Unresponsiveness Score Research Articles

Comparison of the Turkish versions of the Glasgow coma scale and four score used by intensive care nurses for neurological evaluation.

This study aimed to compare the use of the Turkish versions of the Glasgow Coma Scale (GCS) and Full Outline of UnResponsiveness (FOUR) Score by intensive care nurses in neurological evaluation. This cross-sectional study was conducted between July 2018 and March 2019 with 92 patients in the general intensive care unit (ICU) of the training and research hospital of a private university. Data were collected using nurse and patient information forms, the GCS and the FOUR Score. The patients were evaluated by 27 intensive care nurses. To evaluate interrater reliability of the GCS and FOUR Score, each patient in the study was evaluated using both scales by two nurses who were blinded to each other's responses. Comparison of the patients' mean GCS and FOUR Score values from the two nurses revealed no significant difference in subscale or total scores (p>0.05). Evaluation of interrater reliability demonstrated very good agreement (κ=0.935, p<0.001). There was also very good agreement between the results of the two nurse groups when the patients' total scores were categorised according to the cut-off points for the two instruments (κ=0.927, p<0.001). This study demonstrated excellent agreement in the Turkish GCS and FOUR Score values, indicating that both scales can be used in neurological evaluation. Both instruments are reliable and easily applied by ICU nurses. The Turkish versions of the FOUR Score and GCS are both appropriate for use in intensive care units and are reliable tools for use by intensive care unit nurses.

Combination of neuron-specific enolase measurement and initial neurological examination for the prediction of neurological outcomes after cardiac arrest

This study aimed to investigate the efficacy of the combination of neuron-specific enolase (NSE) measurement and initial neurological examination in predicting the neurological outcomes of patients with cardiac arrest (CA) by retrospectively analyzing data from the Korean Hypothermia Network prospective registry. NSE levels were recorded at 48 and 72 h after CA. The initial Full Outline of UnResponsiveness (FOUR) and Glasgow Coma Scale (GCS) scores were recorded. These variables were categorized using the scorecard method. The primary endpoint was poor neurological outcomes at 6 months. Of the 475 patients, 171 (36%) had good neurological outcomes at 6 months. The areas under the curve (AUCs) of the categorized NSE levels at 72 h, GCS score, and FOUR score were 0.889, 0.722, and 0.779, respectively. The AUCs of the combinations of categorized NSE levels at 72 h with categorized GCS scores and FOUR score were 0.910 and 0.912, respectively. Each combination was significantly higher than the AUC value of the categorized NSE level at 72 h alone (with GCS: p = 0.015; with FOUR: p = 0.026). Combining NSE measurement and initial neurological examination improved the prediction of neurological outcomes.

Prognostic Utility of Daily Changes in Glasgow Coma Scale and the Full Outline of Unresponsiveness Score Measurement in Patients with Metabolic Encephalopathy, Central Nervous System Infections and Stroke in Uganda.

Metabolic encephalopathy (ME), central nervous system (CNS) infections, and stroke are common causes of reduced level of consciousness in Uganda. However, the prognostic utility of changes in the daily measurements of the Full Outline of Unresponsiveness (FOUR) score and Glasgow Coma Scale (GCS) score in these specific disorders is not known. We conducted secondary analyses of data from patients who presented with reduced level of consciousness due to CNS infections, stroke, or ME to a tertiary hospital in Uganda. Patients had FOUR/GCS scores at admission and at 24 and 48h. We calculated a change in FOUR score (ΔFOUR) and change in GCS score (ΔGCS) at 24 and 48h and used logistic regression models to determine whether these changes were predictive of 30-day mortality. In addition, we determined the prognostic utility of adding the admission score to the 24-h ΔFOUR and 24-h ΔGCS on mortality. We analyzed data from 230 patients (86 with ME, 79 with CNS infections, and 65 with stroke). The mean (SD) age was 50.8 (21.3) years, 27% (61 of 230) had HIV infection, and 62% (134 of 230) were peasant farmers. ΔFOUR at 24h was predictive of mortality among those with ME (odds ratio [OR] 0.64 [95% confidence interval {CI} 0.48-0.84]; p = 0.001) and those with CNS infections (OR 0.65 [95% CI 0.48-0.87]; p = 0.004) but not in those with stroke (OR 1.0 [95% CI 0.73-1.38]; p = 0.998). However, ΔGCS at 24h was only predictive of mortality in the ME group (OR 0.69 [95% CI 0.56-0.86]; p = 0.001) and not in the CNS or stroke group. This 24-h ΔGCS and ΔFOUR pattern was similar at 48h in all subgroups. The addition of an admission score to either 24-h ΔFOUR or 24-h ΔGCS significantly improved the predictive ability of the scores in those with stroke and CNS infection but not in those with ME. Twenty-four-hour and 48-h ΔFOUR and ΔGCS are predictive of mortality in Ugandan patients with CNS infections and ME but not in those with stroke. For individuals with stroke, the admission score plays a more significant predictive role that the change in scores.

