The Do's and Don'ts of Sternal Rubs

Sternal rubs are one of the most common painful stimuli used by medical professionals, yet sternal rubs are often contraindicated or performed incorrectly.

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The Do's and Don'ts of Sternal Rubs

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:

  • The proper way to perform a sternal rub
  • Why we sometimes use it for the Glasgow Coma Scale
  • When not to use a sternal rub
  • Alternative central pain stimuli techniques

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

  • Spontaneous--open with blinking at baseline (4 points)
  • To verbal stimuli, command, speech (3 points)
  • To pain only (not applied to face) (2 points)
  • No response (1 point)

Verbal Response

  • Oriented (5 points)
  • Confused conversation, but able to answer questions (4 points)
  • Inappropriate words (3 points)
  • Incomprehensible speech (2 points)
  • No response (1 point)

Motor Response

  • Obeys commands for movement (6 points)
  • Purposeful movement to a painful stimulus (5 points)
  • Withdraws in response to pain (4 points)
  • Flexion in response to pain (decorticate posturing) (3 points)
  • Extension response in response to pain (decerebrate posturing) (2 points)
  • No response (1 point)

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:

  • Severe Head Injury: GCS score of 8 or less
  • Moderate Head Injury: GCS score of 9 to 12
  • Mild Head Injury: GCS score of 13 to 15

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:

  1. Assess the sternum. You don't want to sternal rub someone with a presternal abrasion or a fresh sternotomy scar from cardiovascular surgery. If either is present, perform another type of central stimuli (trapezius squeeze, mandibular pressure, or supraorbital pressure).
  2. Make a fist and firmly rub your knuckles up and down the person's sternum. There is no need to rub using all your strength; firm pressure is appropriate. The goal is to not leave a bruise.
  3. Apply pressure and rub the sternum until you elicit a response. Do not rub for more than 30 seconds.
  4. Look for responsiveness. Again, watch the person's hands or feet for movement; it may be a small, slight movement. On the contrary, the person may respond more appropriately and reach toward you to stop the pain.

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

  • The person is intoxicated or sedated. Alcohol is a central nervous depressant. Certain drugs like benzodiazepines, barbiturates, and some sleep medicines also depress the central nervous system, depressing their response to a stimulus.
  • There is a presternal abrasion, or you will leave a bruise.
  • Another team member recently performed it. Collaborate with your team to determine what response they saw or whether they performed it correctly.=
  • The person recently had open heart surgery with a sternotomy. Assess the chest to see if the person has a long midline surgical scar down their chest. Irritating that incision could cause anything from infection to wound dehiscence.
  • The person has polytrauma or suspected rib fractures.

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:

Quote

Hey so during my last clinical staff on the unit were talking about sternal rubs and I got a really mixed message. Is it something that nurses are allowed to do? Or just doctors?

References

  1. Mistovich, J. (2017, May 16). Misinterpreting the results of a sternum rub. EMS1. Retrieved February 21, 2023, from https://www.ems1.com/ems-products/patient-handling/articles/misinterpreting-the-results-of-a-sternum-rub-Zk7mSQgBWXfyvygq/
     
  2. Whitehead, S. (2022, November 10). Test for unconsciousness: The sternal rub. TheEMTSpot. Retrieved February 21, 2023, from https://www.theemtspot.com/test-for-unconsciousness-the-sternal-rub/#So_how_do_we_do_it_properly
     
  3. Jain, S., & Iverson, L.M. (2022, June 21). Glasgow coma scale - statpearls - NCBI bookshelf. National Library of Medicine. Retrieved February 21, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK513298/
     
  4. Centers for Disease Control and Prevention (n.d.). Glasgow coma scale. Retrieved February 21, 2023, from https://www.CDC.gov/masstrauma/resources/gcs.pdf
     
  5. Emergency & Mobile Medicine Learning Network. (2006, July). Beyond the basics: Patient assessment. Retrieved February 21, 2023, from https://www.hmpgloballearningnetwork.com/site/emsworld/article/10322699/beyond-basics-patient-assessment#:~:text=Since the sternal rub does
     
  6. Naalla, R., Chitirala, P., Chittaluru, P., & Atreyapurapu, V. (2014, April 7). Sternal rub causing presternal abrasion in a patient with capsuloganglionic haemorrhage. BMJ Case Reports. Retrieved February 21, 2023, from https://casereports.bmj.com/content/2014/bcr-2014-204028
     
  7. Emergency & Mobile Medicine Learning Network. (2008, August). Beyond the basics: Interpreting altered mental status assessment findings. Retrieved February 21, 2023, from https://www.hmpgloballearningnetwork.com/site/emsworld/article/10320935/beyond-basics-interpreting-altered-mental-status-assessment-findings
     
  8. National Cancer Institute. (n.d.). NCI dictionary of cancer terms: Central nervous system depressant. Retrieved February 21, 2023, from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/central-nervous-system-depressant
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Delaney Schick

About Delaney Schick, RN

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Anyone can preform a sternal rub, it's a part of assessment (think Glascow Coma Scale). If a patient appears to be unresponsive and does not awaken to sound or shaking, illicit a pain response with a sternal rub.

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Specializes in ER trauma, ICU - trauma, neuro surgical.

Agreed! but be careful not to make sternal rubs apart of your routine assessment. I only do that if everything else doesn't work. You can take a penlight and push hard on the nailbed to see if they withdraw....it hurts! Try it on yourself.....you won't last long. Stick a sunction catheter in their mouth and see if they respond. Sweezing the tip of nose is unpleasent and it can make them sneeze. Pinch the back of their arm, pt's hate that. Gently shake them and speak loudly. I think sternal rubs are to be used if the guy looks like he's gonna code and you need to know now. When pt's come from the ER, the whole chest is bruised from people randomly doing sternal rubs. You're mashing the skin against the chest plate, which is why it works, but I think steral rubs should only be used in emergency situations b/c if he doesn't react, he's going on the vent!

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Thanks so much both of you! I've never done it, but I just wanted to know that if I ever had to because a patient was super unresponsive, and if nothing else worked then it is in the scope of practice for an RN, and not only doctors.

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Specializes in ER, progressive care.

Always go from verbal to tactile to painful ;)

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My patient last week was not responisve and I watched the RN do the sternal rub. The pt opened their eyes for a moment but was back to being non responsive as soon as the nurse stopped. It was interesting to watch.

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Specializes in Med Surg.

My dad taught me that when I was a kid. (He was an EMS trainer in a larger metropolitan area).

Painful, but effective. So... I used it on everyone from high school friends who had a little too much to drink (where I was concerned about their level of consciousness) to other random people who I have found unresponsive. (For some reason, I seem to come across THE weirdest situations.

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Another way to assess response to pain that is a little less scary to any family member watching is to put your (closed) scissors or the large part of a metal key flat between two fingers held snugly together, then rotate it just a little bit. Try this on yourself and you'll get an idea of how extremely painful it is to deliver a tiny crush stimulus to your periosteum. This will give you an appreciation for how really unresponsive your patient is, it doesn't look like anything to a family member right there (unlike suprasternal or other more familiar maneuvers), and doesn't leave bruising.

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Specializes in Flight Nurse.

I love this article. I've watched so many doctors and nurses use this technique inappropriately. I'm glad she pointed out that it is to be used once as a baseline to figure out their LOC. It will either illicit a response or not. No need to keep hurting the patient. Thank you for the clarifications! 

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