High Desert State Prison Medical Education - 2009

Acknowledgements: exerpted, in part, from Neuro Assessment from Doctorsecrets.com and Neurological Assessment

Review of Anatomy & Physiology

The function of the nervous system is to control all motor, sensory & autonomic functions of the body. Divided into: Central Nervous System (CNS) Consisting of the brain and spinal cord. Peripheral Nervous System (PNS) Cranial nerves (12) and spinal nerves (31) Autonomic Nervous System Sympathetic Division: fight or flight response Parasympathetic Division:

The Central Nervous System

CNS:The Brain
The brain controls, initiates and integrates all body functions.
Composed of both gray matter and white matter. Protective Mechanisms:
Skull (cranium): Bony container surrounding the brain Meninges: Three additional layers of protection Dura mater, arachnoid mater & pia mater

Potential & Actual Spaces

Epidural Space Subdural Space Subarachnoid Space

Head Injuries

 Broad term to classify sudden trauma to head, which includes injuries sustained to the scalp, skull or brain. Most common causes:
MVA: motor vehicle collisions (50%) Falls (21%) Violence (12%) Sports related-injuries (10%)

Head Injury

The most serious type of head injury is traumatic brain injury (TBI)

Physical
Scalp hematoma Periorbital bruising/swelling

Clear discharge from ear

TBI: Pathophysiology
Primary Injury
Initial damage to the brain that results from the traumatic event.

Secondary Injury
Additional damage to the brain tissue occurring minutes to hours after the initial traumatic event. As a result of the cellular changes that occur with cerebral edema, ischemia and hemorrhage.

TBI: Clinical Manifestations

Neurological Deficits Altered Level of Consciousness Confusion Pupillary Abnormalities Vital sign Changes Altered Reflexes
Gag

Headache Dizziness Impaired Hearing or Vision Sensory or Motor Dysfunction Seizures

Scalp Injury

Very vascular Can distract from more serious injury What about brain and neck???? Bleeding usually NOT enough to cause hypovolemic shock. Exceptions: Children, arterial

Cerebral Concussion
Head injury with temporary loss of neurological function with no structural damage.
Cause: jarring of the brain results in temporary disruption of synaptic activity; often occurs with acceleration-deceleration injuries.

Clinical Manifestations:
Loss of consciousness; usually brief Amnesia regarding events immediately prior to injury

Postconcussion Syndrome
Usually occurs within 24 to 48 hours after injury and may present up to several months later, but will subside in time. S/Sx: HA, lethargy, irritability, memory deficits, dizziness &

Cerebral Contusion
Bruising of the brain tissue; actual structural damage visible on diagnostic testing ( CT scan).
Often caused by deformation or accelerationdeceleration injuries (often two focal areas of bruising)

Clinical Manifestations
Loss of consciousness (more than brief) Vary depending on the location & size of contusion

Secondary injury is possible (i.e.

Intracranial Hemorrhage (ICH)

Trauma can cause bleeding within the brain tissue or within the spaces surrounding the brain.
The result is hematomas or collections of blood within cranial vault; most serious of brain injuries

Classified according to location:

Epidural hematoma Subdural hematoma Intracerebral hematoma

Epidural Hematoma (EDH)

Blood collects between the dura mater & the skull
Most often arise from arterial hemorrhage
Cause usually is injury of middle meningeal artery; resulting in rapid accumulation of blood.

Clinical Manifestations:
+ LOC after initial trauma; usually at the location of injury Lucid interval (30-50% experience) Rapid deterioration in neurologic status; S/Sx of ICP

Management
Medical emergency requiring immediate medical and

Subdural Hematoma (SDH)

Blood collects between the dura mater & the arachnoid mater
Often originating from venous hemorrhage
Cause is usually injury to bridging veins; venous blood tends to accumulate more slowly than arterial blood, therefore signs/symptoms of ICP tend not occur as quickly.

Two Main Types of SDH

Acute (less than 48 hours after injury) Requires immediate medical and /or surgical intervention Chronic (over 2 weeks after injury) Often forget actual injury; common in elderly S/Sx of ICP fluctuate or come and go

Intracerebral Hematoma (ICH)

Blood collects within the brain tissue (parenchyma)
Bleeding causes displacement of brain tissue; even small bleeds can cause significant neurological alterations. Destroys brain tissue Causes cerebral edema Increases ICP S/Sx of ICP maybe be immediate or develop overtime Management: Depends on location of the bleed and size of the bleed
Small ICH will be absorbed overtime Surgical management only if anatomically appropriate; if

Interacerebral Bleeding

Closed Head Injuries

Coup Contra Coup Brain Injury

Open Head Injury

Depressed Skull Fracture

Risks: swelling, bleeding, neural damage, infection. rapid decompensation

Increased Intracranial Pressures

Compensatory mechanisms will eventually be exhausted and clinical manifestations of increased ICP will occur. Causes of Increased ICP:
Traumatic Brain Injuries Brain Tumors Other Causes:
Meningitis or Encephalitis Brain Abscesses Hydrocephalus

