Test For Unconsciousness: The Face Flick

Sometimes, when we get on that outer boundary of established medical practices we start running in to controversy. As an author, and a bit of a non-conformist, I love controversy. One area that falls in the gray realm of medical assessment is testing for unconsciousness. This is a concept familiar to all who work in emergency services and rarely considered by the lay public. I’ll explain.

When we encounter a person who is not responding to us there are several possibilities.

1.) They may be unconscious

2.) They may be semi-conscious

3.) The person may be sleeping

4.) They may be fully conscious and feigning unconsciousness (for various reasons)

We treat all patieint who refuse or are unable to respond to us with a high index of suspicion for injury or illness, but it’s helpful to try to get an idea where the patient actually is mentally. Are they here and not responding to us, or are they just not here?

I’ll be the first one to say that some of the things that have passed as acceptable tests for consciousness are inappropriate. I’m glad that we’re trending away from ammonia inhalants. I don’t want to get in to how I’ve seen those things abused, or how I’ve seen patients abused with them.

I’m also not a big fan of painful stimuli. I much prefer the idea of noxious stimuli. In other words, stimuli that is annoying and / or unexpected. I find that I have a greater talent for being obnoxious than being torturous. My parents recognized this at a young age. What can I say … it’s a gift.

So there are some tests that I like to use and some that I shy away from. And there’s one that I’ve become particularly fond of over time. I do use the hand drop test (Always protect the face of the patient when doing this.) And I’ll also use a gentle sternal rub or trapezius pinch. I like the eye flutter test as well.

I’m not a big fan of cranking on the nail beds with a solid object or pushing on pressure points. It just seems to easy to injure someone if you do it wrong. It’s also inaccurate on patients who are intoxicated or have high pain thresholds. I also don’t ever use ammonia inhalants. Don’t mess with the airway of a potentially unconscious person. Regardless of how effective you think it might be, it’s not a good idea.

The assessment technique I’ve become particularly fond of is the face flick. Yes, it’s just like it sounds. You take your index or middle finger and you flick the patients face right on the upper part of their cheek. It’s really annoying. Try it just a little on yourself right now and you’ll be surprised at just how downright irritating it really is.

I first learned of the face flick in an airway lecture given by Will Dunn. (A frequent contributor to The EMS Garage.)

I like the face flick for a couple reasons. One it that it really hits the corneal reflex of conscious patients. Your corneal reflex is just primed to flinch at the sensation of an impact so close to the eye. If I can flick the face one or twice without any twitching from the surrounding musculature I take that as a reliable sign of deep impairment.

In addition, the urge to move the head away and look towards the stimuli is almost irresistible. When I come out of nowhere and give a few solid flicks to the face combined with a loud, “Hey there!” the urge to look at me is overwhelming.  Then I smile and say hi.

I also like the fact that, unless you just have remarkably poor aim, it’s hard to imagine hurting or injuring someone with this technique. It doesn’t leave marks and the discomfort goes away as soon as you quit flicking them.

I have noticed one downside. You look like a real jerk when you do it. That doesn’t rule it out as medically inappropriate, but you can’t just waltz up to someones unconscious grandma and start flicking her in the face and yelling, “Hey you.” Well … you can, but there’s going to be some explaining later. It just looks horibly disrespectful so you need to use your discretion when and where you do this.

Try it out and tell me what you think.

Related Articles:

Five Assessment Findings That Should Concern You

Understanding Combative Head Injuries

Rapid Diagnosis: Pinpoint Pupils

Comments

  1. I like to flick eyelashes gently with a 4×4- turning to your partner and saying “Hey, you’ve never put a tube down anyone’s throat before have you? Try it on this guy.”- yeah, that works too.

  2. Your a gem Pedro.

  3. Thanks for that one Steve,
    I also don’t like seeing an OPA inserted into anyone that people think are faking unconsciousness (especially when full of alcohol). I haven’t tried the face flick before, as I usually do eye lash stimulus (however, I have heard some Drs say that is an unreliable test), but I will try flicking at the next chance I get. Think I will try it on the sleeping wife now. Wish me luck!!!

