Neurological assessment

• Repeat the GCS.
• Check the pupil size, reactivity and equality.
• Assess arm and leg movements and strength. Document discrepancies.
• Observe posture and tone.
• If the patient is safe to mobilise, observe gait, balance and coordination.
• Monitor vital signs.
• Neurological instability may present as:
• rapid or irregular respiratory rate
• hypertension
• temperature instability
• rise in pulse rate, followed by bradycardia if increased intracranial pressure.

Intracranial pressure (ICP)

• Assess all patients for an acute rise in ICP.
• Increased ICP may present as:
• severe headache
• persistent vomiting
• blurred vision
• change in behaviour or altered mental state
• posturing (decerebrate and decorticate)
• Cushing's triad (a late sign), i.e. irregular respirations, widened pulse pressure and bradycardia.
• If concerned, elevate the head of the bed and escalate urgently as per local CERS protocol.
• Consider cranial nerve examination.