# Gag Reflex testing



## surgicalcric (Jul 30, 2014)

A piece of anecdotal medical advice was passed on recently that bears sharing in order to set the record straight.

As the story goes, a novice medical provider was told to lightly brush the patient's eye lash and if there was no reflex (blink) the patient's gag reflex would not be intact.  Anyone else heard this?  If so it is wrong.

The Facial Nerve (CN V) mediates the corneal (eyelash) reflex and the gag reflex is mediated by the Glossopharyngeal and Vagus (CNs IX and X) nerves respectively.  These nerves do not share any common pathways and the presence of one does not imply anything about the other.  Anesthesia providers often will utilize the method previously outlined to gauge alteration in gross sensory function from a known baseline.  And since there is a correlation (although not perfect) between unconsciousness and loss of the gag reflex, there is some value in the lash test but using it in the field while suggestive, isn't the same.

The history of the lash test is that in the OR after administration of an induction agent, an anesthesia provider would lightly brush the eyelashes to check for a blink. The reasoning behind this practice is not so much to check for a gag but to check for unconsciousness prior to the administration of a neuromuscular blocking agent.  With no blink present, an anesthesia provider could be reasonably certain they were not paralyzing a patient who is "awake".

Hope this clears that up for anyone who had been using this method in the past.


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## medicchick (Jul 30, 2014)

I had never heard of the lash test to check for a gag reflex, we just stopped if they gagged because the pt was generally conscious enough to maintain their own airway or they got a nose tube.

I did however do the lash test plenty during my OR rotations, best way to tell if someone is faking to avoid jail too (along with a nice sternal rub).


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## TLDR20 (Jul 30, 2014)

I wonder if the young provider saw someone do the lash test and formed his own opinion as to why it was done.


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## surgicalcric (Jul 30, 2014)

The young provider asked about NPAs and was given that BS advice by a former support guy turned paramedic who while giving the advice told the young provider to not be like volunteer firefighters who are only 1/2 trained.  I took quite a bit of pleasure in setting him straight in a public venue about passing off anecdotal info as gospel.


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## policemedic (Jul 30, 2014)

surgicalcric said:


> The young provider asked about NPAs and was given that BS advice by a former support guy turned paramedic who while giving the advice told the young provider to not be like volunteer firefighters who are only 1/2 trained.  I took quite a bit of pleasure in setting him straight in a public venue about passing off anecdotal info as gospel.



Half trained?  That was worth at least a public verbal gonad smash. 

FWIW, we see many providers coming out of their program with a knowledge base that is a mile wide but only an inch deep.   They're pretty good on the how, but not so much on the why.  I've always found the biggest knowledge deficits to be in areas like anatomy and physiology.   In-depth knowledge of physical exam techniques was a close second.  When I was precepting young medics, I would always ask them to list the cranial nerves, show me the exam to check them and what each did.   That usually resulted in an interesting conversation.


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## surgicalcric (Jul 30, 2014)

A neuro exam isnt a neuro exam without running through the cranial nerves.


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## Red Flag 1 (Jul 30, 2014)

surgicalcric said:


> The young provider asked about NPAs and was given that BS advice by a former support guy turned paramedic who while giving the advice told the young provider to not be like volunteer firefighters who are only 1/2 trained.  I took quite a bit of pleasure in setting him straight in a public venue about passing off anecdotal info as gospel.


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## Muppet (Jul 31, 2014)

I have heard the lash thing but also have had much contact with very well known and educated M.D.'s and D.O.'s that know better. Just the other day, my medic unit were called for a fall victim, intoxicated, down a flight of stairs. On arrival, unresponsive, snoring and shallow resps. Flaccid, 185/105 for B/P, pulse / heart rate of 50. Pt. was in a confined foyer of a condo complex but we were able to transfer pt. to a longboard. B.L.S. ventilations were started by my partner (An experienced and smart paramedic also). I was working my part time medic gig that runs double medic units. I ask her if the pt. has a gag or trismus. That time, a BLS unit (no paramedics) showed up to assist. The one new EMT-Basic attempts the lash test and sternal rub and I in a short time attempt to educate him and he looks at me like I am on crack. W/O getting into a nerve class here, sternal rub needs to be preformed for at least 5 mins. and we all know lash test is not accurate. 

The pt. displays trismus and Cindy cannot insert an OPA. No blood in nares so a NPA was inserted with snoring relieved. The Basics then yell for intubation. We calm the youngin's down and talk them through 2 person B.V.M. assistance with suction at the ready. See, RSI is not available in P.A. ground EMS. Etomidate IS allowed but the SOP is poorly written (state wide SOP's) and do not allow for follow up sedation and frankly. 3mg/kg as instructed is a small dose. For this reason, that SOP is optional and many progressive places do not use that SOP for fear of misuse (which I have seen). Anyhow, secondary to shallow resps. and bradycardia (vital signs suspected due to herniation syndrome) and pt. did have a sub-dural that was surgically delt with, nasal intubation was deferred. 

