Vivek N. Iyer, MD; Jayawant N. Mandrekar, PhD; Richard D. Danielson, RN;Alexander Y. Zubkov, MD, PhD; Jennifer L. Elmer, RN; and Eelco F. M. Wijdicks, MD, PhD.

Validity of the FOUR Score Coma Scale in the Medical Intensive

Care Unit

Objective

To evaluate the validity of the FOUR score (ranging from 0-16), a new coma scale that consists of 4 components (eye response, motor response, brainstem reflexes and respiration pattern) when used by ICU members.

Patients and Methods

100 critically ill patients were observed for interobserver agreement, comparison by using FOUR score and GCS score.

Observer are randomly assigned to pair (nurse/fellow, nurse/consultant, fellow/fellow, or fellow/consultant)

Result

Interobserver agreement with the FOUR score was excellent (similar to GCS).

In terms of predictive power for poor neurologic outcome, FOUR score is similar to GCS.

Mortality rate for patients with the lowest score is higher with the FOUR score (89%) than GCS (71%)

Conclusion

Interobserver agreement of FOUR score was excellent.

In contrast to GCS, all components of FOUR score can be evaluated in intubated patients.

FOUR score is a good predictor of the prognosis of critically ill patients.

FOUR score has important advantages over the GCS in ICU setting.

Description of FOUR Score

4 components : Eye response Motor response Brainstem reflexes Respiratory pattern

Eye Response

Motor Response

Brainstem Reflexes

Respiratory Pattern

Outcome Assessment

Morbidity was assessed at 3 months with Modified Rankin Scale

0 -> no symptoms1 -> no evident disability, symptoms (+)2 -> slight disability, ADL disturbance (-)3 -> moderate disability, need some help but able

to walk without assistance.4 -> moderately severe disability, unable to walk

without assistance.5 -> severe disability, bed ridden, incontinent,

require constant caring6 -> death

Statistical Analysis

Pairwise weighted k valuesOverall weighted k valuesIntraclass correlation

Cornbach α calculated for assessment of internal consistencySpearman correlation calculated between FOUR score and GCS score

Calculated for FOUR Score and GCS Score

Result

FOUR SCore

FOUR Score

Glasgow Coma Scale

FOUR Score

Glasgow Coma Scale

Cont...

High degree of internal consistency for both FOUR and GCS

For every 1 –point increase in the total FOUR Score, the odds of in- hospital mortality were reduced 15%, poor neurologic outcome was reduced 18% (comparable to GCS)

8 of 9 patient with lowest FOUR score died (89%)

15 of 21 patients with lowest GCS score died (71%)

Discussion

The level of interobserver agreement found in the current study was slightly higher than that found by the first validation study

An ideal coma scale would be reliable,valid, linear and easy to use

The GCS has a number of shortcomings,the verbal component. It could not reliably assesed in 45 of the 100 patients in the study

Cont....

The FOUR score aims to overcome these shortcomings because it is both simple to use and comprehensive.

The FOUR score can be easily used in ICU settings

The FOUR score accurately predicts poor outcome,detect braindeath, and diagnose a locked-in syndrome

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