CRITICAL CARE RN NEUROANATOMY & COMPLETE NEUROASSESSMENT ... · CRITICAL CARE RN NEUROANATOMY & COMPLETE NEUROASSESSMENT Navaz Karanjia, ... Level of consciousness ... Qureshi,,Geocadin,Suarez,

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CRITICAL CARE RN

NEUROANATOMY &

COMPLETE

NEUROASSESSMENT

Navaz Karanjia, M.D.

Director, UCSD Neurocritical Care

UC-San Diego School of Medicine

October 20, 2011

Purpose

Review basic neuroanatomy relevant to critical

care patients

Review the objective complete neuroassessment

of the critical care patient

Understand how each part of the

neuroassessment correlates to neuroanatomy

Practice the neuroassessment to become

comfortable, consistent, and efficient with the

exam

Objectives

The participant will be able to:

Describe the functions of major parts of the nervous

system

Describe the major components of the complete

neurological examination of the awake and comatose

critical care patient

Accurately, consistently, efficiently, and confidently

perform the complete neurological assessment for

awake and comatose critical care patients

Report exam findings and trends objectively

Describe exam findings indicative of increasing ICP

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Why do I want nurses to understand

neuroanatomy/neuroassessment?


neurocritical care physiology and assessment?

Brain Code

Don’t forget,

if the pt has

had an acute

neuro change

in <12h, also

call a stroke

code!

3

Brain Code Pager and Brain Code Box

Webpage Brain, Code (or Hillcrest pharmacy code pager 2619)

Code pharmacist, NCC team will arrive in <3 minutes with brain code box

Contains: 100g 20% mannitol, 30 cc 23% saline, 500 cc 3% saline, phenylephrine premixed syringes (100mcg/1mL), syringes, filters

Code sheet for documentation

>80 episodes of herniation treated

using BrainCodeBox at Hillcrest

in 2 years

75% episodes herniation reversed

60% survivors independent

at 6 mos

Brain Code



We are a team! We need to speak the same language!

Your serial OBJECTIVE neuroassessments are THE most

important marker of our neuro-ICU patients’ progress, and

should drive physicians' clinical decision-making

If you can tie anatomy to assessment, you will know:

Where is the lesion?

What is the lesion?

Structural: pathology that changes structure or exerts

pressure on structure (tumor, hemmorhage,

hydrocephalus)

Physiologic: ischemia, seizure, change in cerebral

metabolism



With this knowledge, you can better understand:

What is wrong with my patient?

How is my patient doing now?

What changes might I expect to see in my patient if

they start to decline?

What effect on outcome will this have on my patient?

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Today’s fun

Neuroanatomy (1:20) Overview

Skull

Meninges

Ventricles

Cellular neuroanatomy

Brain

Vasculature

Spine

Neuroassessment (1:20)

Awake

Unconscious

Spinal

Hands on practice (1:00)

The Nervous System: divisions

CNS: brain & spinal cord

PNS: cranial nerves &

spinal nerves

Somatic/voluntary nervous

system

Autonomic nervous system

Parasympathetic

Sympathetic

The Nervous System: autonomic

Sympathetic Nervous System

Fight/Flight: HR, BP, RR, pupillary dilation

Inhibits: Peristalsis, urination, defecation

Parasympathetic Nervous System

Rest/Digest: HR, RR, BP, pupillary constriction

Stimulates: Peristalsis, urination, defecation

Sympathetic storm

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Today’s fun


Skull

Meninges

Ventricles


Brain

Vasculature

Spine


Awake

Unconscious

Spinal


Skull anatomy

Skull is a rigid box that contains brain, blood, CSF

Cranium has 8 bones

Frontal

Occipital

Sphenoid

Ethmoid

Parietal (2)

Temporal (2)

Face has 14 bones

Sutures

Skull Base

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Skull Base

Sphenoid bone

Sella Turcica

Today’s fun


Skull

Meninges

Ventricles


Brain

Vasculature

Spine


Awake

Unconscious

Spinal


Meninges

Three separate layers that are continuous sheets

that cover the brain and spinal cord

Dura mater: outermost

Arachnoid mater: middle

Pia mater: innermost,

stuck on brain

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Meninges: Dura Mater (outermost)

Tough, thick, inelastic to protect and support brain

Double layer: periosteal, meningeal

Meninges: Dura Mater

Subfalcine Herniation

Cerebral cortex under

falx

Leg weakness

mental status

Central/Upward

Herniation

Brainstem down/up

through tentorium

mental status

Dilated pupil, eye

“down and out” (CN3)

Weakness/posturing

Basilar stroke

Tonsillar Herniation

Cerebellar tonsils in foramen

magnum

Awake, pharynx weakness,

quadriparesis

Arrhythmia/cardiac arrest

Respiratory arrest

Uncal Herniation

Uncus over tentorial

notch

mental status

Dilated pupil, eye


Weakness/posturing

PCA stroke

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Meninges: Arachnoid Mater (middle)

Thin, weblike, avascular membrane under the dura

Subarachnoid space

Between arachnoid and pia

CSF, arachnoid villi (absorb CSF)

Subarachnoid hemorrhage

Meninges: Pia Mater (innermost)

Delicate membrane, contains blood vessels, exiting

nerves

Stuck to the brain

Hugs each gyrus, sulcus of the brain

Meninges: arteries and veins

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Today’s fun


Skull

Meninges

Ventricles


Brain

Vasculature

Spine


Awake

Unconscious

Spinal


Ventricular System: anatomy

Ventricles: fluid filled chambers that contain/circulate CSF

Lateral ventricles (2)