OK. BLS ventilations were successful (I understand the reason for oxygenation and ventilation) and not just tubing people, forcing shit for giggles. Bottom line, I utilize "other" methods for judging gag reflex and I am sure @Red Flag 1 can attest to, gag reflex, backed by numerous studies are difficult to appreciate sometimes. I have seen paramedics attempt to intubate people thinking they have no gag only cause more harm to the pt. with gag including bradycardia, vomiting.....I do say, instead of checking gag and stuff, we should be ventilating, titrating B/P for max CPP and getting to shock trauma, not lashing people, using the old amonia inhalants (if people still use them, they should quit) and not doing what is right for the pt. Not the ego..

Pt. went to surgery for sub dural evacuation / we do not know how that turned out...

F.M.


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## policemedic (Jul 31, 2014)

Here's how you end the spewing of dangerous non-evidence based pseudoscientific vomit from the cockholsters of self-appointed medical gurus.  Simply ask them to define, in as much detail as they can, the anatomical, physiological and scientific basis  e.g. peer reviewed papers and studies for the test they're espousing.  And when they can't, or their answer is, "I learned it in EMT or paramedic school," just bitch slap them into next week.


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## policemedic (Jul 31, 2014)

Firemedic said:


> I.
> 
> The pt. displays trismus and Cindy cannot insert an OPA. No blood in nares so a NPA was inserted with snoring relieved. The Basics then yell for intubation.
> 
> F.M.


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## parallel (Aug 1, 2014)

Here I thought this was going to be about date night... :-"


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## surgicalcric (Aug 2, 2014)

Firemedic said:


> <<SNIP>>
> 
> F.M.



Seems guys always want to jump straight to [more] advanced procedures when the basics! and being good at them is what saves lives.  

Understanding what the body is, does, and needs is the basis for all life saving medicine while bad medicine only need an ego to thrive.

Good job Brother.


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## surgicalcric (Aug 2, 2014)

Red Flag 1 said:


> Law nunber Three: Think twice before disagreeing with this 18-D.



Someone once told me, "God gave you twice as many ears and eyes as his did mouths.  If you practice the former 1/2 as much as the latter you are guaranteed to be 100% smarter."  My fathers words haven't failed me yet.

[[I miss ya dad.]]


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## Muppet (Aug 2, 2014)

surgicalcric said:


> Seems guys always want to jump straight to [more] advanced procedures when the basics! and being good at them is what saves lives.
> 
> Understanding what the body is, does, and needs is the basis for all life saving medicine while bad medicine only need an ego to thrive.
> 
> Good job Brother.



Thanks bro. As some of you know, especially @policemedic , I am anal about the basics even thought I am a paramedic. The basis is correct and so many, even experienced people forget that. I am anal about resp. and shock and I am surprised when I teach, how many people cannot tell me about patho-phys of shock or even why keeping people warm is a good thing in shock and it really gets to me. Instead, I hear from the masses that I should look at more porn and less medicine. That attitude is wide spread in EMS and fire. Until somebody needs me and then it is "hey, can you talk about xyz"...

F.M.


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## Flynnstone26 (Sep 18, 2015)

I am a Paramedic student and I work as an EMT-b on an ALS rig with a medic. I was always 'taught' the eye flick method to determine if the pt has a gag reflex but I have never found use for it in the field. Similar to the sternum rub you can apply pressure to the orbit just above the eye, as long as there isn't any injury to the area, if they are faking that always gets a rise out of them.


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## policemedic (Sep 19, 2015)

The best question you can ask is, "Why?"

If someone teaches you a test, ask them to explain why it does what it says it does.  The more detail they can provide the better.  An inability to do that is a sure sign of a protocol monkey.


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## Flynnstone26 (Sep 19, 2015)

Excellent point, it's easy to become complacent in learning environments and take everything your instructors say as the gospel.


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## Red Flag 1 (Sep 19, 2015)

i


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## Muppet (Sep 20, 2015)

I have used supra orbital pressure, not with the knuckles as we would do with a sternal rub. I used my finger tip for a few secs., in the absence of facial trauma. Using a knuckle on the eye brow would be akin to punching a pt. The other day, I95 north bound, roll over, single vehicle MVC, ejected driver 100 ft., prone position in a ditch. "Off duty fire EMTs" from Jersey I think, come running  to our MICU blasting orders at us. What ever. Go take a breather...

Pt. in prone, agonal, bradycardic with satisfactory pulses and an ok B/P. One EMT says "his pulse ox is 80". No shit. He's dying. Besides the massive head trauma in which he is hernitaing and an obvious closed right femur, all other trauma eval are negative. He has trismus and facial/head trauma. We are able to ventilate but not intubate. My student ventilated him with satisfactory compliance, suction PRN. Lungs stayed up. My plan for crash airway after that would have been a quick trach and we prepped just in case/did not need it. 8 min ride to shock trauma.

