The decision to anaesthetise and intubate is not always an easy one. When learning to anaesthetise and intubate we are often told that a GCS of 8 or less is when the patient scores a tube in trauma. Reality is not that easy. One of the limbo zones that aren’t covered very well by our basic training is managing airways in the agitated head trauma patients or the patients with a GCS greater than 8. A paper from a 2007 Emerg Med J , by Ellis et al, provides some insight into what we are dealing with.
When working on the air ambulance, or as anaesthetists in the ED, we frequently get called out to trauma patients that are agitated. Typically, an ambulance crew or ED staff requests help in sedating a patient that is fighting them or is otherwise unmanageable. Virtually all of those requests are valid I find. The EMTs and ED-dwellers I meet know what they are doing and call us for a reason. There is no use trying to talk these patients to their senses. Holding them down will only agitate them even more and increase their ICP. Expediting a transport of a combative patient is plain dangerous. These patient’s almost always require proper sedating or anaesthesia and intubation. Some neurosurgeons will sometimes tell you to refrain from intubating so that they can make their neurological assessments. I never quite understood that and tend to ignore those requests.
Still, these decisions are often made based on fuzzy you-had-to-be-there logic as the indications for sedation, intubation or doing nothing are now very relative. It is often difficult decisions to make and often difficult to defend. The 2007 paper from Emerg Med J helps me understand what I am dealing with in these situations. It doesn’t specifically deal with agitated patients but looks closer at the trauma patients with a GCS of 13-14. The agitated patients we deal with typically score a GCS of 13-14.
A retrospective review of the London HEMS trauma database covering cases from one year. All adult patients with an intitial prehospital GCS of 13-14 were included. Non-trauma patients, including hangings and drownings, were excluded.
The patients were subgrouped into those who were intubated and those who were transferred awake.
CT scan reports were analysed. Neurosurgical procedures, ISS scores, mechanism of injury and mortality within a week were recorded as well.
The indications for RSI are in the box to the right.
Small numbers as is often the case.
81 patients fulfilled the criteria and were included. 43 had on-scene RSI while 38 were transported awake. In both groups combined, 31,5% had abnormal head scans, 20,5% had intracranial haemorrhage and 7% required some sort of neurosurgical intervention like craniotomies or intracranial pressure monitors.
The numbers were worse in the RSI subgroup.
38% had abnormal CT scans.
28% had intracranial haemorrhages and
13% eventually had some kind of neurosurgical procedure.
Mortality in the RSI group was 16% and 0% in the awake group.
Take home message
In trauma patients a drop of GCS from 15 to only 13-14 is associated with a significant incidence of intracranial injury. One in three will have intracranial pathology. The patients where I am called to intervene, those that that require intubation or sedation, are even more likely to have intracranial pathology, intracranial bleeds and are more likely to require neurosurgical intervention of some kind.
Study is available for free here:
Prehospital rapid-sequence intubation of patients with trauma with a Glasgow Coma Score of 13 or 14 and the subsequent incidence of intracranial pathology. Ellis DY, Davies GE, Pearn J, Lockey D. Emerg Med J. 2007 Feb;24(2):139-41.