Test For Unconsciousness: The Sternal Rub

Ahhh the embattled sternal rub. Revered, reviled … the sternal rub is the Ann Coulter of medical interventions. Abrasive, annoying, loved by many, hated by many more. The subject of the usefulness of the sternal rub is bound to cause controversy in any EMS forum.

In other words … it’s a great subject for The Spot.

Like many controversial assessments and treatments, the sternal rub (sometimes referred to as the sternum rub) got its bad-boy reputation more from its misuse than from its own shortcomings. Never-the-less, the technique does have its shortcomings.

Like so many other tools, it has its place when used appropriately and it has its potential for misuse. So let’s make sure you understand its uses and limitations.

If you’ve never encountered this technique, the sternal rub is a test for unconsciousness. It’s a popular form of painful or noxious stimuli designed to illicit a response from a conscious or semi-conscious person. Establishing an unresponsive patients ability to respond and remove noxious stimuli is perfectly medically appropriate.

Note that on your Glasgow Coma Score, establishing  best eye response and best motor response both require the ability to administer and observe the patients reaction to pain. Having said that, I’m not the biggest fan of the sternal rub. i think there are other more appropriate tests like the face flick and the hand drop that, when done correctly, render more valuable information.

To perform the sternal rub, the care provider makes a fist and places his knuckles against the patients mid-sternum. Applying firm downward pressure the provider then rubs up and down across the sternum. To the uninitiated, this is surprisingly uncomfortable. With even a moderate pressure, the sternal rub is unbearable to most folks.

On the surface (pun intended) the stenal rub seems simple enough. Fairly benign body area … fairly simple technique. What could be the problem?

There are several:

       

We tend to overuse it.

Recall the last time you performed the sternal rub and the patient did not respond at all? What was your reaction? Did you begin aggressive airway management? Did you call for rapid transport? Or .. did you do it harder? … And then maybe a little harder? And then one really good one just for good measure?

And then the nurse at the hospital did the same thing. And then the intern did the same thing. And then the resident and on and on. And by the time the patient regained consciousness they had a big bruise and a sore chest for the next week. We overuse the technique when we think people should be responding but they don’t. Perhaps one reason we overuse it is because we know …

Some people don’t respond to it.

Especially people who are drunk or sedated. People who’ve had it done to them multiple times and the odd person who just has a really insensitive sternum. Because of these outliers we tend to keep trying the technique just a little more aggressively to see if this isn’t just one of those people who doesn’t feel it that much.

Some reports state that many patients don’t reposnd until pressure has been applied for 30 or more seconds. I’m not comfortable with applying the rub for that long or that hard to see if I can illicit a purposeful movement. That makes the results difficult to interpret.

For the record, any painful stimuli that leaves marks on the patient is inappropriate. If the patient arrives at the hospital with marks from your assessment, you did it wrong. No excuses.

It’s not a first line technique.

To many folks walk up and start in on the sternal rub as their first line assessment of unresponsive patients. No gentle shake and shout, no face flick or loud verbal stimuli. Just one good sternal rub. If the patient wakes easily, your patient rapport is pretty much shot after a good sternal rub. This is also a good way to get hit or grabbed because …

It places your arm in a bad spot for combative or dangerous patients.

It’s tough to do a sternal rub from above or out of the way. You pretty much have to offer up your whole forearm to the patients grasp. Beware and be ready to defend yourself if you come out of nowhere with a good hard sternal rub.

So how do we do it properly?

If you rub your knuckles firmly across your sternum you’ll discover that this move hurts. You don’t need to lay into someone with everything you’ve got. Give a good firm rub and then be done with it. Pay attention to the patients hands. For your own safety and because that might be the only response the patient is able to make.

I’d suggest keeping the sternal rub farther down on your assessment checklist. Remember to use less aggressive forms of stimuli first (i.e. noise, shaking, flicking, pinching.) Don’t just walk up to some poor dude and start in on him with this move.

The appropriateness of the sternal rub lies entirely in the hands of the care provider using the technique. When dons properly by someone who understands its benefits and limitations, it can yield valuable information. When done poorly, it is at best useless and at worst abusive.

Hopefully you’ll always use the sternal rub with caution, good intentions and respect for the patient.

       

Related Articles:

Test For Unconsciousness: The Face Flick

Test For Unconsciousness: The Hand Drop

Remembering The Glasgow Coma Score

Understanding Combative Head Injuries

Describing Pain

What Is Blood Anyway?

Comments

  1. Another great read.

    Sadly, this may find trouble finding it’s way to being taught in classes, because in “Scenario land” (Classroom), the sternal rub is the go-to “pain stimuli” for the mannequins.

    -S

  2. I’ve done it on myself, I know just how painful it is. If it doesn’t work the first time thats it, load and go.

  3. Steve Whitehead says:

    @Scott I agree, it’s endemic to our practice. That’s why it’s so important to understand.

    @Aerindel Well said.

