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NERO|OGlOA| ASSESSMENT
KEYWORDS NEUROLOGlCAL CONSClOUSNESS GLASGOW COMA SCALE PRACTICAL PROCEDURES THlS ARTlO|E HAS BEEN DOB|E-B|lND PEER-REvlEWED
REFERENCES
Adam, S., Osborne, S. (2005j Cr|t|ca| Care
Nurs|ng Sc|ence and Pract|ce (2nd edj.
Oxford: Oxford University Press.
Dougherty, L., L|ster, S. (2005j The Roya|
Marsden Hosp|ta| Manua| of C||n|ca|
Nurs|ng Procedures (6th edj. Oxford:
Blackwell Publishing.
Jevon, P. (2007j Treat|ng the Cr|t|ca| Care
Pat|ent. Oxford: Blackwell Publishing.
NICE (2007j Head /njury. Tr|age,
Assessment, /nvest|gat|on and Ear|y
Management of Head /njury |n /nfants,
Ch||dren and Adu|ts. London: NlCE.
AUTHOR PhiI Jevon, PGCE, BSc, RGN,
is resuscitation officer/c|inica| ski||s
|ead, honorary c|inica| |ecturer, Manor
Hospita|, Wa|sa||.
The Glasgow Coma Scale (GCSj is used
to assess level of consciousness in a wide
variety of clinical settings, particularly for
patients with head injuries (NlCE, 2007j.
ln this practical procedure, assessment
of the patient's best eye-opening response
will be outlined and discussed, and, in
next week's article, assessment of the
patient's best verbal and motor responses
will be described.
WHAT THE GCS ASSESSES
The GCS assesses the two aspects
of consciousness:
Arousal or wakefulness: being aware
of the environment;
Awareness: demonstrating an
understanding of what has been said.
The 15-point scale assesses the patient's
level of consciousness by evaluating three
behavioural responses:
Eye opening;
verbal response;
Motor response.
Eye opening
Assessment of eye opening involves the
evaluation of arousal (being aware of
the environmentj:
Score 4: eyes open spontaneously;
Score 3: eyes open to speech;
Score 2: eyes open in response to pain
only, for example trapezium squeeze (caution
if applying a painful stimulusj;
Score 1: eyes do not open to verbal
or painful stimuli.
Record 'C' if the patient is unable to open
her or his eyes because of swelling, ptosis
(drooping of the upper eye lidj or a dressing.
verbal response
Assessment involves evaluating awareness:
Score 5: orientated;
Score 4: confused;
Score 3: inappropriate words;
Score 2: incomprehensible sounds;
Score 1: no response. This is despite
both verbal and physical stimuli.
Record 'D' if the patient is dysphasic
and 'T' if the patient has a tracheal or
tracheostomy tube in situ.
Motor response
Assessment of motor response is designed
to determine the patient's ability to obey a
command and to localise, and to withdraw
or assume abnormal body positions, in
response to a painful stimulus (Adam and
Osborne, 2005j:
Score 6: obeys commands. The patient
can perform two different movements;
Score 5: localises to central pain. The
patient does not respond to a verbal stimulus
but purposely moves an arm to remove
the cause of a central painful stimulus;
Score 4: withdraws from pain. The patient
flexes or bends the arm towards the source
of the pain but fails to locate the source of
the pain (no wrist rotationj;
Score 3: flexion to pain. The patient
flexes or bends the arm; characterised
by internal rotation and adduction of the
shoulder and flexion of the elbow, much
slower than normal flexion;
Score 2: extension to pain. The patient
extends the arm by straightening the elbow
and may be associated with internal
shoulder and wrist rotation;
Score 1: no response to painful stimuli.
Painful stimulus
A true localising response to pain involves
the patient bringing an arm up to chin level.
Painful stimuli that can elicit this response
include trapezium squeeze (Fig 4j,
suborbital ridge pressure (Fig 5j (not
recommended if there is a suspected/
confirmed facial fracturej and sternal rub
(caution, not recommended in some
organisationsj (Fig 6j (Jevon, 2007j.
The procedure
Explain the procedure to the patient.
Ascertain the patient's acuity of hearing.
ldeally, use an interpreter if the patient
does not speak English.
Check the patient's notes for any medical
condition that may affect the accuracy of the
GCS, for example previous stroke, affecting
the movement of the patient's arms (Fig 1j.
Check the neurological observation chart
for the GCS scale (Fig 2j.
Check if the patient opens their eyes
without the need to speak or to touch them;
if the patient does, then the score is 4E.
lf the patient does not open their eyes,
talk to them (Fig 3j. Start off with a normal
volume and speak louder if necessary. lf
they now open their eyes, the score is 3E.
lf the patient does not open their eyes
to speech, administer a painful stimuli, for
example trapezium squeeze (using the
thumb and two fingers grasp the trapezius
muscle where the neck meets the shoulder
and twist j (Fig 4j. Or apply suborbital
pressure (locate the notch on the suborbital
margin and apply pressure to itj (Fig 5j. An
alternative is the sternal rub (using the
Fig 3. lf the patient does not open their
eyes spontaneousIy, taIk to them
Fig 5. AppIy pressure to the notch on
the suborbitaI margin
Fig 6. AppIy grinding pressure to the
sternum {use with caution)
Fig 2. Use a neuroIogicaI observation
chart incorporating the GCS
PART 3 ~ GLASGOW COMA SCALE
C
a
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e
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o
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PROFESSlONA| RESPONSlBl|lTlES
This procedure shou|d be undertaken
on|y after approved training, supervised
practice and competency assessment,
and carried out in accordance with |oca|
po|icies and protoco|s.
knuckles of a clenched fist to apply grinding
pressure to the sternum; not recommended
for repeated assessmentj (Fig 6j.
lf the patient opens their eyes to a painful
stimulus record the score as 2E (Dougherty
and Lister, 2005j. lf the patient does not
respond, then the score is 1E.