Comparison of the Full Outline of Unresponsiveness Score with the Glasgow Coma Scale as a Coma Assessment Scale in Pediatric Intensive Care

AbstractRapid assessment of cerebral dysfunction is crucial for the management of patients in intensive care units. The Glasgow Coma Scale (GCS) evaluates eye, verbal, and motor responses, but is insufficient to effectively evaluate patients on mechanical ventilation, or who are unable to speak. The Full Outline of Unresponsiveness (FOUR) score includes additional information such as brainstem reflexes and respiratory status to provide a more complete clinical assessment. In this study, we aimed to compare the FOUR score with GCS in the assessment of patients with coma. This prospective study included patients between 1 month and under 18 years of age, who were hospitalized in the pediatric intensive care unit due to risk of coma or ongoing impairment of consciousness between May 2018 and June 2019. Information regarding FOUR scores, GCS values, patient demographics, duration of hospitalization, requirement for mechanical ventilation, and patient comorbidities were recorded and analyzed. Among the 80 patients included in the study, a statistically significant correlation was found between (low) GCS and FOUR scores during admission, and mortality and requirement for mechanical ventilation. Monitoring the level of consciousness is important in pediatric intensive care units and may be predictive of the course and disease outcome. Similar to the GCS, the FOUR score is a good indicator for predicting mortality and requirement for mechanical ventilation.

GCS score combined with CT score and serum S100B protein level Can evaluate severity and early prognosis of acute traumatic brain injury

To explore the value of Glasgow Coma Scale (GCS) score and CT score combined with serum S100B protein level for evaluation of injury severity and predicting early prognosis of acute traumatic brain injury (TBI). A total of 108 patients with TBI admitted within 24 h after injury in the Emergency Department of West China Hospital from May, 2019 to May, 2020 were enrolled in this study. The clinical data, laboratory test results, CT examination, GCS score, Full Outline of Unresponsiveness score, Fisher CT classification, Rotterdam CT score, and serum S100B protein level of the patients were collected upon admission. The patients were followed up for 28 days and divided based on their Glasgow Outcome Scale (GOS) scores into poor prognosis group (GOS 1-3) and good prognosis group (GOS 4-5). The indexes related to poor prognosis were analyzed for their efficacy for predicting the patinets' prognosis. According to the results of head CT, the patients were divided into CT- positive (CT+) group and CT- negative (CT-) group, and the efficacy of serum S100B protein level for predicting CT positivity was evaluated. Compared with those with favorable prognosis, the patients with poor prognosis had significantly lower GCS scores (P < 0.01) and higher Rotterdam CT score and serum S100B protein levels (P < 0.01). Among the 3 index, serum S100B protein level had the highest AUC value (0.79); among the combined indexes, GCS score combined with serum S100B protein had the highest AUC value (0.80). Serum S100B protein level was significantly higher in CT+ group than in CT - group (P < 0.05) with a significant correlation with Rotterdam CT score (r=0.26, P < 0.01). Serum S100B protein level, GCS score, and Rotterdam CT score can be used as indicators for evaluating the severity of acute TBI, and they are all closely related with early prognosis of the patients. The combination of serum S100B protein, GCS score and Rotterdam CT score has better performance than any of the 3 indexes alone for predicting early prognosis of the patients. Serum S100B protein level is correlated with head imaging findings of patients with acute TBI, but its value in selection of appropriate imaging modalities awaits further investigation.

