Full Outline Of Unresponsiveness Score Research Articles

The FOUR Score Predicts Outcome in Patients after Cardiac Arrest

Prognostication for survivors of cardiac arrest is a frequent challenge to neurologists. Our aim was to determine whether the FOUR (Full Outline of UnResponsiveness) score is an accurate predictor of outcome in patients after cardiac arrest and to compare its performance to the Glasgow Coma Scale (GCS). We prospectively identified patients surviving cardiac arrest from June 2006 to October 2009. Neurologic exams were grouped into two time intervals following cardiac arrest: 1-2 days and 3-5 days. The FOUR score and the Glasgow coma scale (GCS) were determined for each examination. Primary outcome was in-hospital mortality. Of 136 patients, 112 (82%) were examined on days 1-2 after cardiac arrest and 87 (64%) on days 3-5. Forty-seven patients (35%) survived to hospital discharge and 89 (65%) died during hospitalization. No patients with a sum FOUR score ≤ 4 at exam days 3-5 survived (false positive rate [FPR] 0% C.I. 0.000-0.0345), whereas one patient (2%) with sum GCS score of 3 survived to discharge (FPR 2.2%, C.I. < 0.0001-0.1758). At days 3-5 after arrest, 41 of 45 (91%) patients with a sum FOUR score > 8 survived (P < 0.0001), while 39 of 45 (87%) with a sum GCS > 6 survived (P < 0.0001). A 2-point improvement in FOUR score, but not GCS, in serial exams was associated with survival. Sensitivities, specificities, positive, and negative predictive values were comparable between both scales. The FOUR score, a simple clinical tool, is an accurate predictor of outcome in patients surviving cardiac arrest.

Validation of the FOUR Score (Spanish Version) in Acute Stroke: An Interobserver Variability Study

Background: Methods to assess impaired consciousness in acute stroke typically include the Glasgow Coma Scale (GCS), but the verbal component has limitations in aphasic or intubated patients. The FOUR (Full Outline of UnResponsiveness) score, a new coma scale, evaluates 4 components: eye and motor responses, brainstem reflexes and respiration. We aimed to study the interobserver variability of the FOUR score in acute stroke patients. Methods: We prospectively enrolled consecutive patients with acute stroke admitted from February to July 2008 to the stroke unit of our Neurology Department. Patients were evaluated by neurology residents and nurses using the FOUR score and the GCS. For both scales, we obtained paired and total weighted kappa values (Kw) and intraclass correlation coefficients (ICC). NIH stroke scale was also recorded on admission. Results: We obtained a total of 75 paired evaluations in 60 patients (41 cerebral infarctions, 15 cerebral hemorrhages and 4 transient ischemic attacks). Thirty-three (55%) patients were alert, 17 (28.3%) drowsy and 10 (16.7%) stuporous or comatose. The overall rater agreement was excellent in the FOUR score (Kw 0.93; 95% CI 0.89–0.97) with an ICC of 0.94 (95% CI 0.91–0.96) and in the GCS (Kw 0.96; 95% CI 0.94–0.98) with an ICC of 0.96 (95% CI 0.93–0.97). A good correlation was found between the FOUR score and the GCS (ρ 0.83; p < 0.01) and between the FOUR score and the NIH stroke scale (ρ –0.78; p < 0.001). Conclusions: The FOUR score is a reliable scale for evaluating the level of consciousness in acute stroke patients, showing a good correlation with the GCS and the NIH stroke scale.