Fig 1. Check for any factors that couId
affect the accuracy of the GCS
Fig 4. Use the thumb and two hngers
to appIy a trapezium squeeze
NEXT WEEK
Neuro|og|ca| assessment 4:
G|asgow coma sca|e - part 2
For more Pract|ca| Procedures
|og on to nurslngtlmes.net and
c||ck on NT Cllnloal and Arohlve
NT 22 Ju|y 2008 Vo| 104 No 29 www.nurs|ngt|mes.net 28 NT 22 Ju|y 2008 Vo| 104 No 29 www.nurs|ngt|mes.net 29
|c| rc|e :||||:a| |||c|ra||c| |c c| |c nursingtimes.net a|d hT Clinical and Archive
NERO|OGlOA| ASSESSMENT
KEYWORDS NEUROLOGlCAL CONSClOUSNESS GLASGOW COMA SCALE PRACTICAL PROCEDURES THlS ARTlO|E HAS BEEN DOB|E-B|lND PEER-REvlEWED
REFERENCES
Adam, S., Osborne, S. (2005j Cr|t|ca| Care
Nurs|ng Sc|ence and Pract|ce (2nd edj.
Oxford: Oxford University Press.
Dougherty, L., L|ster, S. (2005j The Roya|
Marsden Hosp|ta| Manua| of C||n|ca|
Nurs|ng Procedures (6th edj. Oxford:
Blackwell Publishing.
Jevon, P. (2007j Treat|ng the Cr|t|ca| Care
Pat|ent. Oxford: Blackwell Publishing.
NICE (2007j Head /njury. Tr|age,
Assessment, /nvest|gat|on and Ear|y
Management of Head /njury |n /nfants,
Ch||dren and Adu|ts. London: NlCE.
AUTHOR PhiI Jevon, PGCE, BSc, RGN,
is resuscitation officer/c|inica| ski||s
|ead, honorary c|inica| |ecturer, Manor
Hospita|, Wa|sa||.
The Glasgow Coma Scale (GCSj is used
to assess level of consciousness in a wide
variety of clinical settings, particularly for
patients with head injuries (NlCE, 2007j.
ln this practical procedure, assessment
of the patient's best eye-opening response
will be outlined and discussed, and, in
next week's article, assessment of the
patient's best verbal and motor responses
will be described.
WHAT THE GCS ASSESSES
The GCS assesses the two aspects
of consciousness:
Arousal or wakefulness: being aware
of the environment;
Awareness: demonstrating an
understanding of what has been said.
The 15-point scale assesses the patient's
level of consciousness by evaluating three
behavioural responses:
Eye opening;
verbal response;
Motor response.
Eye opening
Assessment of eye opening involves the
evaluation of arousal (being aware of
the environmentj:
Score 4: eyes open spontaneously;
Score 3: eyes open to speech;
Score 2: eyes open in response to pain
only, for example trapezium squeeze (caution
if applying a painful stimulusj;
Score 1: eyes do not open to verbal
or painful stimuli.
Record 'C' if the patient is unable to open
her or his eyes because of swelling, ptosis
(drooping of the upper eye lidj or a dressing.
verbal response
Assessment involves evaluating awareness:
Score 5: orientated;
Score 4: confused;
Score 3: inappropriate words;
Score 2: incomprehensible sounds;
Score 1: no response. This is despite
both verbal and physical stimuli.
Record 'D' if the patient is dysphasic
and 'T' if the patient has a tracheal or
tracheostomy tube in situ.
Motor response
Assessment of motor response is designed
to determine the patient's ability to obey a
command and to localise, and to withdraw
or assume abnormal body positions, in
response to a painful stimulus (Adam and
Osborne, 2005j:
Score 6: obeys commands. The patient
can perform two different movements;
Score 5: localises to central pain. The
patient does not respond to a verbal stimulus
but purposely moves an arm to remove
the cause of a central painful stimulus;
Score 4: withdraws from pain. The patient
flexes or bends the arm towards the source
of the pain but fails to locate the source of
the pain (no wrist rotationj;
Score 3: flexion to pain. The patient
flexes or bends the arm; characterised
by internal rotation and adduction of the
shoulder and flexion of the elbow, much
slower than normal flexion;
Score 2: extension to pain. The patient
extends the arm by straightening the elbow
and may be associated with internal
shoulder and wrist rotation;
Score 1: no response to painful stimuli.
Painful stimulus
A true localising response to pain involves
the patient bringing an arm up to chin level.
Painful stimuli that can elicit this response
include trapezium squeeze (Fig 4j,
suborbital ridge pressure (Fig 5j (not
recommended if there is a suspected/
confirmed facial fracturej and sternal rub
(caution, not recommended in some
organisationsj (Fig 6j (Jevon, 2007j.
The procedure
Explain the procedure to the patient.
Ascertain the patient's acuity of hearing.
ldeally, use an interpreter if the patient
does not speak English.
Check the patient's notes for any medical
condition that may affect the accuracy of the
GCS, for example previous stroke, affecting
the movement of the patient's arms (Fig 1j.
Check the neurological observation chart
for the GCS scale (Fig 2j.
Check if the patient opens their eyes
without the need to speak or to touch them;
if the patient does, then the score is 4E.
lf the patient does not open their eyes,
talk to them (Fig 3j. Start off with a normal
volume and speak louder if necessary. lf
they now open their eyes, the score is 3E.
lf the patient does not open their eyes
to speech, administer a painful stimuli, for
example trapezium squeeze (using the
thumb and two fingers grasp the trapezius
muscle where the neck meets the shoulder
and twist j (Fig 4j. Or apply suborbital
pressure (locate the notch on the suborbital
margin and apply pressure to itj (Fig 5j. An
alternative is the sternal rub (using the
Fig 3. lf the patient does not open their
eyes spontaneousIy, taIk to them
Fig 5. AppIy pressure to the notch on
the suborbitaI margin
Fig 6. AppIy grinding pressure to the
sternum {use with caution)
Fig 2. Use a neuroIogicaI observation
chart incorporating the GCS
PART 3 ~ GLASGOW COMA SCALE
C
a
t
h
e
r
in
e
H
o
llic
k
PROFESSlONA| RESPONSlBl|lTlES
This procedure shou|d be undertaken
on|y after approved training, supervised
practice and competency assessment,
and carried out in accordance with |oca|
po|icies and protoco|s.
knuckles of a clenched fist to apply grinding
pressure to the sternum; not recommended
for repeated assessmentj (Fig 6j.
lf the patient opens their eyes to a painful
stimulus record the score as 2E (Dougherty
and Lister, 2005j. lf the patient does not
respond, then the score is 1E.
