Neurological NEURO

Assessment
STUDENT HANDBOOK
 NEURO Neurological
Assessment
Student Handbook

DAN Medical Information Line: +919-684-2948 ext. 6222

Divers Alert Network +1 919-684-2948
DAN Emergency Hotline: +1-919-684-9111

Authors: Nicolas Brd, MD. MMS

Contributors and Reviewers: Jim Chimiak, M.D.; Petar Denoble, M.D., D.Sc.;
Matias Nochetto, M.D.; Patty Seery, MHS, DMT

This program meets the current recommendations from the October 2015 Guidelines
Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
issued by the International Liaison Council on Resuscitation (ILCOR)/American Heart
Association (AHA).

3rd Edition, January 2016

© 2016 Divers Alert Network

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of Divers
Alert Network, 6 West Colony Place, Durham, NC 27705.

First edition published October 2006.

Second edition published January 2012.
 Neurological
Assessment

TABLE OF CONTENTS

Chapter 1: Course Overview.......................................................................................... 2

Chapter 2: Nervous System Overview .......................................................................... 4
Review Questions........................................................................................................... 6
Chapter 3: Stroke........................................................................................................... 7
Review Questions......................................................................................................... 12
Chapter 4: Decompression Illness .............................................................................. 13
Review Questions......................................................................................................... 17
Chapter 5: Conducting a Neurological Assessment..................................................... 18
Review Questions......................................................................................................... 23
Chapter 6: Skills Overview.......................................................................................... 24
Chapter 7: Summary.................................................................................................... 35
Glossary....................................................................................................................... 36
References ................................................................................................................... 39
Review Answers........................................................................................................... 39

Neurological Assessment 1
 1
Neurological
Assessment

Course Overview

According to the American Heart Association 2011 update, stroke is the third-leading
cause of death and the leading cause of long-term disability.1 Familiarizing first aid
providers with a stroke assessment tool is part of the 2015 American Heart Association
Guidelines update for CPR and ECC (emergency cardiac care).2 Decompression illness
(DCI) is a much less common cause of neurological injury. The overall incidence of this
diving-related injury is 2-4 cases per 10,000 dives.3

Regardless of underlying cause, the presence of a neurological injury is

frequently revealed by performance of a neurological assessment.

The Neurological Assessment course trains participants to perform a basic neurological

examination as part of the initial medical evaluation. There are two
primary goals of this program:
1. Provide first responders with the skills necessary to discover signs
of acute neurological injury.
2. Minimize treatment delays through rapid activation of emergency
medical services (EMS).
Successful completion of the Neurological Assessment course includes demonstrating
skill competency and passing a final knowledge assessment. Upon completion, you
will receive a provider card indicating that you have been trained in basic neurological-
assessment techniques.

First Responder Roles and Responsibilities

First aid is the provision of initial care for an injury or illness. The three key aims of first
aid are to (1) preserve life, (2) prevent the condition from worsening and (3) promote
recovery. All skills performed in an emergency should be within the scope of one’s
training. Maintain skills and knowledge proficiency by participating in supervised practice
sessions and reading current literature.

2 Neurological Assessment
 Reading this handbook without instruction and practice will not make
someone competent to complete a neurological assessment.

Prerequisites
There are no prerequisites for this program.

Retraining
Emergency-response skills deteriorate with time. Retraining is required every two years to
maintain Neurological Assessment Provider certification. Your Neuro Instructor can provide
information about retraining programs. In addition, regular practice is encouraged, when

1
possible, to retain skill proficiency.

Continuing Education
Other first-aid programs that may be available through your HMLI instructor include
Basic Life Support: CPR and First Aid, Emergency Oxygen for Scuba Diving Injuries,
Neurological Assessment, and CPR: Health-Care Provider with First Aid. Two
additional programs that encompass content from multiple courses are Dive Emergency
Management Provider and Diving First Aid for Professional Divers.

While certification in these programs is not required for participation in the Neurological
Assessment course, it is strongly recommended that you obtain training in these essential
lifesaving skills.

How to Use this Handbook

Each chapter in this student handbook contains three distinct features.

• The beginning of each chapter has a list of questions to assist with learning. This is
the information you should look for as you read the material, complete the knowledge
development sections, and participate in class discussions.
• Boxes with the word “NOTE” provide explanations that are important
for understanding the material just presented.
• Boxes labeled “Advanced Concepts” contain additional information
beyond what is required for this course. It is enrichment for those students
who want to know more.

Terminology
To help readers who may be unfamiliar with some medical terms introduced in this
student handbook, a glossary of terms is provided in the back of this book. Familiarity
with basic medical terminology will enhance the quality of communications with
emergency and health-care workers.

Neurological Assessment 3
 2
Nervous
System
Overview

Chapter 2 Objectives
1. What are the primary components of the nervous
system?
2. What is the functional unit of the nervous system?
3. What are possible causes of interruptions along neural
pathways?

The primary components of the nervous system are the brain, spinal cord and nerves.
The brain and spinal cord form the central nervous system, and the nerves that extend
from the spinal cord or brain out to the body comprise the peripheral nervous system.
The functional unit of this system is the nerve cell or neuron.

The spinal cord is the interface between the central and peripheral systems and contains
the nerve tracts or columns that conduct impulses either to or from the brain. Sensory
tracts travel up the dorsal or posterior columns, and motor tracts are located along the
ventral or anterior columns.

Trauma, stroke or DCI may result in interruptions of nerve pathways at any point along
a tract or peripheral nerve and may cause symptoms or signs of neurological injury. This
course will provide you with the skills needed to test for and recognize prominent signs
of possible neurological compromise.

