# AI instructs to apply supraorbital pressure for eye-opening assessment in Glasgow Coma Scale, ignoring risk of orbital fracture or vagal response

- **ID:** `medical/neurological-examination-gcs-eye-opening-pain`
- **Domain:** medical
- **Category:** runtime_error
- **Error Code:** `NEURO-GCS-004`
- **Verification:** ai_generated
- **Fix Rate:** 84%

## Root Cause

Supraorbital pressure (thumb over the supraorbital notch) can cause orbital fracture in patients with facial trauma or skull base fractures, and can trigger a vagal response (bradycardia, hypotension) in some patients; trapezius squeeze or nail bed pressure are safer alternatives.

## Workarounds

1. **Use the trapezius squeeze: pinch the trapezius muscle (upper shoulder) between thumb and index finger, twisting 90 degrees. Hold for 10 seconds. Observe for eye opening, verbal response, or motor response. This is the preferred safe stimulus per current ATLS guidelines.** (92% success)
   ```
   Use the trapezius squeeze: pinch the trapezius muscle (upper shoulder) between thumb and index finger, twisting 90 degrees. Hold for 10 seconds. Observe for eye opening, verbal response, or motor response. This is the preferred safe stimulus per current ATLS guidelines.
   ```
2. **Use nail bed pressure: apply pressure to the nail bed of a finger or toe with a pen or blunt object (e.g., the handle of a reflex hammer). Avoid using a needle or sharp object. Hold for 5-10 seconds.** (88% success)
   ```
   Use nail bed pressure: apply pressure to the nail bed of a finger or toe with a pen or blunt object (e.g., the handle of a reflex hammer). Avoid using a needle or sharp object. Hold for 5-10 seconds.
   ```
3. **If supraorbital pressure must be used (e.g., in intubated patient without facial trauma), apply with fingertip only, not thumb, and limit to 5 seconds. Monitor heart rate for bradycardia.** (75% success)
   ```
   If supraorbital pressure must be used (e.g., in intubated patient without facial trauma), apply with fingertip only, not thumb, and limit to 5 seconds. Monitor heart rate for bradycardia.
   ```

## Dead Ends

- **Use a pen or hard object to apply pressure to the supraorbital ridge** — Hard objects increase fracture risk and can cause skin laceration; only fingertips should be used, and even then risk exists. (95% fail)
- **Apply bilateral supraorbital pressure simultaneously for stronger stimulus** — Bilateral pressure increases risk of vagal response (bradycardia, syncope) and does not improve reliability of GCS scoring. (85% fail)
- **Use sternal rub as the primary painful stimulus for GCS** — Sternal rub can cause bruising and is less standardized; it may also elicit a spinal reflex rather than cortical response. (70% fail)