Commentary 3.5.1.

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Neurological examination timing

Vit Marecek and Tomas Beran

 There 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.

In prehospital 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.

References:

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.

2.  Chesnut RM, Marshall LF, Klauber MR, et al: The role of  secondary brain injury in determining outcome from severe head injury. J Trauma 1993; 34:216-222.

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.

5.   Valadka AB, Narayan RK: Emergency room management of the  head-injured patient. In Narayan RK, Wilberger JR, Povlishock JT (eds): Neurotrauma. New York:McGraw-Hill 1996:119-135.

Last updated: 2000-08-04