4 Neurological Assessment
 Spinal cord
DORSAL

Spinal
nerve

Epideral
space
Facet
joint

Vertebra
body
Transverse
process
Intervertebral
disc
VENTRAL DORSAL

VENTRAL
2

Dorsal horns
(interneurons and sensory axons) DORSAL
Anterior radicular Dorsal root
artery ganglion

Sensory nuclei

Spinal nerve Dorsal root

(sensory and motor) ganglion

Anterior root
(motor)

Ventral root Motor nuclei

filaments (motor)
Pia mater Ventral horns
(motor neurons)
Arachnoid
Dura mater

VENTRAL
Anterior radicular
Anterior spinal artery
artery

Neurological Assessment 5
 Chapter 2 Review Questions

1. The nervous system consists of the

a. brain, spinal cord and nerves

b. vertebrae and skull
c. heart, lungs and brain
d. head, torso and limbs

2
2. Neural pathways may be interrupted by

a. stroke
b. decompression illness
c. trauma
d. all of the above

Answers to review questions are on Page 39.

6 Neurological Assessment
 3
Stroke

Chapter 3 Objectives
1. What are the two kinds of stroke?
2. How do strokes manifest?
3. What is the leading cause of long-term disability?
4. How does prompt medical intervention affect injury and
disability from a stroke?
5. What are the signs and symptoms of stroke?
6. What does the mnemonic FAST mean?

Brain injury can result from external trauma (blunt injury, falls) or from interruptions
in blood flow within the brain. The latter of these is known as a cerebral vascular
accident (CVA) or stroke. Strokes are a medical emergency that can result in permanent
neurological injury, disability and death. They result from either blood-vessel blockage
(usually from a blood clot, also known as a thrombus) or from blood-vessel rupture that
causes bleeding (hemorrhage). (See Figure 1A on Page 8.) Some hemorrhagic strokes may
be associated with sudden severe headaches.

Stokes can manifest with sudden loss of motor function (inability to move an affected
part of the body), inability to understand or formulate words, or loss of a visual field.
Approximately 85 percent of strokes are thrombotic and are not usually associated with
headache.1 (See Figure 1B on Page 8.) Most strokes come on suddenly, are painless, and
the persons suffering from them may be unaware of their occurrence. Denial of symptoms
by the victim is common and can lead to delayed treatment resulting in poor outcomes.

Neurological Assessment 7
 Figure 1A
Hemorrhagic
Stroke

Weakened/diseased
blood vessels rupture

Figure 1B

3
Blood supply
to the brain Thrombotic Stroke

Region of
decreased
blood flow

Interuption of blood
supply (blood clot)

blood
flow

8 Neurological Assessment
 Stroke is the leading cause of long-term disability and the third-leading cause of death.
The sooner acute injury is detected and emergency services alerted, the greater the
chances that medical treatment will reduce injury and disability.

Signs of stroke include facial droop, inability to raise or move an arm, and slurred,
garbled or nonsensical speech. If any or all of these are present, call EMS immediately.

To help you remember key signs, use the mnemonic FAST:

Remember: Use FAST first, then call emergency medical services.

Facial Droop
Facial droop occurs on one side of the face and may
involve either the left or right side. This is usually
associated with speech difficulty or reduced vocal
clarity.

Neurological Assessment 9
 Arm Weakness
The presence of arm weakness can
be assessed by asking the injured
person to raise both arms and
bend (extend) his wrists. Ask the
person to hold that position for
about 10 seconds. Watch for lowering
of an arm or straightening of a wrist.

Image depicts a normal response.

Image depicts left arm weakness.

Image depicts left arm paralysis —

the inability to raise or move the arm.

Speech
Inability to speak clearly or verbalize is cause for immediate concern. As mentioned
earlier, speech difficulty or reduced clarity is often associated with facial droop.

10 Neurological Assessment
 Time
Call 911 (or your local emergency medical services number) immediately if any of
these symptoms are present.

The FAST examination is an easy way to determine if signs of neurological injury are
present. Whether from stroke, trauma or diving-associated injury, if signs are present,
call EMS.

Other stroke symptoms include:

• SUDDEN numbness or weakness of face, arm or leg — especially on

one side of the body
• SUDDEN confusion, trouble speaking or understanding
• SUDDEN trouble seeing in one or both eyes
• SUDDEN trouble walking, dizziness, loss of balance or coordination
• SUDDEN severe headache with no known cause

Once EMS is activated, complete the full Neurological Assessment. Your findings will
help medical personnel determine injury progression and create a clinical baseline from
which future changes can be compared.

Neurological Assessment 11
 Chapter 3 Review Questions

1. Strokes may be caused by a blood clot

or bleeding.

a. True
b. False

2. Strokes may be evident by

a. sudden loss of motor function
b. inability to formulate or understand
words
c. loss of visual field
d. all of the above

3. Stroke is the leading cause of long-term

disability.

a. True
b. False

3 4. Prompt medical intervention may reduce

the possibility of permanent disability.

a. True
b. False

5. FAST stands for

a. facts, attitude, sensitivity, talent

b. face, arms, speech, time
c. feet, arms, spine, toes
d. face, ankles, stability, touch

Answers to review questions are on Page 39.

12 Neurological Assessment
 4
Decompression
Illness

Chapter 4 Objectives
1. What two conditions compose decompression illness?
2. What are the most common signs and symptoms
of decompression illness?

The term decompression illness (DCI) describes signs and symptoms arising either
during or subsequent to decompression and encompasses two different but potentially
linked processes:

• decompression sickness (DCS)

• arterial gas embolism (AGE)

Decompression Sickness
DCS results from bubbles from dissolved inert gas (nitrogen or helium) that form
within tissues or blood. The size, quantity and location of these bubbles determine the
location, severity and impact on normal physiologic function. Besides the anticipated
mechanical effects that can cause tissue distortion and blood-flow interruption, bubble
formation may trigger a chain of biochemical effects. These include activation of clotting
mechanisms, systemic inflammation, leakage of fluids out of the circulatory system and
reactive vasoconstriction (narrowing of blood vessels). These effects may persist long after
bubbles are gone and may play a significant role in the duration and severity of clinical
signs and symptoms.

While the presence of bubbles effect on us on a systemic level, specific signs and
symptoms are thought to result from either bubble accumulation or its impact on specific
areas. Examples include joint pain, motor dysfunctions and skin rash.

