From the Guidelines
A thorough neuro exam on a ventilator should include assessment of consciousness level, pupillary size and reactivity, corneal reflexes, oculocephalic and oculovestibular reflexes, motor response to painful stimuli, and deep tendon reflexes, as outlined in the most recent guidelines 1.
Key Components of the Neuro Exam
- Assessment of consciousness level using the Glasgow Coma Scale (GCS) or FOUR Score
- Evaluation of pupillary size and reactivity, including response to light
- Testing of corneal reflexes and oculocephalic (doll's eyes) and oculovestibular (cold caloric) reflexes
- Examination of motor response to painful stimuli in all extremities
- Assessment of deep tendon reflexes and pathological reflexes like Babinski sign
Considerations for Ventilated Patients
- Sedation should be held briefly if possible to obtain an accurate exam, using a sedation vacation protocol (typically 30-60 minutes) 1
- Brain stem reflexes are particularly important as they help evaluate lower brain function when verbal assessment is impossible
- Continuous neuromonitoring with EEG may be indicated for patients with known or suspected seizures or those receiving neuromuscular blockade 1
Importance of Systematic Documentation
- The exam should be performed systematically and documented with precise timing to track neurological changes
- This comprehensive approach allows detection of neurological deterioration early, enabling prompt intervention for conditions like increased intracranial pressure, stroke, or seizures in critically ill ventilated patients who cannot communicate symptoms 1
From the Research
Neuro Exam on Vent
A thorough neuro exam on a ventilator (vent) should include the following components:
- Assessment of consciousness, which can be measured using the Glasgow Coma Scale (GCS) or the Full Outline of UnResponsiveness (FOUR) Score 2
- Evaluation of pain, agitation, and delirium (PAD), which can be challenging in neurologically compromised patients 3
- Examination of brainstem reflexes, such as pupil, cornea, and cough reflexes 4, 2
- Assessment of motor responses, including responses to pain and following simple hand commands 2
- Evaluation of respiration, including breathing rhythm and respiratory drive in ventilated patients 2
Key Considerations
- The use of sedative drugs and neuromuscular blockers may invalidate the use of some clinical examination tools 3, 4
- Sedation interruption to assess neurological status can result in physiological derangement in unstable patients and is not recommended 3
- Simple scales, such as the ACDU (Alert, Confused, Drowsy, Unresponsive) and AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) scales, can be useful in identifying distinct GCS ranges and may be better at identifying early deteriorations in conscious level 5
Additional Tools
- The Numeric Rating Scale, Behavioral Pain Scale, and Critical Care Pain Observation Tool can be used to assess pain in patients who are not able to respond 3
- The Nociception Coma Scale-Revised may be useful in patients with severe disorders of consciousness 3
- The Richmond Area Sedation Scale (RASS) and Sedation-Agitation Scale (SAS) can provide reasonable tools for assessing sedation in some neurocritical care patients 3