title: 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.
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.
  
  
  BACKGROUND
  NCT00112398.
authors: CareFlight, Wentworthville, New South Wales, Australia.
authors: Alan A
authors: AA
authors: Garner
authors: NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.
authors: Kristy P
authors: KP
authors: Mann
authors: Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia.
authors: Michael
authors: M
authors: Fearnside
authors: Research Nurse, CareFlight, Wentworthville, New South Wales, Australia.
authors: Elwyn
authors: E
authors: Poynter
authors: Biostatistics and Research Methodology, NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.
authors: Val
authors: V
authors: Gebski
mesh_terms: D000328:Adult; D000368:Aged; D000488:Allied Health Personnel; D004632:Emergency Medical Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D005260:Female; D015600:Glasgow Coma Scale; D016489:Head Injuries, Closed / Q000401:mortality / Q000628:therapy*; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010820:Physicians; D011446:Prospective Studies
keywords: Trauma, head; comparitive system research; emergency ambulance systems, effectiveness; prehospital care, doctors in PHC; prehospital care, helicopter retrieval