FOUR Score Coma Scale

Full Outline of Unresponsiveness

Geschiedenis
1974 Teasdale and Jenett Attempt to bring uniformity to the clinical examination and clinical communication about the level of consciousness
GCS Not designed to capture distinct details of the neurologic examination

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Voordelen
Measurement of brainstemreflexes Determination of eye opening, blinking and tracking A broad spectrum of motor responses Presence of abnormal breath rhythms and a respiratory drive NO assessment of verbal responses (intubation)

Eye response
Differentiation between
Vegetative state
(eyes open but do not track)

Locked in syndrome
(eyes open, blink and track vertically on command)

Motor assessment
Combination:
Withdrawal reflex Decorticate rigidity

Complex command (alert) Severe cerebral dysfunction (Myoclonic status epilepticus)

Brainstem components
Pons Mesencephalon Medulla oblongata Various combinations

Breathing components
Cheyne-Stokes respiration Irregular breathing
Bihemispheric or lower brainstem dysfunction Intubation: presence or absence of a respiratory drive

Studie
Different types of examiners
Watched a 20min instruction on the FOUR score (videos with patient examples)

Exclusie sedation/neuromuscular function blockers

Studie
4 categories:
Alert Drowsy Stuporous Comatose

Each patient was rated on both scales by two different raters (1 hours)

Outcome assessment
A robust predictor of:
In-hospital mortality (withdrawal of life support) Functional outcome at hospital discharge

Clinical diagnosis of brain death Morbidity at 3 months Modified Rankin Scale

Rankin score
0 : No symptoms 1 : No evident disability despite symptoms 2 : Slight disability, with an inability to carry out all previous activities 3 : Moderate disability, with the need for some help but the ability to walk without assistance

Rankin score
4 : Moderately severe disability, with the inability to walk without assistance or to attend to bodily needs without assistance 5 : Severe disability, with the patient being bedridden and incontinent and requiring constant nursing care 6 : Death

Ideal coma scale

Reliable (measures what it is supposed to measure) Valid (yields the same results with repeated testing) Linear (gives all component equal weight) Easy to use (provides simple instructions without the need for tools or cards)

Shortcomings GCS
Verbal component
Orientation
Quickly abnormal (agitation/confusion) Conversely no respose alert

Intubation

Poorly assessing patients with less severe degrees of coma

Shortcomings GCS
No assessment of brainstem reflexes
(eye movements, complex motor responses)

Reliability Numerically toward motor responses Linearity May not detect subtle changes

Attempts to improve GCS (lengthy)

FOUR: Voordelen
High degree of:
Internal consistency Interrater reliability (interobserver agreement)*

Intubated patients Brainstem reflexes Respiratory patterns Further characterizes the severity of the comatose state in patients with lowest GCS (Mortality)
* High proportion alert patient (ER)

FOUR: Voordelen
Detects early changes in consciousness (Acute metabolic derangements, sepsis, shock, other nonstructural brain injuries)
Frequent use of mild sedation affects:
Eye opening Motor response

NOT:
Brainstem reflexes Respiration.

Limitations
4 maal: familiarity Number of patients Nurse/nurse
Target enrollment cohort Alert patients Single center study

Conclusion
Easily taught, simple to administer and provides essentiel neurologic information
limited experience neuroscience

Accurately predicts pour outcome Interobserver agreement (GCS)

Detect occurence of brain death Diagnose a locked-in syndrome

Referenties
Vivek et all. Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clinic Proc. 2009;84(8):694-701 Latha et all. Validation of a new coma scale, the FOUR score, in the emergency department. Neurocrit Care. 2009; 10:50-54 Chris et all. Further validation of the FOUR score coma scale by intensive care nurses. Mayo Clin Proc. 2007; 82(4):435-438 Eelco et all. Validation of a new coma scale: the FOUR score. Ann Neurol. 2005;58:585-593