Full Outline Research Articles

A Comparative Study to Evaluate Prognostic Value of Glasgow Coma Score and Full Outline of Unresponsiveness Scale to Predict the Outcome of Unconscious Child in the Paediatric Intensive Care Unit

Background: The current issue of improving mortality and care in paediatric patient is very challenging. Early anticipation and intervention will be helpful in improving the outcome in emergency and paediatric intensive care unit (PICU) by the use of Glasgow Coma Scale (GCS) and Full Outline of Unresponsiveness (FOUR) score. Decreasing in GCS and FOUR score is associated with worsening level of consciousness. Aim: The Aim of the study was to compare the prognostic value of FOUR and GCS score in unconscious children to predict the survival in unconscious children to predict the morbidity pattern. Materials and Methods: The present observational study was done from June 2019 to June 2020 at PICU of Department of Paediatrics, BRD Medical College, Gorakhpur, following Ethical Clearance from the Institutional Ethics Committee of BRD Medical College. All the admitted unconscious children in PICU were included in our study. Data entry and analysis were done using SPSS. Data were analysed using appropriate statistical test. Results: In our study, 65 (50.0%) patients were 9–12 years old and male was predominant. Seventy-eight (60%) patients had symptoms of <3 days. GCS score of E, V, M response at the time of admission was assessed in which maximum patients seen in E2 i.e., 60 (46.2%), V2 50 (38.5%) patients and M5 47 (36.1%) patients, while after 12 h patients, maximum GCS were seen in E3 54 (41.5%) patients, V2 54 (41.5%) patients and M5 (42.3%) patients and after 72 h patients maximum GCS was seen in E4 80 (61.5%) patients, V 54 (41.5%) patients and M51 (39.2%) patients. FOUR score baseline eye response was maximum in E2 39 (30%), motor response in M2 76 (58.5%), brain stem function response in B4 118 (90.8%) and respiration response in R4 44 (33.8%). Similarly, after 12 h score was E3 44 (33.8%), M3 48 (36.9%), B4 74 (56.9%), R4 56 (44.4%) while after 72 h score was E3 75 (57.7%), M4 75 (57.7%), B4 88 (67.7%) and R4 88 (67.7%). On final diagnosis, maximum was of AES 40 (30.7%). Thirty-two patients expired during the study period. Conclusion: FOUR and GCS score both is the good predictor of severity of disease and of mortality and may help in prioritising the treatment of sick as well as the counselling of parents about disease severity.

Communicating With Unconscious Patients: An Overview.

Nurses are told to speak to their unconscious patients because hearing is said to be the last sense to depart. There was little reliable evidence before the 1990s that patients in an unconscious state could hear and understand what was being said. That led to reluctance on the part of health professionals to communicate with these unresponsive patients. This historical overview aims to present researched evidence from the 1990s to the present detailing awareness that occurs in unconscious patients, when that awareness increases, and how to detect that awareness. It also includes research about the benefits of communicating with unconscious patients and descriptions of how registered nurses and other health care professionals, from a postsurvey after a continuing education course on experiences of unconscious patients, plan to communicate with unconscious patients. A literature search was conducted, which included more than 150 articles and books about experiences of unconscious patients in several electronic databases, including PubMed, CINAHL, and the British Nursing Index. In addition, an analysis of 105 postcourse responses by registered nurses (89%) and other health professionals (11%), licensed practical nurses, emergency medical technicians, and cardiac technicians after taking a continuing education course on experiences of previously unconscious patients were analyzed. The Glasgow Coma Scale and the Full Outline of Unresponsiveness scale are helpful behavioral tools to identify levels of coma but miss detecting awareness in patients who can hear and understand but cannot move. The estimates are that 25% to 40% (J Trauma. 1975;15:94-98; J Neurosci Nurs. 1988;20:223-228; J Neurosci Nurs. 1990;22(1):52-53; Am J Crit Care. 1995;3:227-232) of patients diagnosed with a disorder of consciousness can hear and understand what is being said in their environment. Substantial evidence supports that isolation and loneliness, such as experienced by some patients perceived to be unaware, can be physically and psychologically harmful. Strong evidence shows that some patients diagnosed as being in a vegetative state can hear and understand what is being said in their environment. Interviews with previously unconscious patients and electrophysiological methods show that awareness can be detected in patients perceived to be unconscious. There is documented evidence that patients experience awareness when going into unconsciousness, even when they appear unaware and when moved. To our knowledge, these times have not been researched using electrophysiological devices but established from interviews.

