S A K M Saleem



Altered level consciousness is a common presentation in emergency setting. Misconception of equating a low Glascow Coma Scale (GCS) with indication of intubation is not uncommonly seen. The act of juvenile decision to intubate prior to detailed assessment, has lead to unnecessary intubation and raise intubationassociated complications.


33 year-old female presented to emergency department with sudden onset of quadriplegia and aphasia, shortly after having quarrel with her husband. On arrival to Emergency department, noted patient GCS was E4V1M1. Patient was normoglycemic with normal cardiac rhythm on immediate assessment. She was able to respond to some questions by blinking her eyes. No prior history of fever, substance abuse, alcohol intake, recent medications or any previous illness. On examination, pupils were reactive, spontaneous breathing effort, absent gag reflex, power all 4 limbs 0/5 however tone and reflex normal. Further blood investigations, urine toxicology, CT brain were unremarkable. Intubation was not performed, as patient was able to maintain airway spontaneously with no respiratory distress and no features of traumatic brain injury. Case referred to medical team, who subsequently treated the patient as meningoencephalitis and started on empirical antibiotic. Miraculously, on 3rd day of admission, patient suddenly recovered completely and was treated as pseudocoma.


The concept of GCS in deciding need of intubation is revisited. It should be emphasized that interpretation of GCS score of patients should be individualized case-by-case basis. In the end, good history taking with thorough clinical examinations will gives limitless amount of benefits in deciding treatment plans.


As a primary responder, we have to shift our thinking process in managing patients with altered level of consciousness. The role of GCS should be kept as a first line guide rather than sole indication of intubation.


Supplementary Issue