3rd ventricle

4th ventricle

Choroid plexus:

produces CSF,

in the ventricles

Arachnoid villi:

resorbs CSF from

subarachnoid

space

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Ventricular system: CSF

Function: Cushion in which brain “floats” When ICP , some CSF can be pushed out of the skull to lower ICP

Composition: Color: clear Protein: 16-45 mg/dl Glucose: 40-80 mg/dl (50-80% serum glucose) WBC: 0-5 cells/mm3 Lactate: 10-20 mg/dl

Formation: Produced by choroid plexus/ependymal cells 500 mL/day, 25 ml/hr 150 mL in circulation at any given time

Resorption: By arachnoid villi into the cerebral sinuses (veins)

1. Lateral ventricle

2. Interventricular foramen

3. Third ventricle

4. Cerebral aqueduct

5. Fourth ventricle

6a. Median aperture 6b. Lateral aperture 6c. Central canal (spinal cord)

7. Subarachnoid space

8. Arachnoid villi

9. Dural sinuses

Marieb 12.26b

CSF CIRCULATION

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Today’s fun


Skull

Meninges

Ventricles


Brain

Vasculature

Spine


Awake

Unconscious

Spinal


12

Cellular neuroanatomy: CNS

2 main cell types: neurons and neuroglia

Neuron: basic anatomic functional unit of the nervous system

Dendrites

Cell body

Axon

Myelin

Cellular neuroanatomy: CNS

Neuroglia: support the neurons, mitotic

Astrocytes

BBB

Astrocytoma, GBM

Oligodendrocytes

Myelin

Oligodendroglioma

Ependymal cells

Produce CSF

Ependymoma

Microglia

Immune protection, phagocytic

Cellular neuroanatomy: PNS

Neurons (ganglia)

Schwann cells

Myelin

Multiple

sclerosis

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BREAK FOR 5 MINUTES


Skull

Meninges

Ventricles


Brain

Vasculature

Spine


Awake

Unconscious

Spinal


Functional areas of the brain

-Personality/exec fxn

-Concentration

-Motor

-Speech

(Broca’s/fluency)

-Hearing

-Speech

(Wernicke’s/comprehe

nsion)

-Sensory

-Neglect

-Vision

Brodman’s Areas

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Cerebral Hemispheres: frontal lobes

High level cognitive function: personality, reasoning,

judgement, attention, social graces, moral behaviors

Level of consciousness

Motor control

motor cortex=just anterior to central sulcus

Motor Speech (Broca’s area)

Broca’s (expressive/nonfluent) aphasia: broken

speech

“I...can’t..can’t…talk!!!” (but follows commands)

Long term memory

Cerebral Hemispheres: parietal lobes

Sensory

Sensory cortex (posterior to central sulcus)

Attention to space, spatial relations, L vs R

Hemineglect after parietal stroke

Calculation

Reading, writing

THE HOMUNCULUS

MOTOR HOMUNCULUS SENSORY HOMUNCULUS

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Cerebral Hemispheres: temporal lobes

Auditory processing

Speech comprehension: Wernicke’s area

Wernicke’s (fluent/receptive) aphasia: nonsensical

“I cat beautiful lamppost!”

Short term memory (hippocampus)

Taste, smell

Especially seizuregenic

Cerebral hemispheres: dominance

Dominant hemisphere

Language (grammar, content)

? Handedness (L hemisphere dominant = R handed)

Non-dominant hemisphere

Prosody (intonation, musicality of speech)

Spatial relations

Artistry

Left hemisphere is dominant in 90% of population

Most left handed people are also left hemisphere dominant

Cerebral Hemispheres: occipital lobes

Vision

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Vision pathway

Deep Structures and connections

Brainstem

Diencephalon (thalamus, hypothalamus, pituitary)

Basal Ganglia

Deep Structures: basal ganglia

Masses of gray matter deep within the cerebrum

caudate, putamen, globus pallidus, substantia nigra, subthalamic nucleus

Regulate movement

Refines gross movements to fine motor

Tremors, Parkinson’s, Huntington’s

Reward learning, motivation

addiction, obsessive-compulsive disorder

Susceptible to spontaneous ICH

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Deep Structures: diencephalon

Thalamus

Hypothalamus

Posterior pituitary

Pineal gland

Deep Structures: diencephalon

Thalamus

Relay station of the brain: all sensory pathways have connections here (except olfactory). Susceptible to ICH.

Hypothalamus

Homeostasis

Temperature control

Water balance: ADH

Feedback loop with pituitary: GH, FSH, oxytocin

Sleep-wake cycle

Pituitary

Anterior: GSH, ACTH, TSH, FSH, LH, prolactin

Posterior: ADH, oxytocin

Sits on top of optic chiasm

Connections: white matter

Corpus Callosum Big axon bundle connecting

hemispheres (MS)

Internal capsule

Tiny concentrated bunch of

axons connecting motor and

sensory cortex w/

deep

structures

and

spinal

cord

(stroke)

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Deep Structures: brainstem

Anatomy: Midbrain, Pons, Medulla

Contains cranial nerve nuclei, reticular activating system

Function: primitive reflexive functions necessary for

life (if you have no brainstem function, you are

“braindead”)

Midbrain

Pons

Medulla

Reticular Activating System

MIDBRAIN

CN 3—pupils, open eyelid, medial/superior/inf rectus (EOM’s exc lateral)