Fig 1. Check for any factors that couId
affect the accuracy of the GCS
Fig 4. Use the thumb and two hngers
to appIy a trapezium squeeze
NEXT WEEK
Neuro|og|ca| assessment 4:
G|asgow coma sca|e - part 2
For more Pract|ca| Procedures
|og on to nurslngtlmes.net and
c||ck on NT Cllnloal and Arohlve
Fig 4. Use the thumb and two fingers to
apply a trapezius squeeze
Fig 5. Apply pressure to the notch on
the supra-orbital margin
Annex 3
Neurological assessment using the Glasgow Coma Scale
The procedure
Explain the procedure to the patient.
Ascertain the patients acuity of hearing.
Ideally, use an interpreter if the patient does not speak English.
Check the patients notes for any medical condition that may affect the accuracy of the GCS, for
example previous stroke, affecting the movement of the patients arms (see figure 1).
Check the neurological observation chart for the GCS scale (see figure 2).
Check if the patient opens their eyes without the need to speak or to touch them; if the patient does,
then the score is 4E. If the patient does not open their eyes, talk to them (see figure 3). Start off with
a normal volume and speak louder if necessary. If they now open their eyes, the score is 3E.
If the patient does not open their eyes to speech, administer a painful stimulus, for example
trapezius squeeze (use the thumb and two fingers to grasp the trapezius muscle where the
neck meets the shoulder and twist) (see figure 4). Or apply supra-orbital pressure (locate the
notch on the supra-orbital margin and apply pressure to it) (see figure 5). If there is any doubt
in distinguishing between flexion to a painful stimulus and localisation to pain, supra-orbital
notch pressure should be used. If supra-orbital notch pressure is contraindicated due to bruising
or swelling in this region then finger nail pressure could be used.
If the patient opens their eyes to a painful stimulus record the score as 2E. If the patient does not
respond, then the score is 1E.
ANNEXES
58
EARLY MANAGEMENT OF PATIENTS WITH A HEAD INJURY
Annex 3
continued
Eye opening
Assessment of eye opening involves the evaluation of arousal (being aware of the
environment):
Score 4 Eyes open spontaneously.
Score 3 Eyes open to speech.
Score 2
Eyes open in response to pain only, for example trapezius squeeze (caution if
applying a painful stimulus).
Score 1 Eyes do not open to verbal or painful stimuli.
Record C if the patient is unable to open her or his eyes because of swelling, ptosis (drooping
of the upper eye lid) or a dressing.
Verbal response
Assessment involves evaluating awareness:
Score 5 Orientated.
Score 4 Confused.
Score 3 Inappropriate words.
Score 2 Incomprehensible sounds.
Score 1 No response. This is despite both verbal and physical stimuli.
Record D if the patient is dysphasic and T if the patient has a tracheal or tracheostomy tube
in situ.
Motor response
Assessment of motor response is designed to determine the patients ability to obey a command
and to localise, and to withdraw or assume abnormal body positions, in response to a painful
stimulus:
Score 6 Obeys commands. The patient can perform two different movements.
Score 5
Localises to central pain. The patient does not respond to a verbal stimulus but
purposely moves an arm to remove the cause of a central painful stimulus.
Score 4
Withdraws from pain. The patient flexes or bends the arm towards the source of
the pain but fails to locate the source of the pain (no wrist rotation).
Score 3
Flexion to pain. The patient flexes or bends the arm; characterised by internal
rotation and adduction of the shoulder and flexion of the elbow, much slower
than normal flexion.
Score 2
Extension to pain. The patient extends the arm by straightening the elbow and
may be associated with internal shoulder and wrist rotation.
Score 1 No response to painful stimuli.
Painful stimulus
A true localising response to pain involves the patient bringing an arm up to chin level. Painful
stimuli that can elicit this response include trapezius squeeze (see figure 4), supra-orbital ridge
pressure (see figure 5) (not recommended if there is a suspected/ confirmed facial fracture).
Adapted from Phil Jevon. Neurological assessment Part 3 Glasgow Coma Scale. Nursing Times; 104: 29, 28-29 by
kind permission of the Nursing Times
143
59
The SCAT Card
(Sport Concussion Assessment Tool)
Athlete Information
What is a concussion? A concussion is a disturbance in the
function of the brain caused by a direct or indirect force to the head.
It results in a variety of symptoms (like those listed below) and may,
or may not, involve memory problems or loss of consciousness.
How do you feel? You should score yourself on the following
symptoms, based on how you feel now.
What should I do?
Any athlete suspected of having a concussion should be
removed from play, and then seek medical evaluation.
Signs to watch for:
Problems could arise over the first 24-48 hours. You should not be
left alone and must go to a hospital at once if you:
Have a headache that gets worse
Are very drowsy or cant be awakened (woken up)
Cant recognize people or places
Have repeated vomiting
Behave unusually or seem confused; are very irritable
Have seizures (arms and legs jerk uncontrollably)
Have weak or numb arms or legs
Are unsteady on your feet; have slurred speech
Remember, it is better to be safe. Consult your doctor after a
suspected concussion.
What can I expect?
