The essential neurological examination of the unconscious patient in the emergency room

The Neurological Exam of a Comatose Patient: An Essential Practical Guide

A thorough examination of a comatose patient is essential given the spectrum of clinical diagnoses. The most immediate threat to patients is airway, breathing and circulation. All attending physician should employ a structured and focused approach in dealing with a comatose patient. It is important to recognise the urgent steps needed at the time to prevent further deterioration, followed by the final diagnosis of patient’s neurologic status. Here we provide the essential practical guide to the neurological exam of a comatose patient that would assist to determine the aetiology, location and nature of the neurological lesion.

The current significance of the FOUR score: A systematic review and critical analysis of the literature

BACKGROUND

The Full Outline of Un-Responsiveness Score (FOURs) is a scale for clinical assessment of consciousness that was introduced to overcome disadvantages of the widely accepted Glasgow Coma Scale (GCS).

OBJECTIVE

To carry out a systematic review and critical analysis of the available literature on the clinical application of FOURs and perform a comparison to GCS, in terms of reliability and predictive value.

METHODS

Initial search retrieved a total of 147 papers. After applying strict inclusion criteria and further article selection to overcome data heterogeneity, a statistical comparison of inter-rater reliability, in-hospital mortality and long-term outcome prediction between the two scales in the adult and pediatric population was done.

RESULTS

Even though FOURs is more complicated than GCS, its application remains quite simple. Its reliability, validity and predictive value have been supported by an increasing number of studies, especially in critical care. A statistically significant difference (p = .034) in predicting in-hospital mortality in adults, in favor of FOURs when compared to GCS, was found. However, whether it poses a clinically significant advantage in detecting patients' deterioration and outcome prediction, compared to other scaling systems, remains unclear.

CONCLUSIONS

Further studies are needed to discern the FOURs' clinical usefulness, especially in patients in non-critical condition, with milder disorders of consciousness.

The essential neurological examination of the unconscious patient in the emergency room

OBJECTIVE

To determine whether neurologists with long-term experience in the emergency room are in general agreement about the essential components of the neurological examination (NE) used on unconscious patients in whom an obvious cause for coma is lacking.

METHODS

We surveyed 31 board-certified practicing neurologists who regularly examine unconscious patients in the emergency room and asked them to list the specific components of the NE that they would normally choose to apply in at least 80% of cases.

RESULTS

Twenty-seven neurologists rated 24 of 38 items as essential steps of the neurological examination of the unconscious patient, with a high level of agreement amongst survey participants.

CONCLUSIONS

There was a high degree of consensus amongst the neurologists surveyed about which steps are essential for the NE of the unconscious patient. These findings provide an important source of validation for teaching this particular NE to medical students, as well as nonneurologists working in an emergency setting.