A comprehensive clinical examination is the basis for selecting further diagnostic steps. In principle, an emergency physical examination must be performed first in persons who are unconscious:
Glasgow Coma Scale (GCS) – scale for estimating impaired consciousness.
| Criterion | Score | |
| Eye opening | spontaneous | 4 |
| on request | 3 | |
| on pain stimulus | 2 | |
| no reaction | 1 | |
| Verbal communication | conversational, oriented | 5 |
| conversational, disoriented (confused) | 4 | |
| incoherent words | 3 | |
| unintelligible sounds | 2 | |
| no verbal reaction | 1 | |
| Motor response | Follows prompts | 6 |
| Targeted pain defense | 5 | |
| untargeted pain defense | 4 | |
| on pain stimulus flexion synergisms | 3 | |
| on pain stimulus stretching synergisms | 2 | |
| No response to pain stimulus | 1 |
Assessment
- Points are awarded for each category separately and then added together. The maximum score is 15, the minimum 3 points.
- If the score is 8 or less, a very severe brain dysfunction is assumed and the there is a risk of life-threatening respiratory disorders.
- With a GCS ≤ 8, securing the airway by endotracheal intubation (insertion of a tube (hollow probe) through the mouth or nose between the vocal folds of the larynx into the trachea) must be considered.
Subsequently, takes place:
- General physical examination – including blood pressure, pulse, body weight, height; furthermore:
- Inspection (viewing).
- Skin and mucous membranes
- Auscultation (listening) of the heart
- Auscultation of the lungs
- Palpation (palpation) of the abdomen (abdomen) (tenderness?, knocking pain?, coughing pain?, defensive tension?, hernial orifices?, kidney bearing knocking pain?)
- Inspection (viewing).
- Neurological examination – including checking reflexes and cranial nerve function; examination:
- Eyes (gaze, pupillomotor function (dynamic change in the pupil of the eye), corneal reflex (eyelid closure reflex), assessment of vestibulo-ocular reflex (VOR)* ).
- Motor function (movement excursion to pain stimuli, pyramidal tract signs (neurologic symptoms denoted that arise due to a lesion of the pyramidal tract))Note: Meningismus (painful neck stiffness) may be absent in patients with meningitis (meningitis) in deep coma.[due todifferential diagnoses:
- Apoplexy (stroke)
- Basilar artery thrombosis – occlusion of a basilar artery of the brainstem associated with severe neurologic damage.
- Chronic subdural hematoma (cSDH) – hemorrhage between layers of the meninges that can lead to various neurological symptoms.
- Coma vigile (akinetic mutism) – muteness with general inhibition of motor functions, which is mainly conditioned in psychiatric diseases or injuries/tumors of the brain.
- Epilepsy
- Increased intracranial pressure
- Brain abscess – encapsulated collection of pus in the brain.
- Brain mass hemorrhage
- Cerebral sinus thrombosis – occlusion of a venous cerebral blood duct.
- Brainstem hemorrhage
- Brainstem infarction
- Intracranial hemorrhage (bleeding within the skull).
- Meningoencephalitis – combined inflammation of the brain (encephalitis) and meninges (meningitis).
- Subarachnoid hemorrhage (SAB) – bleeding between the spinal meninges and the surface of the brain; in 75-80% of cases, the cause is an aneurysm (bulging of an artery)]
* By transmitting information from the labyrinth via the vestibular nerve (balance nerve) to core areas in the brainstem and ultimately the eye muscles, the reflex enables postural regulation, gaze stabilization and orientation in space. Square brackets [ ] indicate possible pathological (pathological) physical findings.
