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Acute brain injury is a commonly encountered clinical problem that can make appropriate clinical assessment challenging. A key limitation in the neurological intensive care unit is how examiners assess a patient’s level of arousal or responsiveness. The vast majority of providers are trained to use either nail bed pressure or a sternal rub technique to achieve such responses. While these noxious stimuli do elicit findings in non-comatose patients, comatose patients may be exposed to unnecessary harm with these techniques. In fact, reports in the literature have shown that sternal rubbing causes iatrogenic complications including skin tears, abrasions, and ecchymosis.1 Such consequences should be considered during formal neurological assessment. Here, we present a case of repetitive noxious stimuli leading to diffuse sternal bruising, which the authors formally refer to as the “coma sign” (Figure 1). Figure 1. The “coma sign” from repetitive sternal rubs

The “coma sign”; an iatrogenic complication of neurological assessment