Faktor-Faktor yang Berhubungan dengan Kejadian Luka Dekubitus Akibat Penggunaan Alat Medis di Ruang PICU

The use of medical devices in patients treated at the Pediatric Intensive Care Unit (PICU) is very high. Patients who are treated in intensive care are also at risk for medical device-related pressure injury (MDRPI). This study aimed to determine the factors associated with the incidence of MRDPI in the Pediatric Intensive Care Unit (PICU) RSUP DR. Wahidin Sudirohusodo Makassar. This study used an observational analytic method with a prospective cohort approach. The Sampling method used a simple random sampling of 76 people. This research was conducted on 8 May - 6 July 2019. The data collection technique used an observation sheet with the research instrument used in the form of the Pediatric Early Warning Scoring System to assess critical conditions, the level of awareness was fully used Full Outline of UnResponsiveness score (FOUR Score). The data were analyzed tested by using the statistical the Chi Square with a confidence level of 95%. All data were analyzed using the SPSS version 21.0 program (SPSS, Inc. Chicago, IL). Factors associated with the MDRPI incidence include critical conditions based on PEWSS (p = 0.002), level of awareness based on the FOUR Score (p = 0.025), number of devices installed (p = 0.015), and fixation techniques (p = 0.025). As for peripheral tissue perfusion (p = 0.268), albumin (p = 0.309), skin moisture (p = 0.888) were not related. Factors associated with the incidence of MDRPI include critical condition, level of awareness, number of devices installed, and fixation techniques. It’s recommended to make preventive efforts.

Brain Injury in Critical Illness and a Note on the Virus

Brain Injury in Critical Illness and a Note on the Virus

Full Outline of Unresponsiveness Score and Brainstem Sign Score Application to Predict Mortality of Patients with Severe Head Injuries at Gambiran Public Hospital of Kediri

There are many factors and variables that influence the prognosis in patients with severe head injuries make determining the prognosis for patients with severe head injuries become difficult. There are two parameters that can predict the prognosis of severe head injury patients with optimal full outline of unresponsiveness score (FOUR score) and brainstem sign score (BSS). FOUR scores can provide a wealth of information about the scale of neurological signs that are quick and easy used for unconcious patients. BSS is an assessment to predict the death of a person permanently to determine whether there is a physiological function that is not function normally. The aimed of this study was to determine ratio of FOUR score and BSS in determining the prognosis of patients with severe head injury at RSUD Gambiran Kediri. The type of study was cross sectional approach. The sampling technique used consecutive sampling technique and obtained a sample of 60 people. The data was analyzed by using chi-square test for comparison of FOUR score and BSS in determining the prognosis of severe head injury patient at RSUD Gambiran Kediri. Based on the results of study by chi-square test showed that p FOUR score = p BSS = 0,004, which meant the FOUR score and BSS was determined the prognosis of patients with severe traumatic head injury at RSUD Gambiran Kediri. The study showed that there was no difference between the FOUR score and BSS in determining the prognosis of severe head injury patient at RSUD Gambiran Kediri but FOUR score could be used in incubated or ventilated patients. Based on the results of this study, it is advisable to use scoring method more easily and according to the condition of the patient is with the installed ventilator or non ventilator.

FOUR Score sebagai Alternatif dalam Menilai Derajat Keparahan dan Memprediksi Mortalitas pada Pasien Cedera Otak Traumatik yang Diintubasi

