Physical Examination

The Glasgow Coma Scale (GCS) score should be obtained, and the test repeated as needed. Although not part of the original concept, separate constituent parts of the total GCS score (e.g., eye opening, verbal response) are more informative when communicated to another health professional than merely the total score, which is useful in generalized triage and classification of the severity of the injury as minor (GCS score >14), moderate (GCS score <13 and >9), or severe (GCS score < 8) (4).

In performing a neurological examination, begin by specifically looking for signs of skull base fracture (raccoon eyes, hemotympanum, CSF rhinorrhea or otorrhea, the Battle sign), usually after 8 to 12 hours. If fractures are suspected or confirmed, especially those of the facial bones, perform careful auscultation of the carotids for possible carotid dissection.

Other highlights of a neurological examination in such cases are listed in Table 17.1.

Although the popular Mini-Mental State Examination disproportionately emphasizes left hemisphere functioning, studies have documented its usefulness even in the long-term. For example, one study indicated that 23% of patients with mild head injuries score less than 24 out of 30 points 1 year after injury. Motor regulation can be assessed rapidly using the Luria "fist, chop, slap" sequencing task (5).

An antisaccade task, in which the patient looks away from the offered visual stimulus, recently has been shown to be impaired in patients with symptomatic whiplash injury compared to controls, although the sensitivity of this test in detecting brain injury has been questioned.

Letter fluency, in which the patient names as many words as possible beginning with a specific letter in 1 minute, and category fluency, in which the

Table 17.1. Neurological signs in acute trauma.



Visual acuity

If the level of consciousness allows assessment

Pupillary light reflexes

Both direct and consensual must be tested

Fundus examination

Look for signs of retinal detachment, hemorrhages,

(direct or indirect)

or papilledema

Spinal tenderness

May be assessed by wincing and avoidance in unconscious

patients; such assessment is controversial and results are hard to


Limb movements

In a cooperating conscious patient


In all patients

Plantar response

Babinski sign should be addressed specifically

Motor weaknesses

In a cooperating, conscious patient

Gross sensory deficits

In a cooperating, conscious patient

Source: Data from Working Party of the Royal College of Surgeons of England (2) and Procac-cio et al. (4).

Source: Data from Working Party of the Royal College of Surgeons of England (2) and Procac-cio et al. (4).

patient names as many items as possible in a certain category in 1 minute, provide further information about self-generative frontal processes.

An untimed Trails B test, in which the patient alternates between number and letter sequences, allows further qualitative testing of frontal functioning (2).

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