Podcast 862: How to Apply a Painful Stimulus

<p dir="ltr"><strong>Contributor: Travis Barlock MD</strong></p> <p dir="ltr"><strong>Educational Pearls:</strong></p> <p dir="ltr">When might you need to apply a painful stimulus in a medical setting?</p> <ul> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">The main reason is to assess the patient's level of consciousness, such as when they are waking up from anesthesia or have potentially suffered a brain injury.</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">It can be part of the Glasgow Coma Scale (GCS) if patients are not responding to auditory stimuli.</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Possible levels of consciousness include Alert, Lethargic, Obtunded, and Comatose (ALOC)</p> </li> </ul> <p dir="ltr">What are the approved ways to apply a painful stimulus to assess central nervous system function?</p> <ul> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Trapezius squeeze. Grab the trapezius muscle and twist (contraindicated in clavicle fractures).</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Supraorbital rim pressure. Find the notch in the supraorbital rim of the patient and push hard with your thumb (contraindicated in facial fractures).</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Mandibular pressure (not mentioned). Press hard at the angle of the jaw on the mandibular nerve (contraindicated in mandible fractures).</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Sternal rub. Push down with your knuckles into the patient’s sternum and rub vigorously (contraindicated in chest injury/surgery).</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Each technique should be done for between 15 and 30 seconds.</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">If skin damage is observed in one location, move to a different location. This is especially true of the sternal rub.</p> </li> </ul> <p dir=