Neurological Examination
MENTAL STATUS
Level of Consciousness: Note whether the patient is:
Orientation: Assess the patient’s ability to provide:
Language: Note the fluency and appropriateness of the patient’s response to questions. Note patient’s ability to follow commands when assessing other functions (e.g., smiling, grip strength, wiggling toes). Ask the patient to name a simple object (e.g., thumb, glove, watch).
Speech: Observe for evidence of slurred speech.
CRANIAL NERVES
All patients:
MOTOR
Tone: Note whether resting tone is increased (i.e. spastic or rigid), normal, or decreased (flaccid).
Strength: Observe for spontaneous movement of extremities and note any asymmetry of movement (i.e. patient moves left side more than right side). Lift arms and legs, and note whether the limbs fall immediately, drift, or can be maintained against gravity. Push and pull against the upper and lower extremities and note any resistance given. Note any differences in resistance provided between the left and right sides.
(NOTE: it is often difficult to perform formal strength testing in TBI patients. Unless the patient is awake and cooperative, reliable strength testing is difficult.)
Involuntary movements: Note any involuntary movements (e.g., twitching, tremor, myoclonus) involving the face, arms, legs, or trunk.
SENSORY
If patient is not responsive to voice, test central pain and peripheral pain.
Central pain: Apply a sternal rub or supraorbital pressure, and note the response (e.g., extensor posturing, flexor posturing, localization).
Peripheral pain: Apply nail bed pressure or take muscle between the fingers, compress, and rotate the wrist (do not pinch the skin). Muscle in the axillary region and inner thigh is recommended. Apply similar stimulus to all four limbs and note the response (e.g., extensor posturing, flexor posturing, withdrawal, localization).
NOTE: In an awake and cooperative patient, testing light touch is recommended. It is unnecessary to apply painful stimuli to an awake and cooperative patient.
GAIT
If the patient is able to walk, observe his/her casual gait and note any instability, drift, sway, and so forth.
Ultrasonic Assessment of Optic Nerve Sheath Diameter
If a patient is unconscious (i.e. does not follow commands or open eyes spontaneously), they may have elevated ICP. There is no reliable test for elevated ICP available outside of a hospital; however, optic nerve sheath diameter (ONSD) measurement is a rapid, safe, and easy-to-perform ultrasonographic assessment that may help identify elevated ICP when more definitive monitoring devices are not available.
Technique
CAUTION: ONSD measurements are contraindicated in eye injuries. NEVER apply pressure to an injured eye.
Glasgow Coma Scale
TBI severity classification using the GCS score:
Richmond Agitation Sedation Scale (RASS)
Signs and Symptoms of Elevated Intracranial Pressure
Hypertonic Saline (HTS) Protocol (goal Na 140-165 meq/L)
Military Acute Concussion Evaluation 2 (MACE 2) Form, 2021
Open the attachment on the side menu or open the below link to print or fill out electronically.
MHS Progressive Return to Activity Following Acute Concussion/Mild TBI
Open the attachment on the side menu or open the below link to print or fill out electronically.