What is the frequency of neuro checks in a patient with a head injury?

Neurological Assessment Frequency After Head Injury

For moderate traumatic brain injury (TBI) patients with Glasgow Coma Scale (GCS) 9-13, perform neurological checks every 30 minutes for the first 2 hours, then hourly for the following 4 hours; for severe TBI patients, continue hourly assessments until GCS 15 is achieved, with the understanding that prolonged hourly checks beyond 48-72 hours may cause more harm than benefit through sleep deprivation. 1

Initial Assessment Framework

The frequency of neurological assessments depends critically on injury severity and initial presentation:

• Severe TBI (GCS ≤8): Hourly neurological examinations should continue until the patient achieves GCS 15, with documentation required on a half-hourly basis per UK guidelines 1
• Moderate TBI (GCS 9-13): These patients carry significant risk of secondary neurological deterioration and require structured monitoring 1:
  • Every 30 minutes for the first 2 hours
  • Every hour for the following 4 hours
  • Then adjust based on clinical stability
• Mild TBI (GCS 14-15): If initial CT is negative and patient is neurologically intact, hourly checks are generally unnecessary 1, 2

Key Clinical Triggers

A decrease of 2 or more points in GCS score or any new neurological deficit mandates immediate repeat CT imaging, regardless of the time interval from initial scan. 1, 2

The motor component of the GCS remains the most robust indicator in sedated or intubated patients, as extensive prehospital sedation has made eye and verbal responses less reliable 1

Duration Considerations and Practical Limitations

Recent evidence challenges the traditional approach of prolonged hourly assessments:

• Most neurosurgical interventions occur within 48 hours of injury; only 2 patients in one study required surgery after 48 hours, both for chronic subdural hematomas 3
• Patients maintained on hourly checks beyond 4 days had significantly longer ICU stays (23 days vs 9 days, P=0.001), suggesting potential harm from sleep deprivation 3
• Neurological decline was detected in only 14% of nursing shifts performing hourly checks, and 55% of detected declines resulted in no change to the treatment plan 4
• Scheduled hourly neurochecks detected changes 67% of the time, with the remaining 33% identified at other times, questioning the necessity of strict hourly intervals 4

Risk-Stratified Approach

High-Risk Features Requiring Intensive Monitoring:

• Anticoagulation therapy (3-fold increased risk of hemorrhage progression) 2
• Age >60 years 2
• Presence of intracranial hemorrhage on initial CT 1, 2
• Suspected open or basilar skull fracture 1
• Coagulopathy 1, 2

Low-Risk Features Allowing Less Frequent Monitoring:

• GCS 15 with negative initial CT 1, 2
• No loss of consciousness or post-traumatic amnesia 1
• Normal neurological examination 1

Specific Clinical Scenarios

For patients on anticoagulation (including apixaban): Even with negative initial CT, brief observation of 4-6 hours is reasonable before discharge, though routine admission is not necessary if neurologically intact 2

For patients with positive initial CT: Follow-up imaging at approximately 6 and 24 hours is recommended to assess for hemorrhage expansion, which occurs most commonly within the first 6 hours 2

For delayed symptom onset: 18% of patients who deteriorate do so between days 2-7 after injury, emphasizing the importance of clear discharge instructions about warning signs 5

Common Pitfalls to Avoid

• Continuing hourly checks beyond 48-72 hours in stable patients without expansible hemorrhage or malignant edema, which may cause sleep deprivation and prolonged ICU stays 3
• Failing to obtain initial CT in anticoagulated patients, even with minor mechanisms 2
• Delaying repeat imaging when neurological deterioration occurs, regardless of time since initial scan 2
• Performing routine repeat CT in mild TBI patients with negative initial scan and normal exam, which lacks clinical utility 1, 6

Algorithm Summary

1. Initial assessment: GCS with emphasis on motor response, pupillary examination 1
2. Stratify by severity:
   • Severe (GCS ≤8): Hourly until GCS 15 achieved
   • Moderate (GCS 9-13): Every 30 min × 2 hours, then hourly × 4 hours
   • Mild (GCS 14-15) with negative CT: Discharge with instructions
3. Reassess frequency at 48-72 hours in stable patients to avoid prolonged unnecessary monitoring 3
4. Immediate repeat CT for: ≥2 point GCS drop, new focal deficit, or delayed symptom onset 1, 2, 5