Safety of withholding intubation in gamma-hydroxybutyrate- and gamma-butyrolactone-intoxicated coma patients in the emergency department

Abstract

Objective The objective of this study was to determine if supportive care without endotracheal intubation in the emergency department (ED) was safe in the absence of complications in gamma-hydroxybutyrate (GHB)/gamma-butyrolactone (GBL) intoxicated patients with a decreased Glasgow Coma Scale (GCS) score. Methods This was a retrospective chart review of patients presenting to a Dutch tertiary urban ED with a reduced level of consciousness related to alleged GHB/GBL intoxication between April 2011–December 2014. Primary endpoint was major adverse events, defined by: upper airway obstruction not resolved with mayo tube or nasopharyngeal airway, hypoxia not resolved with 15 l of oxygen delivered via non-rebreathing mask, bradypnea not resolved after stimulation, intubation, bradycardia not resolved after intravenous atropine bolus, hypotension for which inotropes were started. Results Data of 209 patients were retrieved. Major adverse events were reported in five patients (2.4%; 95% CI: 0.8–5.5). Intubation with subsequent ICU admission was required for 1.4% of patients (95% CI: 0.3–4.1). The most frequently seen minor adverse events (N = 209) were: airway obstruction (22%), hypothermia (14.8%), hypoxia (12.9%), bradycardia (8.1%), hypotension (6.7%), bradypnea (5.7%), vomiting (5.3%). There were no deaths. None of the patients had signs of aspiration pneumonia or returned to our ED due to complications. Conclusion Our study suggests that conservative airway management for patients with a decreased GCS due to suspected GHB intoxication may be safe. Major adverse events were present in 2.4% of patients, only 1.4% of patients required intubation. All minor adverse events were managed effectively with conservative treatment.

Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review

“…Publication dates range from 1991 to 2019. Seven studies involved non-traumatic unconscious patients (poisoned or intoxicated patients) [6,8,[16][17][18][19][20], 4 studies enlisted traumatic brain injury (TBI) patients [11,[21][22][23]. A study enrolled adult patients who required intubation for traumatic and non-traumatic cases [24]; a study enrolled pediatric mixed traumatic and non-traumatic cases [12].…”

“…All studies were observational: 4 enrolled patients prospectively [8,16,18,21], while the remaining 9 were retrospective [6,11,12,17,19,20,[22][23][24]. Only one study, among those prospective, specified the consecutive enrollment of patients [8].…”

“…Only one study, among those prospective, specified the consecutive enrollment of patients [8]. Five studies were conducted in an Emergency Department (ED) [8,16,17,19,20], 7 related to the pre-hospital environment [6,11,12,[21][22][23][24], and one study was conducted both in the prehospital setting and in the ED. [18] The sample size ranged from 26 to 21,242 patients.…”

“…The average reliability was moderate or low. Many studies were retrospective, so the risk of bias not precisely assessable [6,11,12,[17][18][19][20][21][22][23][24]. We did not identify any randomized clinical trials.…”

“…Among the studies, there was no agreement for the outcome considered. Some studies evaluated the cases of aspiration complication (pneumonia or pneumonitis) [8,16,17,20,21,24], other studies considered a clinical outcome [8,11,12,16,19,21,23], like mortality, ICU length of stay, or hospital length of stay, related to an aspiration event.…”