CN 4—superior oblique

PONS

CN 5—facial sensation, corneal reflex input

CN 6—lateral rectus

CN 7—facial strength, corneal reflex output

CN 8—hearing, balance

MEDULLA

CN 9, 10—throat sensation/muscles, vagus

CN 11—shoulder shrug, head turn

CN12—tongue muscles

Respiratory control, HR, BP

Deep Structures: Brainstem

Midbrain

Pons

Medulla

Deep Structures: Brainstem

Pons

Medulla

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Herniation syndromes



falx

Leg weakness

mental status

Central/Upward

Herniation

Brainstem down/up

through tentorium

mental status

Dilated pupil, eye


Weakness/posturing

Basilar stroke



magnum


quadriparesis


Respiratory arrest

Uncal Herniation


notch

mental status

Dilated pupil, eye


Weakness/posturing

PCA stroke

Cerebellum

Anatomy: posterior fossa, attached to brainstem by

cerebellar peduncles, sits behind 4th ventricle and

brainstem

Function:

Coordination

Equilibrium/balance

Herniation syndromes



falx

Leg weakness

mental status

Central/Upward

Herniation

Brainstem down/up

through tentorium

mental status

Dilated pupil, eye


Weakness/posturing

Basilar stroke



magnum


quadriparesis


Respiratory arrest

Uncal Herniation


notch

mental status

Dilated pupil, eye


Weakness/posturing

PCA stroke

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Purpose of nursing neuroassessment

Herniation: early detection saves lives

MA Koenig, M Bryan, JL Lewin, III, MA Mirski, RG Geocadin and RD Stevens

Neurology 2008;70;1023-1029; originally published online Feb 13, 2008

Long-term outcome after medical reversal of transtentorial herniation

in patients with supratentorial mass lesions Qureshi,,Geocadin,Suarez, Ulatowski, CRITICAL CARE MEDICINE 2000;28:1556-1564

11/28 (40%) survived to discharge

7/11 (59%) survivors functionally independent

253 cases TTH (acute onset uni/bilateral pupillary dilation, loss of

reactivity, GCS decrease >2 pts, intracranial space occupying lesion)

30cc 23.4% saline bolus reversed clinical signs of TTH in 75% of pts

Herniation: early detection saves lives

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Today’s fun


Skull

Meninges

Ventricles


Brain

Vasculature

Spine


Awake

Unconscious

Spinal


Cerebral Vasculature: arterial

ACA

PCA

MCA

Cerebral Vasculature: arterial

Anterior circulation (fed by internal carotid)

Anterior cerebral arteries (ACA)

Anterior communicating artery (A. Com)

Middle cerebral arteries (MCA)

Posterior circulation:

Posterior cerebral arteries (PCA)

Posterior communicating arteries (P. Com)

Basilar artery

Vertebral arteries

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Cerebral Vasculature: venous

Today’s fun


Skull

Meninges

Ventricles


Brain

Vasculature

Spine


Awake

Unconscious

Spinal


Spinal anatomy

Vertebral Column

Discs

Spinal Nerves

Spinal Cord

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Spinal anatomy

Vertebral Column

33 bony vertebrae 7 cervical- C1-C7

12 thoracic- T1-T12

5 lumbar- L1-L5

5 sacral (fused)-S1-S5

4 coccygeal (fused)

Separated by intervertebral disks

Connected by ligaments

Function

Body's basic structural support

Protects the spinal cord

Spinal anatomy: vertebrae

Spinous process

Spinal anatomy: discs

Anatomy: Stiff jello like center (nucleus

pulposa) surrounded by layers of connective fibers (annulus fibrosis)

Function: Shock absorbers

Shrivel with age (1-2 inches)

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Spinal anatomy: spinal nerves

31 spinal segments/pairs of spinal nerve roots

8 cervical

12 thoracic

5 lumbar

5 sacral

Spinal anatomy: spinal nerves

Deltoids (C5)

Biceps (C5-6)

Triceps (C6-7)

Wrist extension (C6-7)

Finger extension (C8)

Hip flexion (L2-3)

Hip extension (L3-4)

Knee extension (L3-4)

Knee flexion (L5-S1)

Foot dorsiflexion (L4-5)

Foot plantarflexion (S1-2)

Toe extension/EHL (L5)

Spinal anatomy: spinal cord

Spinal cord:

ends at L1 or L2

conus medullaris: bulbous end of spinal cord

cauda equina (horse’s tail): collection of nerve roots

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ANTERIOR

POSTERIOR

Sensory

Motor


S

E

N

S

O

R

Y MOTOR

MOTOR Motor tracts

Corticospinal

Voluntary

movement

Medial=arms

Lateral=legs

Rubrospinal,

reticulospinal,

vestibulospinal,

tectospinal

Postural reflexes


S

E

N

S

O

R

Y MOTOR

MOTOR Sensory tracts

Spinothalamic

Pain, temp, light touch

Contralateral

Posterior columns

Proprioception,

vibration, discrim. touch

Ipsilateral

Spinocerebellar

Unconscious

proprioception

Spinoreticular

Deep pain

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Spinal anatomy: blood supply

Anterior spinal artery

Only 1, so can infarct easily

Supplies anterior 2/3 of cord: motor and some sensory

Posterior spinal artery

Two

Supplies dorsal columns

Autonomic System

Sympathetic

Neuron bodies in

lateral horns of T1-L3

spinal cord gray matter

Synapse in sympathetic

chain

Parasympathetic

Neuron bodies in

brainstem (CN 3, 7, 9,10)

and S2-S4 spinal cord

gray matter


COMPLETE NEUROASSESSMENT

FOR AWAKE AND COMATOSE

CRITICAL CARE PATIENTS

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Objectives

The participant will be able to:

Describe the major components of the complete

neurological examination of the awake and

comatose critical care patient

Accurately, consistently, efficiently, and confidently

perform the complete neurological assessment for

awake and comatose critical care patients

Report exam findings and trends objectively

Describe assessment findings that are indicative of

increasing ICP.

