Traumatic brain injury physical examination
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Joanna Ekabua, M.D. [2] Deekshitha Manney, M.D.[[3]]
Overview
Physical examination is the most important, first most, inexpensive, and quick component of the assessment of a patient with acute traumatic brain injury. This includes vital signs, general examination with trauma survey of the whole body and most importantly neurologic examination. The neurologic exam of a traumatic brain injury patient includes the following key components.
- Level of consciousness/Glasgow Coma Scale (GCS)
- Cranial nerve examination
- Motor examination
- Sensory examination
- Examination of cerebellar function and gait
Physical Exams
Measuring vital signs is the first thing to do. A wide pulse pressure in the setting of a new onset bradycardia and bradypnea could mean elevated intracranial pressure. Cushing's reflex is a physiological response to an acute increase in intracranial pressure, leading to a triad of widened pulse pressure, bradycardia and irregular respirations.
General examination with trauma survey includes assessment of injuries else where, including contusions, fractures, dislocations, and/or soft tissue injuries.
Neurologic examination is obviously the most important part of physical examination. Level of consciousness, as assessed by GCS is considered to be the best predictor of the prognosis in the acute traumatic brain injury. The components of GCS include assessment of best verbal, eye and motor response, followed by scoring. The minimum score is 3 and the maximum score is 15. A GCS of score 3 to 8 represents severe TBI, scores 9 to 12 represents moderate TBI and scores 13 to 15 represents mild TBI.
The examination of cranial nerves, sensory system, motor system and co-ordination is important to find any focal neurological deficit, as that might indicate injury or sometimes can signify brain herniation. Examples of focal neurological deficit are:
- Irregular pupils or unresponsive pupils, ptosis, impaired extraocular movements
- Other cranial nerve deficits
- Focal gross motor weakness
- Focal numbness
- Coordination deficits
- Gait imbalances