  4. I never use the sternal rub, in the city we come across drunks and druggies far too gone for a stimuli that useless I just give a pinch between the pt’s thumb and index finger. Works 99 percent of the time.

  5. Steve Whitehead says:

    I haven’t had great success with the thumb webbing pinch myself. there must be some technique to it that I’m not mastering. I’ll give it another go.

  6. The biggest problem for me with the Sternum rub is that it can cause peripheral pain response, therefore I don’t know if they have a 4 or 5 motor score.

  7. christy morris says:

    i was having a seizure and this dumb ass EMT did this on me and I couldnt respond.
    Thanks Homer Medic

  8. oh oh I’ve got one! Lift up an eyelid and blow on the eye. You’ll see the eye twitch if they’re shooting for the Oscar.

  9. Charlie says:

    The best alternative method I’ve ever seen was from a ER Doc. He grabbed the patients nipple and twisted. I had a flash back of elementary school and the titty twister, lol

  10. Charlie says:

    Btw from my earlier post, I would recommend against doing it. I could see a law suit coming from it

  11. You’ve just identified yourself as a liberal by throwing the name Ann Coulter into your comments. Typical libtard, trying to denigrate a conservative.

  12. melissa wolford says:

    i had a seizure on May14 and they did that to me it hurt so bad that im steal sore from it. Wouldnt wish it on anyone.

  13. I’ve had this done to me a couple if times and let me tell you it is not pleasant. It was the greeting that the emt came with I wish they would’ve done somethin else. My chest was swollen and sore for a week.

  14. Shannon says:

    EMTs did this to me today. So did the nurses, three doctors, several techs and an intern. My chest looks like I’ve been in a bad game of “Open Chest” and hurts like hell. If I didn’t respond the first ten times, why the hell would I respond the next ten times?! Seriously? And it was like there was nothing else to try…like smelling salts, pulling my toes. pinching, lifting my eyelids, hell even blasting a horn in my ear would have been less painful.

  15. Oh goodness, this might explain a lot. Before I begin, don’t get me wrong… The EMTs and doctors and nurses who took care of me the other night might have saved my life, after I was drugged and found crumpled on the sidewalk, completely unresponsive (however, of note: I did not hit the ground; the girl who found me before I became unconscious caught me and helped me down and called the ambulance). But since I left the hospital, even walking up or down my stairs, leaning, laying down… Anything that moves an area of my chest or causes anything to touch the area just above my breasts at my sternum is unbearably painful. Just sitting is extremely uncomfortable. I’ve contemplated calling the hospital for chest X-rays. However, since I was barely breathing (almost had to intubate) and completely unresponsive, this makes since. Hopefully it won’t last long… But it has already been nearly 72 hours.

  16. Gah I’m so tired y’all, but I promise I’m not as uneducated or generally moronic as all of my typos made me sound. (Ie: “since” should be “sense”). Obviously the pain/discomfort is making sleeping rather difficult :(.

  17. Anonymous says:

    I am one of those people who do not respond to this as a conscious person. To me it feels no different than applyibg pressure anywhere else. The person who tested it on me was very surprised as he had done it on several other people and I had no idea what he was doing and didn’t react to it in any way.

  18. KyDerbyCharl says:

    I fell backwards after being pushed a way from a family member and since I have been off balance, it doesn’t take much to throw me off balance. Upon falling, I fell over the couch and hit the floor with the back of my head, my family stated that they tried to arouse me but did work, they called EMS and one of the Paramedic performed the sternum rub on me at the about a month ago. I am still pain in my chest at the site . . . .

  19. Does your blog have a contact page? I’m having a tough
    time locating it but, I’d like to send you an email.

    I’ve got some ideas for your blog you might be interested in hearing.
    Either way, great blog and I look forward to seeing it develop over
    time.

  20. Tara wood says:

    I suffer with passing out quite a lot and everytime I have been in hospital from it they have done the rub and I never woke up from it when I did finally come round I have allways had massive bruises the last time I was in about 8 days ago a nurse tried waking me up with the rub but did it nicely then another nurse did it really hard my sister couldn’t believe her eyes she said the whole bed was shakin sometimes you get the good nurses and sometimes you get the shit ones x

  21. Sooooo many typos in that article…

  22. Interesting article and coments…
    I used the “rub” on a pt unresponsive after found with O2 off. Tried all the first simple techniques as
    suggested above, no response….
    Used pressure once, no response and a code was called …

  23. what os the test of lifting eyelids? How does it work?

Trackbacks

  1. […] He then made a fist with his massive hand and started rubbing his knuckles over my customer’s sternum. He rubbed vigorously over and over and said “this is supposed to work. He’s the first […]

  2. […] down instantly. She most likely kicks him in the lower sternum, the same place that EMTs do the sternal rub. The reason is that doing anything to that spot is extremely, EXTREMELY painful. In fact, kick or […]

Speak Your Mind