Neurological Assessment 13
 Important aspects about DCS to remember include:
• Symptom onset usually occurs after surfacing but can occur during ascent.
• Factors contributing to bubble formation include excess nitrogen, rapid ascent and
decreasing ambient pressure (such as when flying after diving).
• DCS symptoms may differ throughout the body.
• Any area of the body may be involved.

Arterial Gas Embolism

AGE in divers
typically results
from lung-
overexpansion
injury
(pulmonary
barotrauma). The
greatest risk for
this injury occurs
in shallow water
and may result
from breath-
holding in as
little as 4 feet
(1.2 meters) of
seawater. Lung-
tissue trauma

4 can allow the

entrance of
breathing gas into
the blood vessels
returning to the
heart (pulmonary
veins). These
bubbles can
cause rapid
and dramatic
effects if they are
transported to the
brain. AGE is the
most severe result
of pulmonary
barotrauma and
often presents
suddenly either
near or at the Pulmonary barotrauma with subsequent AGE and representation of
surface. brain (cerebral) injury. Recreated by Divers Alert Network from Lancet.4

14 Neurological Assessment
 The primary risk factor for AGE is breath-holding during ascent. Other potential risk
factors include any condition that could trap air, such as lung infections, asthma and
previous lung trauma.

Common Signs and Symptoms of DCI

Injured divers may have one or more of the following signs and symptoms, which are
ranked in order of initial presenting symptom. This frequency is based on Project Dive
Exploration (PDE) data from 2,346 recreational dive accidents reported to DAN from
1998 to 2004.4

• Pain (initial symptom in 40 percent of cases). Commonly associated with

neurological symptoms, the pain has been characterized as a dull, sharp, boring or
aching sensation in or around a joint or muscle. It may begin gradually and build in
intensity or be so mild that it is disregarded.

o Movement of the effected joint or limb may or may not make a

difference in the severity of the pain. The pain may be out of
proportion to the amount of work or exercise the diver associates
with the discomfort and may be referred to as unusual or just a
“different” type of pain.
o DCI pain can be difficult to distinguish from normal aches and pains.
Symptoms can mimic other illness such as viral infections, muscle or
joint pain, or fatigue from exertion and other nonspecific discomforts.

• Numbness and paresthesia (initial symptom in 27 percent of cases). Paresthesia /

anesthesia/dysesthesia are terms that refer to altered sensations and may
present as abnormal feelings (paresthesia), decreased or lost sensation (anesthesia)

4
or hypersensitivity (dysesthesia). Paresthesia is commonly characterized as a
pins-and-needles sensation. These altered sensations may affect only a small patch
(or patches) of skin and may go unnoticed by the diver until they are revealed by
a thorough medical evaluation. A diver may complain that an extremity has “fallen
asleep” or a “funny bone” has been hit. Numbness and tingling most often occur
in the limbs and may be associated with complaints such as a cold, heavy or
swollen sensation.

• Constitutional symptoms (initial symptom in 14 percent of cases). These are

generalized symptoms that do not impact a particular part of the body. Examples
include extreme fatigue, general malaise and nausea.

o Extreme fatigue: It is not unusual to be fatigued after a scuba dive or other

physical activity. The fatigue associated with DCI is typically more severe and
out of proportion with the level of exertion required by the dive. The diver may
want to lie down, sleep or ignore personal responsibilities such as stowing gear or
cleaning equipment.

Neurological Assessment 15
 • Balance and equilibrium (initial symptom in 6 percent of cases)

o Vertigo (spinning sensation): Vertigo presenting during or after the dive should
be considered a serious symptom suspicious of inner-ear/vestibular involvement.
There are several causes not related to DCI for such symptoms, and these include
round- or oval-window rupture (associated with difficulty equalizing), alternobaric
vertigo (each ear experiencing a different pressure exposure) and caloric vertigo
(each ear experiencing a different temperature exposure).

o Dizziness: A feeling of unsteadiness, which may also be characterized as

lightheadedness, is commonly associated with nausea.

• Muscular weakness (initial symptom in 4 percent of cases). This symptom may

present as difficulty walking due to decreased muscular strength or limb paralysis.

• Cutaneous (skin) symptoms (initial symptom in 3 percent of cases). Skin signs

are often located on the chest, abdomen, back, buttocks or thighs. Rashes
commonly migrate (move to different parts of the body). Affected areas may be
tender or itch and are thus often confused with allergies or contact dermatitis.

• Altered mental status (initial symptom in 1.2 percent of cases). Symptoms may
include confusion, personality changes or speech disturbances (slurring of words
or nonsensical speech).

• Bowel and bladder (initial symptom in 0.04 percent of cases). Spinal cord DCS
may injure the nerves responsible for bladder and bowel control. Sometimes
people will require urinary catheterization.

4 Note:
Any suspicion of neurological symptoms should prompt immediate use of oxygen
therapy and transportation to a medical facility.

Other Signs and Symptoms of DCI

• Lymphatic DCS: Identified as an initial symptom in 0.3 percent of cases, this
symptom is often characterized as localized swelling affecting the trunk and
shoulders.

• Altered level of consciousness: Identified as an initial symptom in 0.4 percent

of cases.

• Audiovestibular or inner-ear DCS: This is an alteration of balance or hearing

that can be associated with vertigo.

• Visual disturbance: Loss or blurring of vision or loss of visual fields

16 Neurological Assessment
 • Difficulty breathing due to DCI: This may be the result of pulmonary barotrauma
or a severe form of DCS known as the chokes (a rare but life-threatening condition
caused by an overload of venous gas emboli that severely effects cardiorespiratory
function). There are also many other causes of respiratory compromise not
necessarily related to or associated with DCI — all of which should prompt
medical evaluation.

• Convulsions are rare.

Remember the FAST examination is an easy way to determine if signs of neurological

injury are present. Whether from stroke, trauma or diving-associated injury, if signs are
present, call EMS to facilitate entry into advanced medical care and a full neurological
examination.

After reading about the symptoms described above, you
will notice that many are related to the nervous system.
For more information about dive emergencies and how
to provide first aid to injured divers, refer to the DAN
Emergency Oxygen for Scuba Diving Injuries course.

