In a patient with a Glasgow Coma Scale (GCS) score of 8 and active bleeding, should bleeding be controlled first or airway intubation according to Advanced Trauma Life Support (ATLS)?

Airway Management in Trauma Patients with GCS 8 and Active Bleeding

In a trauma patient with GCS 8 and active bleeding, controlling the airway through immediate intubation should be prioritized first, followed by hemorrhage control, according to Advanced Trauma Life Support (ATLS) principles. 1

Rationale for Airway First Approach

The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma (2023) clearly recommends:

• Endotracheal intubation or alternative airway management should be performed without delay in patients with:
  • Altered consciousness (GCS ≤ 8)
  • Airway obstruction
  • Hypoventilation
  • Hypoxemia 1

This recommendation carries a Grade 1B evidence level, indicating strong support for immediate airway management in patients with GCS ≤ 8.

ABCDE Approach in Trauma

The ABCDE approach to trauma management dictates a sequential priority:

1. Airway with cervical spine protection
2. Breathing and ventilation
3. Circulation with hemorrhage control

This sequence is fundamental to trauma management because:

• Without a secure airway, the patient may die within minutes from hypoxia
• Even with active bleeding, addressing the airway first ensures oxygen delivery to tissues
• Proper oxygenation actually supports hemodynamic stability and tissue perfusion

Clinical Considerations

For patients with GCS 8:

• Risk of airway compromise is significant due to:
  • Inability to protect their airway
  • Risk of aspiration
  • Potential for further neurological deterioration 1
• Delaying intubation can lead to:
  • Aspiration
  • Hypoxemia
  • Secondary brain injury 2

Hemorrhage Control

After securing the airway:

• Immediately proceed to hemorrhage control measures
• For exsanguinating hemorrhage, immediate surgical and/or interventional radiology intervention is required 1
• During interventions for life-threatening hemorrhage, maintain:
  • Systolic blood pressure > 100 mmHg or
  • Mean arterial pressure > 80 mmHg 1

Potential Pitfalls and Caveats

1. Hypotension during intubation:

   • Fluid administration is usually required concurrently with intubation
   • Introduction of positive intrathoracic pressure can induce severe hypotension in hypovolemic patients 1

2. Intubation technique:

   • Use rapid sequence induction
   • Have vasopressors ready to treat post-intubation hypotension
   • Avoid hyperventilation except in cases of cerebral herniation 1

3. Post-intubation management:

   • Target PaCO2 of 5.0-5.5 kPa (35-40 mmHg)
   • Avoid hypoxemia and extreme hyperoxia 1

Algorithm for Management

1. Assess GCS and bleeding severity
2. For GCS ≤ 8 with active bleeding:
   • Proceed immediately with endotracheal intubation
   • Use rapid sequence induction with manual in-line stabilization
   • Have vasopressors ready for post-intubation hypotension
3. After securing airway:
   • Immediately address hemorrhage control
   • For exsanguinating hemorrhage, proceed to surgical intervention
   • For non-exsanguinating hemorrhage, apply appropriate hemostatic measures
4. Maintain target parameters:
   • SBP > 100 mmHg or MAP > 80 mmHg
   • Normocapnia (PaCO2 4.5-5.0 kPa)
   • Adequate oxygenation while avoiding hyperoxia

By following this approach, you address the most immediate life-threatening condition (airway compromise) first while preparing to rapidly address the second priority (hemorrhage control).