Neuro Assessment

5/7/04
dear all
could i ask about your practise in regard to eliciting a motor response when doing a patient's gcs. I'm familiar with most of the arguments for all of these both positive and negative. Do you
1. nail bed pressure +/- object (eg pen)
2. sternal rub
3. periorbital or is it supra orbital(?) pressure
thanking you all in anticipation

CNS Data Management
Tertiary Referral ICU

5/7/04
At XXX we only illicit central stimuli ie either:
*sternal rub
*trapezius squeeze
and as a last resort
*supraorbital pressure

Nursing Unit Manager Neurosurgical Intensive Care Unit
Tertiary Referral Metropolitan

6/7/04
Hi
I would never use nail bed pressure first, as it can stimulate a spinal reflex and make life confusing. I prefer and use a central painful stimulus, eg supraorbital pressure, pressure to ear lobe, trapezoid pinch. Tend not to use the sternal rub as I work in paediatrics, though would certainly use it in adults.

RN - PICU
Children's Hospital, Westmead

6/7/04
Our practice at XXX ICU is to use central pain stimulus to elicit a central response namely:
Trapezium squeeze
Supraorbital pressure
Sternal Rub.
Clinical Nurse Educator
Tertiary Referral Metropolitan

6/7/04
Our practice would be nail bed pressure, and failing that, supra orbital
pressure.

Clinical Nurse Educator
Cardiac/Thoracic Ward
Tertiary Referral Metropolitan

6/7/04
I agree with NUM Neurosurgical Intensive Care Unit. The literature says that the trapezium squeeze is actually the most effective in eliciting a response in the head injured patient and this is what I teach in the Hunter. Try it yourself. It does hurt but does not leave the bruises that nailbed pressure and a sternal rub can and does.

Area Trauma Coordinator
Rural Area Health Service

6/7/04
What is the specific literature, ? Could you please point us to the references.
Remember what you are trying to achieve - a motor response to a very specific painful response. You don't have to press hard if you press in the right place. That is why specific pressure on the supraorbital nerve (junction of middle third and outer two thirds of the upper edge of the orbit) is so useful, because gentle pressure elicits a specific motor response (and acknowledging that the M component is the only part of the GCS with any prognostic value). Likewise gentle nailbed pressure, though this is a bit less specific. If you cause bruises you are pressing too hard.
I don't routinely use a trapezius squeeze as this is now getting a bit non specific but would be interested in seeing the literature you quote.
Sternal rub is to be deplored. It is extremely nonspecific (therefore impossible to interpret the response you get) and extremely damaging, causing horrible bruising and in extreme cases skin breakdown. See image below.
When I see our trainees doing a sternal rub I let them know I will break their arms if I ever see them do it again. Don't know how many times that needs to be repeated to get the message through.

Staff Specialist Tertiary Referral

6/7/04
ah, my favourite subject!!! The old 'simple' GCS really isn't that simple and when describing methods for eliciting response from painful or noxious stimuli you need recognised forms of stimulus that 'anyone' can reproduce reliably. The literature varies in what it prescribes and proscribes. I don't think I've read a paper that states one form of painful stimulus is better than another. Depending upon the patient and the situation - the stimulus chosen will vary and even when one form is considered better for the patient, it should be rotated with something else to prevent nerve damage, unsightly bruising etc.
I do not teach nail bed pressure as a first line method for eliciting motor movement - due to incidence of reflex response and also a withdrawal from nail bed pressure should not be equated with a localising response - they are different!
Probably the best description I've read for neuro' assessment using the GCS and adding on pupillary assessment and limb strength is that written by Judith Ski-Lower (Lower, "Ski" J. 1992. Rapid Neuro Assessment. American Journal of Nursing. June, 38-45.). Its old (Sally Robertson from the CON says there's a newer version of her article) but the old one is great.
I have not yet seen a sternal rub - related skin breakdown - that sounds terrible! I don't deplore the use of it as having worked in Neuro ICU for many years - it was a useful tool but it did need to be used appropriately and not if the patient had any degree of sternal oedema. I think this (then) small unit with very experienced staff probably avoided instances of 'misuse'. As we all know those hey days are over but I think that at times the sternal rub (grind) is better than trapezius squeeze and supraorbital pressure may not be appropriate with periorbital oedema post surgery or in the presence of facial/skull trauma.
For Ian - I'd probably be there in bilateral plaster casts trying to make my point!

CNC 1Tertiary Referral ICU

6/7/04
thanks for all of the responses, please keep them coming ! is there a definitive best practise? our unit's debate is over the use of sternal rub for a prolonged period causing skin breakdown

CNS Data Management
Tertiary Referral ICU

7/7/04
I agree with CNC 1's comments re neuro assessments. At XXX we elicit central response using trapezius squeeze, supro-orbital pressure in appropriate patients and as a last resort gentle sternal rub. We do not use nailbed pressures because of the possibility of only eliciting a spinal reflex; this applies particulary to patients who are unconscious, in a chemically induced coma, severely neurologically depressed. What one is trying to do is assess central response. I surveyed the major hospitals in Sydney and found that most follow the practice of central nioxious stimuli as outlined above.
Has anyone used pressure at the jawline below the earlobe? On patients who do not have facial or basal skull injuries of course!

CNC 2 ICU Tertiary Referral