The ideal consciousness scoring scale must be linear, reliable, valid, and user-friendly. There is a need to develop and validate a scale to quickly evaluate the level of consciousness, the severity of the disease, and the prognosis of morbidity and mortality. Glasgow Coma Scale (GCS) is the most commonly used tool to assess the level of consciousness and is considered the gold standard. However, GCS has several limitations, such as inability to evaluate verbal components in intubated patients. To overcome these challenges, researchers developed the Full Outline of UnResponsiveness (FOUR) score. FOUR scores is a clinical grading scale to assess the altered state of consciousness. FOUR scores is simpler and able to provide better information, especially in intubated-traumatic brain injury (TBI) patients. Some studies showed that GCS and FOUR scores have the high predictive value in predicting not only the mortality of trauma patients but also the outcome of discharged patients. A multicentre study showed that FOUR scores and GCS do not differ in predicting inpatient mortality. This study suggested that the FOUR scores could be a better diagnostic tool for assessing brainstem reflexes and breathing patterns. Unfortunately, some studies have found conflicting results between GCS and FOUR scores in predicting patient outcomes. These contradictions suggest the need to conduct more studies. Therefore, this literature review will compare GCS and FOUR scores in predicting mortality of TBI patients.

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

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.

Effect of integrative nursing practices on cognitive recovery among severe traumatic brain injury patients

Background and objective: Cognitive recovery after severe traumatic brain injury (TBI) is the biggest challenge facing the critical care nurses (CCNs). Several studies have been reported that the majority of CCNs are concerned with providing conventional nursing practices to severe TBI patients. These practices are directed to stabilize patients’ status rather than to enhance cognitive recovery after TBI. Application of integrative nursing practices for TBI patients can help in enhancing cognitive recovery. Aim: This study aimed to determine the effect of integrative nursing practices on cognitive recovery among severe traumatic brain injury patients.Methods: A quasi experimental research design was utilized. A convenience sample was conducted on 60 adult patients suffering from severe TBI who admitted to the intensive care units of Alexandria Main University Hospital. Patients were assigned into study group (30 patients) and control group (30 patients). One tool was used for data collection namely “Cognitive Recovery Assessment Tool”. This tool was used to assess recovery of cognitive function domains. It consists of level of consciousness using Full Outline of Un-Responsiveness (FOUR) score, level of cognitive functioning using Rancho Los Amigos (RLA) scale and basic cognitive sensory recovery assessment using Western Neuro Sensory Stimulation Profile (WNSSP) scale.Results: The implementation of integrative nursing practices for the study group was associated with statistically significant positive effects. Patients in the study group showed higher means of consciousness revealed by FOUR score and cognitive function revealed by RLA scale. The basic cognitive sensory recovery revealed by WNSSP scale in the study group was also significantly improved.Conclusions: Implementation of integrative nursing practices has been shown to enhance cognitive recovery among severe TBI patients. Thus, it is recommended for use in a nurse’s daily routine of care for severe TBI patients.

Full outline of unresponsiveness score as a predictor of outcomes in critically ill pediatric patients

Background Mortality predictions are very important for improving service quality in the pediatric intensive care unit (PICU). The full outline of unresponsiveness (FOUR) is a new coma scale and is considered capable of predicting mortality and outcome.&#x0D; Objective To assess the ability of FOUR scores to predict outcomes of critically ill patients in the PICU.&#x0D; Methods This prospective cohort study included children aged 1 months - 18 years who were admitted to the PICU. Subjects were assessed by FOUR, grouped into score &lt; 9 or score &gt;9, and followed until outcomes were obtained. Bivariate analysis to assess the risk of death was made by cross-tabulation and the strength of the association in the form of risk ratio by Chi-square test. Multivariate analysis was done by logistic regression test.&#x0D; Results Of 94 subjects, 47 had FOUR scores ≤9 and 47 subjects had FOUR &gt;9. Bivariate analysis revealed that PICU patients with FOUR score ≤9 had a higher risk of death than those with FOUR score &gt;9 (RR 12.5; 95%CI 3.1 to 49.8; P&lt;0.0001). Multivariate analysis revealed that FOUR score, length of stay ≤7 days, and non-surgical disease significantly increased the risk of mortality in PICU patients (by 42.8 times, 8.9 times, and 5.9 times, respectively).&#x0D; Conclusion The FOUR scores have good ability to predict the outcomes of critically ill pediatric patients. A FOUR score ≤9 at the beginning of treatment is significantly associated with the outcome of mortality during treatment in the PICU.

