Neurological Assessment and Monitoring
The bedside set
A complete neuro check has six parts: level of consciousness, pupils, extraocular movements, motor response (best and worst side), respiratory pattern, and blood pressure trend. Consciousness is the most sensitive early indicator of deterioration.
Glasgow Coma Scale
E4 V5 M6 = 15, and the floor is 3, never 0. Report components (for example 'E1 V1T M4'), not just the total, because a single number hides the trend. An intubated patient is V1T - never score verbal as intact for someone who cannot speak. Use the best response when sides differ.
Pupils and herniation
Record size in millimeters and reactivity per eye. A unilaterally dilated, nonreactive pupil suggests ipsilateral uncal herniation from CN III compression - an immediate escalation, not a 'recheck later'. With new pupillary change, verify blood pressure, ICP, head midline position, and that nothing compresses the neck.
Monitoring
CPP = MAP − ICP, and MAP = DBP + (SBP − DBP)/3. A common adult CPP target is 60–70 mmHg. External ventricular drains measure global pressure and allow CSF drainage but carry infection and hemorrhage risk; parenchymal monitors measure focal pressure. Never flush an EVD.
Traps
Confusing the 3–15 GCS range with a 0–15 scale; reporting an isolated ICP value without the CPP; scoring a sedated or paralyzed patient as if that were the baseline; and accepting each value as 'normal' while ignoring a downward trend.
Rule of thumb: deterioration usually appears in this order - level of consciousness, then pupils, then motor response. Assess in that order and escalate at the first change.