Off-Axis Holographic Interferometer with Ensemble Deep Learning for Biological Tissues Identification

This paper proposes a method with an off-axis interferometer and an ensemble deep learning (I-EDL) hologram-classifier to interpret noisy digital holograms captured from the tissues of flawed biological specimens. The holograms are captured by an interferometer, which serves as a digital holographic scanner to scan the tissue with 3D information. The method achieves a high success rate of 99.60% in identifying the specimens through the tissue holograms. It is found that the ensemble deep learning hologram-classifier can effectively adapt to optical aberration coming from dust on mirrors and optical lens aberrations such as the Airy-plaque-like rings out-turn from the lenses in the interferometer. The deep learning network effectively adapts to these irregularities during the training stage and performs well in the later recognition stage without prior optical background compensations. The method does not require an intact sample with a full outline shape of the specimens or the organs to understand the objects’ identities. It demonstrates a new paradigm in object identification by ensemble deep learning through a direct wavefront recognition technique.

Relationship between consciousness level and perfusion computed tomography in patients with prolonged disorders of consciousness.

We assessed the relationship between consciousness level and values of cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP) obtained by whole-brain perfusion computed tomography (pCT) in patients with prolonged disorders of consciousness (pDOC). This study included 29 patients in vegetative state (VS), 34 with minimally consciousness state minus (MCS-), and 13 with minimally consciousness state plus (MCS+). All patients were evaluated using the Coma Recovery Scale-Revised (CRS-R), the Glasgow Coma Scale (GCS), and the Full Outline of UnResponsiveness (FOUR). The values of CBF, CBV, MTT, and TTP were obtained from patients who underwent pCT. Differences in CBF, CBV, MTT, and TTP were compared between the three types of pDOC. Correlations between the CRS-R, GCS, and FOUR scores and the pCT results were analyzed. Among the three groups, patients in VS showed a significantly decreased CBF in the bilateral frontal lobe, thalamus, temporal lobe, occipital lobe, brainstem, and damaged part. CBV was significantly reduced in patients with VS in the bilateral frontal lobe, thalamus, temporal lobe, brainstem, and damaged part. The total CRS-R, GCS, and FOUR scores were positively correlated with CBF, CBV, and TTP in almost all regions of interest. Reductions in CBF and CBV calculated with pCT are associated with impaired consciousness and perfusion CT could be a promising tool in evaluating the conscious level in patients with pDOC.

The association of brainstem and motor recovery with awakening after out-of-hospital cardiac arrest

BackgroundComa is common following resuscitation from cardiac arrest. Few data describe the trajectory of recovery the first days following resuscitation. The objective of this study is to describe the evolution in neurological examination during the first 5 days after resuscitation and test if subjects who go on to awaken have different patterns of early recovery. MethodsProspective study of adult subjects resuscitated from out-of-hospital cardiac arrest. We abstracted demographic information and trained clinicians completed daily neurologic examinations using the Glasgow Coma Scale (GCS) and Full Outline of UnResponsiveness brainstem (FOUR-B) and motor (FOUR-M) scores during daily sedation interruption. The change in scores between Day 1 and Day 5 was analyzed using the Kruskal-Wallis Test and logistic regression models. The relationship of FOUR-B, FOUR-M, and GCS with time to death was estimated by fitting cox proportional hazard models. ResultsFOUR-M and GCS did not differ over time (p = 0.10; p = 0.07). FOUR B increased over time (p < 0.01). Time to recovery of brainstem or motor function differed between those treated at 33 °C and 36 °C (p = 0.0023 and p = 0.0032, respectively). FOUR-B, FOUR-M, and GCS differed between survivors and non-survivors (p < 0.01). Time to recovery of brainstem and motor function differed between survivors and non-survivors. FOUR-M and FOUR-B differed between those with good outcome and poor outcome. ConclusionsThe brainstem clinical examination improved during the first 5 days following resuscitation. Brainstem recovery was common in entire cohort and did not differentiate between survivors and non-survivors. Recovery of motor function, however, was associated with survival.

