Neurological examination timing
is almost „evergreen“ question about the examination by neurologist already
in the emergency room in hospital at patients with severe brain injury (GCS
3-8). These patients are from the place of accident on mostly under
analgosedation, muscle relaxation and arteficial ventilation and they are
examined by a special neurologist as early as in emergency departments of the
hospitals, even at the expense of disturbing of already introduced
analgosedation and relaxation in order to make clinical neurological examination
as exact as possible.
care system with paramedics (US or UK) this question is not hot topic, because
the first patients´ contact with the doctor, and consequently the first
pharmacotherapy as well, use to be made at the emergency departments in
hospitals. But the situation is slowly being changed there too1. Our Continental
situation (in our country and in e.g. Germany) is quite different in the sense
that the emergency physicians are going to the place of accident. Our
emergency physicians are able not only to take basic traumatological and
neurological examination, but also to fight effectively with potential systemic
hypotension or hypoxia of the patient.
And so we believe that in situation when emergency physician decided that the patient with severe brain injury should get analgosedation, eventually muscle relaxation, and arteficial ventilation, it is useful (and for patients with intracranial hypertension just benefitial) to postpone clinical examination by the neurologist until the patient is on ICU bed. There is evidence that even a very short (some minutes) elevation of intracranial pressure is decreasing hope of a severely injured patient for survival and satisfactory state after injury 2-5.
The first meeting with the neurologist should take place only after immediate CT brain examination. On this basis there can considered the ways of following treatment – either operative treatment in the case of postinjury intracranial haemorrhage, or non-operative one by monitoring ICP. In the ICU/CCU bed the patient is observed continually, whereby the degree of clear patient´s consciousness can be better discerned from the postinjury symptoms progression.
1. Marion DW, Carlier PM: Problems with initial Glasgow Coma Scale assessment caused by prehospital treatment of patients with head injury: Results of national survey. J Trauma 1994;36:89-95.
Chesnut RM, Marshall LF, Klauber MR, et al: The role of secondary brain
injury in determining outcome from severe head injury. J Trauma 1993;
3. Miller JD, Sweet RC, Narayan R, et al: Early insults to the injured brain. JAMA 1978;240:439-442.
4. Bouma GJ, Muizelaar JP: Cerebral blood flow, cerebral blood volume, and cerebrovascular reactivity after severe head injury. J Neurotrauma 1992; 9(Suppl 1):S333-S348.
Valadka AB, Narayan RK: Emergency room management of the head-injured
patient. In Narayan RK, Wilberger JR, Povlishock JT (eds): Neurotrauma. New
Last updated: 2000-08-04