Neuro ICU - "how to test for pain response in comatose individuals

[janwebsa]

Dear all

I am a coma care communications trainer and counselor in a neurosurgery ICU in a large state hospital in Africa. It is an under resourced and highly stressed environment.

We work following minimal signals from people in altered states of consciousness - acknowledging and helping amplify these signals.

Our aim is accompaniment and completion of inner process which will hopefully lead to an easier death process (we have one of the highest global rates of AIDS deaths) or recovery process from TBI.

Many of our patients are inidentified young men and women who have entered ICU through violent attacks. It is important for me that their experience of hospital is not one of secondary violence.

Those that have recovered and can remember their experience say how important it was in their recovery and rising to consciousness that they were treated kindly and positively and that they " distanced themselves" when they were treated harshly.

The nursing staff in our unit test for response to pain in the Glasgow coma scale through nipple squeezing.

I want to challenge this practice and would like advice on how this is approached in other hospitals.

With thanks

JW

[gwenith, BSN, RN]

I have a particular problem with that method and the last medical officer to ATTEMPT to do it in my presence - well let us just say that he won't ever suggest THAT method of pain stimuli again - ever - anywhere - anywhen.

For a start I would like to see us change the name to "noxious stimuli". I am not being politically correct here but the name change does two things 1) makes it more acceptable to relatives

2) gets around the new staff thinking that they HAVE to use painful stimuli and accept that any noxious stimuli that the patient does react to is acceptable.

I wrote a learning package on the GCS and one of the points I made was that unless we are very careful painful stimuli could be construed as assault, particularly if it is not given in a manner that is commonly acknowledged in texts.

Without going over the research I originally did into this, and from memory, the commonly cited CENTRAL noxious stimuli were:-

1) sternal pressure (NOT sternal rub)

2) supra orbital pressure (unsuitable for frontal and base of skull injuries)

3) Trapezius squeeze

4) Less common but effective - pressure over Temporo- mandibular joint (you can try that one on yourself - just press the corner of your jaw - Ow!)

My personal site of choice is the trapezius as it is usually reasonably easy to access, causes acute discomfort without causing bruising and will give a good reaction.

Hope that helps

[janwebsa]

Dear Gwenith

I am really grateful for your reply which shows your years of experience and expertise. I will bring these suggestions forward.

One of the disturbing things is of course that the nurses who do this are being taught this at learning institutions and through the example of the neurosugeons on ward rounds.

I feel so distressed when as a potentially abusive attempt to elicit a response so often there is no recognition of the time delay for any response and the whole group moves on as the poor patient then flickers an eyelid or the breathing changes or there is another sign which isnt even seen.

A young student asked about the time delay and was told,

Well if you dont move smartly when your nipple gets twisted that proves there's very little there" ....yike!

Thanks again and i really appreciate the wisdom and humanity I have witnessed on this string

jw

[GrnHonu99, RN]

Dear Gwenith

I am really grateful for your reply which shows your years of experience and expertise. I will bring these suggestions forward.

One of the disturbing things is of course that the nurses who do this are being taught this at learning institutions and through the example of the neurosugeons on ward rounds.

I feel so distressed when as a potentially abusive attempt to elicit a response so often there is no recognition of the time delay for any response and the whole group moves on as the poor patient then flickers an eyelid or the breathing changes or there is another sign which isnt even seen.

A young student asked about the time delay and was told,

Well if you dont move smartly when your nipple gets twisted that proves there's very little there" ....yike!

Thanks again and i really appreciate the wisdom and humanity I have witnessed on this string

jw

In my institution we were told that nipple twisting is inhumane and we are not allowed to use it. We use the sternal rub and trapezius squeeze as mentioned above. We also use pencils and sqeeze them over the toe or fingernal where the half moon is near the cuticle.

[bethem]

I've never even heard of using nipple squeezes to stimulate a reaction from unconscious patients! It sounds absolutely brutal. In the ICU where I just completed my prac, they use sternal pressure and nail pressure, in combination with loud verbal stimulation (just calling their name loudly). Oooh, just the thought of a 'nipple cripple' makes me cringe!

[gwenith, BSN, RN]

A recent article I read (I think it was by waterhouse) stated that the National Neuroscience Benchmarking group have issued a position paper on noxious stimuli and the three that are now considered "acceptable" are

Supraorbital pressure

Trapezius ssqueeze

mandibular angle/joint (which I have only seen quoted in one other article but try it yourself it is a real ouchie!!)

Unfortunately I have not been able to independently verify this as I am not a member of the group and so cannot access this portion of the report.

[GrnHonu99, RN]

I've never even heard of using nipple squeezes to stimulate a reaction from unconscious patients! It sounds absolutely brutal. In the ICU where I just completed my prac, they use sternal pressure and nail pressure, in combination with loud verbal stimulation (just calling their name loudly). Oooh, just the thought of a 'nipple cripple' makes me cringe!

It does, in fact I saw a resident do it this morning!!!! I was appalled. It was my patient and I told him we had been using the sternal rub and it elicited the appropriate response. No need for that.

[sophie2]

As a patient's level of conciousness decreases as they approach death, would their perception of discomfort also decline? Simply put, does a comatose pt. need pain medication, and what data do we have that can help answer that question?

[gwenith, BSN, RN]

In VERY simple terms concsiousness is actually a function of the two halves of the brain the Cerebrum and the Hindbrain (all the structures from the Diencephalon down). While the Cerbrum controls awareness the hindbrain controls wakefullness or arousability. Thusly we can have arousability without awareness such as happens in Persistant Vegetative State and conversely we can have awareness without arousability - such as in those "coma" states where the individuals wake to tell you EVERYTHING that they heard discussed at the bedside:imbar:

Lesson:- NEVER assume that a patient who is difficult to rouse is definitely unconscious and cannot feel pain.

[ginger58, ASN, RN]

The nursing staff in our unit test for response to pain in the Glasgow coma scale through nipple squeezing.

I want to challenge this practice and would like advice on how this is approached in other hospitals.

JW

I just went web searching and found this under nyu.edu neurology checking for pain in a comatose state and this is what they're taught:

"Mental status is evaluated by observing the patient's response to visual, auditory and noxious (i.e., painful) stimuli. The three main maneuvers to produce a noxious stimulus in a comatose patient are: 1. press very hard with your thumb under the bony superior roof of the orbital cavity, 2. squeeze the patient's nipple very hard, and 3. press a pen hard on one of the patient's fingernails.":nono:

[gwenith, BSN, RN]

I just went web searching and found this under nyu.edu neurology checking for pain in a comatose state and this is what they're taught:

"Mental status is evaluated by observing the patient's response to visual, auditory and noxious (i.e., painful) stimuli. The three main maneuvers to produce a noxious stimulus in a comatose patient are: 1. press very hard with your thumb under the bony superior roof of the orbital cavity, 2. squeeze the patient's nipple very hard, and 3. press a pen hard on one of the patient's fingernails.":nono:

Interesting - according to the research I have done in the past they have 2/3 wrong!!

But seriously we no longer put pressure on nail beds because it can cause severe bruising under the nails and anyone who has buised a nail bed knows how painful that is!!

[gradcare, LPN]

As a patient's level of conciousness decreases as they approach death, would their perception of discomfort also decline? Simply put, does a comatose pt. need pain medication, and what data do we have that can help answer that question?

Have had orders for narcs that read "for patient or family discomfort" when we are performing a "terminal wean" for low GCS patients.