The Journal of Medicine, Law & Public Health Vol 2, No 1.

2022 p86

Effects of not intubating non-trauma patients

with low Glasgow Coma Scale scores: A
retrospective study
Loui Alsulimani, Ohoud Baajlan, Khalid Alghamdi, Raghad Alahmadi, Abdullah Bakhsh, and Jameel Abualenain

Abstract—Background: Endotracheal intubation Index Terms—Endotracheal intubation, Intubation

(EI) is a critical life-saving procedure commonly in the ED, Non-trauma patients with low Glasgow
performed on emergency department (ED) patients Coma Scale scores
who present with altered mental status (AMS).
Aims: We aimed to investigate the safety of observ- I. I NTRODUCTION
ing, without EI, patients who present to the ED with
Endotracheal intubation (EI) in acute care settings
decreased levels of consciousness (LOC).
is generally a stress-provoking and high-stakes pro-
Methods: We reviewed the data of all adult ED
cedure, often with no clear cut-off point regarding its
patients with a Glasgow Coma Scale (GCS) score ≤ 8,
indication. Although it has an excellent success rate
during the period between 2012 and 2018, in an
academic tertiary care centre. Trauma patients were
(~100%) [1], serious complications such as oxygen
excluded. The patients were divided into two groups desaturation, cardiac arrest, oesophageal in-
for comparison: those who were intubated and those tubation, and vomiting/regurgitation [2] can occur,
who were not. Data on mortality, morbidity, and even under expert care. Most intubated patients are
baseline clinical characteristics were collected and admitted to the intensive care unit (ICU), which is
analysed. costly (around 4300 US Dollars per day) [3]. There-
Results: After screening 6334 electronic medical fore, EI must be performed for the correct indi-
records of patients presenting to the ED with de- cations; namely, apnoea, respiratory failure, airway
creased LOC, only 257 patients met the inclusion obstruction, loss of airway reflexes, decreased levels
criteria. 173 (67.3%) patients were intubated, while 84 of consciousness (LOC), haemodynamic instability,
(32.7%) were not. Among the intubated patients, 165 and cardiopulmonary arrest [4]. Most EIs are for
(95.4%) were intubated early (within two hours of medical cases [5,6], including severe cognitive im-
presentation). Mortality, morbidity and length of stay pairment, hypoventilation, and airway obstruction
for the intubated group were higher, although the [7, 8].
baseline clinical characteristics were the same.
This study aimed to investigate the effects of ob-
Conclusion: It might be safe to observe non-trauma serving non-trauma patients with a Glasgow Coma
emergency patients with a GCS score ≤ 8 without
Scale (GCS) score ≤ 8 without intubating them
intubation. However, such decision should be taken
during their ED visit, and compare these with pa-
carefully, as delayed intubation can be associated with
higher mortality and morbidity. tients who were intubated, in terms of complications
and mortality. Early EI was defined as intubation
performed during the first two hours after arrival at
Loui Alsulimani, Ohoud Baajlan, Abdullah Bakhsh, Jameel
Abualenain are with Department of Emergency Medicine, the ED [8, 9]; a specific focus was given to identify
Faculty of Medicine, King Abdulaziz University, e-mail: this group.
[email protected], e-mail: [email protected],
e-mail: [email protected], e-mail: II. MATERIALS AND M ETHODS
[email protected]
Loui Alsulimani is the corresponding author. We conducted a retrospective chart review to
Khalid Alghamdi (e-mail: [email protected]) investigate the safety of observing unconscious non-
Raghad Alahmadi (e-mail: [email protected]) trauma patients with decreased LOC who presented
DOI:10.52609/jmlph.v2i1.41
The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p87

