Predictors of the need for rapid sequence intubation in the poisoned patient with reduced Glasgow coma score

In patients presenting to the emergency department (ED) with significant poisoning and reduced Glasgow coma score (GCS), the decision to proceed with rapid sequence intubation can be a difficult one. Traditionally, patients with a GCS of 8 or less are thought to require airway protection. It has been found that a number of these patients can be managed safely without advanced airway support in a well-monitored ward environment. The objective of this study was to define the key physiological indicators of intubation requirement in this complex group of patients.

Prospective parallel group comparison. The study was conducted in the ED of a Scottish teaching hospital over a 12-month period. Group 1 included all poisoned patients admitted to the ED with a GCS of 8 or less who were not intubated and managed conservatively in the short-stay ward. Group 2 included all poisoned patients with a reduced GCS who were intubated. Demographics and physiological parameters were analysed in both groups (intubated vs non-intubated).

12 patients were identified in the intubated group and 14 in the non-intubated group. Demographics were similar in both groups. Analyses of means and medians of physiological parameters indicated minimal predominance of oxygenation/ventilatory failure in the group requiring intubation. This correlated with the physician's perception of inadequate airway protection or ventilatory failure.

Clinical assessment by experienced medical staff rather than physiological variables are the key to determining intubation requirements in the poisoned patient with reduced GCS. GCS alone is not a good predictor of intubation.