Head Trauma C H A P T E R 2 1 259

The oculomotor (CN III), trochlear (CN IV), and abdu- eye) reflex tests the integrity of pontine centers.2,6 A dolls
cens (CN VI) nerves control extraocular eye movements. In eye examination is performed only in an unconscious
the conscious patient, extraocular movements should be as- patient after the cervical spine has been cleared. To perform
sessed. Conjugate gaze is movement of both eyes simulta- the dolls eye examination, briskly rotate the patients head
neously in the same direction. This indicates the brainstem
and cerebral cortex are functioning. Disconjugate gaze is
when one eye is deviated from the normal midposition with Box 21-2  igns and Symptoms of Increased
S
the patient at rest. Ask the patient to follow a finger through Intracranial Pressure
the six directions of gaze. If any of the three CNs are in-
jured, there will be paralysis or paresis of the extraocular EARLY
muscles, leading to a disconjugate gaze. Ptosis (drooping Level of conscious deteriorates: Patient may become, restless,
eyelid) may also be observed with injury to the oculomotor more confused, agitated or combative
nerve. Patients may also complain of diplopia as the eyes Headache
move through the different positions. Injuries can be uni- Nausea/vomiting
lateral or bilateral; therefore it is important to assess each Slowed or slurred speech
eye separately and observe for consensual and/or conjugate Blurred vision or diplopia
response. Pupillary changes: Delayed/sluggish reactivity to light, pupil
With severe brain injury it is important to evaluate the becomes ovoid, unilateral change in pupil size or shape
integrity of brainstem function. The oculocephalic (dolls Decreased strength and sensation
LATE
Progressive decline in level of consciousness to coma
Projectile vomiting (without nausea)
BOX 21-1 Cerebral Perfusion Pressure Speech significantly impaired, may only groan
Impaired brainstem reflexes (corneal, gag)
MAP ICP = CPP Motor posturing
Example: Mean arterial pressure = 90 mm Hg Unilateral or bilateral pupil that enlarges and becomes fixed
Intracranial pressure = 15 mm Hg Irregular respirations
90 mm Hg 15 mm Hg = 75 mm Hg Cushings response
Cardiac dysrhythmias
CPP, Cerebral perfusion pressure; ICP, intracranial pressure; MAP, mean arterial Abnormal reflexes (Babinskis)
pressure.

Table 21-3.
Glasgow Coma Scale
Response Score Significance
EYE OPENING
Spontaneously 4 Reticular activating system is intact; patient may not be aware
To verbal command 3 Opens eyes when told to do so
To pain 2 Opens eyes in response to pain
None 1 Does not open eyes to any stimuli
VERBAL STIMULI
Oriented, converses 5 Relatively intact CNS, aware of self and environment
Disoriented, converses 4 Well articulated, organized, but disoriented
Inappropriate words 3 Random, exclamatory words
Incomprehensible 2 Moaning, no recognizable words
No response 1 No response or intubated
MOTOR RESPONSE
Obeys verbal commands 6 Readily moves limbs when told to
Localizes to painful stimuli 5 Moves limb in an effort to remove painful stimuli
Withdrawal 4 Pulls away from pain in flexion
Abnormal flexion 3 Decorticate rigidity
Extension 2 Decerebrate rigidity
No response 1 Hypotonia, flaccid: suggests loss of medullary function or concomitant spinal
cord injury

From Geegaard WG, Birow MH: Head. In Marx J, Hockberger R, Walls R: Rosens emergency medicine: concepts and clinical practice, ed 6. St. Louis, 2006, Mosby. Modified from
Teasdale G, Jennett B: Assessment of coma and impaired consciousness: a practical scale, Lancet 2(7872):81, 1974.
CNS, Central nervous system.