# Sternal rubs, trap squeezes & motor bikes



## Melclin (May 25, 2009)

Not to sure about where this should be put. Apologies if its been covered before, I did a quick search and didn't see anything jump out at me, but just point me in the right direction if I'm rehashing.

"Eliciting a response using a painful stimulus". Whether it be for a formal GCS, an initial response, or some other kind of conscious state/neurological assessment. What kind of stimulus do you use? 

Sternal rubs and nail bed pressure were the original go as far as I understand it and thats what I learn't last year. My new lecturer has now changed the curriculum to remove sternal rub for trap squeeze. This irked me a little but a quick google search revealed that it may not be a bad idea. I also hear good things about supra-orbital pressure on neuro forums. Anyone use that?

Any links of references to important papers in this area would be especially appreciated. 

On a side note my dad is an avid motorcyclist and was wondering if any of the boffins on this board knew from experience if any of the Kevlar mesh protective gear had been seen to go terribly wrong.


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## Jon (May 25, 2009)

Rid has talked about the trapezius squeeze before... I like it, I've started to use it occasionally, and it works.


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## mycrofft (May 25, 2009)

*Some of my pt's will need the Binford 7000 Mega Trapper to grab 'em.*

These guys are huge.


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## emtjack02 (May 25, 2009)

I like the trap squeeze.  It doesn't make the monitor go crazy and it's effective.  I have talked with several Neuro ICU nurses and they say that things seem to be going away from peripheral painful stimuli such as nail bed pressure.


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## NC13 (May 25, 2009)

Ive had instructors tell me to not use sternum rub because "it has the potential to leave a bruise." I've had others tell me to pull the little hairs at the top of the neck. I don't think thats a good idea. I would go with Trap squeeze.


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## Sasha (May 25, 2009)

NC13 said:


> Ive had instructors tell me to not use sternum rub because "it has the potential to leave a bruise." I've had others tell me to pull the little hairs at the top of the neck. I don't think thats a good idea. I would go with Trap squeeze.



CPR has the potential to break ribs but that doesn't mean you abstain from it so I don't think someone should abstain from a sternal rub because it may or may not leave a bruise. Can't a trap squeeze leave a bruise too?


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## mycrofft (May 26, 2009)

*I was awakened with sternal rub...hurt for a couple weeks.*

And no one told me they had. Guess I can't hold my anesthetic!


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## Scout (May 26, 2009)

What is a trap squeese?

And we we say sternal rub what are we saying. I have read it may take up to 10min to elicit a responce from a sternal rub but i have never rubbed for that long?


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## Ridryder911 (May 26, 2009)

Sternal rub is using one knuckle and rubbing up & down the middle of it eliciting pain. Yes, it will leave bruises and yes, one can be held liable as it serves no medical purpose and there is other approved means. I have found just using the flat of my hand and moving back & forth lightly is just as effective and not as harmful. 

Trapezius squeeze is where one actually squeezes the muscle causing pain. If you do not know where that is this is a good chance to look up your muscles. This is a good measure of those that only respond to a deep painful stimuli. 

R/r 911


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## mycrofft (May 26, 2009)

*Trap Squeeze="Vulcan Death Grip"*

Yes, I know, there IS no Vulcan "death" grip.
They used to dig a thumb into the groove just behind the mandibular joint. Can injure someone that way. Also used to put ice on the genitalia.*
Before you go assaulting people to elicit responses,consider the effect on bystanders. You could start a dukefest getting frisky on Granma or someone's friendd in a bar or streetcorner.


*Some folks pay a tip for that .


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## mikie (May 26, 2009)

mycrofft said:


> Before you go assaulting people to elicit responses,consider the effect on bystanders. You could start a dukefest getting frisky on Granma or someone's friendd in a bar or streetcorner.



So is the nipple-twist out?


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## AJ Hidell (May 26, 2009)

Melclin said:


> I did a quick search and didn't see anything jump out at me, but just point me in the right direction if I'm rehashing.


You should have used "trap" as your search term.

http://www.emtlife.com/showthread.php?t=12067&highlight=trap

http://www.emtlife.com/showthread.php?t=12823&highlight=trap

Those are the two most recent fights, err... I mean _discussions_ about noxious stimuli.

What is appropriate depends upon the point of your exam.  If it is a GCS test, then the stimulus must specifically be CENTRAL stimulation.  Nailbed pressure isn't central.  Sternal rub is not central.  Earlobe pinch is not central.  Central nervous stimulation is:Trap Squeeze
Supraorbital Pressure
TMJ Pressure​Anything else is not justifiable under the guise of assessment.


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## Shishkabob (May 27, 2009)

The whole "A sternal rub can cause a bruise" thing is a crock.


Any rough physical contact, INCLUDING A TRAP SQUEEZE, can cause a bruise.


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## Melclin (May 27, 2009)

Linuss said:


> The whole "A sternal rub can cause a bruise" thing is a crock.
> 
> 
> Any rough physical contact, INCLUDING A TRAP SQUEEZE, can cause a bruise.



