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Volume 2; Issue 8; August, 2015
International Journal of
Comprehensive Nursing
ISSN: 2349 - 5413
The Role of Four Score Scale in the Assessment of Coma
Hema Viswanatha Halasyam1*, Parameswari2 and Delci Rani3
1
Principal, Faculty of Nursing, Dr MGR Deemed University, Chennai, Tamil Nadu, India.
Associate Professor, Faculty of Nursing, Dr MGR Deemed University, Chennai, Tamil Nadu, India.
3
Post Graduate Student, Faculty of Nursing, Dr MGR Deemed University, Chennai, Tamil Nadu, India.
2
A R T I C L E
I N F O
Article History:
Received 21 July 2015
Received in revised form 14
August 2015
Accepted 20 August 2015
Available online 30 August
2015
Key words:
Coma, Four Score Scale, Level
of Consciousness, Consciousness assessment, Eye response, Motor response, Brain
stem reflex respiration.
A B S T R A C T
Consciousness is a state of general awareness of oneself and the environment
and it includes the ability to orient towards a new stimuli. It is always customary
to use a Glascow Coma Scale in order to assess the level of consciousness.
A clinical grading scale called Full Outline of Unresponsiveness Score
Scale (FOUR score scale), developed by Dr. Eelco F.M. Wijdicks takes
only a few minutes to assess patients with impaired level of consciousness
with or without endotracheal intubation. It does not include a verbal response
and can therefore be used to assess artificially ventilated or intubated patients.
Several prospective studies have validated the four score scale as a reliable
tool in assessing stuporous and comatose patients. The FOUR score scale
can be reliably used in the Emergency Department and in the Intensive Care
Units by nursing staff.
Introduction
Consciousness is a state of general awareness of oneself and the environment, it includes the ability to orient towards
a new stimuli. Level of Consciousness is gauged on a continuum, with a normal state of alertness and full cognition
(consciousness) on one end and coma on other end. [1]
Coma is a clinical state of unarousable, unresponsiveness in which there are no purposeful responses to internal or
external stimuli, although non purposeful responses to painful stimuli and brain stem reflexes may be present.[1]
Despite advances in technology, a complete clinical assessment is essential to identify subtle changes in a patient’s
neurological status. More over a thorough assessment is fundamental to the management of neuroscience patients.
The ideal assessment scale should be reliable, valid, linear and easy to use. In addition, these scales may predict
outcome also. However mortality rates in the ICU are also confounded by withdrawal of life support.
Glasgow Coma Scale (GCS) is considered as a standard assessment tool to assess coma. GCS assesses eye response,
verbal response and motor response of patients.[2] Despite its wide use in hospital settings it has a number of
shortcomings such as,
Ø Agitation and confusion can occur among patients without impairment of consciousness. In this situation
the verbal component of assessing level of consciousness can be questioned.
Ø Many patients with little or no verbal response are alert.
Ø It often becomes impossible to assess the verbal response in intubated patients.
Ø Most importantly, the GCS does not assess brainstem reflexes, eye movements, or complex motor responses
in patients with altered consciousness.
Ø In addition, the GCS performs poorly in assessing patients with less severe degrees of coma, such as those
seen in the medical ICU.
Ø Eye opening and motor response becomes difficult to elicit due to the frequent use of mild sedation in the
medical and surgical ICU.
Ø In contrast, all 3 components of the GCS are affected by sedation.
*Corresponding author.
Email address: [email protected]
Hema Viswanatha Halasyam, Parameswari and Delci Rani, The Role of Four Score Scale in the Assessment of
Coma, IJCN, 2015, 2(8):1-3.
August, 2015; Volume 2; Issue 8
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These shortcomings have prompted several earlier attempts to improve on the GCS such as,
o Bouzarth Coma Scale (BCS), (Bouzarth, 1968)
o Maryland Coma Scale (MCS), (Salcman et. al, 1981)
o Glasgow-Liege Scale (GLS), (Born et. al, 1982)
o Comprehensive Level of Consciousness Scale (CLOCS), (Stanczak et.al, 1984)
o Reaction Level Scale (RLS), (Malcolm Elliott, 1985)
o Clinical Neurologic Assessment Tool (CNA), (Crosby and parsons, 1989)
o Innsbruck Coma Scale (ICS), (Benner et. al, 1991)
o Coma Recovery Scale (CRS), (Giacino et.al, 1991, 2004)
These scales are quite lengthy due to many testable components and hence cannot be substituted for the GCS. [3]
This paper has made an attempt to provide an understanding about the role of the recently developed FOUR SCORE
SCALE (2005) which is used to assess the level of consciouseness among patients in ICU.