Purpose of complete RN neuroassessment

Serial objective evaluation and trending of nervous

system function: the nervous system vitals monitor

Identifies exam changes that require intervention and

may be life-threatening

Provides basis for patient management and

prognostication

Monitors treatment response

Identifies etiology and location of pathological processes

Evaluates patient’s functional ability and capacity for self-

care

Evaluates impact of disability on patient and family

Purpose of RN complete neuroassessment

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Common RN neuroassessment pitfalls

Inadequate stimulus to achieve best response

Inadequate baseline assessment

Failure to use objective terminology

Failure to recognize subtle clues in time for

successful intervention

Failure to have confidence in your assessment skills

and go up the chain of command. If you know

something is wrong with your patient, be persistent

in getting help!

Components of the RN complete

neuroassessment

History

Level of Consciousness

Cranial Nerves

Motor exam

Sensation

Coordination

Reflexes

Gait

Not generally done in

neuro-ICU nursing

assessment

Level of consciousness: GCS. Awake/lethargic/obtund/stupor.

Orientation: Name? Date? Place? What brought you in?

Language: Fluency? Name watch, pen. Commands. Repetition.

Neglect: Tactile? Spatial?

Cranial Nerves: Pupils. Visual fields. Acuity. Eye & lid position.

EOMs. Facial sensation. Facial strength. Hearing. Speech.

Cough. Shrug. Head turn. Tongue protrusion.

Motor: Pronator drift. Deltoids. Biceps. Triceps. Grip. Hip flex.

Hip ex. Knee flex. Knee ex. Dorsi/Plantarflex. EHL.

Sensation: Light touch in all 4’s.

Cerebellum: Finger to nose. Heel to Shin.

Complete neuroassessment: awake

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History

Chief Complaint/History of Present Illness

Past Medical/Surgical History

Cataract surgery?

What are their seizures like?

What were their symptoms with their old strokes?

Social History

When was their last EtOH, tobacco, drugs?

Medications

Coumadin, dabigitran, aspirin, plavix, garlic/ginko,

antiepileptics, sedatives

What time was their last dose?

Review of Systems

Level of Consciousness: principles

Level of consciousness consists of 2 parts:

1. AROUSAL/AWAKENESS 2. CONTENT

Level of Consciousness: principles

MOST SENSITIVE AND SPECIFIC INDICATOR OF NEUROLOGICAL CHANGE

Objective

Can change rapidly (neurological deterioration)

Any change for the worse requires immediate physician evaluation and possible intervention

Can be confounded by medications (sedatives, antiepileptics) and withdrawal

Pause sedative drips for exams with physician approval

Frequently reevaluate lowest amount of sedative/pain meds needed to achieve goals

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Level of Consciousness: arousal

Reticular Activating System THINGS THAT AROUSAL

Diffuse cortical dysfunction

Metabolic changes (hypoxia,

hypoglycemia, pH abnl,

hyponatremia)

Medications

Hypotension (decreased CBF)

Increased ICP

Big structural lesions

Lesions of RAS (brainstem or

bilateral thalamus)

Level of consciousness: GCS

Coma = GCS<8

E2

V2

M4


LEVEL OF AROUSAL

Awake (E4)

Awake/arouses easily from sleep with quick, normal cognition

Lethargic (E4)

Awake/arouses easily but slow cognition or motor activity

Obtunded (E3)

Drowsy

Requires non-painful stim to open eyes. May say few words, follow simple commands

Stuporous (E2)

Unresponsive except when stimulated

Requires painful stim to open eyes. May mutter incomprehensible sounds

Comatose (E1)

Unresponsive

No eye opening. Localizes, withdraws, postures, or no response to pain

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Follows commands-M6

Localizes: LOCAtes stimulus & combats it (some cortex)-M5

Withdraws: pulls away from pain (thalamus)-M4

Flexor postures (brainstem)-M3

Extensor postures (brainstem)-M2

No response or leg triple flexion (spinal cord)-M1

Triple flexion: flexion at ankle, knee, hip

Level of Consciousness: assessing arousal

Maximum stimulus for maximum response

Voice

↓

Shout

↓

Shake

↓

Central Pain

↓

Peripheral Pain

Central Pain: more

reliable indicator of

arousal

Trapezius squeeze

Supraorbital notch

Biceps tendon

Peripheral Pain:

Inner bicep/axilla

Inner thigh

Nailbed pressure

(only as last resort)


ADDITIONAL AROUSAL DESCRIPTORS

Posturing

FLEXOR

EXTENSOR

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-Personality/exec fxn

-Concentration

-Motor

-Speech

(Broca’s/fluency)

-Hearing

-Speech

(Wernicke’s/comprehe

nsion)

-Sensory

-Neglect

-Vision

Level of Consciousness: content

Orientation

Language

Fluency

Naming

Comprehension/commands

Repetition

Neglect

Visual

Tactile

Personal

Orientation: A&O x 1, 2, 3, 4

What is your name? What is the date? (if they hesitate, ask year, month, then day) Where are we? What brought you into the hospital?

Language:

Fluency: listen as pt talks. (Normal I…can’t……talk! mute)

Naming: point to a watch and pen and ask pt to name

Comprehension/commands: Close eyes/stick out tongue, show 2 fingers, wiggle toes; “point to the ceiling and then to the door” (complex)

Repetition: Repeat after me, “It is a sunny day in San Diego”

Neglect: (normalneglect to 1 modalityneglect to >1)

Tactile: Ask pt to close their eyes, then touch R arm, ask “where am I touching you?” Then repeat w/ L arm. Then touch both simultaneously.