to the ED in an academic tertiary care university (percentages). Differences among the continuous
centre. We reviewed the electronic medical records variables were compared using Student’s t-tests, and
of all adult patients (≥ 14 years according to the those among categorical variables were compared
hospital system) who presented to the ED between using either the chi-square or Fisher’s exact test. In
January 2012 and December 2018 with decreased statistical testing, a two-sided P < 0.05 was
LOC. considered statistically significant.
The LOC of patients presenting to the hospital’s
III. RESULTS
ED is usually recorded electronically in the triage
notes, using the AVPU scale, by the triage nurses Of the 6334 patients who presented to the ED with
during the initial encounter. The patient’s primary decreased LOC between January 2012 and
nurse then records the GCS once the patient is as- December 2018, 4056 were adults (≥ 14 years). Only
signed to a treatment area. For this study, data from 257 patients met the inclusion criteria with a GCS
the Health Information System (HIS) were retrieved score ≤ 8 and were included in the final analysis
by the hospital’s statistics unit and the HIS data of (Figure 1). Of these, 173 (67.3%) were intubated,
all patients with decreased LOC whose AVPU scale while the remaining 84 (32.7%) were not. Of the 173
was recorded as verbal (V), unresponsive (U), or patients in the intubated group, most (165 [95.4%])
pain (P) [i.e., all categories excluding alert (A)] were were intubated early, i.e., within two hours of
separated. Subsequently, the patients’ electronic presentation to the ED, whereas eight (4.6%) were
medical records (EMRs) were reviewed by the intubated more than two hours after presentation
research team to obtain the GCS scores from the (two on the first day and six on the second day).
nurses’ notes. The research team created an The total mortality and all-cause morbidity among
electronic data collection sheet to record the study the 257 patients included in the study were 28.2%
variables and established and trained a data and 22.6% respectively. 149 (58%) patients were
collection team for data retrieval. The research team male, and 191 (74.3%) had at least one pre-existing
supervised the data collection team and reviewed the comorbidity. The mean length of hospital stay for all
collected data for any inconsistencies or non- 257 patients was 12.5 days. The mean age of
compliance with requirements. included patients was 63.9 years (SD +/- 18.81). The
All patients with a GCS score ≤ 8 were included in mean GCS score at the time of presentation was
the study; those who presented with trauma, cardiac 5.51 (median 6), and the most frequent (mode) was
arrest, and do-not-resuscitate status were excluded. 3. Furthermore, there was a correlation between the
The eligible study population (those with a GCS AVPU responsiveness scale and the GCS score.
score ≤ 8) were divided into two groups: those who Patients who presented as unresponsive (U) had a
were intubated and those who were not intubated lower average GCS score (5) than those who were
during the studied period of hospitalization. The responsive to pain (P) (average GCS score of 6) or
main goal was to compare mortality and morbidity verbal (V) (average GCS score of 7) stimuli.
between the two groups. For this purpose, data were
collected manually by reviewing the saved A. Demographics: The clinical characteristics of
documents. Study data were collected into an elec- the two groups (intubated and non-intubated) are
tronic data collection sheet, from a secure database illustrated in Table 1. In both groups, most of the
only accessible to the research team. After the data patients who presented with low GCS scores were
collection, any patient identifiers were deidentified around 60 years old. Moreover, more than half of
for confidentiality and the original data were kept the patients in both groups were male. It was
by the primary investigator in an encrypted device. observed that the lower the GCS score from 8, the
For statistical analysis, IBM SPSS Statistics for more likely it was that the patient would be intubated,
Windows, version 21.0 (IBM Corp., Armonk, N.Y., and vice versa (P-value < 0.05). Intubation was more
USA) was used. Continuous variables were ex- common in patients presenting with neurological
pressed as mean (standard deviation [SD]), whereas disorders than in those presenting with other
categorical variables were expressed as numbers pathologies, cerebrovascular accident being
The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p88

