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As a Neuro ICU nurse, I used sternal rubs as a go-to method when a painful stimulus was necessary to test a patient's motor response. Thankfully, with some research, I realized it might not be the best practice.
Although it is not wrong, in this article, there are other more effective and safe methods. In this article, we'll cover:
What is a Sternal Rub?
A sternal rub is a firm rub on someone's sternum is a method used when testing an unconscious person's responsiveness. A "painful or noxious stimuli", the purpose is to elicit a response from a patient unresponsive to more gentle interactions. This method is one way to test someone's motor response.
After a patient doesn't respond to more innocuous stimuli such as voice, gentle rubs or the like, a healthcare provider can perform a sternal rub. Some indications for sternal rubs include brain injury or an overdose. With these conditions, sternal rubbing may be a valuable technique to employ.
Sternal rubs are one part of a common neurological assessment called the Glasgow Coma Scale.
What is the Glasgow Coma Scale?
The Glasgow Come Scale (GCS) is the most objective system used in healthcare to rate someone's level of consciousness. It's used in the field by EMTs and paramedics, in the hospital upon admission, and in a hospital unit with every nursing or provider assessment. The scale assesses 3 areas: eye-opening, motor, and verbal responses. The parameters are scored as:
Eye Opening Response
Verbal Response
Motor Response
The average healthy person with no deficits is going to score a 15. One area we often use the GCS is with patients with brain injuries. The lower the number, the more severe their head injury is. The categorization depends on severity:
As a healthcare provider, you perform a test for each area to determine the score. If someone does not respond to voice or touch, then use painful stimulation. Often, that stimulus is a trapezius squeeze, mandibular pressure, supraorbital pressure, or a sternal rub.
Steps to Perform a Sternal Rub Correctly
It's vital to ensure a sternal rub is appropriate in the situation. It should not be your first move on someone who appears unconscious because it is extremely painful (just try it on yourself; it does not take a lot of pressure to cause discomfort). There are other things you should try first.
For example, a good place to start is with a gentle shake and saying, "Hey, are you okay?” If they do not respond to voice or touch, move on to a painful stimulus.
Try peripheral stimuli first. You can apply pressure to the bottom of their nail bed with your thumb and index finger. Pay attention to their hands and feet because they are often the first— and possibly the only—response you will get from a subconscious person.
It's important to note that a peripheral stimulus response does not mean the same as a central stimulus response in a patient. You may only get a spinal reflex response if you apply pain to someone's periphery (hands, lower legs, feet, or nail beds). A sensory nerve tract sends the pain signal to the spinal cord. The spinal reflex immediately responds via a motor nerve tract that travels to the muscle of the extremity experiencing pain. If intact, this will cause the patient to respond by withdrawing from the pain. Because the impulse stopped at the spinal cord, it was never transmitted to the brain. Therefore, a positive peripheral response only indicates that the peripheral nervous system is intact. To be accurate, you must also check their central nervous system.
One method to check the central nervous system response is to provide a painful central stimulus, often a sternal rub. To perform a sternal rub with accuracy, follow the steps:
When to Avoid a Sternal Rub
In many cases, you can avoid sternal rubs altogether. Some say it is the least recommended painful stimulus because it does not distinguish if the person is localizing or withdrawing from pain, which is vital to note when scoring a person on the GCS.
As mentioned before, try other stimuli first. Start with the least invasive and transition to more invasive methods if necessary.
Avoid sternal rubs if
What Are the Potential Risks of a Sternal Rub?
Sternal Rubs Can Cause Bruising or Abrasions
There is a case study of a 50-year-old male in the hospital for an intracerebral hemorrhage. On admission, his GCS was 5 (Eyes-1, Motor-3, Voice-1). Knowing that, providers most likely performed sternal rubs or painful stimuli on him multiple times daily. Unfortunately, he developed a 7cm by 1cm abrasion on his sternum, directly caused by excessive sternal rubs. Always assess the sternum beforehand.
Watch Out for Combative Patients
As you have learned, sternal rubs induce a lot of pain. For some people, they can elicit a response so significant it might involve their hand or arm coming at you and causing an injury. Even in a subconscious state, this type of painful stimulus can cause purposeful or non-purposeful harm.
Infections or Worsened Injury
Avoid sternal rubs when there is an incision, abrasion, or injury to the chest. The last thing the patient needs is for their providers to worsen their condition by blindly sternal rubbing them, which could irritate an incision or open wound on or near the sternum.
You don't want to have to page the cardiothoracic surgeons if you see a sternotomy scar start to dehisce. And you definitely do not want to feel some already broken ribs cracking when you could perform a trapezius squeeze instead.
Bottom Line
Use your clinical judgment to decide if a sternal rub is necessary. Because it is such a common practice, knowing the risks that come with sternal rubs is crucial. Now you understand the risks and when to avoid sternal rubs altogether. You also have learned alternative methods for central painful stimuli, such as the trapezius squeeze, mandibular pressure, and supraorbital pressure.
Painful stimuli are sometimes necessary when scoring someone on the Glasgow Coma Scale. Ensure you take the appropriate action to get an accurate response without causing more damage.
STAFF NOTE: Original Community Post
This article was created in response to a community post. The comments and responses have been left intact as they may be helpful. Here's the original post:
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About Delaney Schick, RN
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