Spatial: Observe pt as you move around room; see if they prefer 1 side. If multiple people in the room, you can ask how many they see.

Personal: They ignore 1 half of their body even though they’re not weak

Level of Consciousness: assessing content

How to report level of consciousness

Pt is awake and oriented x 4

Pt is awake and oriented to name and place

Pt is lethargic/obtunded/stuporous, opens eyes to

voice/shake/painful stim

Speech is fluent/nonfluent, follows simple/complex

commands, naming and repetition intact/not intact

Pt has no/R sided/L sided neglect

Level of Consciousness: assessment

33

Cranial Nerves: what they do

CN 2: acuity, visual fields, pupils

CN 3: pupils, eyelid opening, EOM’s

CN 3/4/6: EOM’s, oculocephalic, cold calorics

CN 5: facial sensation, corneals

CN 7: facial strength, eyelid closure, corneals

CN 8: hearing, balance, oculocephalic, cold calorics

CN 9/10: speech, cough, gag

CN 11: shrug, head turn

CN 12: tongue protrusion, speech

Cranial Nerves: assessment

AWAKE PATIENT

Pupils (2, 3)

Visual fields, acuity (2)

Eye position, eyelid, EOMs (3, 4, 6)

Facial sensation (5)

Facial strength (7)

Hearing (8)

Speech/Cough/Gag (9,10)

Shrug, head turn (11)

Tongue protrusion (12)

COMATOSE PATIENT

Pupils (2, 3)

Threat (2)

Eye position (3, 4, 6)

Oculocephalic (3, 4, 6, 8)

Corneals (5, 7)

Cough (9, 10)

Vitals (10)

Cranial Nerves: awake assessment

PUPILS—CN 2, 3

Size

Normal: 2-5mm

Abnormal: pinpoint <2mm (pontine dysfxn, meds), dilated >5mm

(CN3/midbrain dysfxn from ICP >18, atropine, epinephrine), any

change in size >1mm

Shape

Normal: round, may be irregular from cataract surgery

Abnormal: ovoid (CN3 dysfxn from ICP. Precedes dilated pupil.)

Equality

Normal: equal, may have physiologic anisocoria (1 mm difference)

Abnormal: >1mm difference between two pupils

34


PUPILS—CN 2, 3

Reactivity to light

Direct (look at the pupil you’re shining the light into)

Normal: brisk pupil constriction when light is shone in,

dilation when light is taken away

Abnormal: sluggish or no pupil constriction when light is

shone in (increased ICP, hypothermia, high doses of

sedatives), any decrease or inequality in reactivity

Consensual (look at the pupil you’re NOT shining the light into)

Normal: opposite pupil also constricts when light is shone in

Abnormal: opposite pupil does nothing or dilates when

light is shone in


PUPILS—CN 2, 3

How to assess:

Turn the lights off

Ensure the same ambient light as the previous tester

Observe size and shape of both pupils before you shine light in

Swing a bright (non-LED) flashlight quickly onto one eye and

observe reactivity in that eye and the opposite eye

Do the opposite eye

How to report:

“Pupils were 4 mm, equal and briskly reactive”

“Pupils were small, equal, and briskly reactive” (PERRL)

“R pupil was 4mm and briskly reactive, L pupil was 5mm and

sluggish”


PUPILLARY BADNESS TO REMEMBER

During early increased ICP (pressure on CN3)

1 or both pupils become less reactive than before (catch it!)

1 or both pupils gradually dilate

1 or both pupils may become ovoid

During later increased ICP (pressure on midbrain)

1 or both pupils become fixed and dilated

During really late increased ICP (midbrain is dead, pressure on pons)

Both pupils become pinpoint and fixed

Braindeath

Pupils may stay fixed and dilated/pinpoint, or may return to midposition (2-3mm) and fixed

35


VISUAL FIELDS—globe, CN2

Normal: can count fingers in all 4 quadrants in each eye

Abnormal: changed from baseline (indicates globe, optic

nerve, optic chiasm, or cortical injury depending on field cut)

How to assess:

Face pt a little more than forearm length away, look directly at pt

Cover one of pt’s eyes with your hand, close your same eye

Flash 1 or 2 fingers in each quadrant and ask pt how many they see

If pt uncooperative, test blink to threat (quickly move your hand

toward their eye and see if they blink)

How to report:

Temporal field cut in R eye

Bilateral superior temporal quadrantanopsia

1. Right Monocular Vision Loss

2. Bitemporal Hemianopsia

3. Left Homonymous Hemianopsia

4. Left Homonymous Quadrantanopsia


VISUAL ACUITY—globe, CN 2

Normal: unchanged from baseline

Abnormal: change from baseline (globe/optic nerve problem)

How to assess:

Ensure pt has their own glasses or contacts on

Ask pt if they think their vision has changed

If patient thinks vision is changed or high risk (pituitary or carotid

surgery): eye chart, counting fingers, light perception

How to report:

“Visual acuity grossly unchanged from baseline”

“Visual acuity 20/20 in the R eye, 20/100 in the L eye”

“Counts fingers on R, no light perception on L”

36


EYE POSITION—CN 3, 4, 6, & EYELID OPENING—CN 3

Normal: midposition eyes, eyelids symmetrically open

Abnormal: any change from baseline or asymmetry, ptosis

(eyelid drooping) (CN 3, 4, or 6 pathology)

How to assess:

Observe pt’s eye position and eyelids for

symmetry when they are looking directly at you

How to report:

