From First10EM:
Although it made a bit of a splash when published, this article really didn’t interest me. Obviously, GCS 8 doesn’t mean intubate. I didn’t think anyone was simplistic enough to practice medicine based on a jingle. Clearly trajectory matters. If a patient’s GCS hit 8 and they are on a clinical course where you expect them to continue to deteriorate, with no hope of short term recovery, of course intubation makes sense. (Even in this case, I am never calculating an actual GCS.) However, that doesn’t describe the vast majority of our ED patients. I see many post-ictal patients with a GCS of 3 or 4, and I obviously don’t intubate, as they will improve rapidly. Many of my COPD patients present with CO2 narcosis, and their initial GCS is at or below 8, but they improve rapidly with noninvasive as their CO2 comes down. And most obviously to anyone who has ever worked a Saturday overnight shift in the ED, there are many short lived toxins that will cause significant depression in GCS, but which are managed entirely with a nasal airway and raising the head of the bed, if anything at all. I thought it was obvious that these patients should never be intubated. However, a few recent conversations have made it clear that this is not obvious to everyone, and seeing as I had to read this paper for a journal club anyway, we might as well discuss it here.
The paper
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 NCT04653597
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