Fig. 1. Flow chart of research steps

The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p89

the most common reason. Hypertension was the A review of the literature on this topic revealed
most frequent comorbidity in both groups, followed previous studies showing similar results for intoxi-
by diabetes mellitus and a previous history of stroke cated patients with comparable presentation [7, 10,
(Figure 2). Other comorbidities were also observed 11]. Duncan et al showed no evidence of complica-
which, according to this study’s protocol, were not tions when patients with alcohol intoxication and a
considered major comorbidities, such as liver cir- GCS score ≤ 8 were observed until sobriety was
rhosis, benign prostate hypertrophy and Parkinson’s regained [11]. This indicates that patients with tem-
disease, among others. porary or reversible conditions causing a GCS score
≤ 8 may not necessarily require early intubation. This
B. Patients’ outcomes: There was no statistically study demonstrates that the majority of patients
significant difference in mortality or morbidity be- (91.3%) who were deemed by emergency physicians
tween the two groups: Mortality was 28.7% in the not to require early intubation most likely did not
intubated group vs. 27.2% in the non-intubated require it. Regarding the eight (8.7%) patients who
group, and all-cause morbidity (aspiration pneu- did require subsequent intubation, it is unlikely that
monia, hypoxic brain injury, cerebral oedema and the cause was physicians’ misjudgment, since most
major organ failure) 24.9% in the intubated group vs. of these patients (six out of eight) were able to
17.9% in the non-intubated group (Table 2). All tolerate non-intubation for at least 24 hours. Overall,
organ failure during hospital admission was higher in the patients requiring subsequent intubation only
the intubated group than in the non-intubated group; represent a small percentage of those who were not
however, also not statistically significant (Figure 3). intubated within the first two hours. The AVPU
Most patients who were intubated required a (Alert, responds to Voice, responds to Pain,
prolonged (more than 14 days) admission to the ICU, Unresponsive) scale and the Glasgow Coma Scale
whereas only a quarter of patients who were not (GCS) are the common tools used to assess LOC [10,
intubated needed ICU admission within 14 days of 12, 13]. The AVPU scale is a simple and easy tool
presentation to the ED. The length of stay was longer to rapidly assess altered mental status (AMS).
for the intubated group (almost 13 days); the non- However, it is insufficient for early detection of
intubated group spent approximately two days less changes in LOC, less comprehensive for assessing all
than the intubated group. the levels of an AMS, and difficult to obtain in some
intoxicated patients [13]. The GCS, meanwhile, was
initially used for traumatic head injuries but has now
IV. D ISCUSSION become a common tool for the subjective
measurement of LOC [13, 14]. GCS scores and gag
In this study, we demonstrated the possibility of
reflexes are poorly related; hence the gag reflex may
safely observing medical emergency patients who
be normal or diminished at any GCS score [15, 16].
present to the ED with a GCS score ≤ 8, without
performing intubation. Almost one-third (32.7%) of The presence of a gag reflex is a very specific
criterion for the exclusion of intubation, but not vice
these patients were not intubated throughout their
versa [17]. Nonetheless, the airway should
hospital visit, and this group had lower morbidity
be assessed separately from LOC [15, 16].
rates than those who were intubated. However,
mortality rates were similar in both groups. On Although a GCS score ≤ 8 is a well-known
analyzing certain baseline characteristics (including indicator for intubation in trauma patients, it is still
age, GCS score upon presentation, and comorbidi- controversial in alcohol-intoxicated, drug-poisoned,
ties) of both the intubated and observation groups, no and non-trauma patients [7]. A study of poisoned
significant variability was found; this minimises patients found that the rate of complications in those
possible bias due to baseline variability between the with low GCS scores was low; therefore, the “GCS
compared groups. 8, intubate” rule likely does not apply to these
patients [11]. Some studies assert that using a GCS
score ≤ 8 as an indication for intubation in intox-
icated patients is not appropriate, as those patients
The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p90
Table 1. Demographics and clinical characteristics of patients

Demographic Intubation status

Intubated Not intubated Missing P-value
Count Column Count Column
N% N%
Age Count 171 ---- 84 ---- 2 0.069
Mean 62.47 years 67.04 years (SD
(SD17.78) 20.53)
GCS on Count 173 ---- 84 ---- 0 0.049
presentation
Mean 5.36 (SD 1.69) 5.82 (SD 1.89)
Median 6 6
Mode 6 7
Gender Male 109 63.0% 40 47.6% 0 0.019
Female 64 37.0% 44 52.4%
Final Neurological 73 45.6% 27 35.1% 20 0.319
Diagnosis
Abdominal 21 13.1% 10 13.0%
and renal
Infectious 36 22.5% 27 35.1%
Respiratory 23 14.4% 11 14.3%
Cardiac 7 4.4% 2 2.6%

GCS: Glasgow Coma Scale score

Table 2. Patients’ hospital outcomes

Hospital course Intubation status

Intubated Not intubated Missing P-value
Count Column Count Column
N% N%
Mortality Yes 47 28.7% 22 27.2% 12 0.806
No 117 71.3% 59 72.8%
Morbidity Yes 43 24.9% 15 17.9% 0 0.208
No 130 75.1% 69 82.1%