Often not reported if normal

Pt has R ptosis

“At rest, L eye is laterally deviated”

“At rest, both eyes are down and out”


EXTRAOCULAR MOVEMENTS (EOM’s)—CN 3, 4, 6

Normal: smooth movements w/ full excursion up, down, R,

L (iris buries w/ lateral gaze), a little nystagmus upon end

gaze

Abnormal:

any asymmetry

impaired mobility (CN 3/4/6, midbrain/pons pathology)

forced gaze (stroke/seizure)

jerky movements or nystagmus

(CN8, cerebellum, vestibular system)

double vision

•inferior oblique (IO) •—cranial nerve III

•medial rectus (MR) •cranial nerve III

•superior oblique (SO) •—cranial nerve IV

•inferior rectus (IR) •—cranial nerve III

•lateral rectus (LR) •—cranial nerve VI

•superior rectus (SR) •—cranial nerve III


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How to assess:

Hold your finger at arm’s length from pt, ask them to follow

up, down, left, right

Ask pt if they have double vision in any position

How to report:

“EOM’s full”

“R/L eye partial/complete gaze paralysis on

lateral/medial/upward/downward gaze”

“Forced gaze to the L”

“Nystagmus at rest/with eye movements”

“Double vision on R lateral gaze”




EXTRAOCULAR MOVEMENT ABNORMALITY LOCALIZATIONS

Horizontal

Seizure: away from focus

Destructive lesion of hemispheres (stroke, bleed): towards lesion

Destructive lesion of pons: away from lesion

Skewed: one eye up, one down

Pontine or cerebellar pathology

Ocular bobbing: intermittent, usually conjugate, downward, brisk eye movement followed by slower return to resting position

Severe, destructive lower pontine pathology

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FACIAL SENSATION—CN 5

Normal: symmetric sensation to light touch on forehead (V1),

cheeks (V2), chin V3)

Abnormal: any asymmetry or change from baseline

How to assess:

Lightly stroke both sides of pt’s forehead once, then cheeks,

then chin, asking each time “does this feel the same on both

sides?”

How to report:

“Face has normal sensation”

“Face has decreased sensation in R V2”


FACIAL STRENGTH—CN7

Normal: face is symmetric at rest and with testing

Abnormal: decreased nasolabial fold, facial droop,

decreased smile excursion (CN7, stroke, post-ictal),

slurred speech (CN7, but could also be CN 9, 10, 12,

cerebellum)


FACIAL STRENGTH—CN 7

How to assess:

Observe pt’s face at rest for symmetry (eyelids, nasolabial

fold)

Ask pt to raise eyebrows, close eyes tight and don’t let me

open them, show me your teeth

How to report:

“Face is symmetric with normal strength”

“Pt has R ptosis (eyelid droop) and decreased R nasolabial fold”

“Pt has decreased smile excursion on the R”

“Pt has a L facial droop”

39


HEARING—CN 8

Normal: no asymmetry in hearing

Abnormal: any asymmetry or change from baseline (CN8,

earwax, ear canal pathology)

How to assess:

Rub 2 fingers lightly together near pt’s R ear and ask “can

you hear this?”, repeat on the L, then ask “is there any

difference between the two sides?

How to report:

“Hearing is normal”

“Decreased hearing in R ear”


SPEECH/COUGH/GAG—CN 9, 10

Normal: speech clear, does not cough w/ drinking,

uvula midline, palate elevates symmetrically

Abnormal: slurred/soft/hoarse speech, coughs while

drinking/eating, weak cough, uvula deviates to one side, palate

does not elevate, any asymmetry or change from baseline

How to assess:

Listen to pt’s speech and observe pt while eating/drinking

Ask pt to say “ah” and observe uvula/palate

With qtip, gently touch back of pt’s throat, once on each side

How to report:

“Uvula deviates to the R and decreased gag on R”


SHRUG/HEAD TURN—CN 11

Normal: strong and symmetric

Abnormal: weak or asymmetric

How to assess:

Observe pt’s neck muscles for asymmetry at rest

Ask pt to shrug shoulders while you push down

Ask pt to turn their head against your hand

How to report:

“Shrug and head turn full strength”

“R shoulder shrug 4 out of 5”

“L head turn 3 out of 5”

40


TONGUE PROTRUSION—CN 12

Normal: midline

Abnormal: not midline, slurred speech

How to assess:

Ask pt to stick out tongue and move

side to side

Ask pt to push tongue against cheek

while you provide resistance

How to report:

“Tongue midline”

“Tongue deviates to the L”

Cranial Nerves: comatose assessment

Pupils (2, 3)

Threat (2)

Eye position (3, 4, 6)

Oculocephalic reflex (3, 4, 6, 8)

Vestibuloocular reflex (3, 4, 6, 8)

Corneals (5, 7)

Cough (9, 10)


BLINK TO THREAT—CN2, 7, visual cortex

Normal: blinks bilaterally

Abnormal: does not blink or asymmetry

How to assess:

Hold pt’s eyelids open and move your hand

quickly towards lateral corner of pt’s eye, repeat on other side

How to report:

“Threat present bilaterally”

“Threat absent on the R”

41


OCULOCEPHALIC REFLEX (“Doll’s Eyes”)—3, 4, 6, 8

Normal: eyes move away from

direction of turning as if to stay

looking at examiner

Abnormal: eyes do not move in their sockets

How to assess (DO NOT assess in cspine patients!)

