U Assessment

HISTORY. If the patient cannot report a history, speak to the life squad, a witness, or a significant other to obtain a history. Determine if the patient became unconscious immediately and for how long—a few seconds, minutes, or an hour—at the time of the trauma. Find out if the patient experienced momentary loss of reflexes, arrest of respirations, and possible retrograde or antegrade amnesia. Elicit a history of headache, drowsiness, confusion, dizziness, irritability, giddiness, visual disturbances (seeing stars), and gait disturbances.

Mild cerebral concussions can cause headaches, dizziness, memory loss, momentary confusion, residual memory impairment, and retrograde amnesia; there is no loss of consciousness. Classic cerebral concussions cause a loss of consciousness lasting less than 24 hours; the patient usually experiences confusion, disorientation, and amnesia upon regaining consciousness. A postconcussive syndrome that may occur weeks and even months after injury may lead to headache, fatigue, inattention, dizziness, vertigo, and memory deficits.

PHYSICAL EXAMINATION. First evaluate the patient's airway, breathing, and circulation (ABCs). After stabilizing the patient's ABCs, perform a neurological assessment, paying special attention to early signs of ICP: decreased level of consciousness, decreased strength and motion of extremities, reduced visual acuity, headache, and pupillary changes.

Check carefully for scalp lacerations. Check the patient's nose (rhinorrhea) and ears (otorrhea) for CSF leak, which is a sign of a basilar skull fracture (a linear fracture at the base of the brain). Be sure to evaluate the patient's pupillary light reflexes. An altered reflex may result from increasing cerebral edema, which may indicate a life-threatening increase in ICP. Pupil size is normally 1.5 to 6.0 mm. Several signs to look for include ipsilateral miosis (Horner's syndrome), in which one pupil is smaller than the other with a drooping eyelid; bilateral mio-sis, in which both pupils are pinpoint in size; ipsilateral mydriasis (Hutchinson's pupil), in which one of the pupils is much larger than the other and is unreactive to light; bilateral mid-position, in which both pupils are 4 to 5 mm and remain dilated and nonreactive to light; bilateral mydriasis, in which both pupils are larger than 6 mm and are nonreactive to light.

Check the patient's vital signs, level of consciousness, and pupil size every 15 minutes for 4 hours. If the patient's condition worsens, he or she should be admitted for hospitalization. Continue neurological assessment throughout the patient's hospital stay to detect subtle signs of deterioration. Observe the patient to ensure that no other focal lesion, such as a subdural hematoma, has been overlooked.

PSYCHOSOCIAL. The patient with a concussion has an unexpected, sudden illness. Assess the patient's ability to cope with the potential loss of memory and temporary neurological dysfunction. In addition, assess the patient's degree of anxiety about the illness and potential complications. Determine the significant other's response to the injury. Expect parents of children who are injured to be anxious, fearful, and sometimes guilt-ridden.

Diagnostic Highlights


Normal Result

Abnormality with Condition



Intact cerebral

Identification of size and

Shows anterior to posterior



location of site of injury

slices of the brain to highlight

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