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Overview :
Wijdicks et al developed the Full Outline of UnResponsiveness
(FOUR) score to assess a patient in coma. This has several advantages over the
Glasgow Coma Score but is more complex to administer. The authors are from the
Mayo Clinic.
Advantages over the Glasgow coma score:
(1) provides scoring for an intubated patient
(2) includes the brainstem reflexes
(3) recognizes the locked-in syndrome and possible vegetative
state
(4) may be able to recignise different stages of
herniation
Parameters:
(1) eye response
(2) motor response
(3) brainstem reflexes
(4) respirations
|
Response |
Findings |
Points |
|
eye response |
eyelids open and tracking, or blinking on
command |
4 |
|
|
eyelids open but not tracking |
3 |
|
|
eyelids closed but open to loud voice |
2 |
|
|
eyelids closed but open to pain |
1 |
|
|
eyelids closed with pain |
0 |
|
motor response |
makes sign (thumbs-up, fist, other) |
4 |
|
|
localizing to pain |
3 |
|
|
flexion response to pain |
2 |
|
|
extension response to pain |
1 |
|
|
no response to pain |
0 |
|
|
generalized myoclonus status |
0 |
|
Pupil
Reflexes |
Corneal
Reflexes |
Cough |
Brainstem
Points |
|
present |
present |
present |
4 |
|
one pupil wide and fixed |
present |
present |
3 |
|
absent |
present |
NA |
2 |
|
present |
absent |
NA |
2 |
|
absent |
absent |
present |
1 |
|
absent |
absent |
absent |
0 |
|
Intubation |
Breathing |
Respiratory
Points |
|
not intubated |
regular |
4 |
|
not intubated |
Cheyne-Stokes |
3 |
|
not intubated |
irregular |
2 |
|
not intubated |
apnea |
0 |
|
intubated |
above ventilator rate |
1 |
|
intubated |
breathes at ventilator rate |
0 |
total score =
= SUM(points for all 4 parameters)
Interpretation:
• minimum score: 0
• maximum score: 16
• The lower the score the greater the coma.
Performance:
• The
inter-relater reliability was reported as good to excellent. Whether this
extends to casual users needs to be determined.
• The curve
for prediction of in-hospital death (Figure 3, page 592) shows better
discrimination for the FOUR score. The curve for prediction of a Rankin score of
3-6 look fairly comparable.
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