  4. Ouch!!

    It works, but I didn’t enjoy the slap across the face afterwards!
    Think I need to work on “safe distance” a little more!

  5. Didn’t work on my last 2 customers needing this type of intervention.
    In the past the eyes being held shut when we try to open them is a give away, as is the falling hand.
    When I really need to find out how “out” we are a neck pinch and sternal rub always works wonders on my pickled clients.
    I will keep trying the flick, lord knows I want to flick most of these folks anyways.

  6. When I took my EMT course, the idea our instructor gave us was placing your pen between their fingers(at the knuckle) and simply squeezing their fingers together. He said it works great, and there isn’t much pain.

  7. Steve Whitehead says:

    Brittany, It is helpful to have at least one good technique to use on the hand because the hand is great for determining the difference between patients who are localizing their pain and those who are withdrawing. It’s difficult to do the with a face flick or a sternal rub.

    Thanks for the contribution.

  8. I’m no paramedic, but I did have a question… When someone faints, its usually because of low-blood sugar, not enough oxygen to the brain etc. Isn’t the best state to be in, unconscious, because your body goes into default mode? Why do we put such an importance on reviving the person. Why not let them wake naturally?

  9. JJ, that’s a good question. However, these tests generally are only performed on patients we believe to be faking. Plenty of drunks, drug-seekers, etc try to fake unresponsiveness to avoid jail, get special drugs, etc. These tests will usually pull them out of the pack. The rest, we figure out why they are unresponsive and try to fix them the best way possible.

  10. Miss Medic says:

    Sometimes, casually describing the insertion of a Foley Catheter is enough to wake them. I am also a fan of brushing the eyelashes with a gloved finger. And, although I do not prefer assessing LOC with painful stimuli, I do occasionally use the jaw thrust maneuver. It’s easily explained away as assessing the patient’s airway and breathing. I’ve never been questioned by any family member or bystander as to why I’ve performed this maneuver. One last noxious test of unresponsiveness would be to use a prefilled syringe (normal saline, of course) and drop a cc or so toward the corner of their eye. It has the same effect without having to physically flick the patient. Just a suggestion.

  11. i have found blowing on the face also works, although it can look creepy

  12. Bil ROsen says:

    I would be curious to know what data or research/evidence exists about a facial flick. I like the concept but I am sure there is a right and a wrong way to effect the corneal reflex.
    From a local article I wrote:
    Assessing for responsiveness is often looked at as simply, does the patient respond to something. While this is somewhat true, responses may be spinal reflexes or higher level brain function. There are some very effective ways to elicit non-dangerous pain responses and there are some quite inappropriate ones. There are also appropriate but less then commonly known ways to use some procedures. The hand drop, ammonia inhalants and other means have been easily faked by “regular” patients used to such procedures.
    Is there any good way to measure the amount of pressure used during a sternal rub? How much is too much? If a patient does not respond to your first sternal rub, how much longer and/or harder will you rub? Think of the 90/90 female in a nursing home bed (90 years old/90 lbs). Push too hard and it becomes a spinal rub!
    If not obeying commands- press on the supra-orbital nerve to inflict pain. If the either one hand reaches above the clavicle that scores 5 ie: localizing to pain. If the hand does not come above the clavicles but is moving towards the head, score 4 for normal flexion. If the response is a clenched fist with a flexed wrist and elbow, as in decorticate posturing, score 3. If the patient extends the elbow and flexes a clenched wrist, that is extension to pain and decerebrate posturing scoring 2. And of course no response scores 1. Pressing on nail folds is not informative as you do not know if the patient is localizing (5)or normal flexing / withdrawing (4) to pain. Besides, if that arm is paralyzed or lacks sensation secondary to a peripheral nerve injury you may misjudge the GCS.
    Central pain needs to be central and specific. By far the best is the supraorbital nerve. Another reasonable site is a trapezius squeeze. The ‘sternal rub’ is useless, non specific and also disfiguring (how many times have you seen bruising after too many people have done misguided, violent sternal rubs)

  13. Anonymous says:

    well nice post I have tried all and d are positive dough sternal rub gave me quick response.

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