Post on 08-Jan-2016
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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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