Integral neuroimaging criteria for predicting the outcome of the acute period of spontaneous supratentorial intracerebral hemorrhage on the background of conservative therapy

The aim of the study was to develop criteria for predicting the outcome of the acute period of spontaneous supratentorial intracerebral hemorrhage (SSICH) on the background of conservative therapy, taking into consideration the lesion localization in conjunction with neuroimaging parameters of the quantitative severity assessment of the damage to cerebral structures. Materials and methods. Prospective cohort examination of 314 patients in acute period of SSICH on the ground of conservative treatment. Clinical and neurological examination consisted of using the Full Outline of Unresponsiveness coma scale and NIHHS, neuroimaging with the help of computed tomography with detection of SSICH localization, volume of intracranial hemorrhage, secondary intraventricular hemorrhage and midline shift. Disease acute period outcome was evaluated on the 21st day by the Rankin scale. Results. It was detected that integrated neuroimaging SSICH’s type considering its localization and quantitative severity estimation of cerebral structure injury was closely associated with the disease acute period outcome on the ground of conservative therapy (χ2 Pearson = 308.6, Р &lt; 0.0001). Thus, mortality rate was the highest in patients with posteromedial type of thalamic hemorrhage (50.0 %), global type of thalamic hemorrhage (91.7 %) and massive type of striatocapsular hemorrhage (89.8 %). Unfavorable functional outcome as the modified Rankin scale score 4–5 on 21st disease day predominated among patients with posterolateral types of thalamic hemorrhage (76.5 %) and striacapsular hemorrhage (64.3 %). Whereas the frequency of favorable outcome was the highest among patients with anterior/dorsal type of thalamic hemorrhage (100.0 %), posteromedial (88.0 %), middle (95.0 %), lateral types of striatocapsular hemorrhage (61.9 %) and lobar (74.5 %) hemorrhage. Conclusions. Posteromedial type of thalamic hemorrhage, global type of thalamic hemorrhage and massive type of striatocapsular hemorrhage are the predictors of lethal outcome of the acute period of SSIСH on the background of conservative therapy. Criteria for unfavorable short-term functional outcome are posterolateral types of thalamic and striatocapsular hemorrhage, while anterior/dorsal type of thalamic hemorrhage, posteromedial/middle type of striatocapsular hemorrhage and lobar hemorrhage are associated with favorable outcome of the acute period of the disease.

Comparison of Glasgow Coma Scale with Full Outline of Unresponsiveness Scale for predicting mortality among patients admitted in a Medical Intensive Care Unit

Background: For assessment of unconscious state in Medical Intensive Care Unit, physician mostly rely on Glasgow Coma Scale (GCS). But its verbal component has limitations in aphasic and intubated patient. More over its predilection ability to mortality is hardly challenged. The FOUR (Full outline of unresponsiveness) score, a new coma scale, evaluates 4 components: Eye, motor responses, brain stem reflexes and respiration. Aim of this study was to compare Full Outline of Unresponsiveness (FOUR) scale for prediction of mortality among patients admitted in Medical Intensive Care Unit (MICU) of a tertiary care hospital of Bangladesh with Glasgow Coma Scale (GCS). Objectives: To compare prediction of mortality between Glasgow Coma Scale (GCS) and Full Outline of Unresponsiveness (FOUR) scale. Methods: This is a prospective observational study was carried out in the Department of Critical Care Medicine, BIRDEM General Hospital to compare the mortality predilection in between FOUR score and GCS score. All consecutive adult unconscious patients over the age of 18 years were included in this study. Sedated patients were examined while they were not getting sedation or during routine sedation window period. Altered conscious level was examined by both GCS and FOUR scales. Data were collected using a check list containing demographic information, preexisting chronic illness, biochemical markers, imaging findings etc. Later patients were followed up and data regarding ICU stay, mortality and time of discharged from ICU were recorded. Both GCS and FOUR score were compared between survivor and non-survivor group and compared both score in between non-survivor group. Ultimately data were analyzed by using Statistical Package for Social Sciences (SPSS) software (version 20). Results: Total 105 unconscious patients were enrolled within the study after fulfilling inclusion &amp; exclusion criteria. Among them 34 patients were survivor and 71 patient were non-survivor. The mean and SD of age in this study were 64 .55 ±14.65 years. The peak age distribution was (61-70) 39%. Among them 54.3 % (n=57) were male and 45.7 % (n=48) were female. DM (82.85%) was the most common comorbidity and the predominant diagnosis was Septic shock 33% followed by Ischemic stroke 29%, Meningo encephalitis 19.04 %, and Electrolytes imbalance 17.14%, Cardiogenic shock 12.38% etc. In both GCS and FOUR score their value significantly differ in case of both survival ([7.15± 1.56]; P&lt;.0001 and [7.74± 2.26]; P&lt;.0001) and non-survival group ([5.38± 1.96]; P &lt;0.0001) and ([5.35± 2.83]; P &lt;0.0001). But comparison of FOUR score (5.35± 2.83) with GCS (5.38± 1.96) in terms of predicting mortality their value not significantly differ (P &lt;0.93). So both GCS and FOUR score is equally effective predicting mortality among unconscious patients. Conclusion: Both GCS and FOUR score significantly vary among survivor and non-survivor groups of unconscious patients but while comparing them regarding predicting mortality there is no significant differences in both score. Finally we conclude that both GCS and FOUR score equally good at predicting in hospital mortality among unconscious patients admitted in MICU. Bangladesh Crit Care J September 2022; 10(2): 76-81