Chapter 4 Review Questions

1. Decompression illness includes AGE and

DCS.

a. True
b. False

2. Pain, numbness and paresthesia are

the most common signs of decompression
illness.

a. True
b. False

Answers to review questions are on Page 39.

Neurological Assessment 17
 5
Conducting a
Neurological
Assessment
5

Chapter 5 Objectives
1. When should an emergency assistance plan be
activated if you suspect a neurological injury?
2. What are the basic areas of a neurological assessment?
3. What functions are evaluated in the “mental function”
part of the neurological assessment?
4. What functions are evaluated in the “cranial nerves”
section of the neurological assessment?
5. How do motor-function deficits manifest?
6. How are balance and coordination evaluated?

When faced with a possible neurological injury, regardless of cause, remember the FAST
first principle. Once a problem is identified or you think injury is likely, there are some
initial actions to take.

1. Call your local EMS number

immediately.
2. If the injury is diving related,
provide oxygen first aid.
3. Be prepared to initiate basic
life support (CPR).

18 Neurological Assessment
 Once EMS has been activated, conduct the neurological assessment described in this
course. A neurological assessment should be completed only on a conscious individual.
Their responses and your observations facilitate the process. The information you gather
may influence the initial treatment and subsequent impact of the injury. In the case of
diving accidents, your assessment may also convince an injured diver of the need for
oxygen first aid. Fortunately, most diving injuries are not life threatening, and there is
frequently time prior to EMS arrival where it is both appropriate and helpful to perform
this examination.

Note:
Performing a neurological assessment should never interfere with EMS
activation, evacuation or essential first aid measures.

Taking a History
The patient’s history is a critical aspect of all medical evaluations. Understanding what
happened (the events leading to the injury) as well as any underlying medical issues can
often enable a more accurate context for the assessment.

The mnemonic SAMPLE provides a guide to collect relevant information. This portion of
the evaluation is done first and precedes the actual neurological examination.

• Signs/symptoms
• Allergies
• Medications
• Pertinent medical history
• Last oral intake
• Events leading to the current situation
5
Part of the initial history includes recording pulse and respiration rates (vital signs). Vital
signs, which help provide a baseline of the individual’s condition, should be monitored
because they may indicate a change in the individual’s condition. Each measurement is
recorded in a per-minute format. To quicken the process, count each for 30 seconds and
multiply by two.

Dive History
In the case of injured divers, additional important information includes a description
of all dive profiles during the 24 hours leading up to the injury. Information recorded
should include maximum depths, dive times, use of safety stops, surface intervals,
breathing gases and any problems experienced during the dives. When possible (and if
appropriate), obtain additional information about the incident from the diver’s buddy or
other observer. DAN’s Injury Report Summary slate is useful for recording the dive profile
and other relevant information.

Symptoms are often underreported because many people consider dive-related injuries an
admission of error. Therefore, the seemingly simple act of a diver talking
19 about his or her
symptoms should get your attention and prompt you to ask more questions.

Neurological Assessment 19
 The Four Functional Areas
of a Neurological Assessment

This convenient division allows the examiner to focus on specific nervous-system

functions and simplifies documentation of abnormal findings.

• Mental function
• Cranial nerves
• Motor function
• Coordination and balance

As you conduct the neurological exam, if you find a deficit, verify that EMS has been
called. If the patient has been scuba diving, place him on oxygen and continue the exam.

In the case of severe neurological injury, assessment of certain vocal or motor responses
may not be possible. If the injured person is unable to speak or move a particular limb,
note the deficit and proceed to the next part of the examination.

In the case of garbled, slurred or nonsense speech, defer the medical history and mental
function portions of the examination. Focus on what you can assess, and tell medical
personnel your findings.

Mental Function
A key component of neurological examinations is an assessment of mental function. This
is a subjective process that is susceptible to bias based on factors such as age, education,

5
stress, language barriers and cultural background.

This portion of the examination begins with “orientation” and starts with simple
questions. Ask the individual his name, current location, approximate time and reason
for being there. These four questions are often referred to by the description “person,
place, time, and event” and are written as “alert and orientated (A&O) x 4” — when the
individual answers each question appropriately. In the event that questions are answered
incorrectly, note what was asked and the response.

The level of consciousness the

injured person is exhibiting
should be recorded during the
assessment using the terms

• A lert
• V erbal stimulus
• P ainful stimulus
• U nresponsive

20 Neurological Assessment
 These terms are abbreviated as A V P U on the neurological assessment slate. Be aware
the individual’s level of consciousness can change during or even after the assessment. If
changes do occur, note the change and the time it happened.

Once the levels of orientation and responsiveness are determined, further questions can
help assess mental functions such as memory, speech, comprehension and computational
skills. As with the initial questions for orientation, these are particularly prone to
individual differences that may make their interpretation difficult. What is important to
note is a change from the person’s baseline and not a comparison of their mental ability
relative to yours. Some people may be able to tell you that their memory is off, and in
other cases a close friend or relative will provide a reference point for subtle changes.

Cranial Nerves
There are 12 pairs of nerves emanating from the skull that control the special senses and
muscles of the eyes and face. Neurological injury from DCI or CVA may effect one or
more of the cranial nerves.

Cranial-nerve injury commonly results in facial-movement asymmetry. Examples may

include facial droop, loss of certain eye movements and slurred speech. Deficits or
injuries are frequently detected during your initial interactions as you watch for facial
asymmetry or alterations in eye movements.

Motor Function (Strength)

Neurological injury may affect motor control. Symptoms of injury may range from
weakness to paralysis. Proper examination of strength entails comparison with the other
side of the body. This process often detects or confirms subtle abnormalities.

DCI rarely affects both sides of the body simultaneously. When it does, the abnormality
is obvious and can effect both arms and/or legs. Strokes are usually confined to the brain,
and these effects typically influence one side of the body including the head and neck.
5
Any sign of weakness or paralysis, no matter how slight the abnormality, should prompt
you to seek immediate emergency medical assistance and professional medical evaluation.

