Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXII: Craniocerebral Injury

History and Neurological Evaluation

United States Department of Defense
Peer Review Status: Internally Peer Reviewed

The history should record the time of injury, the type of missile or cause of injury, and the state of consciousness immediately after injury. It is very important to make permanent records of all observations for physicians elsewhere in the evacuation chain to review. The examination should begin with evaluation of consciousness. Consciousness can be described qualitatively with the terms conscious, (awake, aware); lethargic, (conscious, but with slowed reactions); stuporous (arousable only by painful stimuli); and comatose (unarousable).

1. The neurological condition may be expressed quantitatively with the Glasgow Coma Scale (GCS), in which numerical scores quantitate to the best level of motor, verbal, and eye-opening response to standardized verbal and tactile stimuli (Table 13). Coma in the GCS is defined as absence of verbal response (V=1) and eye-opening (E=1), with a motor response that can vary from none to localizing (M=5). A summed GCS of 7 or less, six hours after injury, in a patient with adequate blood pressure and ventilation, indicates severe brain injury. Survival and neurological outcome are accurately predicted by the GCS score.
2. The pupillary size and response to light should be recorded. Progressive dilation of a pupil indicates an expanding intracranial mass and transtentorial herniation that in 85% of cases occurs on the side of the dilated pupil. The oculocephalic reflex, or eye movement in response to head rotation (doll's eyes reflex), should be recorded. Loss of this reflex indicates brainstem injury. Unilateral pontine injury will produce fixed deviation of the eyes to the contralateral side; frontal lobe injury will produce eye deviation to the side of the injury.
3. Motor responses should be tested in each limb. Asymmetries between right and left and between upper and lower limb strength should be noted. Abnormal (extensor) plantar responses should be sought.
4. Blood pressure, pulse rate and rhythm, respiratory pattern (waxing and waning or Cheyne-Stokes, irregular or gasping), and body temperatures should be recorded. Frequent recording of neurological status and vital signs on a time-oriented flow chart is very helpful in revealing neurological deterioration, particularly when patients are transferred from one echelon to another with suboptimal continuity of care along the evacuation route. Although the GCS correlates well with eventual outcome, it is only a shorthand for certain aspects of the neurological examination and does not substitute for detailed notes regarding the patient's condition.  

Add the scores for each category.
A total score of 7 or less indicates a severe injury
The most common patterns for comatose patients are M=5 or less, V=1, E=1.

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