Is Assessing Gag Reflex Still a Thing?

[Nurse-please, BSN]

I work ER. I had a patient that came in high on methamphetamine. The patient was flailing all over the gurney and having a hard time controlling movement, very out of control. We gave 2mg Ativan IM, with minimal relief. So followed with 1 more mg Ativan IM and 7.5 zyprexa IM. Patient fell asleep, I was able to obtain labs, ekg etc.,
I swabbed for COVID in which she fought me off. I placed another IV, in which she kneed me in the side of the head (LOL) and I transferred her up to ICU shortly after this (pt with rhabdo and multiple electrolyte abnormalities/blood gas not obtained in ER) She was the same during transfer of care. She would open her eyes slightly in response to name (not answer) and would respond to painful stimuli, but not much more since she was sedated on the meds I gave her. RR WNL, mid 90s on 2L. Patient was obese and obviously had sleep apnea.

I know I’m rambling... but my point is... my patient was intubated shortly after transferring to the ICU. The RT said she had no gag reflex. To be honest, I have never checked a gag reflex on a patient. Literature that I’ve read it seems checking a gag reflex is old practice and not a good indicator of protection of airway because up to 30% of population has no gag reflex and it’s most likely not present in people with sleep apnea or those who have had multiple intubations in the past. I have never worked ICU, and have not seen a provider or any other nurses check gag reflexes in the ER setting to indicate need for intubation. Is this still common practice as indication for intubation? My concern would be causing an aspiration by checking a gag reflex in an obtunded patient.

I know the ICU is a very different approach to care than that of ER. I just kind of feel like a butt about it... having your patient intubated so fast after transfer of care makes you feel like you did something wrong.

Now the other aspect to this.... I live in an area with a VERY high drug and alcohol population. We have multiple patients that come in during the day/night to “sleep it off.” Some that are high on meth, we sedate and they sleep it off. The ER I worked at prior to this in a different state, I would see providers intubate for airway protection for the substance abuse altered patient that had adequate SpO2. It just doesn’t seem to happen here as much and I wonder if that’s because of the high volume we see of that population..

thoughts/feedback greatly appreciated!!

[Emergent, RN]

I just finished recertifying tncc and they talked about gag reflex a lot, as far as putting in an oral airway, then preparing for intubation. The teacher is a flight nurse and so is familiar with what they do at our Regional level one Trauma Center, Harborview, and she says that they just put people like this on their side and let them sleep it off. They don't have time to be intubating druggies and drunks. That's how we handled it at my last job.

It sounds to me like it's provider preference. Of course, the ICU likes people tubed and sedated whenever possible, it seems like.

[Nurse-please, BSN]

30 minutes ago, Emergent said:

I guess I wasn’t thinking of assessing the gag reflex as putting in an OPA or NPA.. I was speaking more of tongue blade to the pharynx..

An NPA would have been very suitable for this patient

thanks for the response!

Quote

[Emergent, RN]

1 hour ago, Nurse-please said:

I guess I wasn’t thinking of assessing the gag reflex as putting in an OPA or NPA.. I was speaking more of tongue blade to the pharynx..

An NPA would have been very suitable for this patient

thanks for the response!

That's what she said they do at Harborview. NPA and sleep it off in a hallway bed.

[canoehead, BSN, RN]

I would not have checked gag reflex in that situation, and I would not have given anything po...she was too out of it. I've had patients wake up from sedation and I wait for them to get good head control and clear speech. Then getting them to take a small sip of water, and observing their swallow is more informative than sticking a tongue depressor down their throat.

[LovingLife123]

ICU assesses gag reflex. We use it more for neurological assessing. But yes, a gag reflex is still assessed.

[Here.I.Stand, BSN, RN]

I’ve never worked ED but don’t see anything wrong with what you did... if the pt wasn’t protecting his airway and needed to be tubed, 1) I wouldn’t be immediately concerned about that one piece of info, and 2) his gag reflex would be eliminated with the pre-tube paralytic anyway.

In the ICU we do q2 hr oral care/subglottic suctioning... the vast majority of patients are going to gag with that so I don’t necessarily go out of my way to check it.

If the pt has a severe brain injury and in particular if we’re anticipating brain death, I might be more intentional about checking for cough/gag. That way I can notify the team sooner rather than later—or be able to let them know that we’re not yet ready for brain death testing. That seems obvious, but on one or two occasions the neurosurg resident came in, seemingly ready to start getting things lined up and I was able to let them know “hold your horses... he still has a cough/gag.”

[Nurse-please, BSN]

16 hours ago, LovingLife123 said:

ICU assesses gag reflex. We use it more for neurological assessing. But yes, a gag reflex is still assessed.

Do you assess gag reflex by touching the pharynx with a tongue depressor? I would be so cautious to do that, especially in a patient that’s on a substance or has ETOH on board... I’d be afraid for them vomiting then aspirating and then for sure we would be intubating.

[LovingLife123]

4 hours ago, Nurse-please said:

Do you assess gag reflex by touching the pharynx with a tongue depressor? I would be so cautious to do that, especially in a patient that’s on a substance or has ETOH on board... I’d be afraid for them vomiting then aspirating and then for sure we would be intubating.

We do it with suctioning. If I put that tiny catheter back to suction secretions and they don’t gag or cough, that’s a problem.

We use it more for neurological testing like I said. A physician often asks do they have a cough or gag? If I have someone who is a gcs of say 3 or 4, knowledge of whether they have a cough or gag is important.