Coordination and Balance

If the injured person’s responses at this point are normal, then assess coordination and
balance. DCI and CVA may cause nerve-cell injury or impairment of the cerebellum or
spinal proprioception tracts, affecting coordination and balance. (For more information,
see Advanced Concepts on Page 22.) Coordination is evaluated using a finger-nose-finger
test (see Page 33). To assess balance, have the injured person walk a straight line and then
perform a Romberg (or Sharpened Romberg) test (see Page 34).

Neurological Assessment 21
 Note:
Balance, speech and coordination may also suffer temporary impairment from
alcohol intoxication or use of certain medications.

Advanced Concepts
Proprioceptors, which are specialized sensory nerves located within muscles and
tendons, provide the brain with feedback about movement and muscular activity.
These special sensors convey movement information up the spinal cord to the brain.
An example of proprioception is seen with the small posture adjustments that occur
while standing still. Even slight changes in body position result in muscular stretch
that can result in quick postural adjustments.

Advanced Concepts
Nerve tracts refer to “bundles” of nerve fibers within the spinal cord that convey
messages either to or from the brain. Sensory nerve tracts, located primarily in the
dorsal horns of the spinal cord, convey information up the cord to the brain. Motor
tracts, primarily located in the ventral horn, convey movement directives from the
brain.

22 Neurological Assessment
 Chapter 5 Review Questions

1. EMS should be called 4. Which of the following is not part of

the cranial nerves evaluation?
a. as soon as you suspect a
neurological injury a. facial droop
b. after you have conducted a b. eye movements
neurological assessment c. grip strength
c. a period of time after the first d. slurred speech
assessment so you can advise EMS
if there are changes
d. only if requested by the injured person 5. Motor functions may be classified
as normal, evidence of weakness or
2. All of the following are evaluated as paralysis.
part of a neurological assessment
a. True b. False
except
a. mental function 6. The Romberg test assesses
b. cranial nerves
a. motor function
c. motor function
b. cranial nerves
d. flexibility
c. mental status
e. coordination and balance
d. balance
3. Mental function evaluates
a. orientation to person, place, time
and event
b. memory and speech

5
c. comprehension and computational
skills
d. all of the above

Answers to review questions are on Page 39.

Neurological Assessment 23
 6
Skills
Overview

Skill Objectives
1. FAST assessment
• Conduct a FAST assessment on a simulated patient
suspected of having a neurological impairment.
2. History
• Interview a patient in a simulated scenario using the
SAMPLE mnemonic to identify previous medical history
and determine where he might have acute problems or
feel discomfort. Record findings in a usable format.
3. Vital signs
• Demonstrate the proper technique to determine a
person’s pulse rate and breaths per minute, counting
each for 30 seconds then multiplying by two.
4. Mental function
• Determine an individual’s level of consciousness in a
scenario with a simulated injury.
• Utilizing interview techniques, assess an individual’s
- speech and language abilities
- orientation to person, place, time, and event
- short-term memory
• Assess an individual’s ability to do calculations utilizing
a standardized protocol.

24 Neurological Assessment
 5. Cranial nerves
• Assess control of eyes and facial muscles utilizing simple
commands.
• Assess an individual’s ability to hear by rubbing or
snapping fingers 1 foot/30 cm from the ear.
6. Motor function (strength)
• Assess strength of muscle groups utilizing muscle
isolation and resistance.
7. Coordination and balance
• Assess an individual’s coordination using a
finger-nose-finger exercise.
• Determine the presence of functional balance utilizing a
straight walk and a Romberg test.
The skills overview for this course provides general information.
There are specific technique elements that will be covered in the
skill-development portion the class.

FAST Assessment
Objective:
• Conduct a FAST assessment on a simulated
patient suspected of having a neurological
impairment.

Have the patient remain seated during the

assessment.
• Ask the patient to smile. Observe his face for
asymmetry. Is one side drooping? Is the smile
equal on both sides?
• Ask the patient to extend and raise both arms straight out in front. Can he raise both
6
arms? If so, do both arms remain up, or does one drift down?
• Ask the patient to repeat a simple phrase. Are all the words clear? Is there any slurring?
Is the speech garbled?
• If any abnormal signs are present, call 911 or your local EMS number immediately.

Taking a History
Objectives:
• Interview a patient in a simulated scenario using the SAMPLE mnemonic to identify
previous medical history and determine where he might have acute problems or feel
discomfort.
• Record findings in a usable format.

Neurological Assessment 25
 As noted previously, getting information about conditions that may influence the
individual’s assessment is important.

To help you remember what information to gather when taking a history, use the
mnemonic SAMPLE.

• Signs/symptoms
• Allergies
• Medications
• Pertinent medical history
• Last oral intake
• Events leading to the current situation

The neurological assessment slate includes an area for recording your findings.

Taking Vital Signs

Objective:
• Demonstrate proper technique to
determine a person’s pulse rate and
breaths per minute, counting each for
30 seconds then multiplying by two.
Take the individual’s pulse, and note his
respiratory rate. Each measurement is
recorded in a per-minute format. To quicken
the process, count each for 30 seconds and
multiply by two.

Pulse. To take a pulse, place your index and middle finger on the inside of the
patient’s wrist just proximal (toward the heart) to the base of the thumb, and apply
gentle pressure. Refrain from using your thumb to take a pulse. The pulse of the
examiner’s thumb may be confused with the injured person’s pulse and result in a false

6 measurement.

Normal adult pulse rates are between 60 and 100 beats per minute and may be lower
in athletes.

Respirations. Prior to counting breaths per minute, you will already have a sense of the
person’s level of respiratory distress from your previous questions. If he is unable to finish
sentences or is visibly short of breath, more immediate respiratory aid may be necessary.

In an attempt to minimize self-consciousness and the potential influence your

observations may have on respiratory rate, try to count without letting the individual
know that you’re monitoring his breathing. It may be helpful to have a bystander count
respirations, or you can continue to hold the individual’s wrist after taking his pulse for a
full minute while you count respirations for the second 30-second interval.

Normal adult resting respiratory rates are between 12 and 20 breaths per minute.