Sarcopenia in Patients After Severe Brain Injury

Introduction This article deals with the problem of sarcopenia in patients after severe brain injury. It presents the results of the comparative analysis of a group of patients and a group of volunteers with performed muscle fiber ultrasound. Relevance Sarcopenia is a serious complication in a critically ill patient. It appears early and progresses rather quickly during the patient’s critical condition. In order to diagnose sarcopenia, both radiation and ultrasound methods can be used. The use of ultrasound methods is less labor-intensive, energy-consuming, and economically costly and does not involve an increase in radiation exposure to the patient. The paper highlights the use and comparison of these methods in patients after severe brain injuries. Aim of study To assess the severity of sarcopenia in patients after severe brain injuries. Materials and methods 25 patients were included in this study with an average age of 56.75±19.84 years, ranging from 22 to 82 years, after severe brain injury in a minimally conscious state according to the FOUR (Full Outline of Unresponsiveness) scale, median 12 (12; 15) points. The assessment was carried out in the first 3 days from the moment of admission to the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology. For comparison purposes, the study included 19 volunteers aged 35.63±7.02 years, ranging from 21 to 47 years. Results The data obtained indicate that patients after severe brain injuries had pronounced muscle fiber disorders affecting its thickness and echogenicity. The thickness of the biceps on the side of the brain injury was 0.93±0.27 cm (min 0.5; max 1.58) and the thickness of the biceps on the side opposite to the brain injury was 0.62±0.2 cm (min 0.27; max 0.93) with p=0.0007, statistically significant. In terms of echogenicity, the differences were not statistically significant (p=0.1). The thickness of the triceps on the side of the brain injury was 0.5±0.17 cm (min 0.25; max 0.82) and the thickness of the triceps on the opposite side to the brain injury was 0.38±0.14 cm (min 0.2; max 0.8) with p=0.028, statistically significant, while the degree of echogenicity according to the Modified Heckmatt scale on the side of the brain injury was 2.5 [2.0; 3.0] (min 2.0; max 4.0), and on the opposite side — 3.0 [3.0; 4.0] (min 2.0; max 4.0), p=0.01, statistically significant. The thickness of the brachioradialis on the side of the brain injury was 0.59±0.15 cm (min 0.39; max 0.92), on the opposite side — 0.50±0.17 cm (min 0.25; max 0.86), p=0.06, statistically significant; while the degree of echogenicity was 2.0 [2.0; 3.0] (min 1.0; max 4.0) on the side of the brain injury and on the opposite side to the brain injury — 2.5 [2.0; 4.0] (min 2.0; max 4.0), p=0.03, statistically significant. Pronounced statistically significant differences were also obtained in the thickness of the rectus femoris muscle (p=0.06) and its echogenicity (p=0.017). In comparing these indicators with the muscles of healthy volunteers for all indicated parameters p&lt;0.05, in most cases p=0.000001, statistically significant. Using computed tomography of the lumbar spine, a decrease in the cross-sectional area of the psoas muscle was revealed. The following values were obtained from the patients: psoas muscle cross-sectional area on the right side: 7.66±2.72 cm 2 (min 3.84; max 12.95), psoas muscle cross-sectional area on the left side: 7.85±2.64 cm 2 (min 3.7; max 12.6), Skeletal Muscle Index: 53.33±15.34 (min 28; max 81). Conclusion Diagnostic ultrasound methods to assess sarcopenia in patients after severe brain injuries have confirmed their effectiveness. In the present study, this method received a pronounced correlation with radiological techniques to identify patients affected by sarcopenia. We obtained statistically significant differences in the group of volunteers and patients, and some parameters differed by more than 2 times, which indicates the presence of severe sarcopenia in this group of patients.

Hospital to Hospital Transfers of Cerebral Hemorrhage: Characteristics of Early Withdrawal of Life-Sustaining Treatment.

