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Sternal Rubs/Painful Stimulus

Discussion in 'BLS Discussion' started by Sasha, Dec 11, 2009.

  1. Sasha

    Sasha New Member

    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/
    Interpreting a Peripheral Painful Stimulus Response
    Full Article: http://www.ems1.com/ems-products/ed...eting-a-Peripheral-Painful-Stimulus-Response/

  2. BLSBoy

    BLSBoy makes good girls go bad

    Tampa, Fla/OCNJ
    I prefer the eyelid flick first. If no response, then go to sternal rub. 5 sec, max. No response, then yea, priority.
    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.
  3. CaLiEMT

    CaLiEMT New Member

    Lancaster, Ca
    i was taught to put a pen light between the fingers and squeeze. Any one ever try that?
  4. 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.
  5. Sasha

    Sasha New Member

    The pen thing is periphereal stimulation. Stick to the core.
  6. SASHA!
  7. VentMedic

    VentMedic New Member

    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.
  8. Sasha

    Sasha New Member

    You sniped me. With a much better post. Stupid phone. Boo for forgetting laptop.
  9. RyanMidd

    RyanMidd New Member

    Calgary, AB
    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.
  10. Linuss

    Linuss Active Member

    Why not just give a noogie? :p
  11. Pyromedic

    Pyromedic New Member

    Pinch the finger seemed better, less chance for bruising.
  12. bruising is the least of their worries
  13. EMSLaw

    EMSLaw Legal Beagle

    New Jersey
    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.
  14. MSDeltaFlt

    MSDeltaFlt Lawn Dart

    Cleveland, MS
    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.
    Last edited by a moderator: Dec 12, 2009
  15. Two-Speed

    Two-Speed New Member

    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.
  16. VentMedic

    VentMedic New Member

    If the intent was to abuse the patient, the doctor should have expected it.
  17. Two-Speed

    Two-Speed New Member

    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.
  18. VentMedic

    VentMedic New Member

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

    Two-Speed New Member

    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.
  20. Sasha

    Sasha New Member

    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.
    Last edited by a moderator: Dec 13, 2009

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