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Airway patency vs. protection

“GCS <8; intubate” may be endangered, but not totally deserving of extinction


Photo/Pöllö via Wikimedia Commons, CC BY 3.0

This episode of the MCHD Paramedic Podcast was inspired directly by a paramedic question: “In my prior service, we intubated much more often for airway protection, can you explain how you approach this in your practice?”

Whoa buddy, is that a difficult question with numerous caveats or what? Join the podcast crew as they attempt to better define airway patency versus airway protection. We even wade into why “GCS <8; intubate” may be endangered, but not totally deserving of extinction.

Listen to learn more about:

  • Checking for a gag reflex: all risk and minimal reward?
  • Patency over protection when it comes to urgency
  • The 6 S’s to identify patency
  • Resuscitate before we intubate
  • Trauma considerations
  • Watch the DELTA
  • DSI is law of our land and intubation with paralysis is risky

Listen to next: Serial killers: Shortness of breath


  1. Duncan R et al. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med. 2009. PMID: 19272743
  2. Lapostolle F, Alhéritière A. To intubate or not intubate, that is still the question! Eur J Emerg Med. 2020 Oct;27(5):387-388. 
  3. Moulton C et al. Relation between Glasgow coma scale and the gag reflex. BMJ. 1991.
  4. Rotheray KR et al. What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population? Resuscitation, 2012.
  5. Spaite DW, Bobrow BJ, Keim SM, et al. Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study. JAMA Surg. 2019;154(7).
  6. Hedayati T, Aceves G. MGCS Less Than 8? Then Intubate! Emergency physicians monthly.
  7. Woods R. Basic Airway Assessment: It’s as easy as… 1-2-3? CanadiEM

The MCHD Paramedic Podcast was launched in early 2018 in an effort to provide easily consumable core-content EMS education and insights from prehospital care thought leaders. The Clinical Services Department of The Montgomery County Hospital District EMS service developed the podcast as a tool to better engage and disseminate continuing education to our MCHD medics as well as first responders and EMS professionals nationwide.

Dr. Casey Patrick is the assistant medical director for Montgomery County Hospital District EMS and is a practicing emergency physician in multiple community emergency departments across Greater Houston. His EMS educational focus is on innovative paramedic teaching via the MCHD Paramedic Podcast. Dr. Patrick’s prehospital clinical research involves the investigation of paramedic use of bolus dose intravenous nitroglycerin for acute pulmonary edema and the implementation of lung protective ventilation strategies for intubated EMS patients. Casey and his wife, Alyssa, work and live in Conroe, Texas, and Spokane, Washington. Together they have five children: Mia, Ainsley, Brock, Dean and Will.

Dr. Dickson graduated with honors from the University of Texas Health Science Center San Antonio in 2001 and completed emergency medicine training at Indiana University in 2004. He serves as the EMS medical director at Montgomery County Hospital District EMS and an assistant professor of emergency medicine at Baylor College of Medicine in Houston, Texas. His academic interests include systems of care in stroke and other time-sensitive emergencies, neurologic emergencies and education. He is board certified in emergency medicine in both the U.S. and Australasia, and has subspecialty board certification in EMS medicine. He has authored multiple professional articles and presented at regional, national and international conferences on emergency medicine and EMS topics.