GCS (July 2018)

Chou et al. Predictive Utility of the Total Glasgow Coma Scale Versus the Motor Component of the Glasgow Coma Scale for Identification of Patients With Serious Traumatic Injuries. Annals of EM 2017.

Duncan and Thakore, “Decreased GCS Does Not Mandate Endotracheal Intubation in the Emergency Department”. Journal of Emergency Medicine 2009.

AIR: Endocrine 2018

Questions:

For a Review Article

  • How has reading the article changed your practice?
  • What information had you believed in previously that were debunked by reading this article?
  • What new information did you learn from reading this article?
  • What are current areas of uncertainty on this topic that can be potential areas for research?

For an Original Research Article

  • What are some strengths of the study?
  • What are the limitations?
  • What are the main outcomes of the study?
  • Does reading this article change your practice? If so, how?

4 comments

  1. Duncan et al.
    .
    What has been your experience? Do you intubate with GCS < 8?
    .
    Does this article change your management? should it?
    .
    Pay close attention to the study population, and whether they're are more or less risk of aspiration than our population.
    .
    Is aspiration a rare event? Do they have the numbers to pick up on such an adverse event?
    .
    All things to consider when we read on!

    Reply

  3. Duncan et al.

    1. Do you intubate patients presenting with GCS < 8?

    It's clearly situational. If we intubated every patient who comes through the door with a GCS of less than 8 the entire ED would be headed to the MICU. I think confidence in the decision to intubate comes with clinical experience. In my own experience, it is only in rare cases that patient's require emergent intubation when intoxicated. Usually the indications for intubation are either for control of a patient who is interfering with his/her own treatment or for a serious poisoning.

    2. Does this article change your management? Should it?

    I think that this article gives me the confidence to keep doing what I'm doing which is to say, evaluate patients on a case by case basis. GCS should no necessarily be a guide in non-trauma patients.

    3. Study population

    The population in this study resides in the Scottish Highlands which a bit of a hop, skip or jump from the corner of Mass Ave and Albany. That said, the Scots do enjoy a drink! I think that the sheer volume in our ED dictates that we need to evaluate patients on an individual basis.

    4. Is aspiration a rare event?

    This article quotes the incidence of aspiration in poisoned patients as 0.8% for those with a GCS of 15 and increasing to 4.5% when the GCS falls below 15. Other quoted percentages for aspiration are 9% for GCS above 8 and 17% for GCS < 8.

    Reply

  4. Duncan et al.

    1. What has been your experience? Do you intubate with GCS < 8? I haven't intubated too many patients, but have ran cases where I knew intubation was imminent. I don't think a GCS score of 8 should necessarily lead to intubation in every case. This is highly dependent and would vary on a case by case. I've had multiple patients being radio'd in by EMS with GCS < 8 and then come in completely alert, and protecting their own airway. On the flip side, someone with a GCS of 13 can easily deteriorate and end up getting intubated. As with everything in medicine, use your clinical judgment and repeated assessments.

    2. Does this article change your management? I think this article just solidifies the approach I'm already doing and learned from my own clinical practice. This also reiterates the fact that things should e done on a case by case basis as not every patient with a GCS < 8 needs to be intubated

    3. Pay close attention to the study population, and whether they're are more or less risk of aspiration than our population.
    This Scottish population sounds similar to ours, only that we have a larger volume of patients. 22 patients in the study came with alcohol intoxicated and the remainder were overdoses on drugs we frequently see in our ED.

    4. Is aspiration a rare event? Do they have the numbers to pick up on such an adverse event?
    One major drawback to this study was that they wer unable to follow the patients on a longer basis to see if an aspiration event clinically appeared after they were discharged from the ED. This study quotes the percentages of aspiration events from other studies and stated that their study was less than whats been reported. "The incidence of aspiration in poisoned patients has been reported as 0.8% with GCS 15, increasing to 4.5% when the GCS falls below 15. Subgroup analysis of those admitted to the ITU found the rate of aspiration to be 9% when the GCS was 8 and above, increasing to 17% when the GCS fell below 8 (7). Another study found evidence of aspiration in up to 15% of poisoned patients with GCS 9 and in 45% of patients with GCS 9 (8). Our experience suggests that the risk of clinically significant aspiration is less than this"

    Reply

Post Your Comment