Full outline of unresponsiveness score as a predictor of outcomes in critically ill pediatric patients

Background Mortality predictions are very important for improving service quality in the pediatric intensive care unit (PICU). The full outline of unresponsiveness (FOUR) is a new coma scale and is considered capable of predicting mortality and outcome.&#x0D; Objective To assess the ability of FOUR scores to predict outcomes of critically ill patients in the PICU.&#x0D; Methods This prospective cohort study included children aged 1 months - 18 years who were admitted to the PICU. Subjects were assessed by FOUR, grouped into score &lt; 9 or score &gt;9, and followed until outcomes were obtained. Bivariate analysis to assess the risk of death was made by cross-tabulation and the strength of the association in the form of risk ratio by Chi-square test. Multivariate analysis was done by logistic regression test.&#x0D; Results Of 94 subjects, 47 had FOUR scores ≤9 and 47 subjects had FOUR &gt;9. Bivariate analysis revealed that PICU patients with FOUR score ≤9 had a higher risk of death than those with FOUR score &gt;9 (RR 12.5; 95%CI 3.1 to 49.8; P&lt;0.0001). Multivariate analysis revealed that FOUR score, length of stay ≤7 days, and non-surgical disease significantly increased the risk of mortality in PICU patients (by 42.8 times, 8.9 times, and 5.9 times, respectively).&#x0D; Conclusion The FOUR scores have good ability to predict the outcomes of critically ill pediatric patients. A FOUR score ≤9 at the beginning of treatment is significantly associated with the outcome of mortality during treatment in the PICU.

Predictive value of full outline of unresponsiveness (FOUR) score and GLASGOW coma scale (GCS) in outcome of children aged 1-14 years admitted with altered sensorium

Background: Evaluation of altered consciousness in children is a challenge and an important aspect of emergency care. There is no objective measure to communicate and document the severity of coma as distinct from vital signs. Various coma scales have been developed for recording depth of consciousness which are widely used in clinical practice in adults and children. Studies are conflicting on the best quick assessment tool for neurologic status. One of the newer tools is the Full Outline of Unresponsiveness (FOUR) score has been developed to assess the depth of coma in a more detailed manner than the Glasgow Coma Scale (GCS) scale. Objectives: The present study was taken to determine the predictive value of FOUR score and GCS in outcome of children aged 1–14 years presenting with altered sensorium. Materials and Methods: This prospective observational study was conducted in the teaching hospital of Haryana. A total of 150 children aged between 1 and 14 years were included. FOUR score and GCS were obtained within 1 h of admission. This assessment was repeated at 12th h and 24th h after admission. Children who left against medical advice were telephonically contacted to determine the final outcome, and they were called for 1-month follow-up. Results: The mean age was 6.64 ± 4.13 years. Seventy-nine (52.66%) patients were male and 71 (47.33%) were female. GCS at admission, 12th h, and 24th h was 7.76 ± 2.91, 7.22 ± 3.60, and 7.22 ± 4.57, respectively. The mean FOUR score was 10.12 ± 3.92 which decreased continuously at 12th h, 24th h, and finally, at discharge, i.e., 10.29 ± 8.13 (P > 0.05). A total of 53 (35.33%) patients expired and 97 (64.66%) were discharged. A total of 69 patients were admitted to the pediatric intensive care unit (PICU). The mean duration of PICU stay was 5.84 ± 5.25. Patients who expired had lesser GCS score as compared to FOUR score at the time of admission and 12th h, i.e., 5.79 ± 2.18 and 6.54 ± 3.40 and 4.20 ± 2.62 and 4.30 ± 3.70, respectively. The mean GCS at the time of admission was 5.79 ± 2.8 which decreased significantly to 0.679 ± 2.28 and FOUR score decreased from 6.54 ± 3.40 to 0.35 ± 2.21 at the time in expired (P &#A60; 0.001). Conclusions: FOUR score can be used as good as GCS for predicting the inhospital mortality. GCS and FOUR scores both have a significant correlation with death. The study shows an excellent degree of agreement between GCS and FOUR scores at admission, at 12th h, at 24th h, and at discharge. FOUR score has better odds for predicting mortality on admission and at 24th h, whereas GCS at 12th h is better than FOUR score at 12th h in predicting mortality.