Clinical Manifestations: Stages of Increased ICP

Stage I: (Full Compensatory)
Alert & Orientated History of head injury Vital signs / pupillary responses normal May complain of a headache

Stage II: (Partial Compensatory)

Mental Status Changes
Confusion and restlessness

Decreased Level of Consciousness

Lethargy

Vital signs / pupillary responses normal

Clinical Manifestations: Stages of Increased ICP

Stage III (Beginning Decompensation)
Further decrease in level of consciousness
Obtunded Stupor

Cushings Triad:
Systolic HTN (widening pulse pressure) Bradypnea

Bradycardia (bounding, slow pulse)

Small pupils (< 3mm); sluggish responses to light

Clinical Manifestations: Stages of Increased ICP

Stage IV (Herniation)
Comatose Pupillary dilation & fixation (ipsilateral bilateral) Abnormal Posturing:
Decorticate Decerebrate Flaccidity

Cushings Triad Progresses To:

Narrowing pulse pressure Weak, thready pulse Respirations: Cheyne-Stokes Ataxic Respirations

Stage V (Death)

Herniation & Brain Death

Herniation
Result of excessive ICP downward displacement of brain tissue resulting in the cessation of CBF. Leads to irreversible brain anoxia and brain death

Brain Death
Complete, irreversible cessation of function of the entire brain and brain

Brain Tumors
Space-occupying intracranial lesions
Benign or malignant.

Clinical manifestations differ according to area of lesion and rate of growth Common Signs / Symptoms:
Alterations in consciousness Neurologic deficits
Motor & Visual Disturbances

Headaches Seizures Vomiting (maybe sudden and projectile)

Peripheral Nervous System

Peripheral Nervous System (PNS)

Spinal Nerves (31 pairs)
Mixed Nerve Fibers: Exiting the spinal cord to receive information and to transmit information to the cord brain.
Posterior Root Anterior Root = Sensory = Motor

Reflex Arc
Interneurons connecting sensory & motor fibers.

Dermatomes
Sensory depiction of the corresponding spinal nerves

PNS: Cranial Nerves

There are 12 pair of cranial nerves. Sensory: CN I, II & VIII Motor: CN III, IV, VI, XI & XII Mixed: CN V, VII, IX & X

Cranial Nerves
The neurological exam performs many tests at the head of the patient. These are to test if Cranial Nerve function is intact. The exam tests the twelve Cranial Nerves:

I - Olfactory / Smell II - Optic / Vision III - Oculomotor / Eye Movement & Pupil Size IV - Trochlear / Eye Movement V - Trigeminal / Facial Sensation VI - Abducens / Eye Movement VII - Facial / Facial Motor - Expressions VIII - Acoustic / Hearing - Balance IX - Glossopharyngeal / Swallowing X - Vagus / Swallowing - Heart Rate XI - Spinal Accessory / Shoulder & Neck Movement XII - Hypoglossal / Tongue Movement

Cranial Nerves

PNS Injuries
Spinal Injuries

PNS Spinal Map

Spinal Cord Injury Locations

Spinal Nerves

Quad Para

Always properly immobilize an actual or suspected head or spinal injury!

Performing a Neurological Assessment

Neurological Assessment
Health History General Signs & Symptoms Physical Examination Considerations
Level of Consciousness Motor Function Pupillary Function / Eye Movements Vital Signs
Respiratory Patterns

Laboratory & Diagnostic Testing

General Signs / Symptoms

Memory Loss Headache / Pain

Disorientation
Changes in level of consciousness Seizures Speech or Swallowing Difficulties Vision & Pupillary Changes

Weakness
Loss of Coordination Tremors Numbness / Tingling Paralysis Nausea / Vomiting Bowel or Bladder Difficulties

Dizziness

Physical Examination Considerations

Level of Consciousness
Most important aspect of neurologic examination Level of consciousness first to deteriorate; changes often subtle, therefore requiring careful monitoring.

Consciousness:
Composed of Two Components:
Arousal (Alertness) Awareness (Content) Assessment: Orientation vs. Disorientation

Categories of Consciousness
Alert:
Responds immediately to minimal external (visual, tactile or auditory) stimuli.

Lethargic:
A state of drowsiness; client needs increased external stimuli to be awakened but, remains easily arousable; verbal, mental & motor responses are slow or sluggish.