Concussion typically results in the rapid onset of short-lived
impairment that resolves spontaneously over time. You can expect
that you will be told to rest until you are fully recovered (that means
resting your body and your mind). Then, your doctor will likely
advise that you go through a gradual increase in exercise over
several days (or longer) before returning to sport.
Post Concussion Symptom Scale
None Moderate Severe
Headache 0 1 2 3 4 5 6
Pressure in head 0 1 2 3 4 5 6
Neck Pain 0 1 2 3 4 5 6
Balance problems or dizzy 0 1 2 3 4 5 6
Nausea or vomiting 0 1 2 3 4 5 6
Vision problems 0 1 2 3 4 5 6
Hearing problems / ringing 0 1 2 3 4 5 6
Dont feel right 0 1 2 3 4 5 6
Feeling dingedor dazed0 1 2 3 4 5 6
Confusion 0 1 2 3 4 5 6
Feeling slowed down 0 1 2 3 4 5 6
Feeling like "in a fog" 0 1 2 3 4 5 6
Drowsiness 0 1 2 3 4 5 6
Fatigue or low energy 0 1 2 3 4 5 6
More emotional than usual 0 1 2 3 4 5 6
Irritability 0 1 2 3 4 5 6
Difficulty concentrating 0 1 2 3 4 5 6
Difficulty remembering 0 1 2 3 4 5 6
(follow up symptoms onl y)
Sadness 0 1 2 3 4 5 6
Nervous or Anxious 0 1 2 3 4 5 6
Trouble falling asleep 0 1 2 3 4 5 6
Sleeping more than usual 0 1 2 3 4 5 6
Sensitivity to light 0 1 2 3 4 5 6
Sensitivity to noise 0 1 2 3 4 5 6
Other: _______________ 0 1 2 3 4 5 6
Post Concussion Symptoms
Ask the athlete to score themselves based on how
they feel now. It is recognized that a low score may
be normal for some athletes, but clinical judgment
should be exercised to determine if a change in
symptoms has occurred following the suspected
concussion event.
It should be recognized that the reporting of
symptoms may not be entirely reliable. This may be
due to the effects of a concussion or because the
athletes passionate desire to return to competition
outweighs their natural inclination to give an honest
response.
If possible, ask someone who knows the athlete well
about changes in affect, personality, behavior, etc.
For more information see the Summary and
Agreement Statement of the Second International
Symposium on Concussion in Sportin the April, 2005
edition of the Clinical J ournal of Sport Medicine (vol
15), British J ournal of Sports Medicine (vol 39),
Neurosurgery (vol 59) and the Physician and
Sportsmedicine (vol 33). This tool may be copied for
distribution to teams, groups and organizations.
2005 Concussion in Sport Group
This tool represents a standardized method of
evaluating people after concussion in sport. This Tool
has been produced as part of the Summary and
Agreement Statement of the Second International
Symposium on Concussion in Sport, Prague 2004
Sports concussion is defined as a complex
pathophysiological process affecting the brain,
induced by traumatic biomechanical forces. Several
common features that incorporate clinical,
pathological and biomechanical injury constructs that
may be utilized in defining the nature of a concussive
head injury include:
1. Concussion may be caused either by a direct blow
to the head, face, neck or elsewhere on the body
with an 'impulsive' force transmitted to the head.
2. Concussion typically results in the rapid onset of
short-lived impairment of neurological function that
resolves spontaneously.
3. Concussion may result in neuropathological
changes but the acute clinical symptoms largely
reflect a functional disturbance rather than
structural injury.
4. Concussion results in a graded set of clinical
syndromes that may or may not involve loss of
consciousness. Resolution of the clinical and
cognitive symptoms typically follows a sequential
course.
5. Concussion is typically associated with grossly
normal structural neuroimaging studies.
Remember, concussion should be suspected in the
presence of ANY ONE or more of the following:
Symptoms (such as headache), or
Signs (such as loss of consciousness), or
Memory problems
Any athlete with a suspected concussion should
be monitored for deterioration (i.e., should not be
left alone) and should not dri ve a motor vehicle.
Annex 4
Sport Concussion Assessment Tool (SCAT)
49
ANNEXES
60
EARLY MANAGEMENT OF PATIENTS WITH A HEAD INJURY
The SCAT Card
(Sport Concussion Assessment Tool)
Medical Evaluation
Name: ___________________________ Date __________
Sport/Team: _______________________ Mouth guard? Y N
1) SIGNS
Was there loss of consciousness or unresponsiveness? Y N
Was there seizure or convulsive activity? Y N
Was there a balance problem / unsteadiness? Y N
2) MEMORY
Modified Maddocks questions (check correct)
At what venue are we? __; Which half is it? __; Who scored last?__
What team did we play last? __; Did we win last game? __?
3) SYMPTOM SCORE
Total number of positive symptoms (fromreverse side of the card) =______
4) COGNITIVE ASSESSMENT
5 word recall Immediate Delayed
(Examples) (after concentration tasks)
Word 1 _____________ cat ___ ___
Word 2_____________ pen ___ ___
Word 3 _____________ shoe ___ ___
Word 4 _____________ book ___ ___
Word 5 _____________ car ___ ___
Months in reverse order:
J un-May-Apr-Mar-Feb-J an-Dec-Nov-Oct-Sep-Aug-J ul (circle incorrect)
or
Digits backwards (check correct)
5-2-8 3-9-1 ______
6-2-9-4 4-3-7-1 ______
8-3-2-7-9 1-4-9-3-6 ______
7-3-9-1-4-2 5-1-8-4-6-8 ______
Ask delayed 5-word recall now
5) NEUROLOGIC SCREENING
Pass Fail
Speech ___ ___
Eye Motion and Pupils ___ ___
Pronator Drift ___ ___
Gait Assessment ___ ___
Any neurologic screening abnormality necessitates formal
neurologic or hospital assessment
6) RETURN TO PLAY
Athletes should not be returned to play the same day of injury.
