Central vs Peripheral Stimulus & Declining patient (advice?/vent)

[afox]

I'm new to the NSICU and I was taught that for GCS-Motor assessment that when we need to use painful stimulus we should use central stimulus such as Trap Squeeze.

So the other night I had a patient who was declining (hx: afib, resp failure, multiple cva, CHF). 1900 assessment patient could slightly wiggle fingers/toes by command when alert. 2100: patient not alert but slightly withdrawing to trap squeeze. (Neuro Dr. Notified & says consult medical doctor). 2230: Intubated for resp failure (Given 20 etomidate & 2 of versed). Now patient is sedated. so unable to get a good neuro exam. 0100-0200: still nothing, getting nervous! 0300: Patient opens eyes to voice but eyes appear slightly deviated and is not able to move/command. Only responding on LLE to trap squeeze. Resident finally comes to assess the patient at 0500 and does a Peripheral nerve pinch. There is slight flicker of patients right side. The resident then says "why did you call me down here, there is no change. You said he was withdrawing earlier and he still is".

I tried to explain that I was using Central not peripheral stimuli and that his baseline assessment HAD changed (as I was taught that there are receptors in the spinal cord that can react to peripheral pain and so it is not necessarily testing brain function)

The patient was also hypotensive (on Esmolol drip for afib that was stopped during intubation d/t lowering bp) and in Trendelenbur so I finally get the Neuro doctor to agree that we should at least start a pressor to get the BP for perfusion, but i must run it by medical doctor.

By 0700 patient has not improved and has definite eye deviation.

I guess I'm frustrated b/c I feel like the doctor wasn't listening to me & I'm wondering if I'm doing my assessment wrong. Does anyone have any input on how they do their assessment (central/peripheral), how I should have handled it differently, etc??

[Here.I.Stand, BSN, RN]

We test peripherally and chart each extremity's response, as well as a general motor response. But if you had been testing centrally and had a change from his baseline with the same test, I would have been concerned about that too. You were right to call. I would have shown him using your method and tell him your earlier assessment w/ that same method. If he still doesn't listen, then he's being a jerk (well, he WAS being a jerk regardless. The ICU nurse is concerned and you were doing what you were supposed to in calling him), and you might need to take it up the chain if you're still concerned.

[jelly221,RN, MSN]

Waterhouse gives a good explanation in this article: An Audit of Nurses' Conduct and Recording of Observations Using the Glasgow Coma Scale

You are correct that central pressure should be used in the GCS-Motor. A central stimulus is applied to the cranial nerves, NOT to the center of the patient's body, and the preferred method is supraorbital ridge pressure. In patients with facial fractures or trauma in whom fractures have not been ruled out, pinching the trapezius (CN XI) is acceptable. Sternal rub is not recommended.

Peripheral stimulation is transmitted by primary afferent neurons, which end in the dorsal horn of the spinal cord. These neurons branch into two upon reaching the spinal cord- one branch synapses with a second-order neuron causing a spinal reflex, and the other branch decussates (crosses over) and ascends via the spinothalamic fibers and runs through the brainstem to the thalamus.

For the GCS-Eye Opening, if peripheral pain causes the patients eyes to open, this indicates that the spinothalamic fibers are intact. However, for the motor portion, testing a peripheral nerve leaves uncertainty about whether the patient's motor response was due to the spinal reflex, or a purposeful movement motivated by a higher brain center.

You were absolutely right in your actions, and your documentation looks good, too. If it were me, I'd print an article about central vs. peripheral stimulation & leave it lying around where the resident will pick it up...