What are the key components of a thorough nervous system assessment in Cardiovascular Intensive Care Unit (CVICU)?

Key Components of a Thorough Nervous System Assessment in CVICU

A comprehensive neurological assessment in the Cardiovascular Intensive Care Unit (CVICU) should include standardized evaluation of consciousness, cranial nerve function, motor assessment, sensory testing, and monitoring for seizures and delirium to optimize patient outcomes and reduce mortality.

Level of Consciousness Assessment

• Use either the Glasgow Coma Scale (GCS) combined with pupil assessment or the Full Outline of UnResponsiveness (FOUR) score for routine assessment of comatose patients with acute brain injury 1, 2
• Document baseline consciousness status and track changes over time to detect neurological deterioration early 3, 2
• Assess orientation to person, place, and time in patients who are awake enough to participate 2
• Test ability to follow simple commands (e.g., open/close eyes, grip/release hand) to evaluate higher cortical function 3, 2

Pain Assessment

• Use the Numeric Rating Scale (NRS) 0-10 for self-reporting of pain in all neurocritical care patients who are wakeful enough to participate 1
• Implement behavior-based scales such as the Behavioral Pain Scale (BPS) or Critical-Care Pain Observation Tool (CPOT) when patients cannot self-report pain 1
• For patients with severely impaired consciousness (vegetative state or minimally conscious state), use the revised Nociception Coma Scale-Revised (NCS-R) with a threshold score of 4 1
• Remember that brain-injured patients often experience more significant pain than initially presumed, requiring systematic assessment 1

Cranial Nerve Examination

• Systematically assess all 12 cranial nerves, with particular attention to pupillary size, symmetry, and reactivity 3, 2
• Test eye movements for palsy or forced deviation that may indicate neurological deterioration 3
• Evaluate visual fields using confrontation testing to detect potential hemianopia 3, 2
• Assess facial symmetry, looking for nasolabial fold flattening or weakness 3
• Test bulbar function including gag reflex, cough response, and swallowing ability 3, 2

Motor Function Assessment

• Have patients extend arms at 90° (seated) or 45° (supine) for 10 seconds to detect drift or weakness 3, 2
• Ask patients to raise legs 30° and hold for 5 seconds to assess lower extremity strength 3, 2
• Evaluate muscle strength in major muscle groups using the standard 0-5 scale 3, 2
• Perform passive range of motion to assess muscle tone and detect abnormal resistance 3, 2
• Check for abnormal movements such as tremor, myoclonus, or asterixis that may indicate metabolic encephalopathy 2

Sensory and Coordination Assessment

• Test various sensory modalities including light touch, pain/temperature sensation, vibration, and proprioception 3, 2
• Compare symmetry between sides to detect subtle deficits 2
• Assess coordination with finger-to-nose and heel-to-shin testing when patient condition permits 3, 2
• Test for neglect or inattention using simultaneous bilateral stimulation 3

Sedation Monitoring

• Use validated and reliable scales such as the Richmond Agitation-Sedation Scale (RASS) or Sedation-Agitation Scale (SAS) to monitor sedation levels 1
• Avoid routine sedation interruption or "wake-up tests" in patients with intracranial hypertension unless the benefit of neurological assessment outweighs the risk 1
• Consider the timing of neurological assessments in relation to sedation administration for more accurate results 2

Seizure Detection and EEG Monitoring

• Perform urgent EEG in patients with convulsive status epilepticus who do not return to baseline within 60 minutes after seizure medication 1
• Consider continuous EEG monitoring rather than routine spot EEG when feasible, particularly in comatose patients with unexplained altered mental status 1, 4
• Be aware that routine EEG will miss nonconvulsive seizures in approximately half of patients compared to prolonged monitoring 1
• Use EEG during therapeutic hypothermia and within 24 hours of rewarming to exclude nonconvulsive seizures in post-cardiac arrest patients 1

Delirium Assessment

• Screen for delirium using validated tools such as the Confusion Assessment Method for ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) 1
• The ICDSC may be preferred in neurocritical care as it does not score changes in wakefulness and attention directly attributable to recent sedative medication 1
• When delirium is detected in neurocritical care patients, perform a thorough evaluation for new neurologic deficits or specific neurologic processes 1
• Pay attention to level of wakefulness during delirium screening to avoid confounding due to residual sedative effects 1

Hemodynamic Monitoring Considerations

• Use electrocardiography and invasive arterial blood pressure monitoring in all unstable or at-risk patients 1
• Establish hemodynamic monitoring goals that take into account cerebral blood flow and oxygenation 1
• Consider additional hemodynamic monitoring (e.g., echocardiography, cardiac output monitors) in patients with hemodynamic instability 1
• Be aware that cardiopulmonary complications are common after acute brain injury and can significantly impact patient outcomes 1

Practical Implementation Tips

• Perform neurological assessments at regular intervals, with more frequent assessments (every 1-4 hours) in critically ill patients 2
• Always assess both sides of the body for comparison to detect subtle asymmetries 3, 2
• Document medications that may affect the neurological assessment, such as sedatives and analgesics 3, 2
• Use standardized documentation forms to ensure consistency between examiners 5, 2
• Consider the potential for covert consciousness in patients who appear unresponsive on bedside assessment 6

Common Pitfalls to Avoid

• Incomplete motor testing - always assess and compare both sides 3, 2
• Failure to account for systemic factors that may affect neurological status (e.g., hypotension, hypoxemia) 2
• Inaccurate initial examination due to patient factors (uncooperativeness, intoxication) 2
• Neglecting to repeat examinations to detect neurological deterioration 2, 7
• Assuming that neurological assessments are not possible in brain-injured patients 1