Neuro Exam

Head Injury

Head injuries are usually minor and non life-threatening, only 0.2% of poepe that attend ED with a head injry die.

Head injuries can result from blunt or penetrating trauma. Trauma can a=reslunt in direct injury from at the site of impact or force.

Indirect injuries can also occur when the brain moves within the skill leading to contusions on the opposite side of the brain from the inital impact.

The shearing and roational forces in brain movement can also lead to the injury of nerve fibers (axons) and blood vessels.

The brain is contained and protected within the rigid skull. There are openings from the passage of blood vessels, nerves, the brainstem, and the spinal cord. However these openings cannot provide sufficient space when there is bleeding or swelling of the brain after a head injury.

Any increaed intercranial pressure is therefore exerted on the soft tissue of the brain itself.

Traumatic brain injuries can be split into primary or seconday.

Primary is when the damage is done at the time of impact.

Secondary is when the injury occues as a result of cerebral oedema, bleeding and intracraial pressure in the time following the accident.

Falls and assults are the most common cause of minor head injuries and alcohol is though to be involved in over half of all head injuries in adults.


History

How and when did the head injury occur.

Symptoms since the injury such as LOC, confusion, amnesia, seizures, vomiting, headache, neck pain and visual disturbances.

Mechanism of Injury

Fall from height >1m or 5 stairs (especially if 65 years or older)

High-speed road traffic accident (pedestrian, cyclist or in vehicle)

Rollover RTC

Ejection from motor vehicle

Accident involing motor vehicles

Diving accident.


Red Flags

Immediatley transfer to hospital if any one of the following is found:

  • GCS of less than 15 on inital assessment.

  • Any LOC as a result of the injury.

  • Any focal neurological deficit since the injury (difficulty understanding, speaking, reading, writing, reduced sensation, altered balance, general weakness)

  • Any suspision of skull fracture or penetrating head injury.

  • Amnesia for events before or after the injury.

  • Persistant headache since the injury.

  • Any vomitting since the injury. (clinical judgment to be used in those under 12)

  • Any siezure since the injury.

  • Any previous brain surgery.

  • a high-enenrgy brain injury.

  • Any history of bleeding and clotting disorders.

  • Current anti-coagulant or anti-platelet therapy (except asprin monotherepy)

  • Drug or alcohol intoxication.

  • Any safeguarding concerns (possible non-accidental injury or vulnerable person affected)

  • Continuing concern by the ambulance clinicans about the diagnosis.

  • Irritability or altered behaviour, particularly in infancts and children under 5 years.

  • No visible trauma to the head but still of concerns to the ambulance clinican.

  • No one is able to observe injured person at home.

  • Continuing concern by the injured person or their family or carer about the diagnosis.

  • Irritibility or altered behaviour.

  • Child vomiting more than once.

  • Bruising round the eyes.

  • Clear fluid from nose or ear.

  • Impaired hearing.


Anti-coagulants

Patients on dual/multi-antiplatlet theraoy should be conveyed to hospital for further assessment even with minor head injury.

Common anticoagulants:

  • Warfrin

  • Rivaroxaban

  • Apixaban

  • Dibigatran

  • Edoxaban

  • Herparin

  • Dalteparin

  • Enoxaparin

  • Tinzaparin


Common antiplatelets:

  • Clopidigrel

  • Ticagrelor

  • Prasugrel

  • Dipridmole


Examination

An A-E assessment is to be carried out, with time critial interventions to be made as required.

When the situation is not time critical a more focussed head injury assessment should be implimented. This should include a GCS assessment, although this may have already been perfomed in the E portion of A-E.

Physical exam and hx taking are not usually performed seperatly.

  • Face-to-face observation: Many brain functions (cranial nerves) are visible just by talking to and looking at the patient.

  • Behavioural changes: A physical exam alone won't show changes in social behaviour, which is a key sign of injury.

  • Invisible red flags: Many urgent warning signs can only be caught through conversation, not physical touch.

  • Progress matters: Symptoms like "sluggishness" are only worrying if they stay the same or get worse over time.

In short: Take your time, sit the patient in front of you, and observe their reactions while you talk to them.

Next position the patient for an examination of thier head with a good light source.


Cranial Nerve Exam

Position the patient upright wil good lighting.

Perform a general inspection for obviously altered neurology. Look for muscle wasting, facial asymetery, loss of expression, problems with speech or weakness in limbs (BEFAST).

Olfactory

Ask if sense of smell has altered.

Optic

Check visual acuity, visual fields, pupil esponse to light (direct and consensual) and pupil accomodation.

Occularmotor/Trochlear/Abducens

Look for Ptosis (eyelid droop)

Check for eye movements (double H pattern). Look for nystagmus during eye movements and access resting gaze (are both eyes aligned equally)

Trigeminal

Assess facial sensation in forehead, cheeks and lower jaw.

Check corneal reflex (both eyes blink when cornea of one is stimulated with cotton wool).

Assess jaw function. Ask patient to clench jaw and externally palpate the massater and temporalis. Ask patient to open and close mouth and move jaw side to side.

Facial

Ask about sense of taste and any change to hearing.

Assess facial symetery, can the patient raise both their eyebrows, screw up their eyes, smile, show their teeth and puff out their cheeks.

Vestibular

Perform simple hearing test. (Whisper test)

To perform, cover the opposite ear from testing side and then whisper a word or number and have the patient say it out loud.

Glossophryngeal and Vagus

Ask patient to cough and swallow. Inspect soft palate. Ask patient to say AHH and look at movement of uvula.

Accessory

Ask the patient to shrug their shoulders and resist you pushing down. Ask the patient to turn thier head side to side.

Hypoglossal

Look at the patient for wasting and fasciculsations. Ask patient to stick their tounge into their cheek while palpating externally for strength on both sides.


Discharge on scene

Not app patients with a head injury will require hospital admission. When all the following are met, a patient can be discharged at scene.

  • No red flags/JRCALC red critera

  • The patient can be appropriatly saftey netted and suitable supervision arrangements can be made. NICE recommends a responisble adults stays with the patient for 24 hours following the injury.

  • Verbal and written advice is given to the patient and those supervising the patient.

  • Patient, carers and clinicians have no ongoing concerns.


Safety netting

A description of their injury and the severity.

Red flag signs and symptoms and symptoms of deteroration to look out for. You should also include advice on how and where to seek help should symptoms occur.

Information about expected recovery time.

Information about return to everyday activitites.

Advice to avoid alcohol and sedating medications.