four score coma scale
TRANSCRIPT
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FOUR Score Coma Scale
Full Outline of Unresponsiveness
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Geschiedenis
1974 Teasdale and Jenett
Attempt to bring uniformity to the clinical examination and clinical communication about the level of consciousness
GCS
Not designed to capture distinct details of the neurologic examination
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FOUR
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FOUR
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FOUR
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FOUR
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Voordelen
Measurement of brainstemreflexes
Determination of eye opening, blinking and tracking
A broad spectrum of motor responses
Presence of abnormal breath rhythms and a respiratory drive
NO assessment of verbal responses (intubation)
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Eye response
Differentiation betweenVegetative state
(eyes open but do not track)
Locked in syndrome(eyes open, blink and track vertically on command)
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Motor assessment
Combination:Withdrawal reflex
Decorticate rigidity
Complex command (alert)
Severe cerebral dysfunction
(Myoclonic status epilepticus)
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Brainstem components
Pons
Mesencephalon
Medulla oblongata
Various combinations
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Breathing components
Cheyne-Stokes respiration
Irregular breathing
Bihemispheric or lower brainstem
dysfunction
Intubation: presence or absence of a
respiratory drive
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Studie
Different types of examinersWatched a 20min instruction on the FOUR
score (videos with patient examples)
Exclusie sedation/neuromuscular function blockers
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Studie
4 categories:Alert
Drowsy
Stuporous
Comatose
Each patient was rated on both scales by
two different raters (1 hours)
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Outcome assessment
A robust predictor of: In-hospital mortality (withdrawal of life support)
Functional outcome at hospital discharge
Clinical diagnosis of brain death
Morbidity at 3 months
Modified Rankin Scale
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Rankin score
0 : No symptoms
1 : No evident disability despite symptoms
2 : Slight disability, with an inability to carry
out all previous activities
3 : Moderate disability, with the need for
some help but the ability to walk without
assistance
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Rankin score
4 : Moderately severe disability, with the
inability to walk without assistance or to
attend to bodily needs without assistance
5 : Severe disability, with the patient being
bedridden and incontinent and requiring
constant nursing care
6 : Death
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Ideal coma scale
Reliable (measures what it is supposed to measure)
Valid (yields the same results with repeated testing)
Linear (gives all component equal weight)
Easy to use (provides simple instructions without the need for tools or cards)
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Shortcomings GCS
Verbal componentOrientationQuickly abnormal (agitation/confusion)
Conversely no respose alert
Intubation
Poorly assessing patients with less severe degrees of coma
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Shortcomings GCS
No assessment of brainstem reflexes(eye movements, complex motor responses)
Reliability
Numerically toward motor responses
Linearity
May not detect subtle changes
Attempts to improve GCS (lengthy)
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FOUR: Voordelen
High degree of: Internal consistency
Interrater reliability (interobserver agreement)*
Intubated patients
Brainstem reflexes
Respiratory patterns
Further characterizes the severity of the comatose state in patients with lowest GCS (Mortality)
* High proportion alert patient (ER)
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FOUR: Voordelen
Detects early changes in consciousness
(Acute metabolic derangements, sepsis, shock, other nonstructural brain injuries)
Frequent use of mild sedation affects: Eye opening
Motor response
NOT:Brainstem reflexes
Respiration.
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Limitations
4 maal: familiarity
Number of patients
Nurse/nurse
Target enrollment cohort
Alert patients
Single center study
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Conclusion
Easily taught, simple to administer and provides essentiel neurologic information
limited experience neuroscience
Accurately predicts pour outcome
Interobserver agreement (GCS)
Detect occurence of brain death
Diagnose a locked-in syndrome
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Referenties
Vivek et all. Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clinic Proc. 2009;84(8):694-701
Latha et all. Validation of a new coma scale, the FOUR score, in the emergency department. Neurocrit Care. 2009; 10:50-54
Chris et all. Further validation of the FOUR score coma scale by intensive care nurses. Mayo Clin Proc. 2007; 82(4):435-438
Eelco et all. Validation of a new coma scale: the FOUR score. Ann Neurol. 2005;58:585-593