Page 46 - 2022 Spring JSOM

APPENDIX E: TBI RESOURCES

Neurological Examination GAIT
MENTAL STATUS If the patient is able to walk, observe his/her casual gait and note any
Level of Consciousness: Note whether the patient is: instability, drift, sway, and so forth.
■ Alert/responsive
■ Not alert but arouses to verbal stimulation Ultrasonic Assessment of Optic Nerve Sheath Diameter
■ Not alert but responds to painful stimulation If a patient is unconscious (i.e., does not follow commands or open
■ Unresponsive eyes spontaneously), they may have elevated ICP. There is no reliable
test for elevated ICP available outside of a hospital; however, optic
Orientation: Assess the patient’s ability to provide: nerve sheath diameter (ONSD) measurement is a rapid, safe, and easy-
■ Name to-perform ultrasonographic assessment that may help identify ele-
■ Current location vated ICP when more definitive monitoring devices are not available.
■ Current date ■ The optic nerve sheath directly communicates with the intracranial
■ Current situation (e.g., ask the patient what happened to him/her)
subarachnoid space. Increased ICP, therefore, displaces cerebrospi-
Language: Note the fluency and appropriateness of the patient’s re- nal fluid along this pathway. Normal ONSD is 4.1–5.9mm. 30
sponse to questions. Note patient’s ability to follow commands when ■ A 10–5-MHz linear ultrasound probe can be used to obtain
assessing other functions (e.g., smiling, grip strength, wiggling toes). ONSDs. ONSD is measured from one side of the optic nerve
Ask the patient to name a simple object (e.g., thumb, glove, watch). sheath to the other at a distance of 3mm behind the eye immedi-
ately below the sclera. 31
Speech: Observe for evidence of slurred speech.
■ In general, ONSDs >5.2mm should raise concern for clinically
CRANIAL NERVES significant elevations in ICP in unconscious TBI patients. 5,32 The
All patients: ONSD can vary significantly in normal individuals, so one single
■ Assess the pupillary response to light. measurement may not be helpful; however, repeated measurements
■ Assess position of the eyes and note any movements (e.g., midline, that detect gradual increases in ONSD over time may be more use-
gaze deviated left or right, nystagmus, eyes move together versus ful than a single measurement.
uncoupled movements). ■ ONSD changes rapidly when the ICP changes, so it can be mea-
33
■ Noncomatose patient: sured frequently. If ONSD is used, it is best to check hourly along
■ Test sensation to light touch on both sides of the face. with the neurologic examination.
■ Ask patient to smile and raise eyebrows, and observe for symmetry. Technique
■ Ask the patient to say “Ahhh” and directly observe for symmetric 1. Check to make sure there is no eye injury. A penetrating injury to
palatal elevation. the eyeball is an absolute contraindication to ultrasound because
■ Comatose patient: it puts pressure on the eye.
■ Check corneal reflexes; stimulation should trigger eyelid closure. 2. Ensure the head and neck are in a midline position. Gentle se-
■ Observe for facial grimacing with painful stimuli. dation and/or analgesia may be necessary to obtain accurate
■ Note symmetry and strength. measurements.
■ Directly stimulate the back of the throat and look for a gag, tear- 3. Ensure the eyelids are closed.
ing, and/or cough. 4. If available, place a thin, transparent film (e.g., Tegaderm; 3M,
MOTOR http://www.3m.com) over the closed eyelids.
Tone: Note whether resting tone is increased (i.e., spastic or rigid), 5. Apply a small amount of ultrasound gel to closed eyelid.
normal, or decreased (flaccid). 6. Place the 10(–5) MHz linear probe over the eyelid. The probe
should be applied in a horizontal orientation (Figure 1) with as
Strength: Observe for spontaneous movement of extremities and note little pressure as possible applied to the globe.
any asymmetry of movement (i.e., patient moves left side more than 7. Manipulate the probe until the nerve and nerve sheath are visible
right side). Lift arms and legs, and note whether the limbs fall immedi- at the bottom of screen. An example of a proper ultrasonagraphic
ately, drift, or can be maintained against gravity. Push and pull against image of the optic nerve sheath can be seen in Figure 2.
the upper and lower extremities and note any resistance given. Note 8. Once the optic nerve sheath is visualized, freeze the image on the
any differences in resistance provided between the left and right sides. screen.
(NOTE: it is often difficult to perform formal strength testing in TBI 9. Using the device’s measuring tool, measure 3mm back from the
patients. Unless the patient is awake and cooperative, reliable strength optic disc and then obtain a second measurement perpendicular
testing is difficult.) to the first. The second measurement should cover the horizontal
width of the optic nerve sheath (Figure 2). An abnormal ONSD is
Involuntary movements: Note any involuntary movements (e.g., shown in Figure 3.
twitching, tremor, myoclonus) involving the face, arms, legs, or trunk. 10. Repeat the previous sequence in the opposite eye. Annotate both
SENSORY ONSDs on the PFC Casualty Card.
If patient is not responsive to voice, test central pain and peripheral 11. ONSDs should be obtained, when possible, at regular intervals
pain. to help assess changes in ICP, particularly when the neurologic
examination is poor and/or unreliable (i.e., with sedation). Se-
Central pain: Apply a sternal rub or supraorbital pressure, and note rial measurements with progressive diameter enlargement and/or
the response (e.g., extensor posturing, flexor posturing, localization). asymmetry in ONSDs should be considered indicative of worsen-
Peripheral pain: Apply nail bed pressure or take muscle between the ing intracranial hypertension.
fingers, compress, and rotate the wrist (do not pinch the skin). Muscle CAUTION: ONSD measurements are contraindicated in eye injuries.
in the axillary region and inner thigh is recommended. Apply similar NEVER apply pressure to an injured eye.
stimulus to all four limbs and note the response (e.g., extensor postur-
ing, flexor posturing, withdrawal, localization). Spontaneous Venous Pulsations
NOTE: In an awake and cooperative patient, testing light touch is ■ Spontaneous venous pulsations (SVPs) are subtle, rhythmic
recommended. It is unnecessary to apply painful stimuli to an awake variations
and cooperative patient. ■ in retinal vein caliber on the optic disc and have an association
with ICP.

44 | JSOM Volume 22, Edition 1 / Sping 2022