The Case:
EMS brings you a 38-year-old male patient from the street. He is obtunded, GCS 6, smells strongly of vodka, and was reportedly surrounded by liquor bottles at the scene. He is breathing comfortably with both stable and normal vital signs on assessment. What should be done?
The Discussion:
A recent study looked at a multicenter, unblinded, randomized, parallel-group trial conducted in 20 EDs and 1 ICU in France (1). They recruited 225 comatose patients presenting with suspected acute poisoning and with a GCS less than 9. These patients were randomly assigned to conservative airway management (withholding intubation unless certain emergency criteria were met) or routine management. The primary outcome included in-hospital death, length of ICU stay, and length of hospital stay. Secondary outcome included adverse events from intubation such as pneumonia within 48 hours.
The results showed significantly fewer patients were intubated in the conservative group (19, 16.4%) compared to the routine management group (63, 57.8%). No patients died in either group. Median hospital length of time was significantly reduced (21.5 hrs vs 37 hrs) in the conservative management group. Importantly, there were no differences in clinical outcomes between patients intubated in the conservative group (presumably for meeting emergency criteria) and those intubated in the control group. Limitations in the study include it’s unblinded design and relatively small sample size.
Takeaway Points:
The use of the Glasgow Coma Scale for airway intervention has been widely applied and validated in the trauma setting, where patients have a high risk of clinical deterioration. However, the acutely poisoned patient represents a different cohort. With certain ingestions, such as alcohol or benzodiazepines, the patient may ultimately metabolize the substances and return to full alertness in a matter of hours. This study shows that severely obtunded patients with acute intoxication can often be safely managed without intubation. As ED boarding times continue to climb nationwide, it’s important for us to avoid interventions that prolong hospitalizations without clear patient benefit.
Of course, these patients should be observed closely in the ED or ICU for signs of clinical deterioration (shock, hypoxia, seizure, vomiting). While traditional teachings recommended testing gag reflexes, previous studies have shown a significant variability in reflexes among obtunded and awake patients, calling into question the validity of this exam (2,3). While obtunded patients are at risk for aspiration pneumonia, intubation is also a significant risk factor for pneumonia, so these risks should be weighed against the other.
Bottom-line: It is feasible to observe an obtunded poisoned patient if they are otherwise stable. Many of these patients will not require intubation.
Authored by Jorge Aceves, MD.
References:
Freund Y, Viglino D, Cachanado M, et al. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023;330(23):2267-2274. doi:10.1001/jama.2023.24391
Moulton C et al. Relation between Glasgow coma scale and the gag reflex. BMJ (Clinical research ed.), 1991. PMID:1747645
Rotheray KR et al. What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population?. Resuscitation, 2012. PMID:21787740