I would tend to agree with you, in the sense that if its necessary then bruising is hardly a terrible side affect (eg. IV cannulas can leave a bruise). Still if its unnecessary then there's no point in hurting a person. It's hardly barbaric though.

That's not what I'm worried about. I'm looking for what is most effective. And to get a bit of an idea of what the different schools of thought are. Any interesting research is the main point though.

*AJ*: Its was Teasdale and Jennet that actually suggested nail bed pressure as an initial form of stimulation, in the original paper introducing the GCS. To be followed with stimulation "applied to the head, neck and trunk", to test for localization. So sternal rub fits with the GCS as it was intended to be performed by its creators anyway. Also as far as eye opening to pain goes they recommend nail bed because of the problems with grimace response to TMJ/supraorbital pressure closing the eyes. 

I understand things change and may be different now and that there are different schools of thought, but you can't really just say, _by definition_ the GCS does not require the use of NB pressure or sternal rubs  

How are trap, TMJ or supra orbital stims, central nervous simulations. Do you mean cranial nerve stimulations? What do you mean by central. Not the CNS I hope.

Cheers for the links by the way.

*Rid*: I hardly think you would end up on the receiving end of any legal funny business. I understand things get a bit crazy litigious in the states, but here people don't sue the paramedics that turned up to help them, because they woke up with a bruise. Even if they wanted to, they can't. I've noticed alot of these kinds of arguments descend into the territory of the lawyers. Is it just academic, these arguments you have, or do guys actually get sued for stuff like this?


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## Ridryder911 (May 27, 2009)

Linuss said:


> The whole "A sternal rub can cause a bruise" thing is a crock.
> 
> 
> Any rough physical contact, INCLUDING A TRAP SQUEEZE, can cause a bruise.




Really, just how many patients have you cared for? Sorry, but I have seen several with bruises and contusions by zealous EMT's attempting to awaken their patient. Remember, there is only skin on top of sternum (not even much fat tissue) in comparrison of muscle bruising (remember A & P). Seriously, no one ever teaches eye lash response and other non-traumatic methods? 

Or is this just a good excuse that some can inflict pain and attempt to justify it? 

Let's leave the macho crap to the cops. 

R/r 911


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## Shishkabob (May 27, 2009)

SO you're telling me a trap squeeze will leave no bruise?

Yeah... ok.


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## Ridryder911 (May 27, 2009)

Melclin said:


> I*Rid*: I hardly think you would end up on the receiving end of any legal funny business. I understand things get a bit crazy litigious in the states, but here people don't sue the paramedics that turned up to help them, because they woke up with a bruise. Even if they wanted to, they can't. I've noticed alot of these kinds of arguments descend into the territory of the lawyers. Is it just academic, these arguments you have, or do guys actually get sued for stuff like this?




I have seen medics get sued and lost because the head of the bed went from a sitting to a supine position, causing the patient to become scared and with pain. So yes, it is very, very possible. Yeah, and you don't think assault would not be added? Yes, I have seen medics actually loose their job for patients awakening with bruises on the sternum. Amazing many physicians do not agree of always using such violent methods. Now, add the patient that is on anticoagulant such as Coumadin and look at the results. Show me a text that endorses sternal rub? Yeah, I use it (minimal and light with the flat of my palm). As well, there are other approved and better methods. 

R/r 911


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## Ridryder911 (May 27, 2009)

Linuss said:


> SO you're telling me a trap squeeze will leave no bruise?
> 
> Yeah... ok.



Yes, if done properly... remember how bruising occurs? 

R/r 911


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## Shishkabob (May 27, 2009)

Ridryder911 said:


> Yes, if done properly... remember how bruising occurs?
> 
> R/r 911



Break of blood vessels.

Which happens with rough trauma.

Which a trap squeeze can be.

Which is why trap squeezes can cause bruising.





How are we not on the same page?


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## Melclin (May 27, 2009)

Ridryder911 said:


> I have seen medics get sued and lost because the head of the bed went from a sitting to a supine position, causing the patient to become scared and with pain. So yes, it is very, very possible. Yeah, and you don't think assault would not be added? Yes, I have seen medics actually loose their job for patients awakening with bruises on the sternum. Amazing many physicians do not agree of always using such violent methods. Now, add the patient that is on anticoagulant such as Coumadin and look at the results. Show me a text that endorses sternal rub? Yeah, I use it (minimal and light with the flat of my palm). As well, there are other approved and better methods.
> 
> R/r 911



Man you're getting very combative considering I essentially just asked you a question. Did you read my whole post? It seems quite a few people here have been trained to use the sternal rub. Are you saying that they could be sued if they acted as per their training (this was my question, it wasn't combative sarcasm, I'm actually curious as to the situation you guys face over there)? If that's true about medics losing their jobs over bruising people then that is yet another nail in the coffin of American EMS/health system (as if you needed another). 

On the topic of a literature review, Rid, I'll get back to you tomorrow, when I've got a little time to look through some papers and have ganda. That was actually the point of me asking, was that I wanted peoples opinions on research, not a flame war of: 'yes we do'-'no we dont' type stuff. So I'll have a look myself and see what the databases have to offer.


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