Sternal Rubs/Painful Stimulus

Sasha

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A couple good articles on sternal rubs and painful stimulus. I know a lot of people don't like sternal rubs, and I know I generally don't do a sternal rub for 30 seconds.


Misinterpreting the Results of a Sternal Rub

Full Article: http://www.ems1.com/ems-products/ed...Misinterpreting-the-Results-of-a-Sternal-Rub/
When assessing a patient who is not alert and does not respond to verbal stimuli, a painful stimulus may be applied to the body. The sternal rub is the most common stimulus practiced out in the field. However, it is possible to misinterpret the patient’s response to the stimuli depending on the duration the pressure is applied.

Response to the stimulus is used to make assumptions about the integrity of the brain and its function. If the patient responds to the pain with what is interpreted as purposeful movement, it is assumed that the brain received the impulse, was able to interpret it, and responded with some degree of a correct response.

If the patient does not respond, it is assumed the brain either did not receive the impulse or was unable to interpret the stimulus. If the brain is unable to interpret the painful stimulus and send out a correct response, one would think that its integrity is compromised and the patient is at grave risk for losing vital functions. Thus, a patient who does not respond to a painful stimulus would be thought to be critically ill or injured.

Interpreting a Peripheral Painful Stimulus Response
Full Article: http://www.ems1.com/ems-products/ed...eting-a-Peripheral-Painful-Stimulus-Response/
Emergency medical service personnel often work under conditions that can be best described as “extremely uncontrolled.” Under these conditions, patient assessment is expected to be conducted in a rapid manner, in order to collect as much history and physical exam information as possible.

This information is used during the critical thinking process to develop a differential field diagnosis. Further assessment and emergency care is based on the differential field diagnosis; thus, the information collected must be as accurate as possible. Inaccurate information can lead to improper care. However, the results of the exam may not always provide the most accurate information.

Last month’s column discussed the possible misinterpretation of a sternal rub response in a patient with an altered mental status. In addition to the sternal rub, there are a few other situations where the results from a physical exam conducted on a patient with an altered mental status may be misinterpreted.
 

BLSBoy

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I prefer the eyelid flick first. If no response, then go to sternal rub. 5 sec, max. No response, then yea, priority.
Why?
Most normal pts would NOT have such a reaction to that.
Other stimulus such as foot flick (run a pen up the instep), watching pain when you start an IV can judge.

I kinda disagree with the 30 sec rub. That seems overbearing and could cause further injury to the pt.
 

CaLiEMT

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i was taught to put a pen light between the fingers and squeeze. Any one ever try that?
 

Lifeguards For Life

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i was taught to put a pen light between the fingers and squeeze. Any one ever try that?

There are two different types of painful stimuli: central and peripheral. Central stimuli are applied to the core of the body; whereas, pain applied to the extremities is considered peripheral stimuli. In 1974, neurology professors Graham Teasdale and Bryan J. Jennett suggested using fingernail pressure as a form of peripheral painful stimuli to determine if a response is present. A central painful stimulus is then applied to assess for localizing, or the patient's ability to attempt to remove the stimulus. More current literature suggests caution when applying and interpreting the results of peripheral stimuli. When pain is applied to the fingernail bed, lower legs or elsewhere in the periphery, it might elicit a spinal reflex response. That is, the pain impulse travels via a sensory nerve tract to the spinal cord, where it is immediately turned around by a spinal reflex and sent out via a motor nerve tract to the muscle of that extremity, causing the patient to move. The movement may be withdrawal, where the patient pulls the finger or distal extremity away from the painful stimulus, which is interpreted as localizing the pain. Since the impulse was never transmitted to the brain and interpreted by the cerebrum, what appears to be purposeful movement is not a positive indication of cerebral function, but only an indication of intact peripheral nerve tracts. Thus, be skeptical of withdrawal or localizing effects when painful stimulus is applied to the extremities.
 
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Sasha

Sasha

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i was taught to put a pen light between the fingers and squeeze. Any one ever try that?

The pen thing is periphereal stimulation. Stick to the core.
 

VentMedic

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Even patients with brain death will have responses from the spinal reflexes including a painful stimuli to the plantar region. However, if the response is interpreted as purposeful or there is some grimace in facial expression, all you may have done is a coma score to determine the level of cognitive function and not really if the patient is faking being unconscious.
 

RyanMidd

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We were taught the core vs peripheral idea, but the actual "painful/tactile stimulus" was up to us.

Trap-pinch always seemed a little more humane, both for the patient, and for onlookers.
 

EMSLaw

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We were told repeatedly in my EMT-B class that the sternal rub is no longer considered best practice, and we should pinch the neck or earlobe or the skin over the clavicle instead.
 

MSDeltaFlt

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I hardly ever use a sternal rub anymore, not because I'm afraid of it causing bruises, but because it just doesn't work. Trap pinch either. Pts who want will tolerate all kinds of painful stimuli. I've left bruises on pts who would get discharged because they had no illness or injury. They just didn't want to respond to anything.

However, if you try to piss them off, you will generally get a response. The way I do it is to gently to moderately tap on the eyes, nose, and mouth.

I've lost count how may times doctors preparing to intubate a pt due to no response from sternal rubs/trap pinches would rethink their strategy after I would mess with the pts' faces like that.
 
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Two-Speed

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I've only ever seen a sternal rub done on a post-dictal frequent-flyer with a history of being uncooperative, abusive to paramedics, and oftened faked being unresponsive, so the doc used the rub to see if he was conscious or faking or not...End result, doctor almost got punched in the head.
 

VentMedic

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I've only ever seen a sternal rub done on a post-dictal frequent-flyer with a history of being uncooperative, abusive to paramedics, and oftened faked being unresponsive, so the doc used the rub to see if he was conscious or faking or not...End result, doctor almost got punched in the head.

If the intent was to abuse the patient, the doctor should have expected it.
 

Two-Speed

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If the intent was to abuse the patient, the doctor should have expected it.



The intent was to check for consciousness, because he very well could have been out like a light, he seemed rather unconscious and unresponsive to everyone in the room. I most certainly wouldn't have posted the story if the doctor had done it to abuse the patient.

But like I said, the patient had a history of abuse to paramedics and ER staff, so it was expect he would react like that.
 

VentMedic

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The intent was to check for consciousness, because he very well could have been out like a light, he seemed rather unconscious and unresponsive to everyone in the room. I most certainly wouldn't have posted the story if the doctor had done it to abuse the patient.

But like I said, the patient had a history of abuse to paramedics and ER staff, so it was expect he would react like that.

You still don't know the INTENT of the doctor. Your post also confirms whoat might have been the actual INTENT.
 

Two-Speed

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You still don't know the INTENT of the doctor. Your post also confirms whoat might have been the actual INTENT.

I think we should probably agree to disagree on this one. I will admit that I didn't know the intent the doctor had, but I'm giving him the benefit of the doubt due to the pt's perceieved level of consciousness. If I knew for a fact it was abuse, I wouldn't have posted it.
 
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Sasha

Sasha

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I think we should probably agree to disagree on this one. I will admit that I didn't know the intent the doctor had, but I'm giving him the benefit of the doubt due to the pt's perceieved level of consciousness. If I knew for a fact it was abuse, I wouldn't have posted it.

Why? Abuse is not something that should be ignored and kept quiet. Abuse is something people need to be aware of andneeds to be reported. This is a good example of how a providers action can be misinterperted.
 
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