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.

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Treatment of Head Injury

Part three of a three part series

In our last two installments we looked at the way heads get injured and the various ways the brain tends to bleed. In this, our last installment in the head injury series, let’s take a look at basic treatment and management of the head injury patient.

There are a lot of variables that need to be considered when managing a head injury patient in the prehospital environment. Your treatment will be guided by considerations like the mechanism and severity of the head injury, other associated injuries, the patients mental status and their basic stability. 

These are some guidelines when sizing up and prioritizing your care.

Airway Management:

Head trauma management begins with the airway. The brain is sensitive to hypoxia and a poorly managed airway can turn a significant but recoverable head injury into a devastating head injury. Our brain injured patients can present some unique airway challenges. Seizures and posturing can produce trismus and spinal precautions prohibit proper tilting of the head.

In these cases, oral and nasal airway adjuncts are helpful in ensuring proper ventilation while keeping the head midline and neutral. If the Glasgow is less than eight, consider an advanced airway like a king tube, combi-tube or ET tube. All of these should be protected from the possibility of a clenched jaw with some sort of bite block type protection.

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Responding to Head Injuries

Part one of a three part series.

It seems that after the tragic deaths of both Natasha Richardson and Billy Mays, head injuries have been getting a lot of play time in the media. Richardson died of an epidural bleed after a helmetless fall on skis. Mays was found to have an enlarged heart, but the minor head injury he received the night before his death launched speculation that he had died from intracranial bleeding as well.

Both of these incidents bring to light an important element of head injury response and evaluation. Patients with critical, life threatening brain injuries don’t always present as sick. Often they report feeling just fine. The emergency responder needs to approach head injuries with a high index of suspicion.

Today were going to begin a three part series on head injuries. In part one we’ll take a look at the different ways the skull and brain get injured. In part two we’ll talk about how the brain bleeds and how that can change the patients presentation. In part three we’ll look at treatment considerations for the head injured patient.

Let’s do a quick review of what’s inside your head:

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Test For Unconsciousness: The Hand Drop

After I wrote a recent article on the benefits of the face flick for assessing level of consciousness, I received a string of questions and commentary on the effectiveness of another, more well known assessment for unconsiousness - the hand drop test.

The hand drop test is considerably more well known than its cousin the face flick and it remains a fairly reliable, though somewhat controversial test.

There’s a reason why the hand drop test is so well known. It tends to work. It’s a clever and reliable way to force a patient to make a decision and reveal their true mental status.

When done properly it’s harmless and does not require forcing pain or noxious stimuli on the patient. It also has the advantage of  being appropriate to perform in front of family and loved ones. Unlike the face flick which is a bit to obnoxious for public consumption, the hand drop can be performed anywhere and looks like a fairly standard neurological test. If you don’t have this one in your tool box yet, it’s time to add it. If you do know it, let’s review it. There are some subtle elements to doing the hand drop test accurately and safely.

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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?

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