Large intracerebral hemorrhages (ICHs) are associated with significant morbidity and mortality. Patient transfer to higher level centers is common, but care in these centers rarely demonstrably improves morbidity or reduces mortality. Patients may rapidly progress to brain death, but a large number die shortly after transferring because of withdrawal of life-sustaining treatment (WOLST). This outcome may result in poor resource use and unnecessary cost to patients, families, and institutions. We sought to determine clinical and radiographic predictors of early death or WOLST that may alter potential transfer. We performed a retrospective review of patients admitted from outside medical centers to the neurosciences intensive care unit at Saint Marys Mayo Clinic Hospital in Rochester, MN, from January 2014 to December 2019. Patients ≥ 18years old with a spontaneous ICH were included. Exclusion criteria included trauma, subarachnoid hemorrhage, and subdural hematoma. We identified patients who died or underwent WOLST within 24h of transfer. Descriptive characteristics of patients and ICH were collected. Data were analyzed with univariable, multivariable, and logistic regression. Predictive modeling was performed. An additional case-matched study was completed to evaluate for characteristics further. A total of 317 consecutive patients were identified. Forty-two patients were found with early death or WOLST within 24h of transfer. Do not resuscitate/do not intubate (DNR/DNI) code status (odds ratio [OR] 5.23, confidence interval [CI] 3.31-8.28), anticoagulation use (OR 2.11, CI 1.09-4.09), and lower level of consciousness at presentation based on Glasgow Coma Score (OR 1.41, CI 1.29-1.54) and Full Outline of Unresponsiveness (FOUR) score (OR 1.34, CI 1.26-1.46) were associated with WOLST. Associated characteristics on the computed tomography scan included midline shift (OR 4.64, CI 2.32-9.29), hydrocephalus (OR 9.30, CI 4.56-18.96), and intraventricular extension (OR 5.27, CI 2.60-10.68). Case matching restricted to midline shift demonstrated similarity between patients with aggressive care and WOLST. DNR/DNI code status, warfarin use, ICH score, and composite FOUR score were the best predictive characteristics (area under the curve 0.942). Early death or WOLST after ICH within 24h of presentation was most associated with DNR/DNI code status, warfarin use, ICH score, and lower level of consciousness at presentation. These characteristics may be used by clinicians to guide conversations prior to transfer to tertiary care centers.

Comparative Study between Glasgow Coma Scale and Full Outline of Unresponsiveness Scale in Clinical Outcomes Prediction of Neurological Disorders Patients

Comparative Study between Glasgow Coma Scale and Full Outline of Unresponsiveness Scale in Clinical Outcomes Prediction of Neurological Disorders Patients

Comparison of Glasgow Coma Scale and Full Outline of UnResponsiveness score for prediction of in-hospital mortality in traumatic brain injury patients: a systematic review and meta-analysis.

Currently, Glasgow Coma Scale (GCS) is used to assess patients' level of consciousness. Although this tool is highly popular in clinical settings, it has various limitations that reduce its applicability in certain situations. This had led researchers to look for alternative scoring systems. This study aims to compare the value of GCS and Full Outline of UnResponsiveness (FOUR) score for prediction of mortality in traumatic brain injury (TBI) patients through a systematic review and meta-analysis. Online databases of Medline, Embase, Scopus, and Web of Science were searched until the end of July 2022 for studies that had compared GCS and FOUR score in TBI patients. Interested outcomes were mortality and unfavorable outcome (mortality + disability). Findings are reported as area under the curve (AUC) sensitivity, specificity, and diagnostic odds ratio. 20 articles (comprised of 2083 patients) were included in this study. AUC of GCS and FOUR score for prediction of in-hospital mortality after TBI was 0.92 (95% CI 0.80-0.91) and 0.91 (95% CI 0.88-0.93) respectively. The diagnostic odds ratio of the two scores for prediction of in-hospital mortality after TBI was 44.51 (95% CI 23.58-84.03) for GCS and 45.16 (95% CI 24.25-84.09) for FOUR score. As for prediction of unfavorable outcome after TBI, AUC of GCS and FOUR score were 0.95 (95% CI 0.93 to 0.97) and 0.93 (95% CI 0.91-0.95), respectively. The diagnostic odds ratios for prediction of unfavorable outcome after TBI were 66.31 (95% CI 35.05-125.45) for GCS and 45.39 (95% CI 23.09-89.23) for FOUR score. Moderate level of evidence showed that the value of GCS and FOUR score in the prediction of in-hospital mortality and unfavorable outcome is comparable. The similar performance of these scores in assessment of TBI patients gives the medical staff the option to use either one of them according to the situation at hand.