26 Neurological Assessment
 Signs and symptoms. Record any signs and symptoms. In the case of pain, attempt to
describe the severity, quality (sharp, dull, throbbing), its location and association with
movement. Document symptom-onset times, their progression and a description of all
first aid provided.

Performing a Neurological Examination

Perform a neurological examination only on a conscious, breathing person, and
always ask permission prior to initiating any physical contact. As with most medical
examinations, it is a good idea to have a third party present during the examination
to help eliminate concerns about improper contact. A typical neurological assessment
should take about 10 minutes.

The neurological examination begins with simple conversation. This introduction

facilitates some initial evaluation and builds rapport. As you move through the
examination, be sure to record your findings as well as the time the examination was
performed. If subsequent examinations are performed, each should be recorded in the
same manner.

Mental Function
Objectives:
• Determine an individual’s level of consciousness in a scenario with a simulated injury.
• Using interview techniques, assess an individual’s
– speech and language abilities
– orientation to person, place, time, and event
– short-term memory
• Assess an individual’s ability to do calculations using a standardized protocol.
Begin your mental-function assessment by simply talking to the person. You’ve already
been doing this while taking the history, and this observation will help you form an
opinion about the person’s mental status. Although the individual may appear normally
alert, answers to the following questions may reveal underlying changes and should be a

6
standard part of every evaluation.

Level of Consciousness (AVPU)

On your slate, indicate the person’s level of consciousness using the AVPU acronym:

• A lert
• V erbal stimulus
• P ainful stimulus
• U
nresponsive

Neurological Assessment 27
 If he is responding to you timely and
appropriately, note on your slate he is “alert.”
If not, record his level of responsiveness
according to the following descriptions:

• Responds to verbal stimuli (verbal)

— You may need to shout at times.
• Responds to painful stimuli (painful)
— If he is unresponsive to verbal stimuli,
check for a response to painful
stimuli such as a sternal rub.
Example of a sternal rub on an unresponsive person
• Unresponsive
— If the person is unresponsive, immediately begin basic life support.

Orientation to Person, Place, Time, and Event

• Person: Ask the injured person his name and if he knows who you are.
• Place: Ask the injured person if he knows where he is.
• Time: Ask the injured person the time, date and year.
— Time perception can vary, especially in an accident. As an alternative, consider
asking about what period of the day it is (e.g., morning, afternoon or evening).
• Event: Ask the injured person if he knows why he is there or why you are
having this conversation.
— Ask him to describe the events leading to the incident and about the event
itself. Ask him to explain what he was doing prior to the event. Alternately, he
should be able to identify that you are performing the exam because you are
concerned about a possible injury or illness.
The ability to answer these questions correctly is noted as A&O x4 (alert and oriented to
person, place, time, and event).

6 Speech and Language

• Assess ability to understand, follow directions and communicate
effectively.
— Can the individual both understand and respond?
• Test ability to follow a command by asking him to close his eyes
and stick out his tongue.
• Test ability to communicate by asking him to say a simple
phrase such as “red, white and blue” or “no ifs, ands or buts.”
Any simple phrase will do.
• Next, point out three easily identifiable objects and ask the
individual to tell you what they are. Examples may include a mask, pen, watch, light,
scuba tank, snorkel or fins. Any easily recognizable combination of three should suffice.

28 Neurological Assessment
 Abstract Reasoning
Test abstract reasoning by asking the injured person to describe relationships between
objects such as cat and mouse, father and son, water and dirt, student and teacher or
classroom and school.

Such questions are an attempt to determine the individual’s ability to describe the
connection between ideas or words.

Calculations
Assess the ability to perform
simple arithmetic by
asking the person to count
backward from 100 by
sevens. An alternative is to
ask him to repeat his phone
number in reverse.

• Many people struggle

with this task. The goal
is to see if they can figure
out the next answer. Most
evaluators don’t force people to count down to single digits.

Short-Term Memory
Ask the injured person to repeat back to you the three objects previously identified
during the speech and language examination.

Cranial Nerves
Objectives:
• Assess control of eyes and facial muscles utilizing simple commands.
• Assess an individual’s ability to hear by rubbing or snapping fingers 1 foot/30 cm
from the ear.
The next step of the exam assesses facial movement and hearing.
6
Eye Control
This exam assesses the ability of the injured
person to symmetrically move his eyes in
all directions. Hold your finger about 3 feet
(1 meter) away from his face, and while he
keeps his head still, move your finger to the
right, left, up, down and diagonally. Record
any direction the injured person cannot
follow with his eyes.

Neurological Assessment 29
 Facial Control
To evaluate the facial muscles, start by asking the injured person to tightly close his eyes
and then smile. Watch for symmetry of facial movement and skin creases. Facial-muscle
movement and skin creases should be essentially the same on each side of the face. Any
asymmetry should be noted.

Hearing
Test hearing by holding your hand about 1 foot (30 centimeters) from the injured
person’s ear and rubbing together your thumb, index and middle fingers. Check each
ear separately. Do not attempt to determine hearing loss; instead assess if hearing is
symmetrical or if one side is reduced.

If the surroundings are noisy, this test may be difficult to perform. An alternative to
rubbing your fingers is to speak in a quiet voice in each ear.

Motor Function (Strength)

Objective:
• Assess strength of muscle groups using muscle isolation and resistance.

Evaluate the strength and symmetry of specific

muscle groups. Note any differences between right
and left sides. Hand dominance as well as a history
of previous injury are important items to include
in your evaluation and your report to medical
personnel.

The primary muscle groups tested are the

shoulders, biceps, triceps, finger spread, grip
strength, hip flexors, quadriceps, hamstrings and

6
feet.

Check each muscle group independently by

providing gentle resistance. Record strength as
normal, weak or paralysis.

Assess shoulder strength by first bringing up the

elbows level with the shoulders and hands level
with the arms. Instruct the individual to resist while
you push down and then pull up on the elbows.

30 Neurological Assessment
 Test bicep and tricep strength by supporting
the elbow with one hand (to isolate the
muscle group being tested) and asking the
injured person to push and pull against your
hand.

