The sternal rub is a technique employed in medical settings for assessing a patient’s level of consciousness.
This method involves applying a specific type of painful stimulus to the sternum to elicit a response from a patient who is not fully conscious or is unresponsive.
The response, or lack thereof, provides healthcare professionals with vital information about the patient’s neurological status.
While seemingly straightforward, the application of a sternal rub requires a nuanced understanding of its indications, techniques, and potential risks, making it an important procedure in emergency medical care.
What is the Sternum?
The sternum, commonly known as the breastbone, is a long, flat bone located in the center of the chest.
It serves as a major attachment point for several ribs and forms the front part of the rib cage, providing protection to vital organs like the heart and lungs.
The sternum also connects to the collarbones (clavicles) at its top, playing a crucial role in the skeletal structure of the thorax.
What is a Sternal Rub?
A sternal rub is a medical technique used to assess a patient’s level of consciousness. It involves vigorously rubbing the sternum with the knuckles. This action causes discomfort and elicits a response from the patient, helping healthcare professionals determine their alertness and pain response.
The sternal rub is typically used as a part of the neurological assessment in medical settings, particularly to evaluate a person’s level of consciousness.
The indications for a sternal rub include:
- Assessing Responsiveness: It’s used on patients who are not fully conscious or are unresponsive. The discomfort caused by the rub is meant to provoke a response.
- Glasgow Coma Scale (GCS) Evaluation: The GCS is a widely used scoring system to describe the level of consciousness in a person following a traumatic brain injury, and a sternal rub is used to assess the patient’s motor response.
- Differentiating Levels of Unconsciousness: It helps in distinguishing between different states such as deep sleep, stupor, or coma. A lack of response to a sternal rub might indicate a deeper level of unconsciousness.
- Assessment in Emergency Situations: In emergency medical situations, a sternal rub can quickly help determine a patient’s level of consciousness, especially when verbal responses are not possible.
Note: While the sternal rub is a common technique, it should be used judiciously and with care to avoid causing harm, and it is typically performed by trained healthcare professionals.
Contraindications for performing a sternal rub are situations or conditions where this technique should be avoided due to the risk of harm or because it would not provide useful diagnostic information.
Some examples include:
- Suspected Spinal Injury: In patients with a suspected cervical spine injury, any movement or pressure, including a sternal rub, could exacerbate the injury.
- Chest Trauma or Fractures: For patients with known or suspected chest trauma, including fractures of the sternum or ribs, a sternal rub can cause further damage or pain.
- Skin Integrity Issues: If there are burns, wounds, or other skin integrity issues in the sternum area, a sternal rub should be avoided to prevent exacerbation of these conditions.
- Osteoporosis or Bone Fragility: In patients with conditions like osteoporosis, where bones are fragile, applying pressure on the sternum might cause fractures.
- Pediatric Patients: Special caution is needed in pediatric patients, as their bones are more flexible and susceptible to injury.
- Known Cardiovascular Issues: In patients with severe cardiovascular issues, especially those involving the sternum area, additional caution is required.
- Prior Knowledge of Patient’s Responsiveness: If the level of consciousness can be assessed by less invasive means or is already known, a sternal rub might not be necessary or appropriate.
Note: It’s important for healthcare professionals to consider these contraindications and use alternative methods to assess consciousness when necessary.
How to Perform a Sternal Rub
Performing a sternal rub requires careful technique to ensure it is both effective and minimizes the risk of harm.
Here’s a step-by-step guide:
- Position Your Hand: Make a fist with one hand. Use the knuckles of your second and third fingers (those next to your thumb).
- Locate the Sternum: Identify the patient’s sternum, which is the long, flat bone in the center of the chest.
- Apply Pressure: Place your knuckles against the middle of the sternum.
- Perform the Rub: Firmly rub up and down along the sternum. The motion should be vigorous enough to elicit a response but not so forceful as to cause injury. The rub should last for a few seconds.
- Observe the Response: Watch for any reaction from the patient, such as movement, grimacing, or vocalization, which indicates their level of consciousness.
- Use Caution: Be mindful of the force used, especially in patients with frail health, osteoporosis, or known chest injuries.
- Consider Alternatives: If a sternal rub is contraindicated or if you’re uncertain about performing it, consider alternative methods to assess responsiveness, like gently shaking the patient or speaking loudly.
- Document and Report: Record the patient’s response to the sternal rub and report it to the healthcare team for further evaluation and care.
