Secondary Survey – Neurological Overview

Dynamic, cyclic framework guiding paramedic decision-making from first contact to handover
- Life-threat check → Primary Survey → Detailed Assessment → Secondary Assessment (systems-based) → Re-assessment
- Parallel diagnostic reasoning pathway:
- Gather S/Sx + background → Interpret → Form provisional Dx → Plan care → Treat → Evaluate outcomes → Learn from errors/near-misses
Benefits
- Ensures no critical sign missed even in high-pressure scenes
- Supports NSQHSS domains:
- Partnering with Consumers
- Comprehensive Care
- Communicating for Safety
- Recognising & Responding to Acute Deterioration

System block performed after primary life-threats controlled
Three interconnected pillars:
- Level of consciousness → Glasgow Coma Scale (GCS)
- Pupillary examination → Size, symmetry, reactivity
- Motor & sensory function → Strength, tone, sensation
Goal: rapid yet comprehensive snapshot to guide interventions, determine red flags, and streamline handover to receiving facility

Origin & Purpose
- Developed 1974 (Teasdale & Jennett, Univ. of Glasgow) to standardise consciousness description post-TBI
- Advantages: reproducible, trendable, universally understood
Structure
- Eye opening (E) $1!\text{–}!4$
- Verbal response (V) $1!\text{–}!5$
- Motor response (M) $1!\text{–}!6$
- Total score $\text{GCS}_{\text{total}} = E+V+M$ (range $3\le \text{GCS}\le 15$ )
Adult Scoring Matrix
- Eye (E)
- 4 Spontaneous
- 3 To voice
- 2 To pain
- 1 No response
- Verbal (V)
- 5 Oriented
- 4 Confused
- 3 Inappropriate words
- 2 Incomprehensible sounds
- 1 No response
- Motor (M)
- 6 Obeys commands
- 5 Localises pain
- 4 Withdraws
- 3 Flexion (decorticate)
- 2 Extension (decerebrate)
- 1 No response
Indications
- Any assessment of conscious state (trauma, medical, toxicology, metabolic)
Contra-indications & Limitations
- Newborns (use APGAR)
- Requires modification in paediatrics & intubated patients
- Alcohol, drugs, language barriers may confound results
Complications
- Central painful stimulus may trigger violent response in intoxicated/combative patients
- Repeated painful stimuli rarely required—use lowest effective intensity
Documentation & Communication
- Unless score is $3$ or $15$ , transmit component scores (e.g.
  $E2\,V3\,M5\,(=10)$ )
- Note laterality when motor response differs between sides (localising value for focal lesions)

Rationale
- Early indicator of raised ICP, herniation, 3rd nerve palsy, hypoxia, drug effect
- Memorised as PERRL (Pupils Equal, Round & Reactive to Light)
Technique
1. Observe each pupil before light exposure
2. Measure size in $\text{mm}$ using pen torch scale (normal $2\text{–}6\,\text{mm}$ )
3. Assess shape (round/irregular) & symmetry
4. Direct light into one eye → look for brisk constriction; compare consensual reaction
Common Abnormalities & Causes
- Pin-point (< $2\,\text{mm}$ ): opiates, pontine CVA, severe hypoxia, miotic drops
- Dilated (> $6\,\text{mm}$ ): sympathetic surge, anticholinergics, pain, mydriatic drops
- Unequal (anisocoria): stroke, aneurysm, 3rd nerve palsy, tumour, ↑ICP
- Non-reactive: brain herniation, glaucoma, cardiac arrest
- Photophobia: migraine, meningitis
- Nystagmus: congenital, trauma, labyrinthine or neurological disease
Documentation format example:
- “Pupils 4 mm ⇆ 4 mm, round, brisk”

Motor
- Ask patient to raise arms simultaneously; observe drift
- Hand-grip squeeze → compare strength, tone, power
- Double leg raise with push/pull against resistance
- Note involuntary movements, spasticity, flaccidity
Sensory
- Light touch at multiple dermatomes of arms/legs
- Ask patient to report feeling & any asymmetry
- Obtain consent before tactile assessment
Abnormal Findings
- Motor: weakness, paresis, paralysis, uncontrolled movements
- Sensory: numbness, tingling, burning, hyper-/hypo-algesia, pins & needles
Clinical Significance
- Suggests stroke territory, spinal cord level, peripheral nerve lesion, or metabolic/toxic causes

Combine GCS + Pupil + Motor/Sensory to build a concise neurological picture
- Guides airway protection, ventilation, positioning, medication (e.g. hyperosmolar therapy)
- Influences destination decision (major trauma centre vs local ED)
Red Flags warranting immediate escalation
- Sudden drop in GCS ≥ $2$ points
- New anisocoria or bilateral fixed dilatation
- Rapidly evolving unilateral weakness or sensory loss
- Seizure activity or decerebrate posturing

Use minimal painful stimuli; avoid peri-orbital or sternal rub if alternatives suffice
Partner with patient (where conscious) to explain assessments → aligns with Partnering with Consumers
Communicate clearly with team (crew, retrieval, ED) using standardised terminology
Reflect on near-misses & diagnostic errors to improve practice (NSQHSS learning mandate)
Respect patient dignity, obtain consent, maintain privacy especially during motor/sensory testing

Builds on airway-breathing-circulation (ABC) priorities; neuro findings may dictate early airway control
Interlinks with cardiovascular assessment (e.g. hypertension ± bradycardia may signal Cushing’s triad)
Pharmacology: opiate vs anticholinergic toxidromes manifest via pupil changes—link to tox lecture
Communication strategies (ISBAR): include neuro trends for safe handover

Major trauma scene: declining GCS from $14$ to $10$ + unilateral dilated pupil → triggers pre-alert for neurosurgical centre
Suspected stroke: arm drift & slurred speech with preserved pupils; rapid recognition enables fibrinolysis window
Overdose: pin-point pupils + low RR → supports naloxone administration

Neurological assessment is essential, rapid, repeatable, and informs critical interventions
Always integrate findings, document trends, and communicate clearly
Early recognition of deterioration directly improves morbidity & mortality