Test the ability to spread fingers by

attempting to squeeze fingers
together, two at a time.

Test grip strength by asking the

person to grip two of your fingers in
each hand and squeeze as tightly as
she can.

To test hip flexors, ask the person to

raise her foot off the ground. Then
apply gentle downward pressure
above the knee and ask the person to
raise her knee. Do this for each side.

Neurological Assessment 31
 Isolate the quadriceps and hamstrings
by placing your hand under the thigh
just above the knee, supporting the
foot just off the ground.

Test the quadriceps and hamstrings by

asking the injured person to resist
your pressure as you gently but firmly
push then pull the lower leg just
above the ankle of each leg.

To test the injured person’s foot

strength, ask her to pull up her foot
against your hand and to press down
against your hand.

6 Strength deficits that the person was not

previously aware of or that did not exist
prior to injury are of particular importance.

32 Neurological Assessment
 Coordination and Balance
Objectives:
• Assess an individual’s coordination by using a finger-nose-finger exercise.
• Determine the presence of functional balance by using a straight walk and
a Romberg test.

If the injured person’s responses at

this point are normal, then assess
coordination and balance.

Finger-Nose-Finger Test
To test coordination, stand or sit in
front of the person, holding your
finger approximately 18 inches
(45 cm) from the person’s face. Ask
him to touch your finger with his
index finger and then to touch his
nose and touch your finger again.

• Repeat this several times.

• Continue the movement with his eyes closed.
• Perform this with both the left and right arms.
Minor differences may occur between right and left on any of these exams. Significant
variations should be included in your notations.

Walking
Test balance by asking the person to walk forward about 10 feet (3 meters)
while looking straight ahead.

Note if movements are smooth and if the individual can maintain balance without

6
looking down or requiring support.

Be prepared to catch or support the person if he is unsteady or starts to fall.

Performing this test may be difficult while on a moving vessel.

Record whether the person was able to stand and walk without assistance
or support. Note on the slate the degree of any assistance that was required.

Neurological Assessment 33
 Balance and Equilibrium: Romberg and Sharpened Romberg
• Romberg
o Ask the person to stand with her feet
together and arms up and out to her
sides. Ask her to close her eyes and
remain in that position for 60 seconds.
• Sharpened Romberg
o Ask the person to stand with his feet in
a heel-to-toe stance and his arms
crossed. Once he is stable, ask him to
close his eyes and remain in that
position for 60 seconds. As with the
Romberg, be prepared to catch or
support him if he shows signs of falling.

Note:
The Sharpened Romberg test is difficult to
perform for many “neurologically normal”
people. It is a more sensitive test than the
Romberg but may lead to false signs of acute
neurological deficit.

34 Neurological Assessment
 7
Summary

As with any injury or sudden illness, prompt action is always important. Remember
to use the FAST first approach. Any sign of obvious injury should prompt immediate
activation of EMS.

Performing this neurological assessment soon after an incident may provide valuable
information to the physician responsible for treatment. If the results of any of these tests
are abnormal, you should suspect injury to the nervous system.

In some cases you may be unable to perform certain aspects of a neurological

examination. If this occurs, simply note which tests were omitted and the reason they
weren’t performed.

In the case of injured divers, after activating EMS, provide emergency oxygen and
call DAN (+1-919-684-9111). Training for administering oxygen is available in the
Emergency Oxygen for Scuba Diving Injuries course. Contact your Neuro Instructor for
more information.

6
If assistance is not readily available, repeat the neurological assessment (excluding the
history) and record findings every 60 minutes — or more frequently if the condition
visibly changes. Repeating examinations can help emergency personnel appreciate how a
person’s condition has changed over time.

Neurological Assessment 35
 Glossary

acute — rapid onset, brief and severe

alveoli — microscopic air sacs in the lungs where gas exchange occurs with the
circulatory system

anesthesia — general or local insensibility to pain and other sensation induced by

certain interventions or drugs

arachnoid — the serous membrane forming the middle of the three coverings of the
brain and spinal cord

arterial gas embolism (AGE) — gas bubbles in the arterial system generally caused by
air passing through the walls of the alveoli into the bloodstream

asymmetry — disproportion between two or more like parts; lack of symmetry

audiovestibular — of or pertaining to the auditory functions of the inner ear and the
vestibule of the ear

axons — a long, slender projection of a nerve cell, or neuron, that typically conducts
electrical impulses away from the neuron cell body

barotrauma — physical damage to body tissues caused by a difference in pressure

between an air space inside or beside the body and the surrounding fluid

cardiorespiratory — pertaining to the circulatory and respiratory systems

cerebral — of, relating to or affecting the brain or cerebrum

cerebrovascular accident (CVA) — sudden death of some brain cells due to lack of
oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery
to the brain; also referred to as a stroke

cutaneous — of, relating to or affecting the skin

decompression illness (DCI) — dysbaric injuries related to scuba diving; DCI includes
both decompression sickness and arterial gas embolism

decompression sickness (DCS) — a syndrome caused by bubbles of inert gas forming

in the tissues and bloodstream that can evolve from too rapid an ascent from compressed-
gas diving

distal — situated away from the point of origin or attachment, as of a limb or bone;
terminal

dorsal — relating to the back (posterior) part of the body

36 Neurological Assessment
 Glossary

dura mater — the outermost of the three layers of the meninges surrounding the brain
and spinal cord

dysesthesia — distortion of any sense, especially the sense of touch

embolism — a detached intravascular mass clogging capillary beds at a site far from its
origin

