POTD: Putting a pause on "GCS less than 8 - intubate"

Hello all and welcome to my final Trauma Tuesday POTD!

Today we'll be discussing something that many of us were taught in medical school about trauma - "GCS less than 8 - intubate". This phrase has also been said about patients who are altered for other reasons - infection, tox, etc.

The thought process behind this is that patients who have a low GCS are at risk for aspiration, and we should secure the airway to prevent this. In trauma, it's thought that patients with low GCS have severe enough brain injury that they are at risk for depressed respirations, and intubation is done to prevent this. 

Is GCS < 8 associated with decreased airway reflexes?

A study showed that 22% of patients with GCS of 15 had absent gag reflexes, 37% in GCS of 9-14, and 63% in patients with GCS < 8. So, it does appear that lower GCS has a higher percentage of absent gag reflexes, but 22% of patients with a GCS of 15 is a pretty high number to be solely using GCS as our measure. 

Is it associated with more aspiration events?

A prospective study of 73 ED patients showed that none of the patients with a GCS <8 aspirated or required intubation. Actually, the only patient who required intubation in that study had a GCS of 12. 

However, there have not been any RCTs studying this. A systematic review on this topic showed that there isn't enough evidence to draw a conclusion. 

Decreased GCS can be due to a temporary cause, such as alcohol intoxication, as we often see. How often are we intubating someone for alcohol intox? Not frequently. So, it's important that we consider the full clinical picture before jumping to intubation. 

In conclusion - when we need a quick and dirty guide, GCS < 8 is generally the cutoff that's used for us to consider intubation. However, it's important to consider the whole clinical picture and make sure the patient is not getting intubated unnecessarily and suffering the potential side effects of intubation. Also, conversely, GCS > 8 doesn't always mean that the patient is protecting their airway!

References:

Duncan R, Thakore S. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med. 2009;37(4):451-455. doi:10.1016/j.jemermed.2008.11.026

Orso D, Vetrugno L, Federici N, D'Andrea N, Bove T. Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review. Scand J Trauma Resusc Emerg Med. 2020;28(1):116. Published 2020 Dec 10. doi:10.1186/s13049-020-00814-w

Ribeiro SCDC. Decreased Glasgow Coma Scale score in medical patients as an indicator for intubation in the Emergency Department: Why are we doing it?. Clinics (Sao Paulo). 2021;76:e2282. Published 2021 Mar 8. doi:10.6061/clinics/2021/e2282

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

POTD: De-escalating the agitated patient

Today's POTD will be on de-escalating the agitated patient in the emergency department. We frequently encounter patients who are agitated for a variety of reasons, so let's talk about how we can provide the best possible outcomes for the staff and for the patient in these situations. 

When approaching an agitated patient, approach with 4 main objectives:

1) Ensure safety of patient, staff, and others in the area

2) Help the patient manage their emotions and distress and maintain or regain control of their behavior

3) Avoid use of restraints if possible

4) Avoid coercive interventions that escalate agitation

Really, the biggest thing is maintaining patient and staff safety. Make a quick assessment as to whether this patient is mildly, moderately, or severely agitated. 

If your patient is mildly or moderately agitated, verbal de-escalation should typically be your first go-to. Physical and chemical restraints have both been found to increase length of stay and are associated with higher likelihood of psychiatric admission, so if verbal de-escalation is a safe option in your patient encounter, it should be attempted first. 

Guidelines for verbal de-escalation

Richmond et al. (2012) published ten domains for de-escalation that I find to be helpful. They are summarized in this table:

1: Respect personal space

Maintain at least 2 arms' length of distance between you and the patient. Also, make sure you know where the exits are, and make sure the patient is not positioned between you and the closest exit. 

2: Do not be provocative

Pay attention to your body language. Be calm and avoid clenching your fists or concealing your hands. 

3: Establish verbal contact
Have one main point of contact for the patient to avoid confusion and further agitation.

4: Be concise

Try to keep the information you're conveying simple, as agitated patients may not be able to process complex information quickly.

5: Identify wants and feelings

Use open-ended statements to understand what it is that the patient wishes to get out of the encounter.

6: Listen closely to what the patient is saying

Use active listening to understand what the patient is saying.

