Emergency Care & Interventions: Neurological Assessment Chapter 20 EMERGENCY CARE AND INTERVENTIONS Rachel Palmer and Jessica Knight Please note: this presentation is also suitable for use with Foundation Skills for Caring Chapter 20: Neurological Assessment

Introduction This presentation examines the notion of consciousness and walks you through a neurological assessment. Part 1 – Level of Consciousness and Neurological Status Part 2 – Neurological Assessment and the GCS Part 3 – Pain & Noxious Stimuli Part 4 – Pupil Documentation & Assessment Part 5 – Limb Power & Sensation

PART 1: Level of Consciousness and Neurological Status

Consciousness Consciousness is the most sensitive indicator of neurological change and is usually the first to be noted in neurological signs A state of general awareness of oneself & the environment, including the ability to orientate towards new stimuli (Hickey, 2003) Dynamic state, subject to change (Hickey, 2003) Results from integrated activities of numerous neural structures, including the reticular formation and interaction with the cerebral cortex (Marieb & Hoehn 2007)

Level of Consciousness There are three properties of consciousness which can be individually affected by the disease process (Jennett 1992). These are: Arousal or wakefulness (i.e. eyes open to command) Alertness and awareness (i.e. orientation and communication) Appropriate voluntary motor activity (i.e. obeying commands)

D = Disability: Neurological status Emergency Care A = Airway B = Breathing and ventilation C = Circulation D = Disability: Neurological status E = Exposure (American College of Surgeons Committee 2004) Please see the printed chapter for information on A,B,C….E

PART 2: Neurological Assessment and the GCS

Disability: Neurological Status Conscious level - AVPU - GCS Pupils - Size - Reaction Blood glucose

Assessment of Level of Consciousness Common methods of assessing conscious level are: AVPU Glasgow Coma Scale (GCS) Both are potential tools for assessing the conscious level, and either can be used in the Early Warning Score (EWS) system used in many hospitals.

AVPU A – Alert Responds spontaneously V – Verbal Responds to voice P – Pain Responds to pain stimuli U - Unresponsive No response to verbal or pain stimuli

This is an example of a neurological assessment chart When documenting observations on the neurological assessment chart, it is important to: 1. Complete all sections. 2. Use dots not ticks! The chart demonstrates the patients graphical trends over time. Remember that it’s a graph – to see trends, dots not ticks

Glasgow Coma Scale (G.C.S.) The GCS: Is a simple & standardised system to detect changes in level of consciousness Should be quick, easy, objective & accurate if people have been trained to use it correctly Is used internationally Is designed to reduce observer variability and has a high degree of inter-rater reliability Rowley & Fielding 1991, Harrahill 1996, Fairley & Cosgrove 1999, Heron et al 2001, Teasdale 2004

The GCS tool provides a common language for communication between multi-disciplinary groups. (Hickey 2003) It is an important assessment tool. Care should be taken when delegating this assessment to ensure individual competency to perform the procedure GCS is applicable for paediatrics as well as adults, and has been adapted for use in in this area

Glasgow Coma Scale (G.C.S.) Patients in any clinical setting may require assessment of conscious level for a number of reasons: Hypoxia Metabolic imbalance such as hypoglycaemia Falls and trauma to the head Unresponsiveness Neurological disease processes e.g. stroke, brain tumours, epilepsy Post-anaesthesia New admissions to form a baseline assessment Glasgow Coma Scale (G.C.S.)

An example of the Glasgow Coma Scale (G.C.S.)

Below are some GCS chart wording variations: Score Eyes Opens spontaneously 4 Opens to speech 3 Opens to pain 2 No eye opening 1 Verbal Orientated 5 Disorientated, confused Monosyllabic / inappropriate words / confused words / words Incomprehensible sounds None – no response Motor Obeys 6 (5) Localises to pain 5 (4) Normal flexion (withdrawal) 4 (3) Abnormal flexion (decorticate) 3 (N/A) Extension (decerebrate) 2 (2) 1 (1) Eye opening spontaneously indicates functioning of the arousal mechanisms in the brain stem.

PART 3: Pain and Noxious Stimuli

Pain/Noxious Stimuli Central stimuli: Trapezium squeeze - advocated best practice Supraorbital pressure Jaw margin pressure Sternal rub - not advocated Peripheral Stimuli: Finger pressure

Painful Stimuli: 1. Trapezius Muscle Squeeze

2. Peripheral Pain Stimuli Apply pressure to the edge of the finger, just below the interpharngeal joint. Do not apply pressure directly over the nail bed. Correct Incorrect

Extension (decerebrate) In extension the body can become rigid, with the arms externally rotated and toes pointing down

Abnormal Flexion (decorticate) In abnormal flexion the arms are flexed at the elbow and wrists rotate outwards.

Vital Signs Centres for vital signs are located in the brain stem. Complex networks of neurones, the brainstem and reticular formation participate in regulation of cardiovascular, respiratory and other visceral functions.

PART 4: Pupil Documentation and Assessment

Pupils Pupils should generally be equal in size, and in the majority of people they are round in shape. Pupils should react briskly to direct light. Oculomotor nerve (III) - the motor nerve that controls pupillary motor response.

Pupil Documentation Pupil size should be recorded before proceeding to test pupil response to direct light. + is used to indicate a brisk response - is used to indicate no response SL is used to indicate a ‘sluggish’ response C is used to indicate closed eyes due to perirobital oedema.

Pupil Assessment Torch position for testing light reflex Approach from the side. Do not move in from directly in front.

PART 5: Limb Power and Sensation

Limb Power In this section you are assessing all limbs as opposed to the best response in a limb, as in the GCS section. It is a combination of active and active resisted movements (Hickey 2003).

Sensation (dermatones)) Sensation is not routinely checked unless patient diagnosis, signs and symptoms or interventions (e.g. epidural), indicate a potential for sensory loss or disturbance. There are various sensation charts based upon dermatone body maps.