Localization diagnosis of neurological examination in patients with impaired consciousness

Consciousness is a comprehensive manifestation of brain functional activity, including the state of wakefulness, which is maintained and activated by the reticular activation system of the brainstem and non-specific nuclei of the thalamus (drowsiness, lethargy, coma), and the content of consciousness, which belongs to the function of the cerebral cortex (confusion, delirium).

Physical examination of patients with impaired consciousness should determine the level of arousal and whether there is a change
in the content of consciousness.

Awakening level:

Drowsiness: Wake up with a slight stimulus, answer yes
.

Drowsiness: strong stimulus arousal, unclear answer
.

Superficial coma: strong stimulation, slight reaction, brainstem reflexes available
.

Medium coma: strong stimulation, unresponsiveness, weak
brainstem reflexes.

Deep coma: intense stimulation, unresponsive, brainstem reflexes absent
.

The neurological examination of patients with impaired consciousness mainly includes [eye signs] [response to pain stimuli] [signs of paralysis and pyramidal tracts] [brainstem reflexes] [meningeal stimulation signs], which are summarized in three figures in this article:

Coma index

Glasgow Coma Score (GCS)

Lead

The Glasgow Coma Score (GCS) is a medical method for assessing the degree of coma in patients, and it is also the most widely used coma index today, so how to evaluate this score? What are the important details to pay attention to?

Glasgow Coma score

(Glasgow coma scale）

1GCS methods and standards include the following three parts:

Eye opening response (E, Eye opening)

Verbal response (V)

Motor response (M)

2 Figure says how to do it specifically?

3 Interpretation of scoring results

The GCS scoring method has a maximum score of 15 points and a minimum score of 3 points; The lower the score, the greater the impaired consciousness and the worse the
prognosis.

4 Factors that affect GCS scores

(1) Drinking alcohol has a narcotic effect on the brain and nervous system, which can make people unresponsive, prolong the response time to light and sound stimulation, and extend the time of reflex actions, and the function of sensory organs and motor organs such as eyes, hands, and feet is impaired, which affects its accuracy
when making GCS determination.
In some patients with brain trauma and cerebrovascular disease, pay attention to asking whether they have alcohol consumption
.
(2) Patients with epileptic craniocerebral disorders are often accompanied by seizures, especially status epilepticus is still comatose during the interseizure period, and attention should be paid to distinguishing
from the coma caused by the primary disease.
(3) Patients with restlessness, agitation, and sleep disorders often use sedatives such as diazepam, phenobarbital or hibernation mixtures, and are not suitable for GCS assessment, and it is estimated that there is no drug effect
.

5GCS scoring details note

When performing GCS scoring, it is necessary to pay attention to the scoring reflects the actual situation of the patient, quickly check and record the results during scoring, and pay attention to the best response to calculate the score value
when judging.
In addition, the GCS score does not include pupil size, response to light, eye movements, and other brainstem responses, nor does it observe vital signs and examine sensory components, which are important for
central nervous system function.

(1) Regarding the giving of pain stimulation, pay attention to the pain stimulation should be from light to severe to avoid unnecessary pain; Stimulation can be repeated, but not for too long
at a time.
Assessment of painful stimuli is best done once and avoid repeated stimulation
.

(2) Eye opening response score Pay attention to people in a persistent vegetative state spontaneously open their eyes, so that the score does not reflect their actual condition, but we can only score
according to what we see.
Pain stimulation When opening the eyes to score, take peripheral pain stimulation, pain stimulation should be from light to heavy, avoid unnecessary pain, can repeat stimulation, but can not last too long
at a time.

(3) Limb movement score cortex: typical signs: upper limb flexion, lower limb straightening "elbow flexion, shoulder adduction, leg and ankle straightening"
.
Decerebral removal: typical signs: opisthotonus, limb rigidity, increased
muscle tone.
"Extend the elbows, rotate the shoulders and forearms, and straighten the lower limbs"
.

6GCS recording method

The recording method is E___V___M___, and the middle of the letter is indicated
by a number.
For example, E3V3M5=GCS11
.

(1) Patients with eyelid edema or facial fracture:

The open-eye response is unmeasurable, and C is used instead of the score
.
Such as ECV5M6
.
C is an abbreviation
for Closed.

(2) Tracheostomy or endotracheal intubation patients:

The verbal response is unmeasurable, and a T is used instead of a score
.
Such as E4VTM6
.
T is an abbreviation for tracheostomy or endotracheal intubation
.
If the total score of the former is 10 points, it will be recorded
with 10T.

(3) Patients with speech disorders:

The verbal response is unmeasurable, and D is used instead of the score
.
Such as E4VDM6
.
D is an abbreviation
for dysphasia.