Prediction of outcomes among mechanically ventilated patients with acute traumatic brain injury

Background Literature review cites that traumatic brain injury (TBI) worldwide is rising, mainly owing to injuries associated with the increased use of motor vehicles. TBI is a serious public health problem in Egypt. Although the Glasgow coma scale (GCS) is the most commonly used scale, the Full Outline of Unresponsiveness (FOUR) scale is a new coma scale as an alternative to GCS in the evaluation of the level of consciousness. Aim To compare the predicted outcomes among mechanically ventilated patients with acute TBI using the GCS and the FOUR scale. Research design A descriptive comparative design was used to achieve the aim of the study. Setting The study was conducted in one of the ICUs of Cairo University Hospitals. Patients and methods A purposive sample of 124 critically ill adult patients connected to mechanical ventilators and diagnosed as having acute TBI was used. Tools of data collection Three tools were used: tool I, an assessment form for patients with mechanically ventilated acute TBI; tool II, GCS, and tool III, FOUR scale. Results The mean age of the study sample was 29.02±3.41 years, 80.6% were males, and majority of them had road traffic accident as the cause of injury. There was a significant statistical difference between GCS and FOUR with respect to duration/days of connection to mechanical ventilation [GCS (P=0.000) and FOUR (P=0.001)]; no complications (P=0.000); seizure (P=0.000); meningitis (P=0.017); and seizure, brain edema, meningitis, and cerebral hemorrhage (P=0.000). Conclusion High sensitivity and specificity of the FOUR scale for patients’ outcomes (death/survival) were documented in comparison with the GCS. Recommendation Further studies have to be carried out to compare FOUR scale with other tools among a larger probability sample in different geographical locations on a national level.

Predictive Accuracy of Full Outline of Unresponsiveness Score and GCS to Predict Patient’s Poor Outcome in Pediatrics ICU

Aim: To compare the predictive accuracy of Glasgow coma Scale (GCS) versus full outline of unresponsiveness score (FOUR score) for poor out-come prediction in children admitted in paediatric ICU. Study design: Descriptive cross-sectional study. Place and duration of study: Department of Pediatrics, Services Hospital Lahore from 29th June 2017 to 29th December 2017. Methodology: One hundred and seventy children were enrolled. Both GCS and FOUR scale scores were recorded in paediatric intensive care unit (ICU) by clinical examination within 30 minutes of arrival in ICU. Both GCS and FOUR score were calculated on each and every patient. Responses were noted by clinically examining the eye, motor, verbal and brain stem reflexes. Patients were followed upto 7 days and poor outcome was noted. Results: The frequency of pediatric mortality was 52 (30.59%). Predictive accuracy of Full Outline of Unresponsiveness Score (FOUR score) for poor outcome prediction in children admitted in paediatrics ICU showed 63.46% for sensitivity, 86.44% for specificity, 67.35% for PPV, 84.30% for NPV and 79.41% for accuracy rate, whereas predictive accuracy of GCS Score for prediction of poor outcome in children admitted in paediatrics ICU shows 55.76% for sensitivity, 83.89% for specificity, 60.42% for PPV, 81.15% for NPV and 75.29% for accuracy rate. Conclusion: The FOUR and GCS both showed good results in terms of mortality after one week of admission in pediatric ICU. Key words: Children, poor outcome, FOUR score, Glasgow coma scale, predictive accuracy

Presentation of trauma patients in a tertiary care hospital in Pakistan.

Objective: To observe the presentation, nature of injury and outcome of patients presenting with trauma in the leading emergency setting of Pakistan. Study Design: Cross Sectional. Setting: Jinnah Sindh Medical University/Jinnah Postgraduate Medical Center. Period: July 2019 to December 2019. Material &amp; Methods: Patient’s age, location and mode of injury, duration from injury to emergency department, Glasgow coma scale (GCS), full outline of unresponsiveness (FOUR) score and outcome of patients were measured. Results: The most common age group presenting to the emergency department in tertiary care hospital in Karachi was between 18 to 40 (61.4%). The most common head injury was laceration (16.9%) and the most common chest injury was pneumothorax (2.6%). The most common mode of injury was road traffic accidents (76.8%). 73.3% had mild Glasgow coma scale (GCS) and the most common full outline of unresponsiveness (FOUR) score was between 13-16 (79.6%). Conclusion: Road traffic accidents are contributing to a significant number of patients coming to the emergency department with trauma. Head injury is very frequent in patients presenting to patients in ER.

