Examination Conscious Level Assessment

MOTOR RESPONSE - 5 categories (i) Obeys commands

MOTOR RESPONSE - 5 categories (i) Obeys commands

'Hold up your arms'

(ii) Localising to pain

Apply a painful stimulus to the supraorbital nerve, e.g. rub thumb nail in the supraorbital groove, increasing pressure until a response is obtained. If the patient responds by bringing the hand up beyond the chin = 'localising to pain'. (Pressure to nail beds or sternum at this stage may not differentiate 'localising' from 'flexing'.)

(iii) Flexing to pain

Pain (Nailbed pressure)

Pain (Supraorbital pressure)

Pain (Supraorbital pressure)

If the patient does not localise to supraorbital pressure, apply pressure with a pen or hard object to the nail bed. Record elbow flexion as 'flexing to pain'. Spastic wrist flexion may or may not accompany this response.

(iv) Extending to pain

If in response to the same stimulus elbow extension occurs, record as 'extending to pain'. This is always accompanied by spastic flexion of the wrist.

Before recording a patient at this level, ensure that the painful stimulus is adequate.

During examination the motor response may vary. Supraorbital pain may produce an extension response, whereas finger nail pressure produces flexion. Alternatively one arm may localise to pain; the other may flex. When this occurs record the best response during the period of examination (this correlates best with final outcome). For the purpose of conscious level assessment use only the arm response. Leg response to pain gives less consistent results, often producing movements arising from spinal rather than cerebral origin.

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