A.A. Belkin1,2, P.Yu. Bochkarev1, A.L. Levit1, I.B. Zabolotskikh3
1 Sverdlovsk Regional Clinical Hospital № 1, Yekaterinburg, Russia
2 Federal State Budgetary Educational Institution of Higher Education “Urals State Medical University” of the Ministry of Healthcare of the Russian Federation, Yekaterinburg, Russia
3 Federal State Budgetary Educational Institution of Higher Education “Kuban State Medical University” of the Ministry of Healthcare of the Russian Federation, Krasnodar, Russia
For correspondence: Andrey A. Belkin — Dr. Med. Sci., Professor of the Department of Nervous Diseases and Anaesthesiology-Reanimatology of the Ural State Medical University, Yekaterinburg; e-mail: email@example.com
For citation: Belkin AA, Bochkarev PYu, Levit AL, Zabolotskikh IB. Evaluation of consciousness: the FOUR scale or the Glasgow coma scale? Review. Annals of Critical Care. 2019;3:46–51.
Assessing the level of consciousness is one of the key competencies of medical workers involved in the provision of emergency care. For 45 years, the Glasgow Coma Scale has been used for this, which has the highest level of interdisciplinary consistency and reproducibility, for which it was recognized as the gold standard for assessing consciousness when patients are admitted to the intensive care unit. But along with the advantage of simplicity and extensive experience in application, it has a number of significant drawbacks. In particular, the impossibility of verbal contact in intubated patients, the presence of motor aphasia and delirium deliberately reduces the score in the speech section, which is fraught with an underestimation of the overall assessment of the level of consciousness. It is also significant that GCS does not evaluate brain stem reflexes, eye movements, or complex motor reactions, which excludes the possibility of a reliable assessment of the condition of a patient with subtentorial damage and in a state of chronic impaired consciousness.
As our own experience and preliminary analysis of the literature showed, these shortcomings are absent in the Full Outline of UnResponsiveness (FOUR) scale developed by FM Wijdicks at the Mayo Clinic in 2005. The spread of the FOUR scale in many countries and the growing need for effective monitoring of patients with acute cerebral injury motivated Federation of anesthesiologists of Russia (FAR) to initiate a multicenter study. The purpose of the study: validation, assessment of reproducibility and consistency of the results of using the Russian-language version of the FOUR scale for multidisciplinary use in patients with impaired consciousness. Prospective cohort nonrandomized study is completed at three centers that routinely use this scale in their practice for several years (“FOUR-Rus” NCT04018989 ClinicalTrials.gov).
Keywords: FOUR, Full Outline of UnResponsiveness, GCS, acute brain injury
- Teasdale G., Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974; 2(7872): 81–84. DOI: 10.1016/s0140-6736(74)91639-0
- Koziol J., Hacke W. Multivariate data reduction by principal components with application to neurological scoring instruments. J. Neurol. 1990; 237(8): 461–464.
- Teasdale G., Maas A., Lecky F., et al. The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol. 2014; 13: 844–854. DOI: 10.1016/S1474-4422(14)70120-6
- Murray G.D., Butcher I., McHugh G.S., et al. Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J. Neurotrauma. 2007; 24: 329–337. DOI: 10.1089/neu.2006.0035
- Baker M. Reviewing the application of the Glasgow Coma Scale: Does it have interrater reliability? Br. J. Neurosci Nurs. 2008; 4: 342–347.
- Reith F.C.M., Van den Brande R., Synnot A., et al. The reliability of the Glasgow Coma Scale: a systematic review. Intensive Care Medicine. 2015; 42(1): 3–15. DOI: 10.1007/s00134-015-4124-3
- Braine M.E., Cook N. The Glasgow Coma Scale and evidence-informed practice: a critical review of where we are and where we need to be. Journal of Clinical Nursing. 2016; 26(1–2): 280–293. DOI: 10.1111/jocn.13390
- Rowley G., Fielding K. Reliability and accuracy of the Glasgow Coma Scale. Lancet. 1991; 337(8740): 535–538. DOI: 10.1016/0140-6736(91)91309-i
- Meredith W., Rutledge R., Fakhry S.M., et al. The conundrum of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores. J Trauma. 1998; 44(5): 839-44. DOI: 10.1097/00005373-199805000-00016
- Starmark J.E., Stålhammar D., Holmgren E., Rosander B. A comparison of the Glasgow Coma Scale and the Reaction Level Scale (RLS85). J Neurosurg 1988; 69: 699–706. DOI: 10.3171/jns.1988.69.5.0699
- Sternbach G.L. The Glasgow Coma Scale. J. Emerg. Med. 2000; 19: 67–71. doi:10.1016/S0736-4679(00)00182-7
- Safar P. Cardiopulmonary cerebral resuscitation. Laerdal, Stavanger (Norway), 1981; p 149.