When returning athletes to play, they should follow a stepwise
symptom-limited program, with stages of progression. For example:
1. rest until asymptomatic (physical and mental rest)
2. light aerobic exercise (e.g. stationary cycle)
3. sport-specific exercise
4. non-contact training drills (start light resistance training)
5. full contact training after medical clearance
6. return to competition (game play)
There should be approximately 24 hours (or longer) for each stage
and the athlete should return to stage 1 if symptoms recur.
Resistance training should only be added in the later stages.
Medical clearance should be given before return to play.
Return to Play:
A structured, graded exertion protocol should be
developed; individualized on the basis of sport, age
and the concussion history of the athlete. Exercise or
training should be commenced only after the athlete is
clearly asymptomatic with physical and cognitive rest.
Final decision for clearance to return to competition
should ideally be made by a medical doctor.
Neurologic Screening:
Trained medical personnel must administer this
examination. These individuals might include medical
doctors, physiotherapists or athletic therapists.
Speech should be assessed for fluency and lack of
slurring. Eye motion should reveal no diplopia in any
of the 4 planes of movement (vertical, horizontal and
both diagonal planes). The pronator drift is performed
by asking the patient to hold both arms in front of
them, palms up, with eyes closed. A positive test is
pronating the forearm, dropping the arm, or drift away
from midline. For gait assessment, ask the patient to
walk away from you, turn and walk back.
Cogniti ve Assessment:
Select any 5 words (an example is given). Avoid
choosing related words such as "dark" and "moon"
which can be recalled by means of word association.
Read each word at a rate of one word per second.
The athlete should not be informed of the delayed
testing of memory (to be done after the reverse
months and/or digits). Choose a different set of
words each time you perform a follow-up exam with
the same candidate.
Ask the athlete to recite the months of the year
in reverse order, starting with a random month. Do
not start with December or J anuary. Circle any
months not recited in the correct sequence.
For digits backwards, if correct, go to the next
string length. If incorrect, read trial 2. Stop after
incorrect on both trials.
Memory: If needed, questions can be modified to
make them specific to the sport(e.g. periodversus half)
For more information see the Summary and
Agreement Statement of the Second International
Symposium on Concussion in Sportin the April, 2005
Clinical J ournal of Sport Medicine (vol 15), British
J ournal of Sports Medicine (vol 39), Neurosurgery (vol
59) and the Physician and Sportsmedicine (vol 33).
2005 Concussion in Sport Group
Signs:
Assess for each of these items and circle
Y (yes) or N (no).
Instructions:
This side of the card is for the use of medical doctors,
physiotherapists or athletic therapists. In order to
maximize the information gathered from the card, it is
strongly suggested that all athletes participating in
contact sports complete a baseline evaluation prior to
the beginning of their competitive season. This card
is a suggested guide only for sports concussion and is
not meant to assess more severe forms of brain
injury. Please give a COPY of this card to the
athlete for their information and to guide follow-
up assessment.
Annex 4
continued
61
Date / / Time /
Recall of incident: No Yes
Mechanism: Fall Assault RTA Alcohol / Drugs Other
PTA: None < 5 mins 5 60 mins > 1 hr (__ hrs)
Present symptoms: Headache Dizziness Nausea Vomited in last 12 hours
Disturbance of speech / hearing / vision / balance Other
History:
Scalp: Wound (Laceration / Incised or Contusion); Fracture (felt or seen or unsure)
Medication: Warfarin Anticonvulsants Other
PMH:
O/E: Resp. rate /min Pulse rate /min BP
GCS: Eye opening -- Best motor -- Verbal --
Neck injury status: Cleared Immobilised
Head injury assessment in ED
Name:
PATIENT LABEL
Annex 5
Example of a proforma for routine documentation of head injury
in adult patients
ANNEXES
62
EARLY MANAGEMENT OF PATIENTS WITH A HEAD INJURY
Neurological signs ( if normal)
Sensation - scalp / face Hearing R L Romberg's
Smell Tongue & Palate movt Visual Acuity R L Visual fields
Limb mvts. R L Pupil reactions Facial mvt. Eye mvts.
Tympanic membranes normal: R. Yes No Obscured by wax
Signs of basal skull fracture: No Yes _________________________
Other injuries / problems: No Yes _________________________
PLAN
Signature:
ASSESSMENT (List injuries)
L. Yes No Obscured by wax
Date
& Time
Head injury assessment in ED
Continuation
Name:
PATIENT LABEL
Annex 5
continued
63
Patient
Other:
Parent
History
from:
Other Drugs:
Give details of known pre-existing
disorders eg epilepsy, diabetes,
cardiac arrythmias, bleeding disorders,
mental disorders, other medical.
How long?
History
Head Injury History : Children of 5 years and older
/ / Injury Date : Injury Time
/ / Exam Date : Exam Time
Right
Left
Ambidextrous
Hand Dominance
F/S Passenger
B/S Passenger
Motor Cyclist / Pillion
Pedal Cyclist
Pedestrian
Fall
School Accident
Home Accident
Assault or NAI
Sport / Play
Other
Incident Description:
Seatbelt
Helmet
Yes No
Safety Equipment:
Loss of consciousness
Post-traumatic amnesia
Seizure since injury
Headache
Nausea
Vomiting
Drowsy / unusually tired
Visual distrurbance
Evidence of alcohol/drug consumption
Rhinorrhoea / Otorrhoea
Limb weakness
Other neurological symptoms
Yes No Unsure
How long?