Obtunded:
Very drowsy, when not stimulated, but can follow simple commands when stimulated (i.e. shaking or shouting) ; verbal responses include one or two words, but will drift back to sleep without

Categories of Consciousness
Stuporous:
Awakens only to vigorous and continuous noxious (painful) stimulation; minimal spontaneous movement; motor responses to pain are appropriate but, verbal responses are minimal and incomprehensible (i.e. moaning).
Vigorous external stimulation fails to produce any verbal response; both arousal and awareness are lacking; no spontaneous movements but, motor responses to noxious stimuli maybe be purposeful (light coma) or non-purposeful or absent (deep coma).

Comatose:

Assessing LOC
Glasgow Coma Scale (GCS)
Three Categories:
Eye opening Best motor response Best verbal response

Scoring
Highest or best possible score 15 A score of < 8 indicates coma Lowest or worst possible score 3

Glasgow Coma Scale

Pupillary Examination
The pupillary examination can be quickly and easily performed in the unconscious or minimally responsive patient when a TBI is suspected, and can provide valuable information about the degree of initial or progressing brain injury. Several types of TBIs may cause pupillary changes, which indicate the need for rapid interventions to decrease ICP caused by cerebral bleeding and/or edema. Nurses are in a key position to detect early changes in a patient's condition and administer or advocate for

Check pupil size in lighted room, and reactivity to light in a darkened room.

Unequal pupil size can be a sign of a serious brain injury.

Brain Injury with bleeding or swelling

Rapid interventions are needed to prevent death or permanent brain damage TBIs can progress rapidly!

Assessing the Cranial Nerves

CN I Olfactory: smell; skip except in facial trauma CN II Optic: vision; count fingers or movement in all quadrants and periphery in each eye; blink to threat in temporal and nasal quadrants if unable to participate

CN III Oculomotor: moves

eyes in all directions except outward and down & in; opens eyelid; constricts pupil

CN IV Trochlear:
moves eyes down and in..

CN VI Abducens: moves eyes outward

EOMs:
(extraoccular movement) assessment of eye movement in all directions ( III, IV VI)

CN V Trigeminal:
3 branches; sensation to the face, cornea and scalp; opens jaw against resistance

CN VII Facial:
moves the face; taste.
CN VII paralysis

CN VIII Acoustic: 2 branches, acoustic (hearing) and vestibular (balance) CN IX Glossopharyngeal: moves the pharynx (swallow, speech & gag) CN X Vagus: voice quality

CN XI Spinal Accessory:
turns head and elevates shoulders

CN XII Hypoglossal:
moves tongue

Shoulder Shrug

Assessment Tip:
Test CN IX, X, XII all at once: Test gag, swallow and speech together..

CN Tips:
observe for nystagmus with EOMs (2-3 beats normal with lateral gaze). diplopia (double vision): cover one eye, should clear if sixth nerve palsy (offer eye patch over good eye).

Motor Examination
Motor Exam: use the motor grading scale to maintain objectivity and eliminate confusion 5/5: strong against resistance 4/5: weak against resistance 3/5: overcomes gravity; offers no resistance 2/5: cannot overcome gravity; moves with gravity eliminated 1/5: contracts muscle to stimulus 0/5: no muscle movement

Assess hand grips for strength

Drift Assessment
Drift Assessment:
test for motor weakness Arm: hold arms out with palms up; eyes closed Pronator drift: hands pronate (roll over); Motor drift: arm drifts downward Cerebellar drift: arm drifts back toward head or out to side

Leg: no need to close eyes motor: leg driftstoward bed

Movement Assessment
Movements are purposeful or non-purposeful
purposeful: picking at tubings or bed linens, scratching nose localizing: moving toward or removing a painful stimulus; must cross the midline; occurs in the cortex withdrawal: pulling away from pain; occurs in the hypothalamus non-purposeful: do not cross the midline abnormal flexion: (decorticate) rigidly flexed arms and wrists; fisted hands; occurs in upper brainstem abnormal extension: (decerebrate) Decorticate rigidly, rotated inward extended arms with flexed wrists and fisted hands; occurs in midbrain or pons.
Decerebrate

Response to Painful Stimuli

Eliciting movements using central pain
Trapezius pinch: deep pressure to trapezius muscle Supraorbital pressure: pressure under supraorbital ridge Sternal pressure: knuckle pressure to sternum; do not rub!

Peripheral Pain:

Trapezius Pinch

nailbed pressure may elicit a spinal cord reflex which can be reproduced in a brain dead patient

Abmornal Reflexes
Abnormal Reflexes:
Babinski: initial inflection of great toe in response stroking of sole; upgoing toe is abnormal Grasp: involuntary grasp in response to stimulation of palm; abnormal in an adult Dolls eyes: impairment of eye movement to opposite side when head is turned = damage to brainstem; no movement = loss of brainstem

Speech Patterns
Note: speech patterns, fluency, word usage ability to follow 1 or 2 step commands (must cross the midline) ability to name common objects and their use. Aphasia: a disorder in processing Language: Apraxia of speech: disorder in programming of speech (dominant hemisphere) Dysarthria: disorder in mechanics of speech (cranial nerve weakness)

Hemispheres of the Brain

Language & Speech: assessed together; located in the dominant hemisphere (left in most, including lefties). LEFT: written & spoken language, reasoning, number skills, scientific knowledge, right hand control. Left Right RIGHT: insight, 3-D forms, imagination, music awareness, Art awareness, left hand control.