Differences of the Glasgow Coma Scale and the Full Outline of Unresponsiveness Scores on Consciousness Level Examination

Consciousness is an integration between the sensory system, reasoning, imagination and emotions, and memory in receiving and processing information from the internal and external environment. Due to the large spectrum and causes of impaired consciousness, several methods are needed to check the level of consciousness, they are Glasgow Coma Scale and the Full Outline of Unresponsiveness Score. This article summarizes the differences in the use of the Glasgow Coma Scale and Full Outline of Unresponsiveness score methods in measuring the level of consciousness. The method used is literature searching from various national and international journals and using a digital library such as www.ncbi.nlm.nih.gov and Google Scholar with keyword Full Outline of Unresponsiveness (FOUR) score AND/OR Glasgow Coma Scale. The literature used totaled 14 articles which published in 2006 to 2019. The analytical method used is a systematic literature review method by systematically identifying, reviewing, and investigating research in terms of its title, approach, objectives, results, and discussion with a particular topic focus. The results of this literature study indicate that there are differences in the assessment components, inter-rater reliability, and differences in the predictive ability of mortality in the Glasgow Coma Scale method and the Full Outline of Unresponsiveness score so that the Full Outline of Unresponsiveness score can be an alternative or complement to Glasgow Coma Scale in measuring the level of consciousness.

The Full Outline of UnResponsiveness score is more efficient than the Glasgow Coma Scale in the prognosis of stroke

Objectives: After being a solid method of measuring consciousness for decades,the Glasgow Coma Scale (GCS) was offered to bereplaced with a better option: The Full Outline of Unresponsiveness (FOUR) score, which several studies later confirmed to besuperior due to its independence from verbal response and ability to consider brain stem reflexes. In this study, we decided to comparethe two scales in the prognosis of stroke, which has never been conducted before.Patients and Methods: We conducted both methods on 150 stroke patients during admission to the emergency service and assessedthem during a 3-month follow-up after discharge.Results: The type of stroke was 80% ischemic and 20% hemorrhagic. 55.3% survived after a 3-month follow-up. The FOUR score hada significant converse relation with hospitalization, a relation with the GCS lacked. The FOUR score also had a stronger correlationwith the outcome of stroke than the GCS. Additionally, the receiver operating characteristic (ROC) curve showed greater sensitivityand specificity in the FOUR score in the prognoses of stroke patients.Conclusion: We recommend using the FOUR score as the first priority.

Metabolic Encephalopathy - Part I

Encephalopathy can range from the acute confusional state to frank coma, and is broadly defined as a constellation of symptoms and signs reflecting diffuse cerebral dysfunction. The potential causes of encephalopathy are vast requiring a thorough initial assessment and systematic diagnostic approach. Obtaining a comprehensive history may be challenging and ancillary sources of information are often helpful in narrowing the differential diagnosis. The general examination may provide hints as to the cause of encephalopathy and the neurologic examination can guide both acute management and focus the diagnostic investigations on specific etiologies which fit the clinical presentation. The systemic manifestations of infection and toxic exposures are common causes of encephalopathy. In sepsis, not only is brain perfusion compromised, multi system dysfunction is common and additional factors related to the specific infection such as hypoxia in pneumonia or secondary CNS involvement can complicate management. An understanding of the common physical examination findings of toxic exposures can aid in the diagnosis and rapid treatment of reversible toxic encephalopathies such as narcotics, benzodiazepines or environmental toxins. Cardiopulmonary dysfunction can lead to hypoxic-ischemic encephalopathy and advances in critical care, and particularly targeted temperature management following cardiac arrest, have improved the neurologic outcome in these patients. This review contains 2 figures, 3 tables, and 25 references. Key words: encephalopathy, delirium, ascending reticular activating system, acute confusional state, subclinical seizures, Glasgow Coma Scale, Full Outline of Unresponsiveness (FOUR) Score , hypoxic-ischemic encephalopathy, neuroleptic malignant syndrome, serum neuron-specific enolase