Remember: This technique should only be performed by trained healthcare professionals. It’s important to always consider the patient’s overall condition and the potential risks before proceeding.
Who Can Perform a Sternum Rub?
A sternal rub should ideally be performed by trained healthcare professionals such as doctors, nurses, respiratory therapists, paramedics, or emergency medical technicians.
These individuals have the requisite training and knowledge to correctly assess a patient’s level of consciousness and to understand the implications of the response elicited.
They are also trained to recognize and respect the contraindications for such a procedure and can effectively integrate the results of a sternal rub into the patient’s overall clinical assessment.
While it might seem simple, the technique requires a nuanced approach to ensure it is both effective and safe, making professional training and experience crucial.
Alternative Methods to Sternal Rubs
Alternative methods to sternal rubs for assessing consciousness focus on less invasive techniques.
These include verbal stimuli, such as loudly calling the patient’s name or asking simple questions, and physical stimuli, like gently shaking the patient’s shoulder.
The use of pain stimuli, applied away from potential injury sites, is also common. For example, a peripheral pain stimulus like pinching the earlobe or the back of the arm can be effective.
These alternatives are particularly useful when sternal rubs are contraindicated due to a patient’s condition or potential injury risks.
Each method provides valuable information about the patient’s level of responsiveness and consciousness.
FAQs About a Sternal Rub
How Does a Sternal Rub Work?
A sternal rub works by applying a painful stimulus to the sternum (breastbone) to assess a patient’s level of consciousness.
The discomfort caused by vigorously rubbing the sternum with knuckles triggers a response in a conscious person.
This response can range from verbal outcries to grimacing or attempting to push the stimulus away.
It helps healthcare professionals evaluate the patient’s brain function and responsiveness, especially in cases where verbal communication isn’t possible.
Is a Sternal Rub Painful?
Yes, a sternal rub is intended to be painful. The procedure involves applying significant pressure to the sternum using the knuckles, which creates a painful sensation.
This pain is deliberate, as the goal is to elicit a response from the patient.
The level of pain experienced can vary from person to person, but it is generally uncomfortable and used as a last resort when other less painful methods of assessing consciousness have been ineffective.
What are the Potential Risks of a Sternal Rub?
The potential risks of a sternum rub include bruising or abrasions on the sternum, especially if excessive force is used. In patients with fragile bones, such as those with osteoporosis, there is a risk of fracturing the sternum.
The technique can also be risky in patients with suspected spinal injuries or severe chest trauma.
Additionally, if not done correctly, it may cause distress or pain without providing useful diagnostic information.
Therefore, it’s crucial for the sternal rub to be performed by trained medical professionals.
What is the Glasgow Coma Scale?
The Glasgow Coma Scale (GCS) is a clinical tool used to assess and quantify a patient’s level of consciousness, especially after a head injury.
It evaluates three aspects of responsiveness: eye-opening, verbal response, and motor response.
Each aspect is scored individually, and the scores are then combined to give an overall score ranging from 3 (deep unconsciousness) to 15 (fully awake and responsive).
The GCS is widely used in medical settings to assess the severity of brain injuries and to monitor changes in a patient’s neurological status over time.
What if a Patient is Unresponsive to a Sternal Rub?
If a patient is unresponsive to a sternal rub, it suggests a deeper level of unconsciousness or altered neurological status.
In such cases, immediate medical evaluation is necessary to determine the underlying cause. The lack of response should be documented and reported to the healthcare team.
The unresponsiveness could be due to various factors, ranging from severe neurological injury to drug overdose, and each possibility requires specific medical attention.
The sternal rub is a valuable diagnostic tool in assessing a patient’s level of consciousness, particularly in emergency and critical care settings.
Its role in eliciting responses from patients who are otherwise unresponsive makes it crucial for initial neurological assessments.
However, its application must be considered carefully, given the potential risks and the discomfort it causes.
Healthcare professionals must be trained to perform this technique correctly and to interpret the results in the context of the patient’s overall condition.
The sternal rub, while a simple procedure, plays a significant role in guiding critical decisions regarding patient care and management.
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
- Faarc, Kacmarek Robert PhD Rrt, et al. Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
- Naalla R, Chitirala P, Chittaluru P, Atreyapurapu V. Sternal rub causing presternal abrasion in a patient with capsuloganglionic haemorrhage. BMJ Case Rep. 2014.