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GCS 8 – Intubate…Right?

March 23, 2021

Written by Clay Smith

Spoon Feed
Patients with isolated head trauma and GCS 7 or 8 had greater odds of mortality when intubated immediately. But this is not the study to override the GCS 8 = intubate dogma.

Why does this matter?
GCS 8 = Intubate! Right? Both ATLS and EAST recommend this. It seems pretty solid for trauma patients, though it shouldn’t be the default trigger to intubate overdose patients. There is nothing magical in the number 8 in guaranteeing loss of airway reflexes nor should we be falsely reassured that patients >8 will reliably retain protective airway reflexes. Since intubation is not without complications, is this a dogma we need to reconsider?

This study isn’t the one that will change practice
This was a retrospective study using the TQIP database that included 2,727 adult patients with isolated head trauma and GCS of 7 or 8. After adjusting for known confounders (i.e. head injury severity score), intubation within 1 hour of arrival (1,866/2,727; 68.4%), was associated with an increased adjusted odds of mortality when compared with delayed or no intubation, aOR 1.79 (95%CI 1.31-2.44), and more complications (i.e. DVT, VAP). Out of the total, 23.4% (638/2,727) were never intubated. Though a small group, patients with delayed intubation (223/2,727; 8.5%) had the worst mortality outcome. Overall mortality rates were 27.4% (delayed > 1h group); 18.7% (immediate <1h group); and 11.4% (never intubated). Delayed intubation was also associated with more ventilator days, more overall complications, and increased length of stay. The authors propose a policy of only immediately intubating isolated head trauma patients ≤45 years, with GCS of 7, and head AIS score 5. They stated this would have reduced 3 unnecessary intubations and led to 7 early rather than delayed intubations. This recommendation would lower the GCS for intubation to 7, which would raise the threshold for intubation. Yet it seems the policy, as proposed, may actually lead to more early intubation (which actually seems to be a good thing). I find the results of the study and the proposed policy to be conflicting. I am also concerned that sicker patients (i.e. sonorous, gurgling) were most likely to receive immediate intubation, confounding the primary outcome. I am trying to envision a situation with a patient with obvious head trauma and GCS ≤8 that I would not intubate prior to going to CT. Also, we usually don’t know head trauma is isolated prior to obtaining more imaging in altered patients. In short, this study is interesting but shouldn’t change practice.

Isolated traumatic brain injury: Routine intubation for GCS 7 or 8 may be harmful! J Trauma Acute Care Surg. 2021 Feb 16. doi: 10.1097/TA.0000000000003123. Online ahead of print.

What are your thoughts?