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GCS: Indication for intubation

The Glasgow Coma Scale (GCS) is a neurological scoring system introduced in 1974 that was designed to be used to assess and document neurologic function after head injury [1].

Hypoxia, hypercapnia, and aspiration can all worsen neurologic outcome after an insult. Existing guidelines suggest that a Glasgow Coma Scale score (GCS) ≤ 8 indicates a need for urgent endotracheal intubation [2]. However, the need for intubation and airway protection should be based on observed hypoventilation, the loss of protective airway reflexes, and the anticipated risk of aspiration. While reduced GCS scores may be correlated with failures of airway maintenance or failures of ventilation/oxygenation, many patients with a GCS ≤ 8 have intact airway reflexes and may be capable of maintaining their own airway. At the same time, patients with a GCS > 8 can have impaired airway reflexes and therefore may be at risk. Unfortunately, these features cannot be reliably predicted using the GCS alone [3-5].


  1. Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2 (7872):81-84 PubMed Link
  2. Badjatia et al Guidelines for prehospital management of traumatic brain injury 2nd edition. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors 12 Suppl 1:S1-52. doi:10.1080/10903120701732052 PubMed Link
  3. Vad J, Rosenstock C (2006) Glasgow Coma Score < 9, a criterion for tracheal intubation of a patient with a traumatic brain damage?: A-362. European Journal of Anaesthesiology (EJA) 23:95-96 PubMed Link
  4. Duncan R, Thakore S (2009) Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. The Journal of emergency medicine 37 (4):451-455. doi:10.1016/j.jemermed.2008.11.026 PubMed Link
  5. Rotheray KR, Cheung PS, Cheung CS, Wai AK, Chan DY, Rainer TH, Graham CA (2012) What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population? Resuscitation 83 (1):86-89. doi:10.1016/j.resuscitation.2011.07.017 PubMed Link