Podcast 888: Low GCS and Intubation

Contributor: Aaron Lessen MD

Educational Pearls:

Is the adage, "GCS of 8, you've got to intubate" accurate? A recent study published in the November 2023 issue of JAMA attempted to answer this question.

Design

• Multicenter, randomized trial, in France from 2021 to 2023.

• 225 patients experiencing comatose in the setting of acute poisoning were randomly assigned to either a conservative airway strategy of withholding intubation or "routine practice" of much more frequent intubation.

• The primary outcome was a composite endpoint including in-hospital death, length of intensive care unit stay, and length of hospital stay.

• Secondary outcomes included adverse events from intubation and pneumonia within 48 hours.

Results

• Results showed that in the intervention group (with intubation withholding), only 16% of patients were intubated, compared to 58% in the control group.

• No in-hospital deaths occurred in either group.

• The intervention group demonstrated a significant clinical benefit for the primary endpoint, with a win ratio of 1.85 (95% CI, 1.33 to 2.58).

• The conservative airway management strategy also saw a statistically significant decrease in adverse events from intubation and pneumonia.

Conclusion

• Among comatose patients with suspected acute poisoning, a conservative strategy of withholding intubation was associated with a greater clinical benefit.

• This suggests that a judicious approach to intubation is appropriate in many other settings and clinicians should rely on more than the GCS to make this decision.

References

1. Freund Y, Viglino D, Cachanado M, Cassard C, Montassier E, Douay B, Guenezan J, Le Borgne P, Yordanov Y, Severin A, Roussel M, Daniel M, Marteau A, Peschanski N, Teissandier D, Macrez R, Morere J, Chouihed T, Roux D, Adnet F, Bloom B, Chauvin A, Simon T. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023 Dec 19;330(23):2267-2274. doi: 10.1001/jama.2023.24391. PMID: 38019968; PMCID: PMC10687712.

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII