Page 95 - ATP-P 11th Ed

APPENDIX E: TBI RESOURCES
Neurological Examination
MENTAL STATUS MOTOR SECTION 1
Level of Consciousness: Note whether the Tone: Note whether resting tone is increased (i.e.,
patient is: spastic or rigid), normal, or decreased (flaccid).
• Alert/responsive Strength: Observe for spontaneous movement
• Not alert but arouses to verbal stimulation of extremities and note any asymmetry of move-
• Not alert but responds to painful stimulation ment (i.e., patient moves left side more than right
• Unresponsive side). Lift arms and legs, and note whether the
Orientation: Assess the patient’s ability to provide: limbs fall immediately, drift, or can be main-
• Name tained against gravity. Push and pull against the
• Current location upper and lower extremities and note any resis-
• Current date tance given. Note any differences in resistance
• Current situation (e.g., ask the patient what provided between the left and right sides.
happened to him/her) (NOTE: it is often difficult to perform formal
Language: Note the fluency and appropriateness strength testing in TBI patients. Unless the pa-
of the patient’s response to questions. Note pa- tient is awake and cooperative, reliable strength
tient’s ability to follow commands when assess- testing is difficult.)
ing other functions (e.g., smiling, grip strength, Involuntary movements: Note any involuntary
wiggling toes). Ask the patient to name a simple movements (e.g., twitching, tremor, myoclonus)
object (e.g., thumb, glove, watch). involving the face, arms, legs, or trunk.
Speech: Observe for evidence of slurred speech.
SENSORY
CRANIAL NERVES If patient is not responsive to voice, test central
All patients: pain and peripheral pain.
• Assess the pupillary response to light. Central pain: Apply a sternal rub or supraorbital
• Assess position of the eyes and note any move- pressure, and note the response (e.g., extensor
ments (e.g., midline, gaze deviated left or right, posturing, flexor posturing, localization).
nystagmus, eyes move together versus uncou- Peripheral pain: Apply nail bed pressure or take
pled movements). muscle between the fingers, compress, and rotate
• Noncomatose patient: the wrist (do not pinch the skin). Muscle in the
• Test sensation to light touch on both sides of axillary region and inner thigh is recommended.
the face. Apply similar stimulus to all four limbs and note
• Ask patient to smile and raise eyebrows and the response (e.g., extensor posturing, flexor pos-
observe for symmetry. turing, withdrawal, localization).
• Ask the patient to say “Ahhh” and directly ob- NOTE: In an awake and cooperative patient,
serve for symmetric palatal elevation. testing light touch is recommended. It is unnec-
• Comatose patient: essary to apply painful stimuli to an awake and
• Check corneal reflexes; stimulation should cooperative patient.
trigger eyelid closure.
• Observe for facial grimacing with painful stimuli. GAIT
• Note symmetry and strength. If the patient is able to walk, observe his/her ca-
• Directly stimulate the back of the throat and sual gait and note any instability, drift, sway, and
look for a gag, tearing, and/or cough. so forth.

84 SECTION 1 TACTICAL TRAUMA PROTOCOLS (TTPs) ATP-P Handbook 11th Edition 85