Comparative study to assess traumatic head injury patient with full outline of unresponsiveness score scale and glasgow coma scale in neurosurgical intensive care unit

Context: FOUR Score is a more operational tool for critically ill patients who are intubated cause requiring no verbal items. Aim: We aimed to A Comparative Study To Assess Traumatic Head Injury Patient With Full Outline Of Unresponsiveness Score Scale And Glasgow Coma Scale In Neurosurgical Intensive Care Unit At K.H. Karad. setting and design: The study was conducted among 55 patients who were admitted in neurosurgical intensive care unit Krishna hospital karad. A convenient sampling technique was used for selecting the sample. The qualitative research design was used.Analysis: statistical analysis was performed using instat software. Result: Assessed GCS and FOUR score on admission,1st hour,6th hour and 24th hour all time patient found in semiconscious state except in FOUR score at 24 th hour patient found conscious state. Conclusion: FOUR Sore was very useful than GCS, as the FOUR Score contain additional part of brain stem reflexes for pupil’s examination and respiration that will useful to assessment of consciousness in intubated patient.

Assessing validity and reliability of glasgow coma scale and full outline of unresponsiveness score

Background: Monitoring accurately the patient’s level of consciousness is vital to the management and prognosis. Glasgow coma scale (GCS) the gold standard tool is associated with the discrepancy in scoring eye component and the non-usability of verbal component. The full outline of unresponsiveness (FOUR) score a recently validated tool surpasses the deficits of the GCS tool, examined for its accuracy in assessment, and predicting the outcomes of patients with altered level of consciousness. Aim: To evaluate the predictive value of the GCS and FOUR score tool in relation to the outcomes among patients in altered level of consciousness. Design: A systematic review. Data sources: The MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane Central Register of Controlled Trials (Cochrane Library), EMBASE, PsycINFO and Web of Science were searched “between” 2011 – 2021 and presented using PRISMA. Review methods: Research studies, which compared the GCS and FOUR score in predicting the outcome of patients with altered level of consciousness, were included. Results: 23 studies, which compared the GCS and FOUR score, were included in this review based on the inclusion criteria.

TO STUDY THE ROLE AND EFFICACY OF NEUROHYPERBARIC OXYGEN THERAPY IN PATIENTS WITH HEAD INJURY IN A TERTIARY CARE HOSPITAL.

Traumatic brain injury (TBI) is a major health problem worldwide, resulting in signicant morbidity, mortality and the survivors are often left with cognitive and behavioural disabilities. Various treatment options in TBI are focussed on altering the secondary brain injury. Hyperbaric oxygen therapy (HBOT) is one such adjunctive treatments for TBI, which addresses the TBI induced ischemia and hypoxia. The present study was conducted to assess the role and efcacy of HBOT in patients with head injury mainly in terms of improvement of consciousness and cognitive functions. The study also assessed the level of disability and the level of recovery in patients with traumatic brain injury, immediately post therapy. A total of 120 patients with mild and moderate TBI were included in the present study, 60 patients each in the study or HBOT group and the control group. Depending upon the clinical and radiological ndings of the patients, the HBOT/study group received medical management and HBOT, whereas the control group received only medical management. The improvement in level of consciousness was assessed by Glasgow coma scale (GCS) score, Full outline of Unresponsiveness (FOUR) score. The level of cognitive improvement is assessed by the Ranchos Los Amigos scale and Montreal Cognitive assessment score. The level of disability was assessed by Disability Rating Scale (DRS) and the level of recovery was assessed by Glasgow Outcome Scale (GOS) and Glasgow Outcome Scale Extended (GOS-E) The HBOT group showed signicant improvement in the level of consciousness when compared to the control group. In terms of cognitive improvement, mixed results were obtained. However, there was no signicant difference in the level of disability and recovery post therapy in both the groups.

Effectiveness of the Full Outline of UnResponsiveness Score in Patients With Acute Ischemic Stroke.

