Doll's Eye

[NREMT-Basic]

I recently heard of a neuro check technique that I hadnt heard of and wonder if any one else has heard of it and can define it and describe it for me. Its called the Doll's Eye Reflex. It was only mentioned in my EMT course and I am fairly certain that it has to do with brain stem involvement, but would love to know more about it. Thanks.

[Just Plain Ruff]

This is a great question NREMT - I'm glad you asked. And since it is covered in your emt book so thoroughly I'll give you a wonderful link on Coma a little further down in this post.

First off this should never never never be performed on a patient until the c-spine has been ruled clear. If you use it on a patient without a c-spine that has been cleared then the possbility of paralyzing the patient is tremendous.

this is a deep brain stem injury and is a very very ominous sign and very bad for the patient. this may indicate deep brain stem lesion.

here is a wonderful site for this information. read the WHOLE thing. But if you do not wish to read the whole thing scroll down to Eye Movement section and you will see what Doll's eyes are.

http://www.postgradmed.com/issues/2002/02_02/malik.htm

Again DO NOT DO THIS MANEUVER ON A NON-CLEARED C-SPINE. To do so would possibly or more than LIKELY cause irreparable harm and injury to the patient and it would make your career in EMS very very very short.

[ERDoc]

It is a way to test brainstem reflexes (aka the oculocephalic reflex). You take a comatosed pt and turn their head to either side. A normal response in an awake person will cause their eyes to turn with their head. In a comatosed pt, the eyes will stay looking up as the head is turned. The exception to this is if their is a lesion in the pathway involving the reflex.

As Ruff said, obviously don't do this in a pt whose cspine is not cleared. In this case you can do cold calorics where you instill cold water into one ear canal. In a comatosed pt the eyes should look towards the ear you put the water in. This is used as part of a braindeath protocol. No response indicates braindeath. DO NOT do this on a conscious person. They will become very dizzy and violently sick (projectile vomiting).

[JPINFV]

[note, this is a non-EMS book... some tests may not be approprate for field providers, regardless of how fun they might look]

page 209

The Nervous System

...

Cranial Nerves

...

Third, Fourth, and Sixth cranial nerves (oculomotor, trochlear, and abducens)

Inspection of eye movements

...

Doll's head manoeuvre (oculocephalic reflex)

If the eyes have failed to repond to a saccadic or pursuit movement, ask the patient to fixate on your eyes, grasp the patient's head and rotate it, dfirst horizontally then vertically. An inteact response (a measure of vestibular function) allows the patient's eyes to remain on yours.

Page 239

The nervous system

...

The unconscious patient

...

Examination

...

Eye movements

Perform the doll's head manoeycre. If reflex eye movemetns are absent, proceed to the cold caloric test by instilling 50 m: of iced water gently into one ear then the other, with the patient's head about 30 [degrees] above the horizontal. If brainstem reflexes are intact, the eyes deviate to the side of the irrigated ear. For testing reflexes vertical movements, the ears have to be simultaneously irrigated with cold (down-gaze) then warm (up-gaze) water.

- Epstein, O., Perkin, G. D., Cookson, J., Bono, D. P. Pocket Guide to Clinical Examination. Philadelphia: Mosby 2004, Pg. 209, 239

edit, darn, sniped twice while writing this... BTW, ERDoc, thanks for the great idea for a prank... (j/k)

[ERDoc]

edit, darn, sniped twice while writing this... BTW, ERDoc, thanks for the great idea for a prank... (j/k)

Keep it in mind the next time you have a partner that you don't like that falls asleep. Ice water works best. :wink:

[NREMT-Basic]

It is a way to test brainstem reflexes (aka the oculocephalic reflex). You take a comatosed pt and turn their head to either side. A normal response in an awake person will cause their eyes to turn with their head. In a comatosed pt, the eyes will stay looking up as the head is turned. The exception to this is if their is a lesion in the pathway involving the reflex.

As Ruff said, obviously don't do this in a pt whose cspine is not cleared. In this case you can do cold calorics where you instill cold water into one ear canal. In a comatosed pt the eyes should look towards the ear you put the water in. This is used as part of a braindeath protocol. No response indicates braindeath. DO NOT do this on a conscious person. They will become very dizzy and violently sick (projectile vomiting).

Doc-

You say that a "normal response" will cause the eyes to turn with the head. The article linked above says that in a case of brain stem lesion etc, the dolls eye causes the eyes to move in direct opposition to the direction of the head. It says if there is brain stem damage, then the eyes will move with the head. I tried this in a mirror and turned my head, my eyes maintained an opposite angle to the tilt of my head. To my knowledge I have no brainstem injury (boy did I leave myself open with that)

[crazycanuck]

{"It says if there is brain stem damage, then the eyes will move with the head. I tried this in a mirror and turned my head, my eyes maintained an opposite angle to the tilt of my head. To my knowledge I have no brainstem injury (boy did I leave myself open with that)"NREMT-Basic }

The vestibulo-ocular reflex in normals is affected by the response of the semi-circular canals in response to head movement. As you found in your own test of looking in the mirror, if you move your head to the left, the eyes move to the right. In normals, without vestibular dysfunction or brain injury the eye gaze will be in the opposite direction of the head movement.

An abnormal response indicating brain injury or some related problem with the VOR occurs when the eyes move in the same direction as the head movement. The doll's eye test of the oculocephalic reflex should also be performed with the head elevated by 30 degrees. This is because of the interaction of the fluids in the three planes (anterior, posterior, and horizontal)of the semicircular canals, the horizontal canal is actually in the neutral position with this 30 degrees of elevation.

The other point worthy of mention is that the vestibular system is so dynamic that when we're performing these types of provocative such as head turning and caloric testing, as tests in conscious patients to do as a neuro check-often times we are able to suppress nystagmus or abnormal movements, this is why the oculucephalic reflex is only able to be demonstrated in unconscious patients. To avoid suppression of response in clinical vestibular testing, we often perform "alerting tasks" which simply means you distract the patient with mental tasks in order to elicit a true response.

[Ridryder 911]

.... There you go ..

R/r 911