Describe:
Describe:
No of times:
Comment:
Comment:
Comment:
Comment:
Comment:
Details:
None Unknown
Pre-existing disorders
Covered Needs Booster Needs Course Not Known Tetanus State
None
Unknown
Drug Therapy
On warfarin
On aspirin
Yes No
None
Unknown
Drug Allergies
Known Allergies:
Affix Patient Label Here
Person responsible at home:
Male Female
Sex
YO
/ / DOB
Annex 6
Example of a proforma for routine documentation of head injury
in children over five years of age
ANNEXES
64
EARLY MANAGEMENT OF PATIENTS WITH A HEAD INJURY
Discharge home
Request opinion
Refer to surgeons
Admit to ward
Transfer to SGU
C Spine X-ray
Brain CT
C Spine CT
Yes No
Findings on Imaging:
of:
Head Injury Examination : Adults and children of 5 years and older
Normal Abnormal Immobilised
C Spine Examination
Neurological Examination : Score from Glasgow Coma Scale
Investigations and Results
BM
. Temp
Management
Diagnosis from ED
written advice verbal advice
: time
specify:
Vertex Right Parietal Left Parietal Forehead / Face Occiput
Boggy haematoma
Laceration(s)
Bruising
Suspicion of compund skull fracture or
penetrating injury
Sign of base of skull fracture
CSF/Blood leak from right ear
CSF/Blood leak from left ear
CSF/Blood leak from nose
Evidence of injury to neck
Yes No
Comments on injuries, neuro-examination and treatment:
Left Right
Pupil reacting
Left
Right
Normal Abnormal
E
M
V
GCS Eyes
Movements
Cranial N
Tone
Power
Normal Abnormal Normal Abnormal
Left Right
No Yes
Cerebellar signs
Normal Abnormal Gait
Head Examination
BM/Temp not relevant
Head injury
Skull fracture
Other diagnosis
Nose injury
Facial injury
give details in box below:
Yes No Additional notes on ED card
Signature:
Tick the boxes corresponding to the injured areas, and illustrate with appropriate measurements of lacerations and bruises in cms:
Annex 6
continued
65
Patient
Other:
Parent
History
from:
Other Drugs:
Give details of known pre-existing
disorders eg epilepsy, diabetes,
cardiac arrythmias, bleeding disorders,
mental disorders, other medical.
How long?
History (if NAI suspected, see ED Dept Child Protection protocol ~Head Injury)
Head Injury History : Children under 5 years of age
Male Female
Sex
/ / Injury Date : Injury Time
/ / Exam Date : Exam Time
YO
F/S Passenger
B/S Passenger
Motor Cycle / Pillion
Pedal Cyclist
Pedestrian
Fall
School Accident
Home Accident
Assault or NAI
Sport / Play
Other
Incident Description:
Seatbelt
Helmet
Yes No
Safety Equipment:
Loss of consciousness
Post-traumatic amnesia
Seizure since injury
Headache
Nausea
Vomiting
Drowsy / unusually tired
Visual distrurbance
Rhinorrhoea / Otorrhoea
Limb weakness
Other neurological symptoms
Yes No Unable To
Assess
How long?
Describe:
Describe:
No of times:
Comment:
Comment:
Comment:
Comment:
Details:
None Unknown
Pre-existing disorders
Covered Needs Booster Needs Course Not Known Tetanus State
None
Unknown
Drug Therapy
On warfarin
On aspirin
Yes No
None
Unknown
Drug Allergies
Known Allergies:
/ / DOB
Affix Patient Label Here
Person responsible at home:
Annex 7
Example of a proforma for routine documentation of head injury
in children under five years of age
ANNEXES
66
EARLY MANAGEMENT OF PATIENTS WITH A HEAD INJURY
Left Right
Pupil reacting
Discharge home
Request opinion
Refer to surgeons
Admit to ward
Transfer to SGU
Left
Right
Normal Abnormal
C Spine X-ray
Brain CT
C Spine CT
Yes No Findings on Imaging:
of:
Comments on injuries, neuro-examination and treatment:
Head Injury Examination : Children under 5 years of age
Boggy haematoma
Laceration(s)
Bruising
Suspicion of compund skull fracture or
penetrating injury
Sign of base of skull fracture
CSF/Blood leak from right ear
CSF/Blood leak from left ear
CSF/Blood leak from nose
Evidence of injury to neck
Yes No
Normal Abnormal Immobilised
C Spine movements
Neurological Examination : Score from Glasgow Coma Scale
E
M
V
GCS Eyes
Movements
Cranial N
Tone
Power
Normal Abnormal Normal Abnormal
Investigations and Results
BM
. Temp
Management ED Diagnosis
written advice verbal advice
: time
Head injury
Skull fracture
Other diagnosis
Nose injury
Facial injury
give details in box below:
specify:
Left Right
Normal Bulging / tense Fontanelle / Sutures
Head circumference cm
Tick the boxes corresponding to the injured areas, and illustrate with appropriate measurements of lacerations and bruises in cms:
Vertex Right Parietal
Head Examination
No Yes
Cerebellar signs
Normal Abnormal Gait
Sits
Rolls
Crawls
Walks
Observed Not seen
Left Parietal Forehead / Face Occiput
Yes No
Developmental
milestone
consistent with
history
If <1 year old
Signature:
Yes No Additional notes on ED card
BM/Temp not relevant
Annex 7
continued
67
Annex 8
Example advice leaflet for person taking a patient home from the
ED
IMPORTANT THINGS TO LOOK FOR AFTER A HEAD INJURY
Advice for the person taking a patient home from the
Emergency Department
[Name] has suffered a head injury, but does not need to be admitted to a hospital
ward. We have examined the patient, and believe that the injury is not serious. Please
watch the patient closely over the next day or so as very rarely complications may
develop as a result of the injury. Overnight rouse the patient gently every couple of
hours, and follow this advice:
Do not leave the patient alone at home. 1.
Make sure that there is a nearby telephone, and that the patient stays within easy 2.
reach of medical help.
Symptoms to look out for: 3.
Is it difficult to wake the patient up?
Is the patient very confused?
Does the patient complain of a very severe headache?
Has the patient:
vomited (been sick)? -
had a fit (collapsed and felt a bit out of touch afterwards)? -
passed out suddenly? -
complained of weakness or numbness in an arm or a leg? -
complained about not seeing as well as usual? -
had any watery fluid coming out of their ear or nose? -
If the answer to any of these questions is Yes or you are worried about anything else,
you should telephone the Emergency Department on:
TEL. NO.: ....................................................
