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Fri May 16 15:41:53 BST 2008

Guys,

it is no surprise to me that a bunch of you would say, I agree with not intubating a post-ictal patient after a seizure; I know this is the routine care and that's what everyone's doing right now.

What I am saying is that it is wrong. 
Aspiration pneumonia following severe self-poisoning
http://www.resuscitationjournal.com/article/S0300-9572(02)00284-8/abstract
Janne Liisanantti, Päivi Kaukoranta, Matti Martikainen, Tero Ala-Kokko
Received 6 March 2002; received in revised form 7 March 2002; accepted 16 August 2002. 
Abstract 
Purpose: To investigate the risk factors of aspiration pneumonia following severe self-poisoning. Materials and methods: Patients treated due to severe self-poisoning in the ICU of Oulu University Hospital, Oulu, Finland during 1.11.1989–31.10.2000 were analyzed retrospectively. Results: 28.4% of 257 patients fulfilled the criteria of aspiration pneumonia. An unconscious patient who was not intubated until arrival at the emergency room (ER) had an odds ratio (OR) of 3.34 (CI 1.3–8.7) for aspiration pneumonia. If the patient was intubated at the first contact with health care providers, OR was 1.8 (CI 0.6–5.7). The use of gastric lavage or activated charcoal in the case of a non-intubated unconscious patient led to ORs of 2.7 (CI 0.8–9.3) and 3.7 (CI 1.01–12.5), respectively. The mean length of ICU stay was 0.9 (CI 0.8–0.9) days among patients without aspiration pneumonia and 1.9 (CI 1.3–2.6) days among those with aspiration pneumonia. The
 mean length of hospital stay was 2.8 (CI 2.5–3.1) days among the patients without aspiration pneumonia and 6.5 (CI 5.3–7.6) days among those with aspiration pneumonia. Conclusion: To avoid aspiration pneumonia intubation of an unconscious patient on scene before arrival at the ER is recommended. The use of gastric lavage and activated charcoal increase the risk of aspiration pneumonia if the patient is unconscious and not intubated. Aspiration pneumonia significantly prolongs the length of ICU and hospital stay.

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Poster presentation http://ccforum.com/content/10/s1/p69
Correlation between GCS and the risk of aspiration pneumonia in self-poisoning patients
Y Blel1, T Hafedh1, N Brahmi1, N Kouraichi1, A Mokline1, O Béji1, H Ben Mokhtar2, C Hamouda1 and M Amamou1
1Centre d'Assistance Médicale Urgente, Tunis, Tunisia
2Hopital Charles Nicole, Tunis, Tunisia
from 26th International Symposium on Intensive Care and Emergency Medicine
Brussels, Belgium. 21–24 March 2006

Critical Care 2006, 10(Suppl 1):P69doi:10.1186/cc4416
The electronic version of this abstract is the complete one and can be found online at: http://ccforum.com/supplements/10/S1
Published: 21 March 2006 
Introduction
Self-poisoning is a common cause of nontraumatic coma, especially in young people. The management of these patients aims to protect the airway in order to prevent aspiration pneumonia (AP). Some author recommend to intubate when GCS < 8. However, only few studies have examined the relation between GCS, the caught reflex and the frequency of AP in self-poisoning patients (SPP). The aim of our study is to evaluate the relation between GCS and the risk of developing this complication.
Materials and methods
We conducted a retrospective study during 2004 including all admitted SPP in our ICU. GCS was noted on admission or immediately before intubation. The diagnosis of AP was performed according to the usual criteria. Two groups were compared: G1 (without AP) and G2 (with AP). Data were expressed as a mean ± SD and percentage. Tests used for comparisons were the Q square and Student t tests. The ROC curve was used to determinate the cutoff value of GCS associated to high risk of AP.
Results
Five hundred and twenty-four SPP were included. Seventy-eight (14.9%) had developed AP. The characteristic of the two groups are presented in Table 1. GCS was significantly lower in G2. The cutoff value on the ROC curve was 12 with a sensitivity of 86%, a specificity of 70% and an area under the curve of 0.816.
Table 1. 
Conclusion
Criteria used for intubation in SPP must be more rigorous. According to our study, patients with GCS < 12 should be considered for intubation.
 Ivan Hronek MD                                                                              
SFMC, Los Angeles, CA                                                
http://health.groups.yahoo.com/group/Anesthideas/                           Nobody cares if you can't dance well. Just get up and dance. Great dancers are not great because of their technique. They are great because of their passion. Martha Graham
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----- Original Message ----
From: Farhad N Kapadia <fnkapadia at gmail.com>
To: John Holmes <docjohnholmes at hotmail.com>
Cc: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>; ccm-l at ccm-l.org; anesthideas at yahoogroups.com
Sent: Friday, May 16, 2008 1:27:05 AM
Subject: Re: [ccm-l] RE: Intubation post GM seizure: when ?

If you are promoting an invasive interventional therapy, then the onus is on you to first demonstrate that (1) there is actually a real (rather than "theoretical") problem and (2) that performing the intervention leads to better outcomes.  

Agree

IMO we should get rid of this teaching that all GCS < 8 = ETT once and for all.  It is probably valid in trauma. 

Not even sure about that.

However, in many medical and toxicological situations, especially when there is an expectation of reasonably rapid recovery in conscious level, then intubation may do more harm than good.

Agree.

f

-- 
Dr. Farhad Kapadia MD FRCP
Consultant Physician & Intensivist
Mumbai, India

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Intubation post GM seizure: when ?