Testing for response to painful stimulus

[crazydoctorbob]

I've seen a number of instructors advising students that the proper way of checking response to pain when performing AVPU on an unconscious patient is to perform a Babinski or plantar reflex test.

As far as I know,testing plantar reflex is a test for a pathology involving the motor neurons of corticospinal tract. It would seem to me that any response to this test, either a positive Babinski sign or normal plantar reflex, would indicate in tact sensation since such would be required to produce any response at all, but is this the proper test to be teaching to new EMT's to evaluate response to pain ? Also,does lack of any plantar reflex, normal or abnormal, mean that the patient will not respond to painful stimulus.

Seems to me that this is an unecessarily complicated and perhaps unreliable test to teach new EMT's. It would seem to me that simply having them pinch the skin around the ankle or wrist, as I always teach,is more appropriate.

Before critcizing another instructor's methods, I like to do my homework .

I first learned about the Babinski reflex many years ago as an EMT student. It then seemed to disappear from EMT courses. I suspect that it may have been a method adopted by an EMT instructor who saw it done by a physician but didn't understand the purpose or pathology behind it.

[DFIB]

Babinski and painful stimuli have two entirely different diagnostic purposes. I would not find Babinski very useful in determining the LOC. A reflex would be absent or present even if the patient were not alert and oriented.

A good sternal rub is my favorite.

[Kiwiology]

Yep, a good sternum rub is all that is needed

[ERDoc]

A reflex is just that, a reflex to a stimulus. It does not require any input from higher up. The stimulus enters the spinal cord and the reflex exits it. This is why people who have had cord transections can still have reflexes, albeit hyperreflexive. As Defib has said, a Babinski is not a test for level of alertness. As both of the above have said, sternal rubs or pressure on the nailbed or knuckle works well.

EDIT: Major brain fart on my part. I read plantar reflex as patellar reflex. Change my description of plantar reflex to patellar reflex, though the same is almost true for a plantar relfex with can be normal or demonstrate a Babinski sign.

Edited January 31, 2012 by ERDoc

[b.anderson]

Personally, I was taught to use the trap squeeze method. I think even if the plantar reflex was an acceptable method to illicit a response to painful stimuli, I'd assume after shouting at the patient a few times and then going to remove their shoes/socks to use that method would simply be more redundant and complicated than it needs to be.

I am however considering the idea that the plantar reflex may be useful, but perhaps further down the list of assessments, perhaps when checking the patients CMS/PMS in their feet? I have limited knowledge of the plantar reflex (I'll use this as some motivation to learn more) so quite honestly I'm not sure the information gained would be useful during pre-hospital care, though perhaps it would be a useful tidbit for the receiving ED -- I'm not sure how emergent it is to have that information though.

[Chief1C]

bulbocavernosus reflex

That'll wake the patient up, worse depending on the gender I would imagine.

[Happiness]

Trap squeeze or sternum rub for me has always worked. I normally dont take shoes and socks off until my full assessment and personally I think I need to know my LOC before that. Also if I think the pt is faking I take the hand and let it go just above the face, if they smack themselves in the face I was wrong........

[mobey]

Trap squeeze or sternum rub for me has always worked. I normally dont take shoes and socks off until my full assessment and personally I think I need to know my LOC before that. Also if I think the pt is faking I take the hand and let it go just above the face, if they smack themselves in the face I was wrong........

How do you explain the epistaxis running into thier unprotected airway?

First do no harm!

An NPA insertion will sort out the fakers..... If it is that important to you that you are the one to expose thier fakeness.

[Kaisu]

I keep waiting for the decade when the stupid arm drop test is relegated to whackerdom. Providers still bring it up, usually with a stupid grin cause they are oh so smart.

I touch the eyelashes. The corresponding reflex movement of the eyelid is enough to reassure me that my patient is protecting their airway.

[DwayneEMTP]

I'm not a big fan of the trap pinch or stern run only because they seem so aggressive. If you rule out the drunks and drug addicts, a big percentage of the people that I find faking syncope are doing so out of some form of desperation. And of course I'm not saying that I would mistreat the drunks or drug addicts, only that I tend to deal with them a little differently than the categories below.

They felt faint at work and someone called an ambulance. They feel better now, but don't want people to know that all of the commotion was possibly for nothing.

The ill patient at home fighting with their spouse that can't really find any way out of their domestic mess other than having us come and take them away.

The college student having an anxiety attack that is humiliated by all of the drama they've caused and doesn't know how to cope with it once they can breath again. And on and on...

These patients, in my limited experience are usually pretty emotional, embarrassed, often confused about what got them into the situation before they began pretending. I don't want to begin our short relationship by showing them that I'm willing to hurt them to show my medical prowess.

I too touch the eyelashes, or tap lightly on the eyelid. And if I'm lost and really need them to speak with me then I pinch the nail bed which usually makes them jump and 'wake up.', usually looking around as if believing that it happened on accident. But most times any effort to rouse them will be done in the ambulance where they can save some little face at least while admitting that they aren't really dead.

But most often it goes something like this...Tap the eyelid and see a response. Make sure that the vitals speak to a relatively safe patient. Go to the ambulance. Give a little speech like, "Babe..I know that you're having a bad day. I kept quiet inside and let you freak out your family, but now it's time for you to open your eyes and talk to me. If I can't wake you up then you force me to do some painful things to make sure that you're life isn't in danger, so open your eyes and lets sort this out, ok?"

Usually, almost always, whether man or woman, they will start sobbing at that point and assist with their care. If not, I say, "David, could you set me up a couple of IVs, I'm going to have to run some fluid." and as I'm putting on the tourniquet I hear, "Whaaaaa? Whaaaa happened? Where am I?"

Tricks for exposing fakers are nifty, but rarely, in my opinion provide good patient care or significant medical information. Without question the largest class of instances where I see 'testing for responsiveness' is actually providers taking one of their few, safe opportunities to punish people that they're pissed off that they've been called to treat in the first place.

And then of course....What Mobe's said...

Dwayne