BackgroundPredicting the mortality and prognosis of patients with stroke is one of the commonly studied topics. Various scoring systems have been used in this regard. One of them is the Full Outline of UnResponsiveness (FOUR) score. In this study, we aimed to investigate the utility of the FOUR scores in terms of their ability to predict hospital stay duration and mortality in patients who were diagnosed with ischemic stroke upon their admission to the emergency department.MethodsOur study is a prospective observational study. Patients who were admitted to the emergency department of a tertiary hospital and diagnosed with ischemic stroke between August 1, 2020, and August 1, 2021, were included in the study. The inclusion criteria were as follows: being over the age of 18, being diagnosed with ischemic stroke, having symptoms that started within the last 48 hours, and patient consent approved by the patients themselves or their relatives. The patients were divided into two groups according to the FOUR scores (FOUR score = 16 and FOUR score < 16). Patients’ demographic information, vital parameters, symptoms, time to admission, comorbidities, laboratory parameters, length of hospitalization, mortality, and Glasgow Coma Scale (GCS), FOUR, and National Institutes of Health Stroke Scale (NIHSS) scores were recorded.ResultsA total of 79 patients were included in the current study, of which 47 (59.5%) were male. The patients included in the present study had a mean age of 66 ± 13 years. When the two groups of patients with a FOUR score of 16 and a FOUR score of below 16 were compared, the mean platelet count was found to be 248 ± 70 × 103/L in the former group and 170 ± 84 × 103/L in the latter (p = 0.004). Sixty-five (91.5%) of the patients in the group with a FOUR score of 16 and three (37.5%) of the patients in the group with a FOUR score of less than 16 stayed for more than six hours in the hospital (p < 0.001). When the patients were evaluated for intensive care unit (ICU) admission rates, five (62.5%) patients with a FOUR score of <16 were admitted to the ICU. This rate was 2.8% (n = 2) in the group of patients with a FOUR score of 16 and was found to be significantly lower (p < 0.001).ConclusionThe FOUR score was found to be useful in predicting the ICU admission rate of patients with ischemic stroke. It has also been shown that the admission time was shorter in patients with a lower FOUR score, and platelet counts were also lower in this group.

Disorders of Consciousness

The components of consciousness are classically separated into two major groups: level of arousal and content of thought processes (better known as being awake and aware). Disorders can affect both components or can affect only the content of consciousness. Physicians assess consciousness indirectly by observing a patient’s response to stimuli. This chapter covers the clinical approach to the comatose patient, which discusses history, physical examination (general and neurologic), localization principles, bihemispheric syndromes, and brainstem syndromes. Diagnostic tests discussed include blood tests, tests of other body fluids, and neuroimaging (e.g., computed tomography, magnetic resonance imaging, functional neuroimaging and physiologic testing). Also discussed are prognosis and brain death. Figures illustrate the Full Outline of Unresponsiveness (FOUR) scale, the spectrum of pupil abnormalities and causes, as well as anatomic structures and dorsal and ventral pathways involved with the maintenance of consciousness. Tables include the Glasgow Coma Scale, blood gas abnormalities due to toxins, and prognostic factors in nontraumatic coma. This chapter contains 45 references.

A Comparison of Full Outline of UnResponsiveness Score with Glasgow Coma Scale Score in Predicting Outcomes among Patients with Altered Mental Status Admitted to the Critical Care Unit.

ABSTRACTAimComparison of the Full Outline of UnResponsiveness (FOUR) score with the Glasgow Coma Scale (GCS) score to find the better scoring system for predicting outcomes among altered sensorium patients in the critical care unit.Materials and methodsThis is a prospective observational study. It included 100 patients of altered sensorium, whose GCS and FOUR scores were calculated at admission and followed up till death or discharge to note the outcome. Individual demographics and diagnosis were recorded, and the results were analyzed statistically.ResultsThe correlation between the two scores was excellent, with the Spearman's correlation coefficient of 0.88. Discrimination ability of the two scoring systems, as assessed by the area under the receiver operating characteristic curve, was 0.778 for GCS score and 0.883 for FOUR score (p <0.001). When area under the curve (AUC) was calculated exclusively in stroke cases, it was 0.836 for GCS score and 0.944 for FOUR score. Among nonstroke cases, the AUC was 0.756 and 0.859, respectively. However, the 95% confidence limits were overlapping among the corresponding scores.ConclusionThe above study concludes that there is a good correlation between GCS and FOUR scores in predicting outcomes. Superiority of FOUR score could not be established statistically in view of overlapping confidence limits. However, it performed at par with GCS in prognosticating mortality among patients with altered sensorium.Clinical significanceIn critically ill patients with altered sensorium, explaining the prognosis to the attendants is a challenge for the physician. The commonly used GCS score has several shortcomings, especially in intubated patients. Use of the FOUR score can overcome these shortcomings and help in prognostication of these patients. In view of its good correlation with GCS score and equal efficacy in predicting outcomes in varied etiologies, it can be used as a good alternative to the GCS score.How to cite this articleJavvaji PK, Nagatham P, Venkata RR, Puttam H, John SK, Karavalla H, et al. A Comparison of Full Outline of UnResponsiveness Score with Glasgow Coma Scale Score in Predicting Outcomes among Patients with Altered Mental Status Admitted to the Critical Care Unit. Indian J Crit Care Med 2022;26(2):210–215.