Save lives with a rapid neuro exam
A man comes to the ED after being hit on the head with a tree limb and complained of a headache. At first glance, it appears that all the patient needs is suturing for a scalp laceration. But when the triage nurse completes a rapid neurological examination, the evaluation reveals a Glasgow Coma Scale score of 14. The pupil exam shows a delayed response to light and a dilated right pupil. The physician is immediately notified and sends the patient to CT for a noncontrast scan of his head, which reveals a subdural hematoma. As a result, neurosurgery service is consulted, and definitive therapy is completed in a timely manner. The patient survives and is discharged neurologically intact.
Performing a neurological exam can avoid an adverse outcome or even save a patient’s life, says Steve Glow, RN, MSN, FNP, CEN, EMT-P, nursing faculty at Salish Kootenai College in Pablo, MT, and a former ED nurse at Lutheran Medical Center in Wheat Ridge, CO.
Here are items to consider when performing a rapid neurological examination:
• Know which patients need the neurological exam. The majority of ED patients should have a rapid neurologic exam, Glow emphasizes. (See steps to follow for a neurologic screening exam for alert patients, below.) "Any trauma patient with a significant mechanism of injury or evidence of trauma above the waist should have a neurologic exam," he says. This criterion includes anyone with altered mental status or intoxication, neck pain, neurologic symptoms or distracting injury that could mask neck pain, or lack of knowledge of events leading up to an accident, Glow says.
All ED patients need a "AVPU" exam performed, argues Laura M. Criddle, MS, RN, CS, CEN, CCRN, CNRN, emergency, trauma and neurological clinical nurse specialist at Oregon Health & Sciences University in Portland. The AVPU system classifies patients as A (awake), V (responds to verbal stimuli), P (responds to painful stimuli), or U (unresponsive), she notes. "For most, this is as simple as observing that they are walking, talking, and making sense," she adds. Any patient who has deficits in these areas needs to quickly be assessed more in depth, she stresses.
AVPU doesn’t use points
• Understand what the exam must include. In a rapid neurological assessment, the two key items to focus on are "AVPU" and pupils, says Criddle. The "AVPU" system is much simpler than the Glasgow Coma Scale, because no points are assigned or totaled, explains Criddle. "Next, if the patient is not awake, immediately assess pupil size, shape, reactivity, and gaze," she advises.
These two tests quickly will identify patients with major deficits and those at risk for rapid deterioration, she explains. Once these two pieces of information are known and acted upon as needed, the patient’s Glasgow Coma score can be assessed for ongoing tracking, says Criddle.
Other important neurological assessment findings to check as appropriate include the patient’s ability to protect his or her airway such as gag, cough, and swallow reflexes. A brief assessment of the patient’s ability to move and feel each of the extremities, as well as his or her ability to take a deep breath, will identify most patients with significant spinal cord injuries.
• Watch for signs of deterioration. Determine how appropriate the patient is to the situation, says Criddle. "He may be awake and alert, but is he restless, agitated, difficult to arouse, violent, apathetic, distraught?" she asks. "Each of these findings may either be early signs of deterioration or indications of the etiology, such as toxic, metabolic, hypoxic, or psychiatric conditions."
• Use a form that requires documentation of a neurological examination. Frequently, this assessment is either not done or it is not documented, says Glow. "The greatest opportunity for improving compliance with nurse neurological exams would be the inclusion of a better set of neurological parameters on triage and assessment forms," he says. He recommends the use of check boxes to facilitate documentation. (To see Neurological Guidelines Flow Sheet, click here.)
• Perform a motor assessment of the lower extremities. Ask the patients to wiggle their toes, move their leg across the surface of the bed, then lift their leg off the bed, says Criddle. "If the patient cannot do these things, check for rectal tone to see if there is sacral sparing," she adds.
• Assess the patient’s ability to take a deep breath. This is vitally important, says Criddle. "C-4 will innervate the diaphragm so patients can continue to breathe," she explains. "However, without the intercostals [upper thoracic spinal cord] and the abdominal muscles [lower thoracic spinal cord], patients cannot take deep breaths or cough." Therefore, patients with lower cervical spine or upper thoracic spine injuries need to be watched closely for respiratory deterioration, says Criddle. "They commonly poop out’ over time and require mechanical ventilation," she notes.
Because this population probably also is in neurogenic shock, many of the usual signs of respiratory distress, such as accessory muscle use, tachycardia, and diaphoresis will not be evident, Criddle says. "Watch carbon dioxide levels closely," she advises.
Sources
For more information on performing a rapid neurological exam, contact:
• Laura M. Criddle, MS, RN, CS, CEN, CCRN, CNRN, Oregon Health and Sciences University, Mail Code UHS 8Q, 3181 S.W. Sam Jackson Park Road, Portland, OR 97201. Telephone: (503) 494-1350. Fax: (503) 494-7441. E-mail: [email protected].
• Steve Glow, RN, MSN, FNP, CEN, EMT-P, Salish Kootenai College, P.O. Box 117, 52000 Highway 93, Pablo, MT 59855. Telephone: (406) 675-4800 Ext. 335. Fax: (406) 675-4325. E-mail: [email protected].
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