137. FOUR score over GCS score in critically ill patients in the Emergency Department and the Critical Care Department.

Abstract

Introduction: The Glasgow Coma Score, published by Graham Teasdale and Bryan J Jennett, which has been under use for over 4 decades proved to be a reliable and easy method of assessing a patient with neurological deficit of any cause by assessing the eye(4),verbal response(5) and motor response(6), however it had certain shortcomings like not being able to assess the verbal part of a patient who is been intubated. On the other hand The Full Outline of Unresponsiveness(FOUR)score developed by Dr. Eelco F.M. Wijdicks at Mayo clinic is even a more simple scale to assess the higher neurological function of any patient presenting to the hospital, which uses a scale ranging from 0-16,with an assessment of four domains such as eye responses, motor responses, brainstem reflexes and breathing pattern, each domain having a score ranging from 0-4, making it easier to assess a patient who is critically ill as the verbal component is replaced by the brainstem reflexes and respiratory patterns. Methodology: This is a prospective study on 106 patients both in the Intensive Care Unit and the Emergency Department, in which each patient who is critically ill is taken up and tested accordingly in a 1:1 ratio as both the patient is checked using the standard GCS scoring and the new FOUR Score respectively dating from 2016 January to 2018 January in PRS Hospital. PRS hospital is a 300- bedded NABH accredited multispecialty hospital with multiple specialized Intensive Care Units such as Neonatal ICU, Neurosurgical ICU, Cardiac ICU, Critical Care ICU, and a fully functional Emergency Department with Standard Triaging system and Trauma Care. All patients >18 years of age who is critically ill presenting to the ER & ICU were assessed with GCS & FOUR score and later MRS was analyzed during the time of discharge. INCLUSION CRITERIA Patients aged 18 or more Patient who are intubated Patients with traumatic brain injury Patients with altered sensorium EXCLUSION CRITERIA Patients who are medically paralyzed/sedated Patients with hearing or visual impairments Patients with degenerative brain disease or mental retardation Patients with seizures within the last 1 hour Results: In a total of 106 patients; FOUR score proved to have a strong positive correlation (P<0.001, chi square 106.573) in predicting the level of disabilities when assessed with the modified Rankin score. It was seen that an excellent FOUR score predicts mild level of disabilities in 98.3%, while a moderate FOUR score predicted severe impairment at discharge in 38.10%. As for the correlation between Rankin score and GCS, 45.7% patients registered severe score in both Rankin and GCS & 85.7% patients registered mild scores in both scoring system, which shows unanimous nature of both the scales but both the scales have false positives and negatives with a significantly low chi square value of 29.284. Thus giving FOUR score an upper hand in predicting the outcomes as well as providing a much bigger spectrum of classification of critically ill patients in comparison to GCS. Conclusion: The FOUR score proved to have a higher degree of predictability of disability when assessed with the modified Rankin scale score in comparison to GCS in assessing the neurological status of critically ill patients.