1. Betsy Lee PGY 3

2. o 35 y/o M, h/o depression, comes to the ED with history of being found in bed with multiple empty pill bottles, unknown medications. o On exam, he has a GCS 8 with the presence of a gag reflex.

3. Does the presence of the gag reflex mean that the patient is able to protect their airway?

4. o 414 admissions for poisoning o 43 patients admitted IntubationNo Intubation Total GCS ≤ 8371855 GCS > 84334338 Total41352393

5. IntubationNo Intubation Total Gag Reflex11348359 No Gag Reflex 260 Unknown448 Total41352393

6. o Examined 38 patients on presentation to the ER that ranged from combative to comatose o Used a tongue blade to assess for gag reflex o 3 patients lacked a gag o 35 patients had a gag – 6 had been intubated PTA, 12 obtunded o 18 ER staff members then assessed o 4 staff members lacked a gag

7. o 111 patients had GCS and gag assessed GCSAbsentWeakerNormal 13-1561630 9-124810 ≤ 817164

8. Summary Absence of a gag reflex may be an indicator that a patient requires intubation However, presence of a gag reflex is not a useful piece of information 37% of healthy volunteers do not have a gag reflex

9. HUPism: The presence or absence of a gag is not helpful information.

10. o Chan B, et al. “The Use of Glasgow Coma Scale in Poisoning.” The Journal of Emergency Medicine. 11.5 (1993). 579-582 o Kulig K, et al. “Gag Reflex in Assessing Level of Consciousness.” The Lancet. 1.8271 (1982). 565. o Moulton C, et al. “Relation between Glasgow Coma Scale and the gag reflex.” BMJ. 303 (1991). 1240-1241.