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Three Part Question

In [adult emergency department patients with decreased consciousness], does a [Glasgow Coma Scale (GCS) of 8 or less] indicate a [need for endotracheal intubation]?

Clinical Scenario

Patient is a 45-year-old with a history of alcohol abuse who presents to the emergency department intoxicated. On your initial assessment, the patient’s eyes are closed and only open to pain; he only moves when a painful stimulus is applied; he is not speaking. You give the patient a GCS of 8 and you question whether this patient would benefit from being intubated.

Search Strategy

Medline 1966-07/21 using PubMed, Cochrane Library (2021), and Embase
[(Endotracheal Intubation AND Glasgow Coma Scale) AND (emergency medical services OR emergency department OR emergency services)]. LIMIT to English language.

Search Outcome

140 studies were identified. Three studies addressed the clinical question, including one systematic review. Two retrospective studies have since been published that were not included in the review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hatchimonji JS et al. May 2020 USA	6,676 trauma patients who presented to the emergency department with a GCS between 6-8.	Retrospective Cohort Study	Mortality, intensive care unit length of stay (ICU LOS), and total length of stay (Total LOS).	Intubated patients had a statistically significant increase in mortality, ICU LOS (14%), and total LOS (27%).	Retrospective; only studied trauma patients; small effect size; and assumed GCS as indication for intubation
Sauter TC, et al. Feb 2020 Switzerland	3,003 patients who presented to a Swiss Emergency Department with acute alcohol intoxication.	Retrospective cohort study	Incidence of intubations, secondary intubation rate, morbidity and mortality	In patients with GCS less than 9, only 24% of patients were intubated, there were no secondary intubations during ED monitoring, and no increase in morbidity or mortality among the non-intubated group.	Small sample size; did not evaluate clinically significant outcomes; single center study
Orso D, et al Dec 2020 Italy	Thirteen studies (7 on non-traumatic population)	Systematic Review	Incidence of aspiration pneumonia, mortality rate	No difference in mortality rate between intubated and non-intubated, mixed evidence for decreased risk for aspiration.	Extreme heterogeneity making meta-analysis unfeasible; no RCTs included; variable study design

Comment(s)

Advanced airways are currently indicated for patients who are unable to sufficiently oxygenate or ventilate, impending airway compromise, or inability to protect one’s airway. Traditionally, GCS has been used to assess one’s ability to protect their airway. Per Advanced Trauma Life Support (ATLS) guidelines, if the GCS is <8, then that patient requires an advanced airway. However, the evidence behind this statement is sparse and thus, requires review. The above studies are weak by design as there are currently no randomized control trials that have investigated this question. Even the systematic review that was performed had such a high level of heterogeneity that meta-analysis was unable to be performed.

Clinical Bottom Line

For patients presenting to the emergency department with a depressed GCS, there is mixed evidence regarding the utility of advanced airway placement for airway protection; thus, it requires further investigation with high quality studies.

References

1. Hatchimonji JS, Dumas RP, Kaufman EJ, Scantling D, Stoecker JB, Holena DN Questioning dogma: does a GCS of 8 require intubation? Eur J Trauma Emerg Surg 2020 May;7:1–7.
2. Sauter TC, Rönz K, Hirschi T, Lehmann B, Hütt C, Exadaktylos AK, Müller M. Intubation in acute alcohol intoxications at the emergency department. Scand J Trauma Resusc Emerg Med 2020 Feb; 10;28(1):11
3. Orso D, Vetrugno L, Federici N, D'Andrea N, Bove T. Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review Scand J Trauma Resusc Emerg Med 2020 Dec 10;28(1):116.