What is the proper procedure for performing neuro checks after a fall?

Performing Neurological Checks After a Fall

After a fall, neurological checks should be performed systematically every 15 minutes for the first 2 hours, then hourly for the next 4-12 hours, with any decrease of at least two points in the Glasgow Coma Scale prompting immediate CT imaging. 1

Initial Assessment Components

1. Glasgow Coma Scale (GCS) Assessment

• Eye opening response (1-4 points)
• Verbal response (1-5 points)
  • For intubated patients, estimate verbal score using eye and motor components 2
• Motor response (1-6 points)
• Document total score (3-15) and individual component scores

2. Pupillary Assessment

• Check size (in mm), symmetry, and reactivity to light
• Document both direct and consensual responses
• Abnormal findings: fixed, dilated, or unequal pupils

3. Motor Function Evaluation

• Assess strength in all extremities (grade 0-5)
• Compare right versus left side for symmetry
• Test for pronator drift
• Evaluate for abnormal posturing (decorticate or decerebrate)

4. Vital Signs Monitoring

• Blood pressure (maintain systolic BP >90 mmHg) 1
• Heart rate and rhythm
• Respiratory rate and pattern
• Oxygen saturation (maintain SaO2 >90%) 1
• Temperature

5. Level of Consciousness Assessment

• Orientation to person, place, time
• Ability to follow commands
• Appropriate responses to questions

Frequency of Neurological Checks

For patients with GCS 9-13 (moderate TBI):

• Every 15 minutes for first 2 hours
• Then hourly for next 12 hours 1

For patients with GCS 14-15 (mild TBI):

• Every 30 minutes for first 2 hours
• Then hourly for next 4 hours 1

Red Flags Requiring Immediate Action

Any of the following findings warrant immediate medical intervention and consideration of CT imaging:

• Decrease of ≥2 points in GCS 1
• New onset or worsening headache
• Vomiting
• Seizure activity
• Development of focal neurological deficits
• Changes in pupillary response
• Deterioration in vital signs

Special Considerations for Geriatric Patients

For elderly patients (>65 years), additional assessment should include 1:

• Location and cause of fall
• Time spent on floor or ground
• Loss of consciousness/altered mental status
• Orthostatic blood pressure measurement
• Medication review (especially vasodilators, diuretics, antipsychotics, sedatives)
• Gait assessment and "get up and go test" prior to discharge

Documentation Requirements

Document the following in the medical record:

• Time of each neurological check
• Complete set of findings
• Any changes from previous assessment
• Interventions performed in response to changes
• Name of provider performing assessment

Imaging Considerations

Brain CT scan should be performed without delay in patients with:

• GCS ≤8 (severe TBI)
• GCS 9-13 (moderate TBI)
• GCS 14-15 (mild TBI) with any of the following: 1
  • Signs of skull fracture
  • Post-traumatic seizure
  • Focal neurological deficit
  • Coagulation disorders or anticoagulant therapy

Common Pitfalls to Avoid

• Inaccurate initial examination due to uncooperative patient, inebriation, cognitive impairment, or language barriers 1
• Failure to recognize shock (neurogenic or systemic) 1
• Poor interrater reliability - ensure consistent assessment techniques 1
• Premature discontinuation of neurological monitoring
• Missing subtle changes by focusing only on total GCS score rather than individual components

By following this structured approach to neurological checks after a fall, healthcare providers can promptly identify deterioration in neurological status and intervene appropriately to improve patient outcomes.