Full Outline of Unresponsiveness Score (FOUR)

Coma Scales. The Glasgow Coma Scale score (see Section 14, Plate 14-15) for best motor response in either the upper or lower limbs is rated on a scale of 1 (no response) to 6 (patient-obeys commands). If there is no response or an incomplete reaction to verbal stimuli, a noxious stimulus is applied, preferably to the medial side of the arms or legs, to differentiate a localizing response from abnormal flexor or extensor posturing. If the patient moves the limb toward (rather than away from) the noxious stimulus, the response is not consistent with localization. The patient’s reaction is classified as fending-off movements with localization of pain (score 5), fending-off movements without localization of pain (4), abnormal flexion (3), abnormal extension (2), and no response (1). A localizing response indicates that the stimulus at more than one site causes a limb to move so as to attempt to remove it. A flexor response in the upper limb may vary from rapid withdrawal, associated with abduction of the shoulder, to a slower decorticate posture, with adduction of the shoulder. An extensor response is abnormal and usually associated with adduction, internal rotation of the shoulder, and pronation of the forearm. No response is usually associated with hypotonia. The Glasgow Coma Scale score alone is not an adequate assessment of brainstem function. Further, it does not assess vital signs (blood pressure, heart rate, body temperature, blood sugar), ability to protect the airway and clear any airway obstruction (cough and gag), and suggests what support or intervention is required to restore homeostasis. A newer Full Outline of UnResponsiveness (FOUR) scoring system measures impaired consciousness and specific brainstem responses (see Plate 6-4). The four variables assessed are motor response, brainstem reflexes, eye response, and respiratory pattern. The acronym additionally reflects the number of categories and the maximum number of potential points in each category.

After immediate assessment, the next step is to initiate necessary emergency interventions for life support. For example, an adequate airway must be assured, and an intravenous line should be placed. If the patient is hypoventilating, endotracheal intubation with assisted mechanical respiration should be considered. Intravenous fluid bolus and vasopressors may be needed to treat hypotension. Blood samples should be drawn for measurement of electrolytes, glucose, toxicology, and arterial acid-base and blood gases. Serum is saved for further study if necessary. When bedside testing shows the patient to be hypoglycemic, an intravenous bolus of dextrose should be administered. If narcotic abuse is suspected or if the patient does not respond to supportive measures, an opiate-receptor antagonist, such as naloxone, can be given intravenously.

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