The picture below is of a 26 yo female.
Second presentation over a week following poly-pharmacy and alcohol overdoses.
Can you identify the cause if this traumatic injury?
As part of our neurological assessment ( checking level of consciousness or calculating GCS for example) it may be necessary to elicit some form of noxious stimuli on our patients.
These stimuli may be divided into two categories. Central and peripheral.
It is important to remember that peripheral stimulation may illicit a reflex response, completely bypassing the brain and therefore not giving an accurate evaluation of cerebral function.
So we should assess for a central response first.
Central Noxious Stimuli (in order of preference).
Stimulated by gripping or pinching the trapezius muscle (above the clavicle and close to the neck).
Alternate sides during subsequent assessments to minimise soft tissue damage.
If no response on one side you may try the other.
May be difficult to perform in patients with really muscular, or short bull-necks.
Press your first and second finger upwards and inwards just under the angle of the jaw (think: jaw thrust).
Should not be used if suspected fractures of jaw.
Cannot use if hard collar in situ.
The supra-orbital nerve is stimulated by applying pressure to the indentation on the orbital rim near the nose.
It should not be used if there is any facial, orbital or ocular trauma.
Take care if you have long fingernails (which you don’t, right?).
If the above noxious stimuli cannot be used, a stern all rub may be considered. However, this technique is losing favour due to its potential for bruising and trauma. Particularly in the elderly.
So consider the above options first.
We want to assess our patients, not assault them.
The correct method to deliver eternal rubs is NOT to rub your knuckles across the sternum like a washboard….but to rotate them into the sternum as if using a mortar & pestle. Moderate prolonged pressure for 20–30 seconds should elicit a response.
Peripheral Noxious Stimuli.
Firm pressure is applied to the base of the fingernail by placing a pen or pencil across the nail bed and pressing on this. Again, moderate prolonged pressure (20–30 sec) is the key.
Alternate fingers for subsequent assessments.