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
Russell Duncan, MBCHB, MRCS(A&E); Shobhan Thakore, MBCHB, BMSC(HONS), FRCS(A&E) FCEM
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.
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.[25]
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.[711]
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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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.[25]
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.[711]
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.
DOWNLOAD PDF COMPLETE HERE
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