that
the longer a wound festers, the more bacteria will colonize the wound, and the higher the infection risk becomes. So,
I won’t attempt to argue the log-linear relationship between time since injury and bacterial colonization. But how that
translates in to clinical risk of repair and absolute cut-off times for doing so is a different story.

Advancing the golden period (aka, is it a period or a “…” ?)

Research on this topic in the past few decades has sought to extend the golden period. To me, this implies that we
all agree that the golden period is longer than 6 hours, we just don’t know exactly how much longer. Published
research has determined safety in closing wounds up to 10 hours (Kanegaye 1997), 19 hours (Berk 1998) or even up
to 24 hours old (Lammers 2003). The major flaws with these (and many other) studies–in no particular order– are
lack of generalizability (single center, certain wound types only), the observational-only nature of the studies (granted,
an RCT is tough to pull off here), and often in these studies evaluation of the golden period is only a secondary
outcome (not the primary goal of the study). The American College of Emergency Physician’s Clinical Policy cites a
period of 12 hours for traumatic lacerations of the extremities. It’s acknowledged even by ACEP to be way outdated
(1999), though not yet updated.
Where we currently stand
So where does this jumbled data leave us today in terms of what to do in real-life clinical practice?

A meta-analysis published in Injury 2012 attempted to synthesize the existing, best quality data. While the methods
of data extraction for the review were sound, the quality of the studies that met their criteria for inclusion were pretty
low. The problems were many: even the included studies were only observational, the definition of the golden period
varied (4-12 hrs), and the definition of “wound infection” varied. The upshot of the article was that no definite cut-off
time for wound age (beyond which attempt at primary repair of the wound would be too high risk) could be defined.
Probably the largest problems in evaluating these studies is that there are far too many confounders. Wound age is
just one of myriad variables that come in to play when it comes to determining infection risk. To name a few of the
others: wound location, patient comorbidities, and trauma mechanism are all factors which make it very difficult to
isolate time post-injury as a single variable. Or rather, one would have to conduct a very large study and collect data
for a very long time to try to isolate the variable of interest.

But that’s okay, because this is the nature of real world emergency medicine. We consider these confounders every
day in our assessment of traumatic lacerations, and let’s face it, this is how most of us really shape our decision
making in regards to which wounds to close and which to leave alone.

I’ll leave you with this study to consider, published this year by Quinn, et al (after the afore-mentioned meta-analysis).
In this observational study, the golden period (of 6 hrs) was examined, as well as multiple other factors, felt to be of
potential relevance in predicting infection risk. The authors did find variables that were independent predictors for
higher likelihood of infection: a history of diabetes, length of the laceration (>5cm), location of the wound, and level of
contamination. Age of the laceration, interestingly, was not one of them.
Does this mean there was no increased risk to sewing my patient’s 20-hour-old forehead laceration? I highly doubt it.
But, so many other factors needed to be accounted for simultaneously. The location was good and the
contamination was low. She did not have diabetes or other immunocompromising conditions. The wound was long,
which was a negative. But most importantly, the cosmetic appearance of her face was important to her. Once
you’ve educated your patient on the factors which can affect healing of the wound, the best strategy should be to
employ the concept of shared risk tolerance. She understood the risks, and accepted, and her wishes were
concordant with my favored plan of care (were this a 20-hour-old laceration on the back of her knee, this may have
been a different story). Thus, my–or rather, our–decision was made.