What is the management for a patient with a Glasgow Coma Scale (GCS) score of 6?

Management of a Patient with GCS 6

A patient with a GCS of 6 requires immediate endotracheal intubation using rapid sequence induction to secure the airway and prevent aspiration, as this represents severe impairment of consciousness with inability to protect the airway. 1

Immediate Airway Management

Endotracheal intubation should be performed without delay in patients with GCS ≤8, as this is the standard of care across multiple trauma and critical care guidelines. 1 The American College of Critical Care recommends this approach for severe impairment of consciousness. 1

Intubation Technique and Hemodynamic Goals

• Rapid sequence induction is the preferred method for securing the airway, with appropriate hemodynamic management to avoid hypotension. 1
• Maintain systolic blood pressure >110 mmHg and mean arterial pressure >90 mmHg during the peri-intubation period to ensure adequate cerebral perfusion. 1
• Confirm correct tracheal tube placement using standard clinical assessment and waveform capnography, repeating confirmation each time the patient is moved. 1
• Secure the tracheal tube with self-adhesive tape rather than circumferential ties in head-injured patients to avoid impairing venous drainage. 1

Post-Intubation Ventilation Management

• Maintain normocapnia (PaCO₂ 4.5-5.0 kPa) and avoid hyperventilation except as a brief life-saving measure for impending uncal herniation. 1
• Achieve adequate oxygenation (PaO₂ ≥13 kPa) but avoid prolonged hyperoxia, which may worsen outcomes. 1
• Initiate lung-protective ventilation strategies immediately. 1

Neurological Monitoring and Assessment

Intracranial Pressure Monitoring

Patients with GCS ≤8 should be considered for ICP monitoring and treatment, particularly those with clinical evidence of transtentorial herniation or significant intraventricular hemorrhage. 2

• A cerebral perfusion pressure of 50-70 mmHg may be reasonable to maintain depending on the status of cerebral autoregulation. 2
• ICP monitoring devices can be inserted at the bedside using either ventricular catheters (which allow CSF drainage) or parenchymal catheters. 2
• Prior to insertion, evaluate coagulation status and correct any coagulopathy. 2

Serial Neurological Assessment

• Perform frequent neurological assessments using GCS to monitor for improvement or deterioration. 3
• Document individual component scores (Eye, Motor, Verbal) at each assessment rather than just the sum score, as the motor component has the highest predictive value. 4
• Assess pupillary size and reactivity as part of ongoing neurological monitoring. 3
• Consider continuous EEG monitoring to detect subclinical seizures if there is no improvement in mental status. 3

Critical Care Management

Sedation and Medication Management

• Maintain sedation with small, frequent doses of hypnotic drugs (midazolam or propofol) to prevent accidental awareness. 1
• Avoid medications that may further depress the central nervous system. 3
• If seizures develop, avoid phenytoin/fosphenytoin as these medications are associated with excess morbidity in patients with CNS depression. 3
• If hepatic encephalopathy is suspected, avoid benzodiazepines for sedation as they worsen encephalopathy scores. 1

Supportive Care Measures

• Monitor urine output (goal >1 ml/kg/hour) as an indicator of adequate renal perfusion. 3
• Provide DVT prophylaxis due to immobility. 3
• For patients with persistent shock despite 40 ml/kg of fluid, consider central venous catheter placement to guide further fluid management. 3
• Obtain baseline laboratory studies including complete blood count, comprehensive metabolic panel, and drug levels to monitor for potential complications. 3

Diagnostic Evaluation

Neuroimaging

• Do not delay intubation waiting for a CT scan—secure the airway first, then image. 1
• Obtain head CT to assess for intracranial pathology, as 23% of patients with GCS 10-13 have intracranial pathology on CT scan. 5
• A decrease of at least two points in the GCS score or occurrence of secondary neurological deficit should prompt immediate repeat CT scanning. 4

Physical Examination Components

• Perform a thorough but time-urgent neurologic exam using a structured assessment such as the National Institutes of Health Stroke Scale (NIHSS), which can be completed in minutes. 2
• Assess vital signs, as fever is associated with early neurologic deterioration and higher initial blood pressure is associated with early neurologic deterioration and increased mortality. 2
• Recognize confounding factors that may affect GCS assessment, including sedation, intubation, facial trauma, intoxication, deafness, and language difficulties. 4, 5

Important Caveats and Pitfalls

Avoid Routine Intubation Without Clinical Context

While GCS ≤8 is the traditional threshold for intubation, recent evidence suggests that routine intubation based solely on GCS may be harmful in certain populations. In isolated blunt head injury patients with GCS 7-8, immediate intubation was independently associated with higher mortality (OR 1.79) and more overall complications (OR 2.46). 6 Similarly, in a large database study of patients with GCS 6-8, intubation was associated with increased mortality (OR 1.05) and longer ICU length of stay. 7

However, these studies examined isolated head injury or mixed populations, and the guideline recommendation for GCS ≤8 remains the standard of care for immediate airway protection. 1 The decision should prioritize airway protection and prevention of aspiration, particularly when:

• The patient has active bleeding or hemorrhagic shock requiring resuscitation 1
• There is evidence of transtentorial herniation 2
• The patient cannot protect their airway 1
• Serial assessments show declining GCS scores 4

Special Considerations for Non-Traumatic Causes

In poisoned patients with decreased consciousness from drug or alcohol intoxication, observation in an ED short-stay ward may be safe even with GCS ≤8, as one study showed no aspiration or required intubation in 12 such patients. 8 However, this approach requires experienced emergency physicians and close monitoring, and should not be generalized to all causes of decreased consciousness. 8

Monitoring Frequency

Serial GCS assessments provide substantially more valuable clinical information than single determinations, with declining scores indicating poorer prognosis. 4 For patients with GCS 6, consider GCS monitoring every 15 minutes during the first 2 hours, then hourly for the following 12 hours. 4