Dr---Noha Elsayed
2015--2016
1.
Full-body scan.
2.
Direct particular attention to your neurologic assessment.
3.
Assess the patient’s level of consciousness using the AVPU scale is the most
important parameter in evaluating a patient with central nervous injury.
4.
Glasgow Coma Scale (GCS) score calculated.
5.
Pupil assessment.
6.
Cranial nerve assessment.
3-AVPU Scale
 Alert to person,
place, and time
Test responsiveness to painful stimuli
Pinch earlobe
Press down on
above eye
Pinch neck
muscles
Assess Level of Consciousness
P
O
SI
TI
O
N
Midbrain - Pons
Brain – Cervical spinal cord
4. Glasgow Coma Scale (GCS)
• Is the focal point of assessing a critical care patient .
• Total value ranging from 3 to 15
 A score 3………indicate deep coma
 A score 15………indicate normal
as score falls , the morbidity and mortality of patient increases.
• Medications such as anxiolytics ,narcotics, paralytics and the
like all affect GCS therefore where possible the GCS should be
assessed both while the patient is sedated and not sedated.
• Changes in the GCS score are critical to note because they
may indicate increase in ICP …. The 1st sign of ↑ ICP is change
in the LOC
Glasgow Coma Scale (GCS)
Brain injury is classified as:
Severe, with GCS < 8-9
Moderate, GCS 9–12 (controversial)
Minor, GCS ≥ 13.
5. Pupil assessment:
 Must be assessed bilaterally for:
A. Size (1 – 6mm)
May be constricted or dilated
N.B.
 Constriction of pupil may be due to: Medications the
patient is receiving such as: Narcotics, Cholinergics
B. ShapeOval Keyhole
Round
Irregular
Normal ↑
ICP
After iridectomies
After orbital
trauma
C. Reactivity to light (Direct & Consensual)
↓

Brisk, Sluggish or Non – reactive
(Rapid constriction of the pupil to light
followed by dilatation)
↓
Hippus phenomenon
 Unequal pupil size bilaterally may be normal in 17% of
population
↓
Anisocoria
Pupil size and reactivity:
 E - Equal
 R - Round
 R - Regular in size
 R - React to light
On both eyes
E+3R
Unilateral, Dilated, Fixed &
Non-reactive
↑ ICP OR May be normal
Bilateral, Dilated, Fixed &
Non-reactive
Hypoxia OR Severe brain
damage at level of midbrain
Bilateral, Pin point & Nonreactive
Narcotic use OR Severe brain
damage at level of pons OR
Ischemia
Abnormal Pupil Reactions
 Fixed with no reaction to light.
 Dilate with light and constrict without
light.
 React sluggishly.
 Unequal in size.
 Unequal with light or when light is
removed.
6. Cranial nerve assessment:
Cranial nerve III is helpful in assessing the patient
with a neurologic insult …. To assess the extra-ocular
movement that may be the 1st changes seen with
increasing the ICP