EMS — emergency medical services

epidural — a form of regional analgesia involving injection of drugs through a catheter

placed into the epidural space

equilibrium — the condition of a system in which competing influences are balanced

facet — a small, smooth, flat surface, as on a bone or tooth

flexor — a muscle that when contracted acts to bend a joint or limb in the body

ganglion — a biological tissue mass, most commonly a mass of nerve cell bodies

hemorrhagic — pertaining to bleeding or the abnormal flow of blood

interneurons — neurons that process signals from one or more sensory neurons and
relay signals to motor neurons, also called connector neurons

intervertebral — situated between two contiguous vertebrae

ischemic — a decrease in the blood supply to a bodily organ, tissue or part caused by
constriction or obstruction of the blood vessels

lymphatic — pertaining to, containing or conveying lymph

meninges — the system of membranes that envelopes the central nervous system

motor nuclei — collection of cells in the central nervous system giving origin to a motor
nerve

neurological — having to do with the nerves or the nervous system

paresthesia — a sensation of numbness or tingling on the skin

pia mater — the delicate innermost layer of the meninges, the membranes surrounding
the brain and spinal cord

pneumomediastinum — the presence of air in the mediastinal soft tissues

pneumothorax — a collapsed lung

Neurological Assessment 37
 Glossary

postural — position of the body or body parts

proprioceptors — sensors that provide information about joint angle, muscle length and
muscle tension

pulmonary — having to do with the lungs

quadriceps — a large muscle in front of the thigh, the action of which extends the leg or
bends the hip joint

subcutaneous emphysema — the presence of air or gas in subcutaneous tissues

thrombotic — having to do with intravascular coagulation of the blood in any part of the
circulatory system, as in the heart, arteries, veins or capillaries

transverse — crossing from side to side

trauma — a serious injury or shock to the body, as from violence or an accident

vasoconstriction — narrowing of a blood vessel

venous — of, relating to or contained in the veins

ventral — relating to the front (anterior) part of the body

ventral horns — the two roots of a spinal nerve that passes ventrally from the spinal
cord and that consists of motor fibers

vertebra — the bones forming the spinal column

vertigo — a sensation of whirling motion, either of oneself or of external objects

vestibular — relating to the sense of equilibrium

38 Neurological Assessment
 References

1. Roger V., Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics — 2011
update: a report from the American Heart Association. Circulation 2011 Feb;
123(4):e18-e209.
2. Neumar RW, Shuster M, Callaway CW, et al. 2015 American Heart Association
Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care. Circulation 2015 Nov; 132(18), suppl 2.
3. National Stroke Association. Recognizing stroke. Available at: http://www.stroke.org/
4. Vann RD, Butler FK, Mitchell SJ, Moon RE. Decompression illness. Lancet 2011 Jan;
377(9760):153–64.

Review Answers
Chapter 2, Page 12 Chapter 5, Page 23
1. A 1. A
2. D 2. D
3. D
Chapter 3, Page 12 4. C
1. A 5. A
2. D 6. D
3. A
4. A
5. B

Chapter 4, Page 17
1. A
2. A

Neurological Assessment 39
Notes
Notes
 Neurological Assessment
Exam Answer Sheet

The final examination may be administered in written or oral form.

The instructor must review every question with each student so that 100 percent comprehension of the
material is ensured.
Questions have only one correct answer.
Name _____________________________________ Date__________ Test Score__________

A B C D
1 ❑ ❑ ❑ ❑ 11
T❑F❑
2 ❑ ❑ ❑ ❑ 12 T ❑ F ❑
3 T ❑ F ❑ 13 ❑ ❑ ❑ ❑
4 ❑ ❑ ❑ ❑ 14 T ❑ F ❑
5 T ❑ F ❑ 15 ❑ ❑ ❑ ❑
6 T ❑ F ❑ 16 ❑ ❑ ❑ ❑
7 ❑ ❑ ❑ ❑ 17
❑❑❑❑
8 ❑ ❑ ❑ ❑ 18 T ❑ F ❑
9 ❑ ❑ ❑ ❑ 19 T ❑ F ❑
10 ❑ ❑ ❑ ❑ 20 T ❑ F ❑
Neurological Assessment
Practical Evaluation Record
Student Name ________________________________________
Neuro Provider Skills Development Instructor Initials Student Initials
• FAST Assessment _________ _________
• Taking a History _________ _________
• Taking Vital Signs _________ _________
• Mental Function _________ _________
• Cranial Nerves _________ _________
• Motor Function (Strength) _________ _________
• Coordination and Balance _________ _________

I am comfortable with the performance of my skills as a Neurological Assessment Provider.

I have reviewed this examination with the course instructor. I understand the correct response as
indicated by my initials. Any questions regarding this examination and the contents of this course
have been answered to my satisfaction.

Student Signature ___________________________________________ Date _______________

Divers
Alert
Network
®

Divers Alert Network (DAN) is an international nonprofit organization dedicated to

improving dive safety through research, education, medical information, evacuation
support, products and services.
Among the services DAN provides to the diving public is the DAN Emergency Hotline
(+1-919-684-9111). This hotline is available 24 hours a day, seven days a week for
anyone who suspects a diving injury, requires assistance or needs to activate DAN
TravelAssist® (an exclusive benefit of DAN membership). Callers are connected
directly with a member of DAN’s Medical Services department, who can facilitate
medical consultation with dive medicine specialists and coordinate evacuation to
ensure appropriate care.
DAN’s non-emergency safety resources include the DAN Medical Information Line
(+1-919-684-2948), the online Health & Diving libary (DAN.org/Health) and
Alert Diver magazine, as well as Smart Guides, safety quizzes, and more.
Membership dues and insurance purchases support DAN’s nonprofit efforts. DAN
members enjoy benefits such as access to the DAN Dive Accident Insurance program,
medical evacuation support, print copies of Alert Diver magazine, free online seminars
and more.
Your participation in this DAN training course demonstrates your commitment to dive
safety. Continue your education and your commitment by supporting the industry’s
only organization dedicated solely to improving dive safety. Join DAN today.
To learn more about DAN and the multitude of resources it provides, or to become a
member, please visit DAN.org.

www.DAN.org
 FIRST AID PROGRAMS

Emergency Oxygen for

Scuba Diving Injuries

C BLS Basic Life Support:

P
R CPR and First Aid
NEURO
Neurological Assessment

First Aid for Hazardous

Marine Life Injuries

Diving Emergency
Management Provider

CPR Health-Care
Provider with First Aid

Diving First Aid for

Professional Divers

DAN.org
Product Code: 381-3205; Ver. 2.0