Or if you are very worried take the patient straight back to the Emergency
Department.
ANNEXES
68
EARLY MANAGEMENT OF PATIENTS WITH A HEAD INJURY
Annex 9
Example advice leaflet for patient allowed home from the ED
ADVICE FOR A PATIENT ALLOWED HOME FROM THE EMERGENCY DEPARTMENT
FOLLOWING HEAD INJURY
Do you feel well?
Often people can feel unwell after a head injury even when they are back home.
Common symptoms are:
slight headache
dizziness
memory problems
poor concentration
irritability or being easily annoyed
tiredness
poor sleep.
If you have any of these symptoms, do not worry because they should clear up in time
without any treatment.
If you still have any of the symptoms after two weeks you should see your own
doctor.
Some extra advice to help you get well:
Following this advice will help you to recover from your head injury more quickly, and it
may stop some of the symptoms from happening.
DO have plenty of rest and avoid stressful and noisy situations.
DO NOT take any alcohol or any non prescribed drugs.
DO NOT take sleeping pills, sedatives or tranquillisers. If in doubt contact your
GP.
DO NOT play any contact sport (eg football or squash) for at least three weeks
without talking to your doctor first.
69
Annex 10
Example discharge advice leaflet for carers of children who have
sustained a head injury
HEAD INJURY OBSERVATION INSTRUCTIONS FOR PARENTS AND CARERS
Your child has suffered a head injury and should be watched closely for the next 24
hours. If you are worried that he/she is developing a problem, please contact your
doctor or this Emergency Department or, if necessary, make arrangements to bring
him/her back to hospital by ambulance, taxi or car.
Important things to look out for are:
increasing confusion (not knowing where they are, getting things muddled up)
increasing drowsiness (feeling very sleepy all the time)
persisting headache
vomiting (being sick)
weakness of one or more limbs
not seeing or breathing as well as usual
watery fluid or blood coming from the ear, nose or mouth
a fit (collapsing and feeling a bit out of touch afterwards)
any behaviour not normal for your child.
When your child is sleeping, you should arrange to check him/her for the first
night at two-hour intervals to find out:
D oes he/she appear to be breathing normally?
Is he/she sleeping in a normal posture?
Does he/she make the expected response when you rouse him/her gently? (eg
pulling up sheets, cuddling teddy bear)?
If you cannot satisfy yourself that your child is sleeping normally, he/she should be
wakened fully to be checked.
Things you shouldnt worry about:
Your child may feel some other symptoms over the next few days which should disappear
in the next two weeks. These include a mild headache, feeling sick (without vomiting),
dizziness, irritability or bad temper, problems concentrating or problems with their
memory, tiredness, lack of appetite or problems sleeping. If you feel concerned about
any of these symptoms in the first few days after discharge you should bring the
patient to their doctor.
If these problems do not go away after two weeks, you should bring the patient
to see their doctor
CONTACT NO:
ANNEXES
70
EARLY MANAGEMENT OF PATIENTS WITH A HEAD INJURY
Annex 11
Example advice leaflet for patients returning to sport after a head
injury: a return to play protocol.
Adapted from McCrory et al (2005)
49
The majority of sport-related injuries will be simple concussions that will recover spontaneously
over several days. In these situations, it is expected that an athlete will proceed rapidly through
the step-wise return to play protocol.
In the first few days following an injury, it is important to emphasise to the athlete that physical
and cognitive rest is required. Activities that require concentration and attention may exacerbate
the symptoms and as a result delay recovery. The return to play following a concussion follows
a step-wise process.
ADVICE FOR GRADUAL RETURN TO SPORT AFTER A HEAD INJURY
You have sustained a concussion or minor head injury.
Before you return to sport full time it is important that you follow a step-wise
return to play protocol to allow you to return safely.
It is likely that you may experience a number of symptoms as a result of your head
injury, such as: mild headache, dizziness, memory problems, poor concentration,
irritability, tiredness, sleep disruption.
You must be sure that your symptoms have completely cleared at each exercise level
for at least 24 hours before you progress to the next level.
If symptoms develop at any exercise level then you should return to level one and
have 24 hours rest.
Contact your GP if your symptoms are not improving.
You should not return to any full sporting activity in less than one week.
If you were unconscious or had a significant memory loss after your head injury you
should have no full contact activity (level 5) within three weeks. Ask your doctor
for advice before going back to full contact activity.
71
LEVEL 1 No physical activity /complete rest
LEVEL 2
Low levels of physical activity ie symptoms do not come back during
or after the activity.
eg walking, light jogging, light stationary biking, light weightlifting
(lower weight, higher reps, no bench, no squat).
LEVEL 3
Sport specific training or moderate levels of physical activity with
body/head movement
eg running in football, moderate jogging, brief running, moderate-
intensity stationary biking, moderate-intensity weightlifting (reduced
time and/or reduced weight from your typical routine).
LEVEL 4
Heavy non-contact physical activity / training drills
eg sprinting/running, high-intensity stationary biking, regular
weightlifting, routine non-contact sport-specific drills.
LEVEL 5 Full contact in controlled training/practice.
LEVEL 6 Full contact in games/ Return to competition.
RETURN TO PLAY PROTOCOL
Annex 11
continued
ANNEXES
72
EARLY MANAGEMENT OF PATIENTS WITH A HEAD INJURY
Annex 12
Example advice leaflet for patient discharged home after
admission
Whenever possible, this leaflet should be given to the responsible adult taking the patient
home, as well as to the patient.
IMPORTANT ADVICE FOR A PATIENT WITH HEAD INJURY WHEN YOU GET
HOME
Ward ___________________ Ward telephone number: __________________
We think that it is okay for you to leave hospital now. We have kept a close eye on you
since your head injury, and you seem to be well on the road to recovery. So when you
get home you will probably not have any serious symptoms. But if any of the following
symptoms do happen, you should return to the hospital or telephone the ward for
advice.
