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Can a patient in Cardiac Arrest have a gag reflex?

Question# 867

we had a male pt who had been trapped in a car at an mvc. pt had vitals, and was grunting. pt became vsa post extrication. when an opa was attempted there was a loud gag reflex. is this possible? was it a true gag reflex?

Answer:

This sounds like a challenging call with a challenging and dynamic patient. Scanning through some research it appears that movement and reflexes after death can occur. While there is no specific study regarding the gag reflex after death, there are several others that refer to other reflexes occurring even after the patient goes into cardiac arrest. The current definition of brain death is the complete, irreversible cessation of brain function, including the capacity for the brainstem to regulate respiratory and vegetative activities. Therefore, in the patient you describe, this could have simply been a brainstem reflex occurring randomly after death. Reflexive responses as well as resuscitation interference, including apparent gagging, may be observed in cardiac arrest patients

On the other hand, in the patient you are describing, it appears that you attempted to place the OPA right after the patient went into cardiac arrest. At this time, there is a good chance that your patient’s brain had not been impacted by the event and therefore was still able to respond to stimuli. Especially if fast and effective CPR was also being performed on this patient, his brain was being perfused and therefore could have further led to the gag reflex remaining intact in this patient. This patient might even fit within a group of patients experiencing CPRIC. CPRIC, or CPR-Induced Consciousness is currently defined as a demonstration of consciousness whilst undergoing cardiopulmonary resuscitation with no measurable spontaneous cardiac output displayed.

It might also be helpful to consider this finding like that of agonal breathing often seen in cardiac arrest patients. Even though blood flow stops, the brain doesn't die immediately, and many of the primitive brainstem activities will continue for a short period of time after cardiac arrest. Recognize that these signs of life could have prognostic implications - much like agonal breathing in a VF arrest is a sign you could have someone very salvageable, brainstem reflexes in someone with no pulse can be a sign that death recently occurred and warrants an aggressive search for reversible causes. Alternatively, signs of life despite no palpable pulse can also be a clue that there actually is underlying perfusion but with a blood pressure so low as to be unobtainable. Think of the "PEA" arrests that have an ETCO2 of 40mmHg. Could there be blood pressure under there? Often there is, and of course those patients can still show signs of life like agonal breathing and gagging and pupillary reflexes, etc.

Given that cardiac arrest patients could have a true gag reflex based on the literature review, make sure to document such finding in the ambulance call report and keep in mind that using an oropharyngeal airway (OPA) in those cases is not recommended as it can provoke gagging as well as vomiting which may result in aspiration. Consider using other alternative airway adjuncts, such as a nasopharyngeal airway (NPA) if not contraindicated in such cases.

While a definite answer on whether this was considered a “true gag reflex” in this patient is very difficult to determine at this time, referring to the literature, it does appear that this could have been an active reflex from the patient.

References

https://www.amjmed.com/article/S0002-9343(04)00674-6/fulltext

https://www.psychologytoday.com/us/blog/the-future-brain/201810/how-the-brain-can-stay-active-even-after-the-heart-stops?msockid=16a9a6aa07b6672000f1b3a9068d6636

https://www.ncbi.nlm.nih.gov/books/NBK554502/

Diagnosis of brain death - UpToDate https://www.uptodate.com/contents/diagnosis-of-brain-death

Development of an international prehospital CPR-induced consciousness guideline: A Delphi study - Jack Howard, Eystein Grusd, Don Rice, Nikiah G. Nudell, Carlos Lipscombe, Matthew Shepherd, Alexander Olaussen, 2024 (https://journals.sagepub.com/doi/10.1177/27536386231215608)

Olaussen A, Shepherd M, Nehme Z, Smith K, Bernard S, Mitra B. Return of consciousness during ongoing cardiopulmonary resuscitation: A systematic review. Resuscitation. 2015 Jan;86:44-8. doi: 10.1016/j.resuscitation.2014.10.017. Epub 2014 Nov 4. (https://pubmed.ncbi.nlm.nih.gov/25447435/)

Bihari S, Rajajee V. Prolonged retention of awareness during cardiopulmonary resuscitation for asystolic cardiac arrest. Neurocrit Care. 2008;9(3):382-6. doi: 10.1007/s12028-008-9099-2. (https://pubmed.ncbi.nlm.nih.gov/18483881/).

Published

30 January 2025

ALSPCS Version

5.3

Views

78

Please reference the MOST RECENT ALS PCS for updates and changes to these directives.