Is a patient’s GCS score a strong indicator?
Advanced airway management, including tracheal intubation, is used for ventilatory or oxygenation failure, impending airway compromise, or inability to protect the airway. The evaluation of a patient’s risk for aspiration can be highly subjective.
One common adage states: “If the GCS is less than 8, then intubate,” offering a seemingly simple and more objective standard to guide airway management.
Using the Glasgow Coma Scale (GCS) score of 8 or below to evaluate the need for intubation is promoted by the ATLS course and the East Association for the Surgery of Trauma (EAST) practice management guidelines. 
This practice is also commonly applied to patients with non-traumatic causes of obtundation. However, the evidence behind this practice is not clear, prompting many to re-examine this oft-repeated maxim.
Glasgow Coma Scale
The Glasgow Coma Scale was created in 1974 as a system to evaluate and document the level of consciousness in patients with head injuries.  It is comprised of three subscales: motor response, verbal response and eye movement.
While the GCS was not initially designed to be summed into one score, this practice became widely adopted. Today, the GCS remains a key component in the evaluation of patient’s level of consciousness, its use spanning across emergency medicine, pre-hospital care, neurosurgery and trauma surgery.
Despite its widespread use, the GCS score has been criticized for its complexity and lack of consistent reliability, demonstrated across several studies. Concordance between attending emergency physicians in calculating GCS scores have been reported as low as 38%. In a third of cases, GCS scores on the same patient varied by two or more points.
In a prospective study of neurologists evaluating GCS scores, exact inter-rater agreement was 71% for 267 consecutive patients in the ICU. This variation in calculating a patient’s GCS score can have significant changes in therapy if utilizing hard cut-offs to decide critical decisions such as airway management.
Gag and Cough Reflex
The general principle behind intubating a patient for a GCS < 8 is the theoretical loss of protective airway reflexes. Moulton et al. demonstrated a strong correlation with decreasing GCS and the absence of a gag reflex. However, the same study showed that many patients with GCS above 8 also had attenuated or absent gag reflexes, especially when they were exposed to sedative medications.
Conversely, several patients with GCS < 8 maintained their gag reflex.  A subsequent prospective observational study of 208 adult patients by Rotheray et al. revisited this issue. While the analysis showed a significant correlation between reduced GCS and absence of cough and gag reflexes, it also found that 36% of patients with GCS < 8 maintained a normal gag reflex and 24% maintained a normal cough reflex.
Similar to the Moulton study, this study also found that between one-fourth to one-fifth of patients with a normal GCS had an absent gag or cough reflex.
While there is correlation between protective airway reflexes and level of consciousness, exceptions to this rule warrant evaluation of airway reflexes independent of the GCS. A GCS of 3 does not guarantee the absence of airway reflexes in the same manner that a “normal” GCS does not guarantee presence of airway reflexes. Further complicating the matter, evaluation of a patient’s gag reflex also raises the risk of inducing emesis and leading to an aspiration event.
Aspiration with decreased GCS
While assessment of airway reflexes is theoretically important for the evaluation of airway protection, current studies have not shown a consistent relationship between a reduced GCS and adverse events such as aspiration. Adnet et al. found increased frequency of suspected aspiration pneumonia in patients admitted to the Toxicologic ICU with a GCS < 8. However, 10/68 patients with GCS of 9-14 also had radiographic evidence of aspiration, again highlighting the risk of airway compromise in more alert patients.
A 2017 retrospective analysis of 528 patients with carbon monoxide intoxication found that altered mental status (AMS) on arrival, defined as GCS < 8, was strongly associated with the development of aspiration pneumonia with an odds ratio of 9.46.
The same study found significantly increased ventilator use, length of hospital stay and in-hospital mortality. However, this study was limited by its broad definition of AMS, which didn’t factor in the clinical heterogeneity of a GCS range of 3-8.
It is also important to question how often witnessed aspiration leads to development of clinically relevant disease. In a study looking at rates of hospital-acquired pneumonia in 228 patients admitted to a level 1 trauma center ICU, witnessed aspiration was significantly associated with development of hospital-acquired pneumonia. However, the overall mortality, ICU length of stay and duration of mechanical ventilation did not vary significantly with witnessed aspiration.
In contrast, some prospective observational studies found significantly lower rates of aspiration pneumonia/pneumonitis in patients with impaired consciousness. In 2009, Duncan et al followed 73 patients with decreased level of consciousness secondary to intoxication, the GCS ranging from 3 to 14. Twelve of these patients had an initial GCS < 8 and 5 patients with a GCS of 3.
None of these patients had episodes of aspiration and none required endotracheal intubation. Notably the one patient who required intubation had a GCS of 12 on admission.
While several patients required some level of airway support, such as nasopharyngeal or oropharyngeal airways, most patients rapidly improved to their baseline level of consciousness within 24 hours. This evidence suggests that certain unconscious or obtunded patients can be safely monitored for clinical improvement without a definitive airway.
In the trauma setting, early intubation is often considered in the context of traumatic brain injury (TBI) to avoid aspiration and hypoxia leading to secondary brain injury. Additionally, there can be significant uncertainty whether a patient’s decreased cognition is due to TBI or intoxication.
Much of the research in patients with traumatic injuries has focused on mortality as an outcome, rather than aspiration. In a prospective study of 412 adult major trauma victims with severe TBI and initial GCS score of 3-8 per paramedics, the sole use of a GCS score did not accurately predict patient desaturation, clinical aspiration, or duration of ICU stay.
Furthermore, a retrospective analysis of 6,676 patients presenting with a GCS between 6-8, drawn from the National Trauma Data Bank found that more patients with a GCS of 6 were intubated compared to GCS of 8, 64.3% and 56.9% respectively. Additionally, they found that intubation was significantly associated with increased odds of mortality, longer ICU stay, and overall hospital length of stay.
The evidence for using a patient’s GCS score as an indication for intubation is mixed. Recent review articles have highlighted the paucity of strong evidence behind the classic adage of “GCS less than 8, intubate”. The evaluation of a patient’s GCS can vary significantly between providers.
While multiple retrospective studies have shown an association between a depressed level of consciousness and aspiration, several prospective studies have contradicted this and appear to show a significantly lower risk of aspiration in these patients. Furthermore, the presence or absence of airway reflexes should not be assumed based on a patient’s GCS.
One may elect to test a patient’s gag or cough reflexes at bedside, understanding that it may also induce vomiting. The Glasgow coma scale can be utilized as one factor to help dictate airway management, but rigid use of a GCS cut-off for intubation is not currently supported by robust evidence. In light of this, emergency physicians should use their gestalt and individually assess each patient’s likelihood of airway compromise.
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