Non-invasive Airway Management of Comatose Poisoned Emergency Patients

  • STATUS
    Recruiting
  • days left to enroll
    68
  • participants needed
    220
  • sponsor
    Assistance Publique - Hôpitaux de Paris
Updated on 30 May 2021

Summary

A decreased level of consciousness is a common reason for presentation to the emergency department (ED) and is often the result of intoxication (up to 1% of all ED visits and 3% of ICU admission). In France, approximately 165 000 poisoned patients are managed each year. Originally developed in head injured patients, the Glasgow Coma Scale (GCS) is a validated reproducible score evaluating the level of consciousness: a GCS 8 is strongly associated with reduced gag reflex and increased incidence of aspiration pneumonia. Although recommended for patients with traumatic brain injury and coma, it remains unknown whether the benefit of an invasive management of airways with sedation, intubation and mechanical ventilation should be applied to other causes of coma in particular for acute poisoned patients. The investigator hypothesize that a conservative management with close monitoring without immediate endotracheal intubation of these patients is effective and associated with less in-hospital complications (truncated at 28 days) compared to routine practice management (in which the decision of immediate intubation is left to the discretion of the emergency physician).

Description

A decreased level of consciousness is a common reason for presentation to the emergency department (ED) and is often the result of intoxication (up to 1% of all ED visits and 3% of intensive care unit (ICU) admission). In France, approximately 165 000 poisoned patients are managed each year.1 Originally developed in head injured patients, the Glasgow Coma Scale (GCS) is a validated reproducible score evaluating the level of consciousness - a GCS 8 is associated with reduced gag reflex and increased incidence of aspiration pneumonia (with an adjusted odds ratio of 2.32, 95%CI =1.60 to 3.33). However, whether this risk of aspiration pneumonia (AP) may be decreased by early intubation is unknown, and no difference in the risk of AP was reported between patients that were intubated early and patients who were not.

Although it is well established that in trauma patients, a GCS 8 mandates airway management by endotracheal intubation, it remains unknown whether this strategy should be applied to other etiologies of coma, in particular for acute poisoned patients. Tracheal intubation and mechanical ventilation allow to prevent aspiration pneumonia, to optimize oxygenation and gas exchange.

Investigators will include patients with a decreased level of consciousness (defined by a GCS of 8 or less) caused by acute intoxication (alcohol, recreative drugs, or other prescription drugs (with the exception intoxication with cardiotropic drugs, e.g. beta blockers, calcium channel inhibitor, angiotensin conversion enzyme)). These patients will be included at the initial stage of their management: in the ED, or out of hospital with a pre-hospital emergency physician. Patients with clear proven benefit of intubation will be excluded : patients in shock, patients with suspicion of brain lesion, seizure related with poisoning, visualization of regurgitation of gastric content or sign of respiratory distress. Conservative airway management. Patients will be conservatively managed, i.e. close monitoring and no intubation and mechanical ventilation unless the patient presents a clinical event that needs intubation (shock, sign of respiratory distress, visualization of regurgitation or seizure).

Acute poisoning is a common reason for presentation to the ED or MICU intervention (up to 1% of all ED visits and 3% of intensive care unit (ICU) admission). These patients are often intubated (reported rate ranging from 20 to 50% in different cohort studies), when their GCS is below 8, in order to protect their airways. However there is currently no clear demonstration of its efficacy in this specific target population, while it is known that intubation is associated with morbidity and mortality.

Intubated patients need subsequent intensive care unit admission and invasive monitoring, and this can be associated with increased risk of pulmonary complications, length of hospital-stay, nosocomial infections and cost. In a context of expenditures control in health care, appropriate intensive care resource utilization is an important issue. When considering the increasing demand for intensive care among emergency patients, the importance of health care resource allocation and expenditure control, and the possible absence benefit of intubation and intensive care, an endotracheal airway management of poisoned coma patients might be detrimental.

Thus, if our hypothesis is demonstrated, the results of NICO study will change practice and guidelines for management of acute coma poisoned patients, with less exposure to the morbidity of endotracheal intubation and associated with decrease of ICU stay, and reduction of their health costs.

Details
Condition Coma, Depressed Level of Consciousness, Poisoning, Poisoning aspects, comatose
Treatment Endotracheal intubation, Close monitoring
Clinical Study IdentifierNCT04653597
SponsorAssistance Publique - Hôpitaux de Paris
Last Modified on30 May 2021

Eligibility

Yes No Not Sure

Inclusion Criteria

Age 18 years
Clinical suspicion of acute poisoning (either alcohol, drug or medication)
Decreased level of consciousness with a GCS 8 assessed by an emergency physician either in the ED or in the out of hospital field with the mobile intensive care unit (MICU)
Written informed consent signed by the patient / the trustworthy person / family member / close relative or inclusion in case of emergency
Patients affiliated to French social security ("AME" excepted)

Exclusion Criteria

Respiratory failure (SpO2 < 90% with oxygen provided by nasal cannula ( 4 l/min.), clinical signs of respiratory distress)
Sustained systolic blood pressure < 90 mmHg despite fluid resuscitation of 1 liter of critalloid
Witnessed seizure
Acute cerebral aggression (Traumatic brain injury, intracranial hematoma, stroke)
Suspected Cardiotropic drugs poisoning (beta blockers, calcium channel inhibitor, angiotensin conversion enzyme), QRS or QT enlargement on ECG
Suspected sole intoxication with toxic for which there is an antidote
Patient under legal protection measure (tutorship or curatorship) and patient deprived of freedom
Known Pregnant women and breast feeding woman
Participation in another intervention trial
Clear my responses

How to participate?

Step 1 Connect with a site
What happens next?
  • You can expect the study team to contact you via email or phone in the next few days.
  • Sign up as volunteer to help accelerate the development of new treatments and to get notified about similar trials.

You are contacting

Investigator Avatar
Name

Primary Contact

site
Name

0/250
Preferred Language
Other Language
Please verify that you are not a bot.

Additional screening procedures may be conducted by the study team before you can be confirmed eligible to participate.

Learn more

If you are confirmed eligible after full screening, you will be required to understand and sign the informed consent if you decide to enroll in the study. Once enrolled you may be asked to make scheduled visits over a period of time.

Learn more

Complete your scheduled study participation activities and then you are done. You may receive summary of study results if provided by the sponsor.

Learn more

Similar trials to consider

Loading...

Not finding what you're looking for?

Every year hundreds of thousands of volunteers step forward to participate in research. Sign up as a volunteer and receive email notifications when clinical trials are posted in the medical category of interest to you.

Sign up as volunteer

user name

Added by • 

 • 

Private

Reply by • Private
Loading...

Lorem ipsum dolor sit amet consectetur, adipisicing elit. Ipsa vel nobis alias. Quae eveniet velit voluptate quo doloribus maxime et dicta in sequi, corporis quod. Ea, dolor eius? Dolore, vel!

  The passcode will expire in None.
Loading...

No annotations made yet

Add a private note
  • abc Select a piece of text from the left.
  • Add notes visible only to you.
  • Send it to people through a passcode protected link.
Add a private note