Ensure pt’s ET tube firmly taped and has slack

Hold pt’s eyelids open and quickly turn head to R, then L,

observing movement of eyes

How to report:

“Oculocephalic reflex present”

“Oculocephalic reflex absent”


VESTIBULOOCULAR REFLEX (cold calorics)—3, 4, 6, 8

Normal: eyes move away from

direction of cold water

Abnormal: eyes do not move

How to assess (usually by MD, only during braindeath exam)

Examine ear canal for wax or TM perforation

Hold eyelids open, inject 60cc of ice cold saline through

flexible tubing attached to slip tip syringe in 1 ear, watch for

eye movement for 30 seconds, then do other ear

How to report:

Vestibuloocular reflex present/absent


CORNEALS—CN5, 7

Normal: strong blink reflex bilaterally

Abnormal: weak or absent blink

How to assess:

Brush eyelashes on each eye

Saline eyedrop in each eye

If no response, try wisp off of cotton qtip

How to report:

“Corneals present bilaterally”

“Corneals present bilaterally, but R weaker than L”

“R corneal present, L absent”

42


COUGH

Normal: strong cough to suction

Abnormal: weak, absent, or any change

How to assess:

suction patient (ask physician if ok to do if pt has

unsecured aneurysm or ICP problems)

How to report:

“Cough present”

“Weak cough present”

“Cough absent”


VITALS

Normal: normal HR, BP, RR and pattern

Abnormal: brady/tachycardia, arrhythmia

(usually tachy/brady, PAC/PVC’s),

Increased/decreased RR, changing respiratory

pattern, any change in baseline

How to assess:

Watch for trends—change of HR from 80 to 60 could indicate

worsening medullary function

How to report:

You know how

Motor Exam: assessment

1. QUALITY of motor response (GCS motor)

-identifies level of nervous system dysfunction

2. STRENGTH of motor response (5/5 strength)

-trends nervous system function

43

Motor Exam: assessment

QUALITY OF MOTOR RESPONSE

Follows commands (lots of cortex)-GCS M6

Localizes: LOCAtes stimulus & combats it (some cortex)-M5

Withdraws: pulls away from pain (thalamus)-M4

Flexor postures (brainstem)-M3

Extensor postures (brainstem)-M2

No response or leg triple flexion (spinal cord)-M1

Triple flexion: flexion at ankle, knee, hip

Motor Exam: Strength

STRENGTH OF MOTOR RESPONSE

5: Normal; full strength against resistance

4: Some resistance; examiner can overcome patient

3: Can lift body part (antigravity), but provides no resistance

2: Cannot lift body part, but can move it laterally (with gravity eliminated)

1: Muscle contraction detectable

0: No muscle contraction detectable

Motor Exam: awake assessment

Pronator Drift: most sensitive sign of upper extremity weakness

Close eyes

Ask pt to hold arms up like holding a pizza, palms up to ceiling and flat

20-30 seconds

Observe for trembling, finger curl, arm turning inward(pronation), actual drift

Deltoids: arms up like chicken wings, don’t let me push them down

Biceps: pull in towards you

Triceps: push me away

Wrist extension: cock your wrists back

Finger extension: spread fingers out

Grip: squeeze my fingers

44


Hip flexion: ask pt to bend their knee, put your hand on their knee, then ask them to push up on your hand

Hip extension: put one hand under their thigh and ask them to press down on your hand

Knee extension: ask pt to straighten their leg and keep it straight, while you support them with your arm under their knee. With your other hand push down on ankle

Knee flexion: ask pt to keep their knee bent while you try to straighten their leg

Foot Dorsiflexion: ask pt to pull their toes up to nose, or cock foot back at the ankle, while you push down on the top of their foot

Foot Plantar Flexion: push down on gas

Toe extension/EHL: ask pt to pull big toe up to nose against your hand


Pronator Drift

Bicep

Tricep


Grip Finger extension

45


Hip flexion

Knee extension

Knee flexion


Foot dorsiflexion

Foot plantarflexion

Knee flexion

EHL


Tips:

If patient is not moving an

extremity to command, give a

painful stimulus. We are trying

to identify the pt’s BEST

POSSIBLE motor response!

How to report:

Pt follows commands in all extremities with 5 out of 5 strength

Pt follows commands in all extremities and has R pronator drift

Pt follows commands in all 4’s with 5 out of 5 strength, except R bicep is 3 out of 5

Peripheral Pain:

Inner bicep/axilla

Inner thigh

Nailbed pressure


46

Motor Exam: comatose assessment

How to assess:

Put pt’s forearms resting on their belly

Uncover pt completely

Give central painful stim first; if

pt does not do something in all 4’s,

proceed to peripheral pain

How to report:

Pt localizes to central pain in all 4’s

Pt withdraws in the uppers and

triple flexes in the lowers

Central Pain: more

reliable indicator

of arousal

Trapezius squeeze

Supraorbital notch

Peripheral Pain:

Inner bicep/axilla

Inner thigh

Nailbed pressure


Sensation: awake assessment

Light touch (sufficient unless pt needs spinal checks)

Normal: feels the same in all 4 extremities

Abnormal: any asymmetry

How to assess:

Touch pt once lightly on R arm, then L, then ask “does this

feel the same on both sides?” Repeat with legs.

If pt says they feel different, ask “If the good side is 100%,

what percent is the bad side?”

