Neuro Assessment and Increased ICP
Glasgow Coma Scale, pupils, and protecting the brain
Glasgow Coma Scale
| Eye opening | Verbal | Motor |
|---|---|---|
| 4 Spontaneous | 5 Oriented | 6 Obeys commands |
| 3 To voice | 4 Confused | 5 Localizes pain |
| 2 To pain | 3 Inappropriate words | 4 Withdraws from pain |
| 1 None | 2 Sounds only | 3 Abnormal flexion (decorticate) |
| 1 None | 2 Extension (decerebrate) | |
| 1 None |
Total 3–15. ≤8 = severe: protect the airway ("less than 8, intubate"). A drop of 2 or more points is significant.
Signs of increased ICP
- Earliest: change in level of consciousness (restless, confused, sleepy).
- Headache, vomiting (often without nausea), vision changes.
- Pupil changes: one pupil dilating and sluggish = pressure on cranial nerve III: emergency.
- Posturing: decorticate (arms flexed "to the core") → decerebrate (arms extended: worse).
- Late: Cushing's triad: rising systolic BP (wide pulse pressure), bradycardia, irregular breathing.
Normal ICP 5–15 mmHg. CPP = MAP − ICP (target ~60–70).
Lowering ICP: nursing care
- HOB 30°, head and neck midline; avoid neck and extreme hip flexion.
- Avoid Valsalva: stool softeners; no straining, coughing or isometric exercise.
- Cluster care with rest periods; quiet, dim room; limit visitors if stimulation raises ICP.
- Suction only when needed, ≤10 sec, pre-oxygenate.
- Normal temperature (treat fever), normal CO₂ (PaCO₂ 35–45; brief hyperventilation only for impending herniation), oxygenation, glucose control.
- Mannitol or hypertonic saline; sedation; seizure prevention; drain CSF if a ventricular drain is in place.
- Corticosteroids are not used for traumatic brain injury (they raise mortality). Updated Dexamethasone is used for swelling around brain tumors.
Head injury clues
- Epidural hematoma (artery): brief loss of consciousness, a lucid interval, then rapid decline: emergency surgery.
- Subdural hematoma (veins): slower; older adults and people on anticoagulants; can be chronic (weeks).
- Basilar skull fracture: raccoon eyes, Battle's sign (bruising behind the ear), clear fluid from nose or ear (CSF: "halo" on gauze, positive for glucose). No nasal suctioning or NG tube; don't blow the nose.
Pupils and cranial nerves
- PERRLA: pupils equal, round, reactive to light and accommodation.
- Pinpoint pupils: opioids, pontine lesion. Fixed dilated: herniation, anoxia, atropine.
- CN quick checks: gag and swallow (IX, X), facial symmetry (VII), tongue midline (XII), eye movements (III, IV, VI).