Pearl: A BLS airway is of utmost importance. Attempting to intubate with this train wreck airway would have killed him deader as he was gonna be. Even the state protocol for Etomidate was not the correct route of this guy. He died that night, 20 mins prior to gift of life getting there....

M.


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## surgicalcric (Sep 27, 2015)

Muppet said:


> ...The other day, I95 north bound, roll over, single vehicle MVC, ejected driver 100 ft., prone position in a ditch....
> 
> Pt. in prone, agonal, bradycardic with satisfactory pulses and an ok B/P. One EMT says "his pulse ox is 80"... He has trismus and facial/head trauma. We are able to ventilate but not intubate. My student ventilated him with satisfactory compliance, suction PRN. Lungs stayed up. My plan for crash airway after that would have been a quick trach and we prepped just in case/did not need it. 8 min ride to shock trauma.
> 
> ...



Glad to see you sticking with the basics; they save lives. 

Refresh my memory Brother, as I am certain we have discussed this in the past, do you guys RSI by protocol? If so is lidocaine indicated in your protocol for increased ICP prior to Etomidate? Secondarily, there is a good bit of literature suggestive of a decrease in ICP of patients who receive single dose Etomidate.

As for advanced procedures, paramedic students, eager to complete their skills check-offs, and paramedics stuck on single paramedic trucks, fresh out of paramedic school, want to go straight to [more] advanced procedures instead of progressing step-by-step as necessitated by the patients needs.

Flynn26: Paramedic school is your time to question everything.  This includes the basis for every skill, evaluation procedure, and treatment you are being taught. Knowing why is every bit as important as knowing what.


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## Flynnstone26 (Sep 27, 2015)

The other day in class I brought up the question of WHY there is a correlation between eye movement and gag reflex and my instructor didn't even know. We brought the question up to one of the neurologist and his broken down answer is that since the two nerves are so close in proximity that once one is out it's extremely likely that the other is out.


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## Muppet (Sep 27, 2015)

surgicalcric said:


> Glad to see you sticking with the basics; they save lives.
> 
> Refresh my memory Brother, as I am certain we have discussed this in the past, do you guys RSI by protocol? If so is lidocaine indicated in your protocol for increased ICP prior to Etomidate? Secondarily, there is a good bit of literature suggestive of a decrease in ICP of patients who receive single dose Etomidate.
> 
> ...



In P.A. bro, there is not ground 911 R.S.I. We have M.E.I. (Etomidate) but it is not a true R.S.I. Only the Etomidate w/o Lido, Atropine is used and that is under dosed. I have seen personally, Etomidate used on massive head trauma with sub par results including multiple tube attempts, bradycardia, vomiting.... Our medical director (since we have state protocols but the M.E.I. SOP is agency used) says that this was poorly written protocol and he would rather have true R.S.I. Our oversight on the Q.A. aspect is progressive and tight but again, the way it was written. We used to use Versed for M.E.I. until Etomidate was rolled out in "13". I have had 3, yes, 3 events where I needed R.S.I. and again, I fell back to B.L.S. ventilations, all were satisfactory used with Etco2 attached to B.V.M. Hope that answers that brother. Miss ya!

M.


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## surgicalcric (Sep 27, 2015)

Muppet said:


> In P.A. bro, there is not ground 911 R.S.I. We have M.E.I. (Etomidate) but it is not a true R.S.I. Only the Etomidate w/o Lido, Atropine is used and that is under dosed. I have seen personally, Etomidate used on massive head trauma with sub par results including multiple tube attempts, bradycardia, vomiting.... Our medical director (since we have state protocols but the M.E.I. SOP is agency used) says that this was poorly written protocol and he would rather have true R.S.I. Our oversight on the Q.A. aspect is progressive and tight but again, the way it was written. We used to use Versed for M.E.I. until Etomidate was rolled out in "13". I have had 3, yes, 3 events where I needed R.S.I. and again, I fell back to B.L.S. ventilations, all were satisfactory used with Etco2 attached to B.V.M. Hope that answers that brother. Miss ya!
> 
> M.



That sucks ass... Now that you typed it out, I remember the MEI crap.

Looks like I will be back at WRNMMC in a few weeks. We should get together.


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## surgicalcric (Sep 27, 2015)

Flynnstone26 said:


> The other day in class I brought up the question of WHY there is a correlation between eye movement and gag reflex and my instructor didn't even know. We brought the question up to one of the neurologist and his broken down answer is that since the two nerves are so close in proximity that once one is out it's extremely likely that the other is out.



Glad to see you followed up on your question. It is unfortunate that a paramedic instructor is passing on institutional medicine without understanding it. What BS.


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## Muppet (Sep 27, 2015)

surgicalcric said:


> That sucks ass... Now that you typed it out, I remember the MEI crap.
> 
> Looks like I will be back at WRNMMC in a few weeks. We should get together.



Let me know bro. Maria and I will be there...

M.


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