Intubation in acute alcohol intoxications at the emergency department

Abstract

Background: Guidelines recommend endotracheal intubation in trauma patients with a Glasgow coma scale (GCS) < 9 because of the loss of airway reflexes and consequential risk of airway obstruction. However, in patients with acute alcohol intoxication guidelines are not clear. Thus, we aimed to determine the proportional incidence of intubation in alcohol intoxication and compare the clinical characteristics of intubated and non-intubated patients, as well as reasons for intubation in all patients and in the subgroup of patients with reduced GCS (< 9) but without traumatic brain injury. Methods: We performed a retrospective analysis of all consultations to an urban ED in Switzerland that presented with an acute alcohol intoxication between 1st June 2012 and 31th Mai 2017. Patient and emergency consultations' characteristics, related injuries, intubation and reason for intubations were extracted. As a subgroup analysis, we analysed the patients with a GCS < 9 without a traumatic brain injury.Results: Of 3003 consultations included from 01.06.2012 to 31.05.2017, 68 were intubated, leading to a proportional incidence of 2.3% intubations in alcohol-intoxication. Intubated patients had a lower blood alcohol concentration (1.3 g/kg [IQR 1.0-2.2] vs. 1.6 g/kg [IQR1.1-2.2], p = 0.034) and less often suffered from chronic alcohol abuse (1183 [39.4%] patients vs. 14 [20.6%], p = 0.001) than non-intubated patients. Patients with trauma were intubated more often (33 patients [48.5%] vs. 742 [25.3%], p < 0.001). In subgroup analysis, 110/145 patients (74.3%) were not intubated; again, more intubated patients had a history of trauma (9 patients [25.7%] vs. 10 [9.1%], p = 0.011).Conclusions: Intubation in alcohol-intoxicated patients is rare and, among intoxicated patients with GCS < 9, more than two thirds were not intubated in our study -without severe complications. Trauma in general, independent of the history of a traumatic brain injury, and a missing history of chronic alcohol abuse are associated with intubation, but not with blood alcohol concentration. Special caution is required for intoxicated patients with trauma or other additional intoxications or diseases.

Clinical profile and outcome of acute organophosphate poisoning in children of Upper Egypt: a cross-sectional study

“…In Duncan and Thakore study [26], none of poisoned patients with GCS of 8 or less suffered aspiration or required intubation. Also, in Sauter et al [27], study, more than two thirds of intoxicated patients with GCS ≤ 8 were not intubated without any severe complications. Leucocytosis was significantly higher in non survivors agreeing with several previous studies [28,29].…”

Aspiration risk in relation to Glasgow Coma Scale score and clinical parameters in patients with severe acute alcohol intoxication: a single-centre, retrospective study

“…Many studies were performed in heterogeneous cohorts of mixed intoxication, 7 9 29–31 in patients with trauma 8 32 or without any data on the risk of aspiration. 8 29 While some authors and recommendations refer to a GCS score ≤8 as an indication for intubation in alcohol intoxicated patients, the association of a low GCS score with a higher risk of aspiration has not been sufficiently substantiated in these patients. In their prospective observational study, Duncan et al 7 did not find a higher rate of aspiration in patients with a GCS score ≤8.…”

“…Thus, even for a GCS score=3 the PPV is too low (16%) to guide the decision for intubation. However, Sauter et al 8 described that a GCS score ≤8 was the main reason for emergency teams to decide for intubation in intoxicated patients. In our cohort, emergency physicians—according to their emergency protocols—made a more differentiated decision for intubation based on GCS score, presence of the gag reflex, vomiting and the suspicion of aspiration.…”

“… 7–11 The clinical benefit of intubating intoxicated patients with a GCS score ≤8 in order to prevent aspiration is still controversially discussed. 8 9 12–14 Apart from adverse events like hypotension and cardiac arrest, prehospital intubation bears a risk of approx. 8% for the development of an intubation-related aspiration pneumonia.…”

“…In patients with trauma with impaired consciousness, a Glasgow Coma Scale (GCS) score of 8 or less is widely accepted as an indication for an airway protection by endotracheal intubation 6. Although alcohol intoxicated patients often present with impaired consciousness and a GCS score of less than 8, the reported intubation rate of 0%–2.3% is low compared with the overall intubation rate of 3%–5% in prehospital emergencies 7–11. The clinical benefit of intubating intoxicated patients with a GCS score ≤8 in order to prevent aspiration is still controversially discussed 8 9 12–14.…”