1. 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

2. 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

3. PART 1: Level of Consciousness and Neurological Status

4. 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)

5. 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)

6. 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

7. PART 2: Neurological Assessment and the GCS

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

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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.)

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

16. 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
(5)
Localises to pain
(4)
Normal flexion (withdrawal)
(3)
Abnormal flexion (decorticate)
(N/A)
Extension (decerebrate)
(2)
(1)
Eye opening spontaneously indicates functioning of the arousal mechanisms in the brain stem.

17. PART 3: Pain and Noxious Stimuli

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

19. Painful Stimuli: 1. Trapezius Muscle Squeeze

20. 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

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

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

25. 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.

26. PART 4: Pupil Documentation and Assessment

27. 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.

28. 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.

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

30. PART 5: Limb Power and Sensation

31. 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).

32. 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.