Brudzinski's sign: Excerpt from Handbook of Signs & Symptoms (Third Edition)

Brudzinski's sign: Excerpt from Handbook of Signs & Symptoms (Third Edition)

 
A positive Brudzinski's sign (flexion of the hips and knees in response to passive flexion of the neck) signals meningeal irritation. Passive flexion of the neck stretches the nerve roots, causing pain and involuntary flexion of the knees and hips.
Brudzinski's sign is a common and important early indicator of life-threatening meningitis and subarachnoid hemorrhage. It can be elicited in children as well as adults, although more reliable indicators of meningeal irritation exist for infants.
Testing for Brudzinski's sign isn't part of the routine examination, unless meningeal irritation is suspected. (See Testing for Brudzinski's sign.)

Emergency interventions

If the patient is alert, ask him about headache, neck pain, nausea, and vision disturbances (blurred or double vision and photophobia) — all indications of increased intracranial pressure (ICP). Next, observe the patient for signs and symptoms of increased ICP, such as an altered level of consciousness (LOC) (restlessness, irritability, confusion, lethargy, personality changes, and coma), pupillary changes, bradycardia, widened pulse pressure, irregular respiratory patterns (Cheyne-Stokes or Kussmaul's respirations), vomiting, and moderate fever.
Keep artificial airways, intubation equipment, a handheld resuscitation bag, and suction equipment on hand because the patient's condition may suddenly deteriorate. Elevate the head of his bed 30 to 60 degrees to promote venous drainage. Administer an osmotic diuretic, such as mannitol, to reduce cerebral edema.
Monitor ICP and be alert for ICP that continues to rise. You may have to provide mechanical ventilation and administer a barbiturate and additional doses of a diuretic. Also, cerebrospinal fluid (CSF) may have to be drained.

History and physical examination

Continue your neurologic examination by evaluating the patient's cranial nerve function, noting motor or sensory def-icits. Be sure to look for Kernig's sign (resistance to knee extension after flexion of the hip), which is a further indication of meningeal irritation. Also look for signs of central nervous system infection, such as fever and nuchal rigidity.
Ask the patient or his family, if necessary, about a history of hypertension, spinal arthritis, or recent head trauma. Also ask about dental work and abscessed teeth (a possible cause of meningitis), open-head injury, endocarditis, and I.V. drug abuse. Ask about sudden onset of headaches, which may be associated with subarachnoid hemorrhage.

Medical causes

❑ Arthritis. With severe spinal arthritis, a positive Brudzinski's sign can occasionally be elicited. The patient may also report back pain (especially after weight bearing) and limited mobility.
❑ Meningitis. A positive Brudzinski's sign can usually be elicited 24 hours after the onset of meningitis, a life-threatening disorder. Accompanying findings may include headache, a positive Kernig's sign, nuchal rigidity, irritability or restlessness, deep stupor or coma, vertigo, fever (high or low, depending on the severity of the infection), chills, malaise, hyperalgesia, muscular hypotonia, opisthotonos, symmetrical deep tendon reflexes, papilledema, ocular and facial palsies, nausea and vomiting, photophobia, diplopia, and unequal, sluggish pupils. As ICP rises, arterial hypertension, bradycardia, widened pulse pressure, Cheyne-Stokes or Kussmaul's respirations, and coma may develop.
❑ Subarachnoid hemorrhage. Brudzinski's sign may be elicited within minutes after initial bleeding in subarachnoid hemorrhage, a life-threatening disorder. Accompanying signs and symptoms include the sudden onset of severe headache, nuchal rigidity, altered LOC, dizziness, photophobia, cranial nerve palsies (as evidenced by ptosis, pupil dilation, and limited extraocular muscle movement), nausea and vomiting, fever, and a positive Kernig's sign. Focal signs — such as hemiparesis, vision disturbances, or aphasia — may also occur. As ICP rises, arterial hypertension, bradycardia, widened pulse pressure, Cheyne-Stokes or Kussmaul's respirations, and coma may develop.

Special considerations

Many patients with a positive Brudzinski's sign are critically ill. They need constant ICP monitoring and frequent neurologic checks in addition to intensive assessment and monitoring of vital signs, intake and output, and cardiorespiratory status. To promote patient comfort, maintain low lights and minimal noise and elevate the head of the bed. The patient usually won't receive an opioid analgesic because it may mask signs of increased ICP.
Prepare the patient for diagnostic tests. These may include blood, urine, and sputum cultures to identify bacteria; lumbar puncture to assess CSF and relieve pressure; and computed tomography scan, magnetic resonance imaging, cerebral angiography, and spinal X-rays to locate a hemorrhage.

Pediatric pointers

Brudzinski's sign may not be useful as an indicator of meningeal irritation in infants because more reliable signs (such as bulging fontanels, a weak cry, fretfulness, vomiting, and poor feeding) appear early.