Objective To explore evidence relating to the airway management (ranging from observation to intubation) of patients presenting to the emergency department with drug overdose and decreased consciousness.

Introduction Recreational and prescription drug overdoses are a common reason for patients to present to the emergency department. Patients often have a reduced level of consciousness due to the effects of the drugs involved. There are no evidence-based guidelines identifying which patients can be safely observed, compared with those requiring advanced airway management such as intubation.

Inclusion Criteria Adult patients presenting to the emergency department with drug overdose (recreational drugs, e.g., gamma-hydroxybutyrate and alcohol, and prescription drugs, e.g., benzodiazepines and opioids). Management strategies from intubation (e.g., rapid sequence intubation, emergency airway management) to observation/no intubation (e.g., high flow nasal oxygen, observation, monitoring, recovery position) were included. Studies are needed to describe an approach to airway management in overdose patients with decreased consciousness, which included all primary research. Outcomes included predictors of intubation, mortality, hospital admission, length of stay and complications.

Methods With the assistance of a Systematic Review Accelerator, we searched PubMed, Cochrane CENTRAL and Embase. Databases were searched from inception to 2nd April 2024, with no publication language restrictions. We additionally conducted a backward and forward citation search.

Results Forty-five studies were included (one randomised controlled trial, 14 prospective observational studies, 25 retrospective observational studies and five with other methodology). Four major narrative themes were identified: (1) risk stratifying the decision to intubate; (2) noninvasive monitoring of the patient with overdose; (3) scoring systems predicting the need to intubate; (4) targeted gamma-hydroxybutyrate-specific literature.

Conclusions Literature on the airway management of emergency department patients with overdose and decreased level of consciousness provides mostly low-quality evidence, with only one RCT. Further higher-level research and evidence are required.