Four Score Scale
The FOUR score scale “FULL OUTLINE OF UNRESPONSIVENESS” is a clinical grading coma scale which was
designed by Dr. Eelco F.M. Wijdicks and his colleagues in Neuro-Critical care at the Mayo Clinic in Rochester, in the
year 2005.[4]
This scale helps to calculate the depth of coma and provide better assessment of unconscious patients. It has four
components – Eye response, Motor response, Brainstem reflexes, and Respiration. Here the four components are not
totalled. FOUR score scale, takes into account the respiratory component when the patient is intubated. Each component
measures on a 0 to 4scale, with 0 indicating the complete lack of response and 4 indicating a normal response.[5]
Components
EYE RESPONSE (E)
In testing the EYE RESPONSE, the patient’s eye opening will be assessed.[5] The Eye Response is scored as follows:
4 - Eyelids open or opened, tracking or blinking to command
3 - Eyelids open but not tracking
2 - Eyelids closed but open to loud voice
1 - Eyelids closed but opens to pain
0 - Eyelids remain closed with pain
MOTOR RESPONSE (M)
In testing the Motor Response, the patient is asked to make a ‘fist’ or ‘thumbs up’, ‘victory’, or ‘peace’ sign. A patient
who’s able to perform these actions may have good understanding and capacity to perform a motor response.[5] The
motor response is scored as follows:
4- Thumbs up, fist, or peace sign to command.
3- Localizing to pain.
2- Flexion response to pain.
1- Extensor posturing
0- No response to pain or generalized myoclonus, Status epilepticus.
BRAIN STEM REFLEX (B)
In testing the Brain stem reflex response, the patient’s pupillary and corneal response and cough reflex is assessed.[5]
(For avoiding corneal damage, a drop of saline solution is instilled into the eye.) Brainstem reflex testing may give an
idea about progression to brain death and is scored as follows:
4 - Pupil and corneal reflexes present
3 - One pupil wide and fixed
2 - Pupil or corneal reflexes absent
1- Pupil and corneal reflexes absent
0 - Absent pupil, corneal and cough reflex
RESPIRATION (R)
In testing the Respiration Response a score of either 0 or 1 is given depending on whether the patient is breathing at
or above the preset ventilator rate.[5] The respiration score is graded as follows
4 - Not intubated, regular breathing pattern
3 - Not intubated, Cheyne -Stokes breathing pattern
2 - Not intubated, irregular breathing pattern
1 - Breathes above ventilator rate
0 - Breathes at ventilator rate or apnoea
Implications
· The FOUR score can be used in variety of ICU settings including paediatrics.
· Useful for the patients with acute metabolic derangements, sepsis, shock and /or with the other non-structural
brain injuries.
· It can be applied for the patients with catastrophic neurologic event that result from the complication of
medical illness or surgery.
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Volume 2; Issue 8; August, 2015
Nursing students can also be taught to assess the patient’s level of consciousness using FOUR Score Scale.
Comparison can be made with the other types of coma scale.
Evidence based practices in the use of Coma Scale has to be performed.
Research Evidence
Vivek N.Iyer, Jayawant N. Mandrekar (2009) evaluated the validity of FOUR score and also prospectively evaluated the
use of FOUR score scale by comparing with Glasgow Coma Scale in 100 critically ill patients from May 1, 2007 to April
30, 2008 from all ICUs of Mayo Clinic’s Saint Marys Hospital.[6] For each patient, the FOUR score and the GCS score
were determined by a randomly selected staff pair (nurse/fellow, nurse/consultant, fellow/fellow, or fellow/consultant).
Results showed that the inter rater agreement of FOUR score was excellent among medical intensivists. The study
concluded that the FOUR score is a good predictor of the prognosis of critically ill patients.
Seel RT et al (2010) conducted a systematic review of behavioural assessment scales for disorders of consciousness
(DOC). The objective of this review was to provide evidence-based recommendations for clinical use based on their
content validity, reliability, diagnostic validity, and ability to predict functional outcomes; and provide research
recommendations on DOC scale development and validation. Thirteen primary terms that defined DOC were paired
with 30 secondary terms that defined aspects of measurement.[4] The initial search yielded 580 articles. After paired
rated review of study abstracts, guideline development was based on 37 articles representing 13 DOC scales. The Full
Outline of Unresponsiveness Score (FOUR) showed substantial evidence of internal consistency and good inter rater
reliability. The FOUR score scale was not recommended for bedside behavioral assessment of DOC at this time because
of a lack of content validity, lack of standardization, and/or unproven reliability.
Anita Mercy S (2013) conducted a study to assess the reliability of the FOUR score scale in critically ill patients of main
ICU of PGIMER, Chandigarh. In this study, scoring of GCS and FOUR score were performed by anaesthetists and
nurses on 21 patients. In a total of 100 pair-wise ratings, the inter-rater agreement for both the FOUR score (k = 0.65) and
the GCS (k = 0.66) was good among nurse - anaesthetist pair.[7] The internal consistency for both the FOUR score (á =
0.97) and the GCS scale (á = 0.94) was excellent. A good correlation was found between the FOUR score and the GCS
(ñ = 0.94, p = 0.001). The predictive validity of the FOUR score is slightly higher than the GCS in this population.
Conclusion
Many ICUs still rely on the Glasgow Coma Scale as it is very simple and easy to use. It is very vital that nurses keep
abreast on the recent trends in all aspects of patient care starting from assessment. It is also recommended that nurses
working in critical care areas be trained and made proficient in using the FOUR score scale. For better patient assessment
in neuro-critical care areas a complimentary grading system FOUR score scale, can be used.
Nurses should also focus on research studies to test the reliability of FOUR Score Scale. Nursing Research in use of
Coma Scales should be geared up so as to enhance evidence based practice.
Conflict of Interest: NIL
Source of Support: NIL
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