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The Head Injury Retrieval Trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management by paramedics only
  1. Alan A Garner1,
  2. Kristy P Mann2,
  3. Michael Fearnside3,
  4. Elwyn Poynter4,
  5. Val Gebski5
  1. 1CareFlight, Wentworthville, New South Wales, Australia
  2. 2NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
  3. 3Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
  4. 4Research Nurse, CareFlight, Wentworthville, New South Wales, Australia
  5. 5Biostatistics and Research Methodology, NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Alan A Garner, CareFlight, Locked Bag 2002, Wentworthville, NSW 2145, Australia; alang{at}careflight.org

Abstract

Background Advanced prehospital interventions for severe brain injury remains controversial. No previous randomised trial has been conducted to evaluate additional physician intervention compared with paramedic only care.

Methods Participants in this prospective, randomised controlled trial were adult patients with blunt trauma with either a scene GCS score <9 (original definition), or GCS<13 and an Abbreviated Injury Scale score for the head region ≥3 (modified definition). Patients were randomised to either standard ground paramedic treatment or standard treatment plus a physician arriving by helicopter. Patients were evaluated by 30-day mortality and 6-month Glasgow Outcome Scale (GOS) scores. Due to high non-compliance rates, both intention-to-treat and as-treated analyses were preplanned.

Results 375 patients met the original definition, of which 197 was allocated to physician care. Differences in the 6-month GOS scores were not significant on intention-to-treat analysis (OR 1.11, 95% CI 0.74 to 1.66, p=0.62) nor was the 30-day mortality (OR 0.91, 95% CI 0.60 to 1.38, p=0.66). As-treated analysis showed a 16% reduction in 30-day mortality in those receiving additional physician care; 60/195 (29%) versus 81/180 (45%), p<0.01, Number needed to treat =6. 338 patients met the modified definition, of which 182 were allocated to physician care. The 6-month GOS scores were not significantly different on intention-to-treat analysis (OR 1.14, 95% CI 0.73 to 1.75, p=0.56) nor was the 30-day mortality (OR 1.05, 95% CI 0.66 to 1.66, p=0.84). As-treated analyses were also not significantly different.

Conclusions This trial suggests a potential mortality reduction in patients with blunt trauma with GCS<9 receiving additional physician care (original definition only). Confirmatory studies which also address non-compliance issues are needed.

Trial registration number NCT00112398.

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