Paroxysmal Sympathetic Hyperactivity After Traumatic Brain Injury

A 35-year-old male was the unrestrained driver in a rollover motor vehicle accident from which he was ejected. He was initially comatose, with anisocoria and bilaterally unreactive pupils, absent oculocephalic, corneal, cough and gag reflexes, and no motor response to painful stimulus, but initiating respirations on his own (GCS 3T, FOUR score E0 M0 B0 R1 [1]). Shortly after admission, he developed extensor posturing, elevating his exam to GCS 4T, FOUR score E0 M1 B0 R1. However, his exam did not improve further. Head CT demonstrated small petechial hemorrhages at the gray/white junction, corpus callosum, basal ganglia, and in the interpeduncular cistern, consistent with diffuse axonal injury (Fig. 1). An intracranial pressure monitor was placed, and intracranial pressures were wellcontrolled over the next several days without requiring any interventions. Three days after the accident, the patient developed intermittent episodes of tachycardia with tachypnea, hypertension, fever, profuse sweating, and brisk extensor posturing, consistent with paroxysmal sympathetic hyperactivity [2, 3] (Video in Supplementary material). Paroxysmal sympathetic hyperactivity (PSH) can occur following traumatic brain injury with axonal shear injury, due to disinhibition of subcortical sympathoexcitatory structures [3]. This may have an early and late onset, and is most frequently seen in younger patients. The classic features of these episodes include at least four of the following: profuse sweating, tachycardia, hypertension, tachypnea, fever and extensor posturing, and occur transiently without any other cause [4]. PSH has been previously called diencephalic seizures, but EEGs in these patients have always been normal. The typical clinical features were present in our patient, and were never associated with twitches or decrease in responsiveness that may indicate seizures. PSH typically responds most effectively to a combination of opiate agonist and nonselective beta blockade [4, 5]. Bromocriptine and clonidine may also be used, but with less consistent results [4, 5], and gabapentin is gaining more widespread use for long term effectiveness. In our patient, the episodes were initially treated with beta blockade with propranolol, but did not respond. A combination of clonidine and morphine given during acute episodes was most effective in halting them. Gabapentin was started two days later for longer-term control. However, his neurologic exam failed to improve, care was withdrawn at the strong request of the family and he expired soon after extubation. Paroxysmal sympathetic hyperactivity is a common occurrence in catastrophic neurologic injuries leading to persistent vegetative state. These manifestations are often mistaken for rigors or convulsions and are commonly inadequately treated. Electronic supplementary material The online version of this article (doi:10.1007/s12028-010-9381-y) contains supplementary material, which is available to authorized users.

Imminent brain death: point of departure for potential heart-beating organ donor recognition

PurposeThere is, in European countries that conduct medical chart review of intensive care unit (ICU) deaths, no consensus on uniform criteria for defining a potential organ donor. Although the term is increasingly being used in recent literature, it is seldom defined in detail. We searched for criteria for determination of imminent brain death, which can be seen as a precursor for organ donation.MethodsWe organized meetings with representatives from the field of clinical neurology, neurotraumatology, intensive care medicine, transplantation medicine, clinical intensive care ethics, and organ procurement management. During these meetings, all possible criteria were discussed to identify a patient with a reasonable probability to become brain dead (imminent brain death). We focused on the practical usefulness of two validated coma scales (Glasgow Coma Scale and the FOUR Score), brain stem reflexes and respiration to define imminent brain death. Further we discussed criteria to determine irreversibility and futility in acute neurological conditions.ResultsA patient who fulfills the definition of imminent brain death is a mechanically ventilated deeply comatose patient, admitted to an ICU, with irreversible catastrophic brain damage of known origin. A condition of imminent brain death requires either a Glasgow Coma Score of 3 and the progressive absence of at least three out of six brain stem reflexes or a FOUR score of E0M0B0R0.ConclusionThe definition of imminent brain death can be used as a point of departure for potential heart-beating organ donor recognition on the intensive care unit or retrospective medical chart analysis.

Inter-rater reliability of the Full Outline of UnResponsiveness score and the Glasgow Coma Scale in critically ill patients: a prospective observational study