Brain Teaser

Brain Teaser

Neuro Aessessment Quiz

a) b) c) d) e) 1. Peripheral Nervous System (PNS) is made up of the following except:: Cranial nerves (12) Ventricles Axons and Neurons Spinal nerves (31) Cerrebellar nerves 2. The Autonomic Nervous System contains both the Sympathetic Division of nerves and the Parasympathetic Division of nerves. True or False________________. 3. Intracranial Hemorrhage can occur in the following places except: Epidural space Subdural space Subarachnoid space Ethmoid space .4. A Coup Contracoup injury is defined as: When the head strikes a fixed object, the coup injury occurs at the site of impact and the contrecoup injury occurs at the opposite side. True or False____________________ 5. The Facial nerve controls: Movement of the chin, tongue and parotid glands. Movement of the tongue, soft palete and eyebrows. Movement of the chin and cheeks muscles. Movement of all the facial expression muscles. 6. Which nerve controls movement on the neck and shoulders? Abducens Accoustic Spinal Assesory Occulomotor

a) b) c) d) a) b) c) d)

a) b) c) d)

7. A serious injury to the

a) b) c) d)

a)
b)

c) d)

cervical spine and spinal cord most likely will result in the following condition: Hemiplegia Quadraplegia Paraplegia Contralateral paralysis 8. Any suspected head, neck or spine injured victim should immediately be given spinal immobilization precautions, except: When the victim complains of pain only upon turning his head to one side. When the victim refuses to allow spinal immobilization even after listening carefully to multiple attempts to explain the dangers and risk involved. When the victim is intoxicated on alcohol and cannot speak clearly. When the victim was never unconscious and denies any pain.

a)

b)

c)

d)

9. When assessing a patient with altered LOC, you feel his state of awareness/arousal is best described as Obtunded, this means: Very drowsy, when not stimulated, but can follow simple commands when stimulated (i.e. shaking or shouting); verbal responses include one or two words, but will drift back to sleep without stimulation. A state of drowsiness; client needs increased external stimuli to be awakened but, remains easily arousable; verbal, mental & motor responses are slow or sluggish. Awakens only to vigorous and continuous noxious (painful) stimulation; minimal spontaneous movement; motor responses to pain are appropriate but, verbal responses are minimal and incomprehensible (i.e. moaning). Vigorous external stimulation fails to produce any verbal response; both arousal and awareness are lacking; no spontaneous movements but, motor responses to

 a) b) c) d) a) b) c) d) a)

b)
c) d)

10. The Glasgow Coma scale tests for three kinds of responses, they are: Eye Opening Motor Response Verbal Response Auditory Response 11. The best and worst possible score on the GCS is: 15 and 0 13 and 3 15 and 3 18 and 5 12. When assessing pupillary response, you are looking for the following conditions except: Coordinated eye movement and bilateral blinking. Reactivity to and accommodation to light. Symmetry of pupils and accommodation to light. Abnormal pupil shape.

a) b) c) d) e) a) b) c) d)

a)

b) c)

13. A constricted pin point pupil indicates: (best answer) Brain Stem herniation Cardiac Arrest Cerebral Infarction of the parietal lobe Cerebral Infarction of the occipital lobe A wide variety of conditions, some being extremely life threatening. 14. What Cranial nerve(s) controls the movement of the eyes down and in? CN VI Abducens CN III Oculomotor CN IV Trochlear CN II Optic 15. The Motor strength scale goes from 0/5 to 5/5, 0 being no strength at all and 5 being normal strength. A person with a motor strength of 4/5 would be: overcomes gravity; offers no resistance strong against resistance weak against resistance

 16. Match the following postures with its definition: Decerebrate_____________ Decorticate______________ a) Abnormal flexion: rigidly flexed arms and wrists; fisted hands; occurs in upper brainstem b) Abnormal extension: rigidly, rotated inward, extended arms with flexed wrists and fisted hands; occurs in midbrain or pons. 17. The Babinski reflex is the initial inflection (extension) of great toe in response stroking of the sole of the foot, select the correct answer: a) An upgoing great toe is abnormal. b) An upgoing great toe is normal. c) An upgoing great toe is

Answers 1 e 2 True 3 d 4 True 5 d 6 c 7 b 8 b 9 a 10 d 11 c 12 a 13 e 14 c 15 c 16 Decer = b. Decor = a 17 c&d