Medical professionals rely on quick, reliable methods to gauge a patient’s level of consciousness, especially in emergency situations. Procedures for determining responsiveness to painful stimuli have long been part of emergency protocols. Like all medical techniques, these practices are continuously reviewed based on new evidence and evolving consensus regarding patient safety. The sternal rub was once a commonly taught technique for this purpose, but it has now largely been discouraged from standard practice, reflecting a move toward less harmful and more precise assessment methods.
Defining the Sternal Rub and Its Historical Purpose
The sternal rub is a technique historically employed to provide a central noxious stimulus to patients unresponsive to verbal or gentle physical prompts. The procedure involves making a closed fist and using the knuckles, typically of the second and third fingers, to rub vigorously across the patient’s sternum (breastbone). This action generates localized pain intended to elicit a motor or verbal response.
This technique was favored because the sternum is a central bony structure. A response to a central stimulus is considered a more reliable indicator of brain function than a response to a peripheral stimulus, such as pinching a limb. The sternal rub was often incorporated into neurological assessments, like the AVPU scale, serving as a rapid, equipment-free method for triaging an unconscious patient’s level of awareness.
Specific Risks and Physical Trauma
The primary reason for the sternal rub’s obsolescence is its potential to cause significant physical trauma and its unreliable nature as an assessment tool. The vigorous rubbing action can result in severe bruising, skin abrasions, and deep tissue injury to the chest wall. These injuries are particularly common in elderly or frail patients, or those with underlying conditions affecting tissue integrity.
Beyond superficial damage, there is a risk of fractured cartilage or ribs, especially if excessive force is applied, which directly violates the medical principle of “do no harm.” Because the degree of pressure and duration of the rub often lacked standardization, the results were inconsistent, further complicating its utility.
The procedure also raises serious ethical and psychological concerns regarding patient dignity. Applying such a highly painful and aggressive stimulus to an unresponsive individual can be perceived as undignified. Moreover, the diffuse pain it causes makes it difficult to determine if the patient is truly localizing the pain—a specific neurological sign—or simply withdrawing from a widespread, uncomfortable sensation. The unreliability, combined with the clear potential for physical harm, led medical consensus to seek safer, more targeted alternatives.
Current Standard Practices for Assessing Consciousness
Modern medical guidelines recommend alternative methods for applying central noxious stimuli that are less likely to cause physical harm. These techniques are generally more localized and allow for a more precise assessment of the patient’s reaction.
One preferred method is the trapezius squeeze, which involves pinching and twisting a portion of the trapezius muscle between the neck and shoulder. This area is sensitive enough to elicit a central pain response without causing lasting tissue damage.
Another accepted method is supraorbital pressure, applied by pressing a thumb onto the bony ridge above the eye, near the nose. These alternatives are favored because they are quick, effective, and pose a lower risk of abrasion or bruising compared to the sternal rub. For a peripheral stimulus, firm pressure can be applied to a nail bed, often using a knuckle or pen, though central stimuli are still preferred for assessing the highest level of brain involvement.
The shift in practice demonstrates a commitment to using methods that minimize patient discomfort while still providing reliable data on neurological status. By utilizing localized pressure points like the trapezius or supraorbital ridge, clinicians can more safely gauge the patient’s level of consciousness. These targeted approaches ensure that the assessment remains focused on the patient’s neurological function.