Background: Acutely intoxicated / poisoned patients are commonly encountered in the ED, with the classic teaching that a GCS < 9 is an indication to intubate for airway protection. But we’ve probably all had a patient who was borderline, or who we thought was still protecting their airway pretty well despite a lower GCS. Are we risking our patient’s health and our careers by holding off on intubation? Maybe not. 

The NICO trial, a multicenter, randomized controlled trial, looked at patients presenting by EMS with GCS <9 due to suspected poisoning, without immediate indication for intubation (defined by signs of respiratory distress with hypoxia, clinical suspicion of any brain injury, seizure, or shock with systolic BP <90 mmHg). They found that withholding intubation with close monitoring, compared to the standard practice of intubating at the EMS or ED physician’s discretion, resulted in: 

• No deaths in either group
• Fewer intubations (18.1% vs 59.6%; AR difference 41.5%, 95% CI -54.1 to -30.9)
• Fewer intubation-associated adverse events (6% vs. 14.7%; 95% CI -16.6 to -0.7)
• Decreased incidence of pneumonia (6.9% vs 14.7%; 95% CI -15.9 to 0.3)
• Fewer ICU admissions (39.7% vs. 66.1%) and decreased hospital and ICU LOS

Comparing the patients who were intubated in each group, there was no significant difference between groups in:

• Rate of intubation-associated adverse events or first-pass failure
• Median ICU or hospital length of stay

Notes: 

• French study – EMS setup there is different from ours in the US
• Median GCS = 6, study population skewed young and male (mean age 33yo, 62% male) 
• Mostly alcohol or benzodiazepine intoxication
• Unblinded study

Bottom Line: Without clear indication for intubation such as respiratory distress or accompanying head bleed, etcetera, intubation for mental status alone shouldn't be dogma in acute intoxication. Close monitoring will identify need for intubation, without apparent worsened outcomes due to a watchful waiting approach.

References

Freund Y, Viglino D, Cachanado M, et al. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023; 330(23):2267-2274. doi: 10.1001/jama.2023.24391.