7: Agree or agree to disagree

Find something about the patient's position to agree with - even if you don't agree with their whole statement. 

8: Lay down the law and set clear limits

The patient should know about acceptable and unacceptable behaviors, and boundaries should be clearly set.

9: Offer choices and optimism

The ability to choose can empower a patient.

10: Debrief the patient and staff

Have a discussion amongst the staff about what the plan is if the patient continues to be agitated or escalates their behavior. Also, discuss with the patient and family why certain measures were necessary. 

If verbal de-escalation doesn't work or is not safe to attempt:

Physical or chemical restraints can be used. Physical restraints should never be used on their own without chemical sedation. 

I won't go into all the nitty gritty about physical/chemical restraints in this POTD, but generally, if you're having to sedate the patient or physically restrain them, make sure the patient is somewhere visible to a staff member at all times and their ABCs are being monitored. 

Finally, know your resources!

Luckily for us, we have an on-site ED psychiatry team, mental health workers, and security who are all trained in how to manage an agitated patient, so if you ever find yourself in a potentially unsafe situation, know your resources and don't go into it alone. 

References:

Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25. doi:10.5811/westjem.2011.9.6864

https://www.crisisprevention.com/blog/general/de-escalation-tips/

https://www.crisisprevention.com/en-GB/blog/general/cpi-top-10-de-escalation-tips/

https://litfl.com/de-escalation/

https://emergencymedicinecases.com/emergency-management-agitated-patient/

POTD: Green spaces and violence

Happy Friday!

As previously mentioned, public health is a passion of mine, and this is one of my favorite public health topics to talk about. Today, we're talking about green spaces and their impact on violent crime. 

Green spaces (parks, community gardens, tree-covered sidewalks) have been shown to have a multitude of healthy benefits, such as reduced stress and anxiety, improving access to physical activity, social connection, and environmental benefits. However, a lesser-known benefit of green spaces is its association with reduced violence. 

Multiple studies as cited below have shown that neighborhoods with higher green space coverage are associated with lower rate of homicide, assault, and robbery. Several theories have been proposed to explain this association. Some are listed above (benefits of neighborhood green spaces), others include improved perceived quality of life, increased perceived order, and improvement in enfranchisement of residents in the community. Shepley et al. made a nice diagram with the theorized variables here:

However, as with many public health topics, this cannot be tested via a randomized controlled trial and only observational studies have been done, thus we only have data for correlation and not causation. Additionally, many studies do not account for confounding factors that may also affect rates of violent crime. The couple of studies I did find that accounted for confounding factors (Sanciangco et al, 2021 and Ogletree et al, 2022) still found that green spaces were correlated with reduced rates of violent crime. 

So, the data is not perfect, but there are a decent amount of observational studies on this topic. Anyways, I hope some of you guys found this interesting!

References

Sanciangco, J. C., Breetzke, G. D., Lin, Z., Wang, Y., Clevenger, K. A., and Pearson, A. L. (2021). The Relationship Between City “Greenness” and Homicide in the US: Evidence Over a 30-Year Period. Environment and Behavior. Advanced online publication. https://doi.org/10.1177/00139165211045095

Shepley M, Sachs N, Sadatsafavi H, Fournier C, Peditto K. The Impact of Green Space on Violent Crime in Urban Environments: An Evidence Synthesis. Int J Environ Res Public Health. 2019;16(24):5119. Published 2019 Dec 14. doi:10.3390/ijerph16245119

Venter ZS, Shackleton C, Faull A, Lancaster L, Breetzke G, Edelstein I. Is green space associated with reduced crime? A national-scale study from the Global South. Sci Total Environ. 2022;825:154005. doi:10.1016/j.scitotenv.2022.154005

Kim YJ, Kim EJ. Neighborhood Greenery as a Predictor of Outdoor Crimes between Low and High-Income Neighborhoods. Int J Environ Res Public Health. 2020;17(5):1470. Published 2020 Feb 25. doi:10.3390/ijerph17051470

University of Virginia Health System. "How green space can reduce violent crime." ScienceDaily. ScienceDaily, 27 February 2020. <www.sciencedaily.com/releases/2020/02/200227144253.htm>.