- Kho M.E., McDonald E., Stratford P.W., Cook D.J. Interrater reliability of APACHE II scores for medical-surgical intensive care patients: a prospective blinded study. Am. J. Crit. Care. 2007; 16(4): 378–383.
- Born J.D., Albert A., Hans P., Bonnal J. Relative prognostic value of best motor response and brain stem reflexes in patients with severe head injury. Neurosurgery. 1985; 16(5): 595–601.
- Wijdicks E.F., Kokmen E., O’Brien P.C. Measurement of impaired consciousness in the neurological intensive care unit: a new test. J. Neurol. Neurosurg. Psychiatry. 1988; 64(1): 117–119. DOI: 10.1136/jnnp.64.1.117
- Wijdicks E.F.M., Bamlet W.R., Maramattom B.V., et al. Validation of a new coma scale: The FOUR score. Annals of Neurology. 2005; 58(4): 585–593. DOI: 10.1002/ana.20611
-  Wolf C.A., Wijdicks E.F., Bamlet W.R., McClelland R.L. Further validation of the FOUR score coma scale by intensive care nurses. Mayo Clin. Proc. 2007; 82(4): 435–438. DOI: 10.4065/82.4.435
- Пирадов М.А., Супонева Н.А., Рябинкина Ю.В. и др. Шкала подробной оценки состояния ареактивных пациентов (Full Outline of UnResponsiveness, FOUR): лингвокультурная адаптация русскоязычной версии. Анналы клинической и экспериментальной неврологии 2019; 13(3): 000–000. DOI: 10.25692/ACEN.2019.3.7. [Piradov M.A., Suponeva N.A., Ryabinkina Yu.V., et al. [Full Outline of UnResponsiveness (FOUR) scale: translation and linguistic and cultural adaptation of the Russian language version.] Annals of clinical and experimental neurology. 2019; 13(3). (In Russ)]
- Iyer V.N., Mandrekar J.N., Danielson R.D., et al. Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clin Proc. 2009; 84(8): 694–701. DOI: 10.1016/S0025–6196(11)60519-3
- Idrovo L., Fuentes B., Medina J., et al. Validation of the FOUR Score (Spanish Version) in Acute Stroke. An Interobserver Variability Study. European Neurology. 2010; 63(6): 364–369. DOI: 10.1159/000292498
- Hickisch A., Holmefur M. Swedish Translation and Reliability of the Full Outline of Unresponsiveness Score. Journal of Neuroscience Nursing. 2016; 48(4): 195–205. DOI: 10.1097/jnn.0000000000000205
- Foo C.C., Loan J., Brennan P.M. The relationship of the FOUR score to patient outcome: a systematic review. Journal of Neurotrauma. 2019; 36(17): 2469-2483. DOI: 10.1089/neu.2018.6243
- Said T., Chaari A., Hakim K.A., et al. Usefulness of full outline of unresponsiveness score to predict extubation failure in intubated critically-ill patients: A pilot study. Int. J. Crit. Illn. Inj. Sci. 2016; 6(4): 172–177. DOI: 10.4103/2229-5151.195401
- Mishra R.K., Mahajan C., Prabhakar H, et al. Comparison of Full Outline of UnResponsiveness (FOUR) score and the conventional scores in predicting outcome in aneurysmal subarachnoid haemorrhage patients. 2019. Indian J Anaesth. 2019; 63(4): 295-299. DOI: 10.4103/ija.IJA_786_18
- Zeiler F.A., Lo B.W.Y., Akoth E., et al. Predicting Outcome in Subarachnoid Hemorrhage (SAH) Utilizing the Full Outline of UnResponsiveness (FOUR) Score. Neurocritical Care. 2017; 27(3): 381–391. DOI: 10.1007/s12028-017-0396-5