All organ Yes 18 10.4% 4 4.8% 0 0.158

failure No 155 89.6% 80 95.2%
The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p91
ICU 98 62.8% 18 25.4% 30 0.000
Medical 39 25.0% 26 36.6%
Dispatch
Surgical 8 5.1% 4 5.6%
Discharged 11 7.1% 23 32.4%
Mean SD Mean SD Mean SD 31 0.553
Length of
stay 12.46 13.14 ±21.19 11.05 ±30.75
±24.68
days

86
90
74
80
70
60 47
44 44
50
40 30 2724 28
30
20 10 6 12 9 6 6 5 4
10 2 2 2 3 0
0

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Intubated Not intubated

Fig. 2. Patients’ comorbidities on presentation

may be able to maintain ventilation and protect their two scores. Moreover, the closer to 8 the GCS score,
airway unassisted [7, 10, 11]. In contrast, Chan et al the more likely it could be for the physician to avoid
concluded that a GCS score ≤ 8 is a sensitive early intubation if the clinical condition persists. It is
indicator for intubation in poisoned patients [17]. important to note that the mean and median GCS
Various scores have been used to aid the decision scores in both groups were similar. This equality in
to intubate patients with decreased LOC. For ex- the baseline GCS scores of both groups gives more
ample, the Bispectral Index (BIS) was described as a validity to the findings of this study by minimizing
useful tool to determine the need for intubation in variation in a major baseline characteristic.
opioid-poisoned patients [18]. In this study, we used This study has some limitations. The relatively
mainly the GCS and AVPU scores. The AVPU values small sample size overall, and especially in the
correspond to GCS scores of 15 (A), 13 (V), 8 (P), delayed intubation group, may limit the generaliz-
and 3 (U), respectively, with narrow ranges and ability of the results. Future studies should include a
some overlap [13]. Interestingly, this study showed a larger sample size and use of specific diagnoses for
similar pattern of correlation between the more clinical applicability. Furthermore, this
The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p92

study does not include data relating to vital signs and VIII. E THICAL APPROVAL
blood gas results, as these were available in paper- This research was approved by the Unit of
based documents, making them difficult to retrieve Biomedical Research Ethics Committee in the Fac-
and creating the problem of a large proportion of ulty of Medicine (Reference No. 584-18) in Novem-
missed data. It is not clear whether these variables ber 2018.
would have an effect on the study’s outcome.
Moreover, it was difficult to determine from the IX. A CKNOWLEDGMENTS
EMRs whether the low GCS score at presentation was We would like to thank the data collection team.
a baseline score for the patient or an acute We also thank Editage by Cactus© for editing the
presentation. Nevertheless, we believe that the study manuscript.
addresses the concept of safety of observation
(without intubation) in general. Further studies are X. R EFERENCES
needed to address the abovementioned limitations.
1. Bernhard M, Bax SN, Hartwig T, Yahiaoui-
Doktor M, Petros S, Bercker S, et al. Airway
V. C ONCLUSION Management in the Emergency Department (The
Although most non-trauma patients presenting to OcEAN-Study) - a prospective single centre
the ED with a GCS score ≤ 8 require intubation observational cohort study. Scandinavian journal of
within the critical initial few hours after presenta- trauma, resuscitation and emergency medicine.
tion, a significant percentage can be safely observed 2019;27(1):1-9.
without undergoing intubation. If patients with a 2. Ono Y, Kakamu T, Kikuchi H, Mori Y, Watanabe
GCS score ≤ 8 can safely pass the critical first two Y, Shinohara K. Expert-performed endotracheal
intubation-related complications in trauma patients:
hours after presentation without requiring intuba-
incidence, possible risk factors, and outcomes in the
tion, it is unlikely that they will need intubation later
prehospital setting and emergency department.
during their hospitalization. However, emergency Emergency medicine international. 2018;2018.
physicians should be careful in selecting the right 3. Halpern NA, Pastores SM. Critical care medicine
candidates for observation without intubation if the beds, use, occupancy and costs in the United States: a
GCS score is ≤ 8. methodological review. Critical care medicine.
In conclusion, the physician’s clinical assessment 2015;43(11):2452.
plays a paramount role in deciding whether patients 4. Şahiner Y. Indications for Endotracheal
with a GCS score ≤ 8 need immediate intubation or Intubation. Tracheal Intubation 2018.
further observation without intubation. Many clinical 5. Brown III CA, Bair AE, Pallin DJ, Walls RM,
parameters may aid this decision. Clinical decision Investigators NI. Techniques, success, and adverse
protocols are required that follow the best available events of emergency department adult intubations.
guidance, based on existing knowledge, clinical Annals of Emergency Medicine. 2015;65(4):363-70.
judgment, and hospital policies, to assist ED e1.
physicians during such critical and stressful 6. Alkhouri H, Vassiliadis J, Murray M, Mackenzie
moments. Further exploration of variables from this J, Tzannes A, McCarthy S, et al. Emergency airway
study and others may help guide the development of management in Australian and New Zealand
such beneficial tools. emergency departments: a multicentre descriptive
study of 3710 emergency intubations. Emergency
Medicine Australasia. 2017;29(5):499-508.
VI. S OURCE OF FUNDING: 7. Sauter TC, Rönz K, Hirschi T, Lehmann B, Hütt
No funding was received. C, Exadaktylos AK, et al. Intubation in acute alcohol
intoxications at the emergency department.
Scandinavian journal of trauma, resuscitation and
VII. C ONFLICT OF INTEREST: emergency medicine. 2020;28(1):1-10.
The authors have no conflicts of interest. 8. Sise MJ, Shackford SR, Sise CB, Sack DI, Paci
GM, Yale RS, et al. Early intubation in the
management of trauma patients: indications and
outcomes in 1,000 consecutive patients. Journal of
The Journal of Medicine, Law & Public Health Vol 2, No 1. 2022 p93

