Hhj

1. GENERAL PHYSICAL EXAMINATION-
Vital signs-
Look for bradycardia , hypertension and abnormal respiratory
pattern.
•Patient with increased intracranial pressure show
bradycardia and hypertension.
•The respiratory pattern may indicate the level of the lesion.

2. •Cheyne Stokes breathing is observed in diencephalic
involvement
•Apneustic and ataxic breathing patterns suggest progressive
brainstem compression.

3. Look for signs of head trauma-
•Racoon eyes
•Battle sign(ecchymosis at
mastoid equals basilar skull
fracture)
•Retinal hemorrhages
•Bulging fontanelle

4. Clues to etiology on examination Include-
• evidence of injury and tongue bite(trauma)
•Jaundice and fetor hepaticus(liver disease)

5. •Petechiae(coagulopathy)
•Ketotic breath odor (metabolic
disease)
•Dry flushed skin(belladonna
poisoning)
•Moist skin with increased salivation
(organophosphorus poisioning)

6. Neurological examination
The severity of coma assessed by Glasgow coma scale modified for use
in children.

7. NEUROLOGICAL EXAMINATION:-
the severity of coma assessed by Glasgow coma scale modified
for use in children.

8. •Response to verbal, response to pain, unresponsive scale is administered
(using a deep painful stimulus by a strong pinch or pressure on the nailbed
or supraorbital area)
-Meningeal sign:
suggesting the diagnosis of meningeal irritation in intracranial infection.
Meningeal irritation sign – 1. neck rigidity
2. kernig ’s sign
3.brudzinski’s sign

9. POSTURING
• Decerebrate posturing suggest injury to upper
pons.
• Decorticate posturing indicate bilateral cortical
lesion with preserved brainstem function.
• Flaccid areflexia : indicate loss of all cortical and
brainstem function up to the pontomedullary
junction.

10. Brainstem reflexes :-
1.PUPILLARY REFLEX :
•Pupil are pinpoint in pontine lesion and morphine
poisoning.
•Small , equal, reactive and impaired eye movement
due to metabolic or toxic causes.
•Bilateral and fixed dilated pupils are seen in severe
ischemia with atropine and belladonna poisoning.
•Unilateral unreactive pupil in trans tentorial
herniation.

11. 2.CORNEAL REFLEX:-
It can be supressed acutely contralateral to a large, acute cerebral
lesion , and also with intrinsic lesion in brainstem.
•Bilateral brisk corneal reflexes -suggest the patient in only mildly
necrotized.
•Absence corneal reflex – after 24 hours of cardiac arrest is usually
but not invariably.
It is good test for mid & low pontine dysfunction.

12. 3.OCULAR MOVEMENTS :-
•OCULOCEPHALIC REFLEX [ doll’s eye]:-
Tests - Sensory from 8th
nerve
It can only be done in patient with stable spine.
•OCULOVESTIBULAR REFLEX:-
Test the same pathway as doll’s eyes but can be
done in patient with unstable cervical cord.

13. Papilledema , hypertension, bradycardia , abnormal breathing pattern
Posturing and third & sixth cranial nerve palsies suggest raised
intracranial pressure.