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Why we need to perform the neurological assessment?

Is to assess patients level of consciousness as a baseline

To monitor the trend

To detect any changes of level of consciousness or deterioration quickly

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1. A GCS should be performed on all patients in the ICU at least every 4 hours

2. A GCS is often performed hourly on Neurosurgical and Neurological patient

admissions

3. A GCS assessment should be performed more frequency if a change in the patients

neurological status is observed, eg. They become more confused or drowsy.

4. A GCS should not be performed on patients who are very heavily sedated or

receiving paralysis agents or thiopentone. However, a pupil assessment should be

attended hourly.

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Answer:

- AVPU is used most commonly in emergency situations to rapidly assess whether a

patient is responsive.

- The GCS is used to provide a comprehensive assessment of a patients LOC and

includes pupil assessment and limb strength assessment

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In the ICU environment we experience a number of barriers to performing a

comprehensive neurological assessment on a patient. These barriers include:

Sedation and paralysis agents - If the patient has been sedated, sedative medications

may need to be paused or turned off to facilitate assessing the patients GCS. If the

patients has been paralysed recently then their GCS should not be attended until the

paralysis has worn off.

Language and communication barriers - Patients who are deaf, NESB, have an ETT or are

dysphasic/aphasic are difficult to assess. Alternative methods such as a translator,

hearing aid or communication aids may be required for these patients.

Physical barriers - patient with a spinal injury, trauma or hemiplegia are difficult to

perform a comprehensive assessment on.

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AVPU initially due to the emergency situation.

Call for help.

Assess patient using ABC

Commence basic life support if necessary

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AVPU Scale

The AVPU scale is a tool to rapidly assess whether a patient is responsive. It is a

simplification of the Glasgow Coma Scale (GCS), which is often used during the ABCDE

approach to evaluate their level of disability.

It assesses the patients LOC by assessing if they are A (alert), V (responsive to voice), P

(responsive to pain) or U (unresponsive)

To assess the patient using the AVPU score, observe whether the patient responds

spontaneously, to voice, to pain or not at all.

If the patient is fully awake and talking (although not necessarily orientated), they are

alert (A).

If the patient is not alert, check if they are responding to voice (V), such as opening their

eyes, making a verbal response or moving.

If the patient does not respond to voice, administer a painful stimulus and check for a

response to pain (P), such as eye opening, verbal response or movement.

If the patient does not respond to pain they are unresponsive (U).

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AVPU of the patient is A - Alert

Assess the patients GCS, pupils and limb strength. Call for help using the ISBAR

communication tool.

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Glasgow Coma Scale is a tool to perform a comprehensive assessment to assess

patients level of consciousness

By assessing eye opening, verbal response & motor response

Introduced in 1974 by two neurosurgery professors in Glascow, Scotland

Helps to reduce the subjectivity of our responses to LOC though has come under

pressure for poor reliability due to its subjectivity

No full proof alternative has been developed yet

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Procedure

Eye response:

If the patient is opening his or her eyes spontaneously, the score is a 4.

If the patient has his or her eyes closed, check to see if they open them to speech. If so,

the score is 3.

If the patient does not open his or her eyes to speech, then apply central pain using a

trapezius squeeze, sternal rub or supraorbital pressure. If the patient opens his or her

eyes to pain, the score is 2.

If the patient does not open his or her eyes to central pain, the score is 1.

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Verbal response:

Ask the patient to state the current day and date, location and his or her name. If the

patient is orientated to all questions, the score is 5.

If the patient answers questions but is confused about any question related to time,

place or person, the score is 4.

If the patient cannot answer questions correctly and is not able to participate in

conversational exchange, the score is 3.

If the patient is moaning or groaning and unable to articulate any words, the score is 2.

If the patient makes no verbal response, the score is 1.

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##Can ask a student to illustrate what is localized pain and withdraw from pain

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Top picture also known as decorticate posturing

Bottom picture also known as decerebrate posturing

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Why do we use central painful stimulus to elicit a response? Using peripheral pain to

judge may illicit a natural spinal reflex

When to use painful stimulus- when a patient is not responding spontaneously or to

speech.

How to apply painful stimulus- trapezius, supraorbital, sternal rub

When to use which method avoid supraorbital if facial fractures, raised ICP, avoid

trapezius if fractured clavicle, avoid sternal rub if recent chest surgery or fractured ribs

To aware of patients clotting profile

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Call for help

Assess airway

A decrease in GCS of 2 or more points signifies a significant deterioration in neurologic

function.

A patient with a GCS of

How to assess pupils

What to assess- size, shape, reactivity to light.

What conditions may cause pupil abnormalities- diseases/conditions, medications,

ROUND - Normal shape

OVOID - The intermediate phase between a normal pupil and dilated and fixed pupil, can

be a sign of intracranial hypertension

IRREGULAR - May be seen with traumatic orbital injury

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How to assess consensual light reflex

Why assess?

The introduction of light into one eye should cause the pupil to constrict, called the

direct response, and should cause a similar constriction to occur in the other pupil. This

indicates that the afferent pathways are intact. The lack of a consensual response

indicates a presence of a lesion or damage to the optic nerve, oculomotor nerve or

brainstem.

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Answer:

Assess the patient. Perform an rapid ABC assessment and a neurological assessment

(GCS).

If the GCS is 3- Call for help! A GCS of 3 with fixed and dilated pupils is a medical

emergency.

If the patient is responsive consider other causes of fixed and dilated pupils. Medications

that effect the pupils such as atropine.

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How to assess lower limb strength

Why assess

To look for any neurological deficit

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The motor assessment can yield valuable information about the function and integration

of the structures as the frontal lobe, cerebellum, and spinal cord

Patient with a slight weakness in one arm wont be able to keep the affected arm raised

and ultimately the palm may begin to pronate, or turn downward, this is called pronator

drift

This is an indication of the abnormal function of the corticospinal tract(the upper

neurone in the brain and mediated the voluntaory muscle movement ) in the

contralateral hemisphere

How to assess upper limb strength (including pronator drift)

How to do it:

Ask patient to raise both upper limbs with palm facing up closed the eyes if one

arm is weaker it will drift from the original position (either drifts outwards or

downwar

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Cardiac and respiratory centres are located in the brainstem. Changes in a patients vital

signs can indicate compression on these centres due to increased intracranial pressure

and impending herniation. Such as:

1) RR: Decreased respiratory rate or irregular breathing pattern

2) Heart rate: Bradycardia or arrythmia

3) Blood pressure: Increased systolic blood pressure or widened pulse pressure.

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