How to report:

Sensation intact in all 4’s

Pt has decreased sensation in RUE

Sensation: comatose assessment

Assessed during level of consciousness/motor

47

Cerebellum: awake assessment

Normal: accurate, smooth, quick movements

Abnormal: inaccurate, jerky, slow movements

How to assess:

Face: watch EOM’s for nystagmus, jerky eye movements

Listen to speech for dysarthria

Upper extremities: finger to nose, finger tapping

Dysmetria: horizontal wobbling

Past-pointing: overshooting the mark

Lower extremities: heel to shin, foot tapping

How to report:

Pt has normal finger to nose and heel to shin

Pt with dysmetria on R finger to nose

Cerebellum: comatose assessment

Watch eyes for nystagmus and jerky movements

Comatose Patient Assessment Recap

1. Observe meds, vitals

2. Observe patient

3. Level of consciousness/motor

4. Cranial nerves

48


MEDS AND VITALS

Pause sedation if possible (propofol for 5 minutes,

versed for 15)

Keep in mind if pt had any long acting sedatives

Vitals are part of your brainstem exam! (medulla)

HR: bradycardia can indicate increased ICP,

tachycardia/arrhythmia can indicate pain or severely

increased ICP

BP: unusual HTN can indicate rebleed or stroke

RR: are they overbreathing the vent? (they may have the

capacity to if you turn the mandatory rate down…) If not,

they may be braindead…


OBSERVE PATIENT

Take off sheets to observe spontaneous movements

or seizure-like activity

Notice if patient’s HR or BP goes up when they hear

you talking—it’s possible a patient who looks

comatose can hear you talking


LEVEL OF CONSCIOUSNESS/MOTOR

Voice

↓

Shout

↓

Shake

↓

Central Pain

↓

Peripheral Pain

LOCALIZES

WITHDRAWS

FLEXES

EXTENDS

NO

RESPONSE/TRIPLE

FLEXION

49


CRANIAL NERVES

Pupils (2, 3)

Threat (2)

Eye position (3)

Oculocephalic (3, 4, 6, 8)

Corneals (5, 7)

Cough (9, 10)

Vitals (10)

Findings of Increased ICP

Earliest: Decreasing LOC, loss of orientation, forgetful,

restless

Early: Headache, nausea, vomiting, blurred/

double vision, sudden quietness

Later: pupils more sluggish, unequal, enlarging,

worsening motor exam

Late: dilated fixed pupils, posturing, unarousable to

deep pain, losing corneals, blood pressure, HR,

irregular respirations

Cushing’s triad: bradycardia, HTN, irregular respirations

Spinal Assessment

Only done if specially ordered

Typical patients:

Spinal cord injury

Polytrauma, head trauma

s/p back surgery

Consists of:

Motor exam

Sensory exam

50

Spinal Assessment

MOTOR EXAM (same as full motor exam awake assessment)

Assess motor strength

Pronator drift

Deltoids (C5)

Biceps (C5-6)

Triceps (C6-7)

Wrist extension (C6-7)

Finger extension (C8)

Grip

Hip flexion (L2-3)







Spinal Assessment

SENSORY EXAM

Assess light touch, pin

Touch pt once on each

dermatome with sharp object

Spinal Assessment

Hip flexion (L2-3)







51

When your patient’s exam changes

THINK:

What do I see?

What does it mean?

How does it relate to my baseline/previous exams?

Should I call somebody?

Who should I call?

What now?

PRACTICE, PRACTICE, PRACTICE

Find a system that works for you and memorize it

You can complete a focused neuro exam that tells you

everything you need to know about that patient’s

neurologic status in a few minutes

Always report changes, even if you’re not sure if it’s

significant

Don’t be afraid to ask questions

Don’t be afraid to call up the chain of command

Don’t be afraid to call my cell phone 650-906-9521 or

email me [email protected]

TIME IS BRAIN!

52

Remember, it’s all about our patients

Mr. C. was in NCSE x 73

days.

He underwent treatment

with ativan, valium,

clonazepam, versed,

propofol, phenytoin,

topamax, lacosamide,

depakote, phenobarbital,

pentobarbital, keppra,

lamictal, isoflurane,

lidocaine, ECT, ketamine,

hypothermia,

immunosuppressants, and

epilepsy surgery. The

ketogenic diet stopped his

seizures within 24 hours.

Thank you!

Cassia Chevillon

Laura Dibsie

Patricia Graham

Juana Burkhart

Mobe Montesa

Shannon Hall

Margarita Baggett

Filissa Casserta, Betsy Zink and all the Hopkins NCCU and

University of Maryland Shock Trauma RN’s

UCSD Departments of Surgery, Neurosciences, Anesthesia

Level of consciousness: GCS. Awake/lethargic/obtund/stupor.

Orientation: Name? Date? Place? What brought you in?

Language: Fluency? Name watch, pen. Commands. Repetition.

Neglect: Tactile? Spatial?

Cranial Nerves: Pupils. Visual fields. Acuity. Eye & lid position.

EOMs. Facial sensation. Facial strength. Hearing. Speech.

Cough. Shrug. Head turn. Tongue protrusion.

Motor: Pronator drift. Deltoids. Biceps. Triceps. Grip. Hip flex.

Hip ex. Knee flex. Knee ex. Dorsi/Plantarflex. EHL.

Sensation: Light touch in all 4’s.

Cerebellum: Finger to nose. Heel to Shin.

Complete neuroassessment: awake

53

Vitals

Observe patient

Level of consciousness/motor: voice/shout/shake/painful

stim to see if pt

localizes/withdraws/flexes/extends/nothing

Cranial nerves: Pupils. Threat. Eye position. Oculocephalic.

Corneals. Cough.

Complete neuroassessment: comatose

CRITICAL CARE RN NEUROANATOMY & COMPLETE NEUROASSESSMENT ... · CRITICAL CARE RN NEUROANATOMY & COMPLETE NEUROASSESSMENT Navaz Karanjia, ... Level of consciousness ... Qureshi,,Geocadin,Suarez,

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