Situation
How often do you take handover of a patient and get told “they’re on neuro obs?” Or get asked by the assessing clinician “can we start this lady on neuro obs please?”. Yet I recently had a conversation with one of our healthcare assistants who said she wasn’t trained to do neuro obs, only normal obs, and it got me thinking what is the difference and why do we do it?
Let’s relate this to a patient… Dave is a 30-year-old patient who has been involved in an altercation on a night out and sustained a couple of blows to the head. He wasn’t knocked out and seemed fine at the time, although his friends say he’s had “a few pints”, but now they’re worried he seems to be appearing “more drunk” despite not having had any more alcohol since the incident.
Background
So what actually are neurological observations? Well we’re collecting information on what the patient’s central nervous system is doing, specifically the brain and spinal cord. This is important when establishing a patients baseline, after an injury, or if we want to know if they are deteriorating.
According to the most recent guidelines the minimal observations which should be done in patients with a head injury are: GCS; pupil size and reactivity; limb movements; respiratory rate; heart rate; blood pressure; temperature; blood oxygen saturation.[i]
Firstly let’s look at how we measure GCS. Hands up those who can’t calculate it off the top of their head and need to look at the chart…. Because I certainly do! It’s better to have the chart in front of you and get an accurate assessment, than to say ‘oh its about 13’ and have the next person come along and get a different number despite the patient’s condition having not changed, or worse: miss a deteriorating patient because it hasn’t been worked out correctly.
If the patient is scoring less than 15/15 then document what they are scoring down on, or break the numbers down when you write it, for example “appears confused E 4/4, V 4/5, M 6/6” will only take a few seconds to document but will make it much simpler for the next nurse to understand why they were only scoring 14/15.
When looking at motor response it is important to understand the differences between purposeful movement, withdrawal, flexion and extension. When applying a trapezial squeeze, if the person actively tried to whack your hand away, or at least gets their hand higher than the nipple line, that’s purposeful movement. If the person flinches away from you then that’s withdrawal. Take a look at the infographic from @perkleberry for the differences between decorticate and decerebrate posturing.
Please please PLEASEremember that this is based on a BEST response. If a patient has had a stroke and can’t lift one arm but they can lift the other as normal then they score a 6/6 on motor response.
Limb function should also be checked at this point, although it may be documented on a separate area of the obs chart. Limb function is normally categorised as one of the following:
· Normal power
· Mild weakness
· Severe weakness
· Spastic flexion
· Extension
· No response
If your patient is responsive (GCS 15) it may be that this can be measured simply by asking them to squeeze your hands. Once they have hold of your hands ask them to pull you towards them then push you away so you can test their power against resistance. If they can do this against gravity but not resistance then its mild weakness, and if they cant hold their arms up against gravity then its severe weakness.
Likewise with the legs ask them to raise their leg and stop you from pushing it back into the bed, and then do the same in the opposite direction so they are trying to put their leg back on the bed and you are stopping them.
Spastic flexion is where the muscles appear to have tightened so the patient cannot full straighten their limbs out. Extension is the opposite of this.
It may be that some trusts use AVPU scales, which is simpler to work out, but only shows level of response, not motor function.
To check pupils first look if they appear to be equal in size. With a pen torch shine the light into each eye in turn checking for pupil contraction. Then do it again in each eye but whilst watching the other eye to check that one is contracting too. This shows the eyes are working together. Pupil size should be recorded in diameter range of 1-9mm.
Assessment
So Daves first set of obs is all normal, and his GCS is 15/15. His friends still think he’s “not quite right” so you get Emma, one of the clinicians, to come and have a look to see if he needs a scan. NICE uses the following criteria to ascertain whether a patient requires an immediate scan:
"Adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:
· GCS less than 13 on initial assessment in the emergency department.
· GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
· Suspected open or depressed skull fracture.
· Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).
· Post-traumatic seizure.
· Focal neurological deficit.
· More than 1 episode of vomiting."
As Dave has none of these symptoms Emma decides he doesn’t need to be scanned at the moment, but we need to keep a close eye on him. The NICE guideline advocates doing observations a minimum of half-hourly for the first two hours in the department, after which they can be hourly for the next four hours, then two hourly for anything longer (sadly more common recently).
The evidence suggests that we aren’t great at doing them at the right times, or rather that the clinician assessing the patient doesn’t document how often they want obs doing[ii]
For the half hour Dave seems fine, but shortly after going in to check on him his friend comes out to say he’s getting worse. He is now vomiting and not making any sense. His GCS is now 13/15 (E 4/4, V 3/5, M 6/6).
The NICE guidelines also states when you should alert senior help:
"Any of the following examples of neurological deterioration should prompt urgent reappraisal by the supervising doctor:
· Development of agitation or abnormal behaviour.
· A sustained (that is, for at least 30 minutes) drop of 1 point in GCS score (greater weight
· should be given to a drop of 1 point in the motor response score of the GCS).
· Any drop of 3 or more points in the eye-opening or verbal response scores of the GCS, or 2 or more points in the motor response score.
· Development of severe or increasing headache or persisting vomiting.
· New or evolving neurological symptoms or signs such as pupil inequality or asymmetry of limb or facial movement.
· To reduce inter-observer variability and unnecessary referrals, a second member of staff competent to perform observation should confirm deterioration before involving the supervising doctor. This confirmation should be carried out immediately. Where a confirmation cannot be performed immediately (for example, no staff member available to perform the second observation) the supervising doctor should be contacted without the confirmation being performed"
You go to get Emma, who agrees with you that Dave now needs a scan, and is found to have a subdural haematoma. After discussion with the neurosurgeons it is agreed that he should be transferred to theatre.
Recommendation
1. Make sure you have a copy of the GCS chart if it isn’t on your trusts neuro obs sheet so you don’t have to try and work it out in your head.
2. Have a watch of this video from the team over at #EM3 https://youtu.be/b58zU_mjAQc
3. Make yourself familiar with your own departments head injury guidelines.
Hope this helps!
Liz xx
RCN Emergency Care Competencies: CD1 3.1.3, CD1 3.2.1, CD1 3.2.2, CD1 3.2.1.
[ii]Qureshi AA, Mulleady V, Patel A, et al. Are we able to comply with the NICE head injury guidelines? Emergency Medicine Journal 2005;22:861-862