IntroductionThe Glasgow Coma Scale (GCS) is the most widely used scoring system for comatose patients in intensive care. Limitations of the GCS include the impossibility to assess the verbal score in intubated or aphasic patients, and an inconsistent inter-rater reliability. The FOUR (Full Outline of UnResponsiveness) score, a new coma scale not reliant on verbal response, was recently proposed. The aim of the present study was to compare the inter-rater reliability of the GCS and the FOUR score among unselected patients in general critical care. A further aim was to compare the inter-rater reliability of neurologists with that of intensive care unit (ICU) staff.MethodsIn this prospective observational study, scoring of GCS and FOUR score was performed by neurologists and ICU staff on 267 consecutive patients admitted to intensive care.ResultsIn a total of 437 pair wise ratings the exact inter-rater agreement for the GCS was 71%, and for the FOUR score 82% (P = 0.0016); the inter-rater agreement within a range of ± 1 score point for the GCS was 90%, and for the FOUR score 92% (P = ns.). The exact inter-rater agreement among neurologists was superior to that among ICU staff for the FOUR score (87% vs. 79%, P = 0.04) but not for the GCS (73% vs. 73%). Neurologists and ICU staff did not significantly differ in the inter-rater agreement within a range of ± 1 score point for both GCS (88% vs. 93%) and the FOUR score (91% vs. 88%).ConclusionsThe FOUR score performed better than the GCS for exact inter-rater agreement, but not for the clinically more relevant agreement within the range of ± 1 score point. Though neurologists outperformed ICU staff with regard to exact inter-rater agreement, the inter-rater agreement of ICU staff within the clinically more relevant range of ± 1 score point equalled that of the neurologists. The small advantage in inter-rater reliability of the FOUR score is most likely insufficient to replace the GCS, a score with a long tradition in intensive care.

Fast decay of 4p and 4s core holes in Sb4 clusters

The 4s and 4p photoelectron spectra of a vapour phase Sb4 antimony cluster have been recorded using synchrotron radiation excitation. Relativistic multiconfiguration Dirac–Fock calculations have been used to predict the spectral features. The strongly different lifetime widths of the two energetically close-lying orbitals have been observed and the existing fast Auger channels are modelled.

Interrater Reliability and Predictive Validity of the FOUR Score Coma Scale in a Pediatric Population

The Glasgow Coma Scale (GCS) was developed in 1974 to objectively describe neurological status and predict outcome in neuroscience patients. Through the years, the GCS has become the gold standard for coma assessment. Despite its widespread use, the GCS has many limitations that are well documented in the literature. The Full Outline of Unresponsiveness (FOUR) score is a new coma scale that was recently developed and validated in adults as a proposed replacement for the GCS. The purpose of this study was to compare the interrater reliability and predictive validity of the FOUR score and the GCS in pediatric patients. The interrater reliability for the GCS was good (k(w) = .738), and that for the FOUR score was excellent (k(w) = .951). Outcome prediction analysis showed that the FOUR score and the GCS are both able to predict in-hospital morbidity and poor outcome at the end of hospitalization. The results from this pediatric study were consistent with the adult studies which suggest that the FOUR score is a reliable and valid tool for use in a wide variety of neuroscience patients.

Interrater Reliability and Predictive Validity of the FOUR Score Coma Scale in a Pediatric Population

Interrater Reliability and Predictive Validity of the FOUR Score Coma Scale in a Pediatric Population

Validity of the FOUR Score Coma Scale in the Medical Intensive Care Unit

To evaluate the validity of the FOUR (Full Outline of UnResponsiveness) score (ranging from 0 to 16), a new coma scale consisting of 4 components (eye response, motor response, brainstem reflexes, and respiration pattern), when used by the staff members of a medical intensive care unit (ICU). This interobserver agreement study prospectively evaluated the use of the FOUR score to describe the condition of 100 critically ill patients from May 1, 2007, to April 30, 2008. We compared the FOUR score to the Glasgow Coma Scale (GCS) score. For each patient, the FOUR score and the GCS score were determined by a randomly selected staff pair (nurse/fellow, nurse/consultant, fellow/fellow, or fellow/consultant). Pair wise weighted kappa values were calculated for both scores for each observer pair. The interrater agreement with the FOUR score was excellent (weighted kappa: eye response, 0.96; motor response, 0.97; brainstem reflex, 0.98; respiration pattern, 1.00) and similar to that obtained with the GCS (weighted kappa: eye response, 0.96; motor response, 0.97; verbal response, 0.98). In terms of the predictive power for poor neurologic outcome (Modified Rankin Scale score, 3-6), the area under the receiver operating characteristic curve was 0.75 for the FOUR score and 0.76 for the GCS score. The mortality rate for patients with the lowest FOUR score of 0 (89%) was higher than that for patients with the lowest GCS score of 3 (71%). The interrater agreement of FOUR score results was excellent among medical intensivists. In contrast to the GCS, all components of the FOUR score can be rated even when patients have undergone intubation. The FOUR score is a good predictor of the prognosis of critically ill patients and has important advantages over the GCS in the ICU setting.

