Objectives The objective was to examine the effect of endotracheal intubation on emergency department (ED) length of stay (LOS) and admission rates for patients with gamma-hydroxybutyrate (GHB) overdose. Methods A 3-year retrospective electronic and paper audit of recreational drug presentations was carried out at two major inner-city EDs in Melbourne, Australia. Different GHB overdose management strategies exist at the respective audit sites, namely: 1) all patients with a Glasgow Coma Scale (GCS) score of 8 or less are intubated or 2) uncomplicated patients with GCS scores of 8 or less are managed without intubation (conservative management), unless further complications arise. This difference allows for comparison of the effects of intubation. All suspected GHB-related cases (defined as cases where GHB or its analogs gamma-butyrolactone or 1,4-butanediol were recorded) in which altered consciousness state was noted as a presenting symptom at triage were selected from all recreational drug-related presentations occurring between January 2008 and December 2010. The relationship between intubation and the primary outcome, ED LOS, was examined using robust regression after adjustment for potential confounders. The relationship between intubation and admission status (admission to hospital versus discharge) was also examined using logistic regression. Results After adjustment for potential confounders such as GCS score, intubation of GHB-related cases in the ED was associated with an increase in mean LOS of 41 (95 confidence interval [CI] = 19 to 65 ) and an increase in the odds of admission to hospital of 9.95 (95 CI = 2.36 to 41.88) at one hospital site, compared to conservative airway management. Conclusions Conservative airway management (no intubation) is associated with shorter ED LOS in cases of uncomplicated GHB-related coma in the ED and may also be associated with lower admission rates for these patients.