Metabolic Encephalopathy - Part I

Encephalopathy can range from the acute confusional state to frank coma, and is broadly defined as a constellation of symptoms and signs reflecting diffuse cerebral dysfunction. The potential causes of encephalopathy are vast requiring a thorough initial assessment and systematic diagnostic approach. Obtaining a comprehensive history may be challenging and ancillary sources of information are often helpful in narrowing the differential diagnosis. The general examination may provide hints as to the cause of encephalopathy and the neurologic examination can guide both acute management and focus the diagnostic investigations on specific etiologies which fit the clinical presentation. The systemic manifestations of infection and toxic exposures are common causes of encephalopathy. In sepsis, not only is brain perfusion compromised, multi system dysfunction is common and additional factors related to the specific infection such as hypoxia in pneumonia or secondary CNS involvement can complicate management. An understanding of the common physical examination findings of toxic exposures can aid in the diagnosis and rapid treatment of reversible toxic encephalopathies such as narcotics, benzodiazepines or environmental toxins. Cardiopulmonary dysfunction can lead to hypoxic-ischemic encephalopathy and advances in critical care, and particularly targeted temperature management following cardiac arrest, have improved the neurologic outcome in these patients. This review contains 2 figures, 3 tables, and 25 references. Key words: encephalopathy, delirium, ascending reticular activating system, acute confusional state, subclinical seizures, Glasgow Coma Scale, Full Outline of Unresponsiveness (FOUR) Score , hypoxic-ischemic encephalopathy, neuroleptic malignant syndrome, serum neuron-specific enolase

Extracorporeal Cardiopulmonary Resuscitation in a Cardiac Arrest Patient Due to Digoxin Overdose Who Was Awake During Conventional Cardiopulmonary Resuscitation

Introduction: Digoxin overdose, which may cause rhythm disturbances, such as atrioventricular blocks, can ultimately cause cardiac arrest. Extracorporeal life support may provide time until specific antidotes show an effect. Case Report: A 75-year-old male patient presented with dyspnea with a known history of congestive heart failure. His medications included digoxin, and his initial electrocardiography showed an idioventricular rhythm. His digoxin level was over the upper normal limit, and he had hyperkalemia (7.9 Meq/L). The patient collapsed during conventional therapies, including insulin-glucose infusion, atropine administration, and catheterization for emergency hemodialysis, and while awaiting digoxin-specific fragment antibodies. During mechanical cardiopulmonary resuscitation, the patient was awake and had a Full Outline of Unresponsiveness score of 8, which led us to initiate veno-arterial extracorporeal membrane oxygenation. Conclusion: Extracorporeal Cardiopulmonary Resuscitation, might be a useful option for intoxicated patients when conventional therapies fail. However, more experience is needed for the increase in survival rate.

The Relationship of the FOUR Score to Patient Outcome: A Systematic Review.

The Full Outline of UnResponsiveness (FOUR) score assessment of consciousness replaces the Glasgow Coma Scale (GCS) verbal component with assessment of brainstem reflexes. A comprehensive overview studying the relationship between a patient's FOUR score and outcome is lacking. We aim to systematically review published literature reporting the relationship of FOUR score to outcome in adult patients with impaired consciousness. We systematically searched for records of relevant studies: CENTRAL, MEDLINE, EMBASE, Scopus, Web of Science, ClinicalTrials.gov, and OpenGrey. Prospective, observational studies of patients with impaired consciousness were included where consciousness was assessed using FOUR score, and where the outcome in mortality or validated functional outcome scores was reported. Consensus-based screening and quality appraisal were performed. Outcome prognostication was synthesized narratively. Forty records (37 studies) were identified, with overall low (n = 2), moderate (n = 25), or high (n = 13) risk of bias. There was significant heterogeneity in patient characteristics. FOUR score showed good to excellent prognostication of in-hospital mortality in most studies (area under curve [AUC], >0.80). It was good at predicting poor functional outcome (AUC, 0.80–0.90). There was some evidence that motor and eye components (also GCS components) had better prognostic ability than brainstem components. Overall, FOUR score relates closely to in-hospital mortality and poor functional outcome. More studies with standardized design are needed to better characterize it in different patient groups, confirm the differences between its four components, and compare it with the performance of GCS and its recently described derivative, the GCS-Pupils, which includes pupil response as a fourth component.