Important symptoms to look out for:
severe headache which is not helped by pain-killers such as paracetamol
vomiting (being sick)
confusion (not knowing where you are, getting things muddled up)
drowsiness (feeling very sleepy all the time)
a fit (collapsing and feeling a bit out of touch afterwards)
passing out suddenly
fluid coming out of your ear or nose
not seeing as well as usual.
Other symptoms
People who have had a head injury sometimes have other symptoms. You may feel a
slight headache, dizziness, memory problems, poor concentration, irritability (being
easily annoyed), tiredness, or poor sleep. These symptoms usually clear up after two
weeks or so without any treatment, so do not worry about them.
But if these symptoms do not clear up after two weeks, you must go and see your
own doctor.
Some extra advice to help you get well:
Following this advice will help you to recover from your head injury more quickly, and
it may stop any symptoms from happening.
DO have plenty of rest and avoid stressful and noisy situations.
DO NOT take any alcohol.
DO NOT take sleeping pills, sedatives or tranquillisers. If in doubt contact your
GP
DO NOT play any contact sport (eg football or squash) for at least three weeks
without talking to your doctor first.
73
NEUROSURGICAL
CHECK LIST and REFERRAL FORM
Referring Hospital:
Name:
Address:
Consultant
Sex: Male c Female c
Age:
DOB:
ID LABEL
Date of Incident: ____ / ____ / ____
Date: ___ / ___ / ___
From Glasgow Royal Infirmary
RR HR BP
eye motor verbal
ARMS
R L R L
LEGS
reacts size reacts size
Time
GCS RIGHT Pupil Limb Movement LEFT Pupil
0
2
sat
History:
on arrival
on transfer
Physiological Observations
Extra-cranial injuries (proven or suspected)
NB: Have you excluded all possible sites of blood loss?
Time of Incident: ____ : ____
Transfer: ___ : ___ Accepted: ___ : ___ Referral Time: ___ : ___
Past Medical History:
Current Medication: Warfarin: c Other: c
Urinalysis:
Cranial Injuries:
Interventions
Blood Tests
CT Scan at referring hospital:
Cleared c Controlled c
Yes c No c
Yes c No c
Yes c No c
Yes c No c
Yes c No c
Yes c No c
Yes c No c
Yes c No c
Yes c
Allergies:
No c
= Normal
= Diminished
= Absent
C-spine:
Pelvis
Thoracolumbar:
Limbs:
Other:
Airway:
Ventilation:
Urinary catheter:
Drugs given
Tetanus immunoglobulin
Tetanus toxoid
Dose Time
Patent:
Spontaneous
Yes
Next of kin
Signed: Print: Grade:
Receiving
Neurosurgeon:
Valuables:
Transfer with the patient: Observation charts c Medical notes c X-rays c
patient c relatives c police c none c
Intubated
IPPV
No
Other c
Fi0
2
_________ %
c
c
c
CT Scan c
ED Ward Consultant: c c
c
c
c
Chest:
Abdomen:
Face/Neck:
Drugs given Dose Time
Time:
p0
2
pC0
2
H
+
HCO
3
Hb
WCC
Platelets
Glucose
Na
+
K
+
Urea
Creat.
PT
APTT
TCT
X-match
IV FLuids
crystalloid
colloid
blood
Volume (cc)
M
I
S
1
4
0
1
5
3
NEUROSURGICAL
CHECK LIST and REFERRAL FORM
Referring Hospital:
Name:
Address:
Consultant
Sex: Male c Female c
Age:
DOB:
ID LABEL
Date of Incident: ____ / ____ / ____
Date: ___ / ___ / ___
From Glasgow Royal Infirmary
RR HR BP
eye motor verbal
ARMS
R L R L
LEGS
reacts size reacts size
Time
GCS RIGHT Pupil Limb Movement LEFT Pupil
0
2
sat
History:
on arrival
on transfer
Physiological Observations
Extra-cranial injuries (proven or suspected)
NB: Have you excluded all possible sites of blood loss?
Time of Incident: ____ : ____
Transfer: ___ : ___ Accepted: ___ : ___ Referral Time: ___ : ___
Past Medical History:
Current Medication: Warfarin: c Other: c
Urinalysis:
Cranial Injuries:
Interventions
Blood Tests
CT Scan at referring hospital:
Cleared c Controlled c
Yes c No c
Yes c No c
Yes c No c
Yes c No c
Yes c No c
Yes c No c
Yes c No c
Yes c No c
Yes c
Allergies:
No c
= Normal
= Diminished
= Absent
C-spine:
Pelvis
Thoracolumbar:
Limbs:
Other:
Airway:
Ventilation:
Urinary catheter:
Drugs given
Tetanus immunoglobulin
Tetanus toxoid
Dose Time
Patent:
Spontaneous
Yes
Next of kin
Signed: Print: Grade:
Receiving
Neurosurgeon:
Valuables:
Transfer with the patient: Observation charts c Medical notes c X-rays c
patient c relatives c police c none c
Intubated
IPPV
No
Other c
Fi0
2
_________ %
c
c
c
CT Scan c
ED Ward Consultant: c c
c
c
c
Chest:
Abdomen:
Face/Neck:
Drugs given Dose Time
Time:
p0
2
pC0
2
H
+
HCO
3
Hb
WCC
Platelets
Glucose
Na
+
K
+
Urea
Creat.
PT
APTT
TCT
X-match
IV FLuids
crystalloid
colloid
blood
Volume (cc)
M
I
S
1
4
0
1
5
3
Annex 13
Example of a neurosurgical referral form
ANNEXES
74
EARLY MANAGEMENT OF PATIENTS WITH A HEAD INJURY
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ISBN 978 1 905813 46 9
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8 -10 Hillside Crescent
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