A new score to validate coma in emergency department — FOUR score

The Glasgow Coma Scale (GCS) is the most widely used method for evaluation of coma, but it has a number of shortcomings, including limited utility in intubated patients and an inability to assess brainstem reflexes. A new coma score, the Full Outline of Un Responsiveness (FOUR) has been developed. to overcome these shortcomings and to provide further neurological details that might predict outcome in coma. Four different components are included in the FOUR score (eye, motor, brainstem and respiration), each of which has a maximal score of 4. In contrast to the GCS, verbal response is not a component of the FOUR score, making it fully applicable in intubated patients.

Le FOUR score en français, un nouveau score d’évaluation de la profondeur du coma

Background Comatose state is a major cause for admission to the intensive care unit. The most commonly used assessment score is the Glasgow coma scale (GCS). Although widely accepted, this score has several limitations. Recently, the full outline of unresponsiveness score (FOUR) has been validated and tested as reliable as the GCS. Methods We translated this score in French and tested its reliability in a neurological critical care unit. This study included eight critical care patients and eight intensive care patients. The patients were successively evaluated by two neurologists, four experienced nurses and five inexperienced nurses; a total of 176 evaluations were performed. The weighted kappa (κ W) was used to determine the reliability of the evaluation for both the FOUR score and the GCS. Results The mean age of the patients was 62 years. The interobserver reliability of the French version of the FOUR score was high (κ W = 0.86; IC 95%: 0.83–0.89) comparable to that of the GCS (κ W = 0.85; IC 95%: 0.82–0.88). Conclusion The French version of the FOUR score has an excellent interobserver reliability. This score is easy to perform and well accepted, only requiring simple and short training.

Comparison of the Full Outline of Unresponsiveness Score Coma Scale and the Glasgow Coma Scale in an emergency setting population

The Glasgow Coma Scale (GCS) is the most widely used tool for the evaluation of the level of consciousness. The Full Outline of Unresponsiveness (FOUR) Score is a new coma Scale that was developed considering the limitations of the GCS, and has been found to be useful in an intensive care setting. We aimed to compare FOUR Score and GCS in the emergency setting. All patients older than 17 years who presented with an altered level of consciousness, after any trauma to the head or with neurological complaints were included in this study. Three-month mortality, in-hospital mortality, and poor outcome using a Modified Rankin Scale (MRS) of 3-6 points were used as the primary outcome measures. A total of 185 patients were included in the study. Area under the curve (AUC) values in predicting 3-month mortality for GCS was 0.726 [P=0.0001 and 95% confidence interval (CI): 0.656-0.789] and 0.776 (P=0.0001 and 95% CI: 0.709-834) for FOUR Score. AUC in predicting hospital mortality for GCS was 0.735 (P=0.0001 and 95% CI: 0.655-0.797) and 0.788 (P=0.0001 and 95% CI: 0.722-0.844) for FOUR Score. AUC in predicting poor outcome (Modified Rankin Scale: 3-6) was 0.720 (P=0.001 and 95% CI: 0.650-784) for GCS and 0.751 (P=0.0001 and 95% CI: 0.682-0.812) for FOUR Score. The new coma Scale, FOUR Score, is not superior to the GCS. However, the combination of the eye and motor components of FOUR Score is a valuable tool that can be used instead of either the FOUR Score or GCS.

The Comatose Patient.

The Comatose Patient.

Endorsement of the FOUR Score for Consciousness Assessment in Neurosurgical Patients

The Full Outline of UnResponsiveness (FOUR) score was previously developed for neurological assessment, but has not been validated in neurosurgical patients, so was compared to the Glasgow Coma Scale (GCS) in practice. Four groups of raters, expert clinicians, novice clinicians, experienced nurses, and inexperienced nurses, assessed 64 patients in awake, drowsy, stuporous, and comatose conditions to investigate rater reliability. Then, 36 patients were evaluated by 1 expert clinician and 1 from the other groups randomly to test the difference. Spearman's correlation was used to find the correlation between both scores from 68 patients. The estimation of FOUR score cut points was validated by weighted kappa compared with the GCS to establish the risk prognosis. Score feasibility was analyzed by nonparametric test. Intraclass correlation in each group was over 0.9, with no difference between expert and inexperienced raters (p > 0.05). The correlation was 0.78. Low, intermediate, and high risk prognosis were associated with 0-7, 8-14, and 15-16 FOUR scores with kappa of 0.92. The feasibility of the FOUR score was lower than that of the GCS (p < 0.01). The FOUR score is reliable and valid for consciousness evaluation with some consequences for practicability. Extensive implementation would increase familiarity.

