Decreased Glasgow Coma Scale Score Does Not Mandate Endotracheal Intubation in the Emergency Department

Russell Duncan, MBCHB, MRCS(A&E); Shobhan Thakore, MBCHB, BMSC(HONS), FRCS(A&E) FCEM

Disclosures

J Emerg Med. 2009;37(4):451-455. 

In This Article

Abstract and Introduction

Abstract

Background: Decreased consciousness is a common reason for presentation to the emergency department (ED) and admission to acute hospital beds. In trauma, a Glasgow Coma Scale score (GCS) of 8 or less indicates a need for endotracheal intubation. Some advocate a similar approach for other causes of decreased consciousness, however, the loss of airway reflexes and risk of aspiration cannot be reliably predicted using the GCS alone.
Study Objective: A survey of all poisoned patients with a decreased GCS who were admitted to an ED short-stay ward staffed by experienced emergency physicians, to establish the incidence of clinically significant aspiration or other morbidities and endotracheal intubation.
Methods: A prospective, observational study was conducted of all patients admitted to the ED short-stay ward with a decreased level of consciousness (GCS < 15).
Results: The study included 73 patients with decreased consciousness as a result of drug or alcohol intoxication. The GCS ranged from 3 to 14, and 12 patients had a GCS of 8 or less. No patient with a GCS of 8 or less aspirated or required intubation. There was one patient who required intubation; this patient had a GCS of 12 on admission to the ward.
Conclusions: This study suggests that it can be safe to observe poisoned patients with decreased consciousness, even if they have a GCS of 8 or less, in the ED.

Introduction

A decreased level of consciousness is a common reason for presentation to the emergency department (ED) and is often the result of intoxication. Originally described in head-injured patients, the Glasgow Coma Scale (GCS) was devised as a tool for recording the level of consciousness at a particular moment, whatever the cause of impairment, systematically and reproducibly.[1] Repeated recordings can give an impression of deterioration or improvement. It has gained acceptance in the management of trauma and poisoned patients presenting to the ED.[2–5]

Established trauma teachings describe a GCS of 8 or less as necessitating endotracheal intubation in recognition of the high risk of secondary brain injury resulting from hypoxemia and hypercapnia caused by airway obstruction or respiratory compromise.[2,3]

It has also been said that a GCS of 8 or less is a useful guide for the requirement of endotracheal intubation where the cause of coma is poisoning.[5,6] Poisoned patients are unlikely to suffer from secondary brain injury, but decreased consciousness and loss of protective airway reflexes predispose to respiratory failure and aspiration injury.[6] However, the risk of aspiration is not confined to patients with a GCS of 8 or less, and the loss of airway reflexes cannot be reliably predicted using the GCS alone.[7–11]

Respiratory failure and aspiration can be prevented by endotracheal intubation and mechanical ventilation, however, intensive care beds are a limited and expensive resource and must be used judiciously.

This observational study aimed to examine the profile of poisoned patients admitted to the ED short-stay ward with a decreased GCS, including their diagnoses, length of stay, and occurrence of significant events. The aim was to establish the incidence of clinically significant aspiration or other morbidities, and endotracheal intubation.

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