Clinical scenario

A comatose 20 year old man is brought to the emergency department with a GCS of 3/15 and in respiratory arrest. Acute overdose with γ-hyroxybutyric acid is suspected. Ventilation is initially assisted with a bag and mask. Your anaesthetic colleagues are very reluctant to intubate the patient as they state that the patient will wake up soon and there are no beds in the intensive care unit.

Three part question

In [patients with presumed GHB intoxication and respiratory depression] is [endotracheal intubation more effective than non-invasive airway management] at [reducing the complications of an unprotected airway]?

Search strategy

Medline 1966–09/04 using the OVID interface. [exp Hydroxybutyrates OR gamma hydroxybutyric acid.mp. OR GHB.mp] AND [exp Poisoning OR intoxication.mp OR exp Overdose OR overdose.mp] LIMIT to English language.

Search outcome

Altogether 95 papers were found. Two papers were relevant to the three part question (see table 1).

Comment(s)

The evidence for and against endotracheal intubation is scanty. These reports show no evidence for aspiration but the numbers involved (of non-intubated patients) are small. There is insufficient evidence here to change the standard approach to airway management in the unconcious patient. The reduced GCS is an indication for airway protection that would normally be achieved using a rapid sequence induction of anaesthesia.

CLINICAL BOTTOM LINE

In patients with suspected GHB toxicity, reduced GCS and a threatened airway, rapid sequence induction and intubation should be performed.