Prognostic Value of Magnetic Resonance Imaging in Post-Resuscitation Encephalopathy

Prediction of the prognosis of comatose survivors after cardiopulmonary arrest (CPA), so-called post-resuscitation encephalopathy (PRE), relies on neurological examination findings. Early laboratory indicators of poor prognosis (vegetative state/death) are not sensitive enough. We analyzed the results of magnetic resonance (MR) imaging with fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) in 22 consecutive patients with PRE. Clinical details such as arrest place and anoxia time along with neurological examination findings including items of Glasgow coma scale (GCS) and the Full Outline of UnResponsiveness (FOUR) score were determined. Receiver Operator Characteristics (ROC) curves were produced to determine prognostic yield of the parameters studied. Prognosis was classified as 'poor' (Glasgow-Pittsburg Cerebral Performance -CPC-score 4 or 5) in 16 and 'better' (CPC score 1-3) in 6 patients. The lower limit of confidence interval (CI) of the area under the curve (AUC) of the ROC was higher than 0.5 for visual, motor and total scores of GCS and FOUR score. Presence of a lesion pattern of multilobar, or diffuse, cortical involvement, termed as "extensive cortical lesion pattern" in MR imaging was a very good predictor of poor prognosis with an AUC of ROC of 0,937. Sensitivity of GCS motor part score and MR was 87.5% (95% CI: 61.6%-92.6%). Motor part of the FOUR score has a slightly lower sensitivity (68.7% with 95% CI from 41.4% to 88.9%). Incorporating of MR to the motor scores (either GCS or FOUR score) improved sensitivity to 100 % (95% CI: 79.2%-100%). AUC of the ROC was 1.000 (95%CI: 0.844-1.000) for the combination of MR and GCS motor score. This study provides the preliminary evidence that MRI, when used in conjunction with a neurological examination, may have potential in terms of predicting outcome in patients with PRE.

Diagnostic value of Geneva score combined with rapid plasma D-dimer assay for pulmonary embolism

Objective To study the value of Geneva score assessment combined with simplified rapid plasma D-dimer assay(SRPDDA)for early diagnosis of pulmonary embolism(PE).Methods Clinical data of 658 suspected cases of PE hospitalized at Shanghai Pulmonary Hospital during January 1,1995 to November 30,2007 were retrospectively analyzed.The patients were divided into three categories based on their Geneva score assessment,highly suspected with equal to or greater than 9 scores,intermediately suspected with 5-8 scores and mildly suspected with equal to or less than 4 scores,respectively.Clinical diagnosis for PE of the patients was made based on their probability Geneva score developed by Wicki,SRPDDA,and both Geneva score assessment and SRPDDA,respectively,and compared with results of lung imaging.Results Finally,PE diagnosis was established in 267 cases.Sensitivity for Geneva score and SRPDDA to diagnose PE was 88.4%and 90.3%,with negative predictive value(NPV)of 88.9%and 90.2%and Youden Index(YI)of 51.7%and 51.4%,respectively.And,sensitivity of both Geneva score assessment combined with SRPDDA wag 97.8%,with NPV and YI of 97.3%and 53.8%,respectively,with a likelihood ratio(LR)for both positive test results of 2.62 and a LB for both negative test results of 0.04,respectively.Conclusions As a routine and non-invasive diagnostic test,Geneva score assessment,as well as SRPDDA,play a screening role in early diagnosis for PE,which can help to save unnecessary cost of imping,and complement each other so to improve accuracy of diagnosis and reduce misdiagnosis. Key words: Pulmonary embolism; Diagnosis; Clinical assessment; D-dimer