Trauma and Acute Care Surgery. 2009;66(1):32-40. 14. Zadravecz FJ, Tien L, Robertson‐Dick BJ, Yuen
9. Trupka A, Waydhas C, Nast-Kolb D, TC, Twu NM, Churpek MM, et al. Comparison of
Schweiberer L. Early intubation in severely injured mental‐status scales for predicting mortality on the
patients. European journal of emergency medicine: general wards. Journal of hospital medicine.
official journal of the European Society for 2015;10(10):658-63.
Emergency Medicine. 1994;1(1):1-8. 15. Moulton C, Pennycook A, Makower R. Relation
10. Rajabi Kheirabadi A, Tabeshpour J, Afshari R. between Glasgow coma scale and the gag reflex.
Comparison of three consciousness assessment BMJ: British Medical Journal. 1991;303(6812):1240.
scales in poisoned patients and recommendation of a 16. Moulton C, Pennycook AG. Relation between
new scale: AVPU plus. Asia Pacific Journal of Glasgow coma score and cough reflex. The Lancet.
Medical Toxicology. 2015;4(2):58-63. 1994;343(8908):1261-2.
11. Duncan R, Thakore S. Decreased Glasgow 17. Chan B, Gaudry P, Grattan-Smith T, McNeil R.
Coma Scale score does not mandate endotracheal The use of Glasgow Coma Scale in poisoning. The
intubation in the emergency department. The journal Journal of emergency medicine. 1993;11(5):579-82.
of emergency medicine. 2009;37(4):451-5. 18. Eizadi-Mood N, Yaraghi A, Alikhasi M,
12. Romanelli D, Farrell MW. AVPU (alert, voice, Jabalameli M, Farsaei S, Sabzghabaee AM.
pain, unresponsive). Treasure Island: StatPearls Prediction of endotracheal intubation outcome in
Publishing. 2019. opioid-poisoned patients: A clinical approach to
13. Kelly CA, Upex A, Bateman DN. Comparison bispectral monitoring. Canadian journal of respiratory
of consciousness level assessment in the poisoned therapy: CJRT= Revue canadienne de la therapie
patient using the alert/verbal/painful/unresponsive respiratoire: RCTR. 2014;50(3):83.
scale and the Glasgow Coma Scale. Annals of
emergency medicine. 2004;44(2):108-13.

Fig. 3. Morbidity on admission