Validation of a New Coma Scale, the FOUR Score, in the Emergency Department

Full Outline of Unresponsiveness (FOUR) score has previously been validated scale in the Neurosciences Intensive Care Unit. In this study, we sought to validate the use of FOUR score in the emergency department (ED) using non-neurology staff. We also compared its performance to the Glasgow Coma Scale (GCS) and correlated it to functional outcome at hospital discharge and overall survival. We prospectively rated 69 patients with initial neurologic symptoms presenting to the ED. Three types of examiners performed the FOUR score: ED physician, ED resident, and ED nurse. Patients were followed through hospital discharge; functional outcome was measured using modified Rankin Score (mRS). Interrater reliability for FOUR score and GCS was excellent (respectively, kappa(w) = 0.88 and 0.86). Both FOUR score and GCS predicted functional outcome, and overall survival with and without adjustment for age, sex, and alertness group. The FOUR score can be reliably used in the ED by non-neurology staff. Both FOUR score and GCS performed equally well, but the neurologic detail incorporated in the FOUR score makes it more useful in management and triage of patients.

Effect of H-bonding on the ambivalence of SCN − towards copper(II)

Condensations of 2-(2-aminoethyl)pyridine with 4-methylimidazole-5-carboxaldehyde and 1-methyl-2-imidazolecarboxaldehyde generate the tridentate N donor ligands L and L′ respectively. Reactions of Cu(NCS) 2 with L and L′ yield respectively CuL(SCN)(NCS) ( 1) containing a CuN 4S core and CuL′(NCS) 2 ( 2) having a CuN 5 core. Both the cores are square pyramidal with SCN − bound in 1 at the axial position through the S end. This differential behaviour of SCN − in the two complexes despite the ligands being very similar, is investigated by DFT calculations at the B3LYP/TZV level. It is found that DFT calculations predict isolation of the Cu(ligand)(NCS) 2 species for both the ligands L and L′. Presence of an offsetting intermolecular H-bonding between the N atom of the thiocyanate and the N–H proton of the ligand L of an adjacent molecule makes the binding of SCN − via the S end feasible in 1 resulting in the H-bonded dimer Cu 2L 2(SCN) 2(NCS) 2. The strength of the H-bond is estimated as 27.1 kJ mol −1 from the DFT calculations. The question of such H-bonding does not arise with L′ as it lacks in a similar H atom. Dimeric 1 represents a case of two non-interacting spins.

Cardiac Arrest, Mild Therapeutic Hypothermia, and Unanticipated Cerebral Recovery

Animal and human studies support mild therapeutic hypothermia as an effective means of preventing brain injury in comatose patients resuscitated from cardiac arrest. However, there is little clinical experience with predicting neurologic outcome in this patient population. We present 4 comatose patients resuscitated from cardiac arrest treated with mild hypothermia whose in-hospital neurologic prognosis was determined by board-certified neurologists to be grave, yet were ultimately discharged from the hospital with no or minimal neurologic sequelae. We report 4 comatose patients resuscitated from cardiac arrest treated with mild hypothermia. On hospital admission, all patients had a Glasgow Coma Score between 3 and 6 and a FOUR Score between 1 and 5. Mild hypothermia (32 degrees C - 33 degrees C) was implemented for 24 to 40 hours. Examination by board-certified neurologists before and during hypothermia or the rewarming phase suggested a grave prognosis. All 4 patients had sudden and dramatic neurologic recovery 9 to 24 hours after rewarming to normothermia and were ultimately discharged with no or minimal neurocognitive sequelae. This case series suggests that neurologic assessment-based prognosis of patients after cardiac arrest undergoing therapeutic mild hypothermia should be considered unreliable for at least the first 72 hours. Use of additional assessments such as brain injury markers or evoked potentials, in addition to clinical examination, should be strongly considered to help determine an estimated prognosis. Functional reversibility after a global insult could be an intrinsic potential of the brain, similar to myocardial stunning, and deserves investigation.

108: Comparing the FOUR Score and Glasgow Coma Scale Performed by Diverse Evaluators

To compare the overall score assigned by diverse evaluators using the FOUR (Full Outline of UnResponsiveness) Score and Glasgow Coma Scale (GCS) when evaluating patients with altered mental status.