Hypoxemic - Anoxic Brain injury

Several factors are important prognostic findings, particularly in patients who have not received significant sedation The outcome of hypoxic–ischaemic brain injury worsens if:

• The patient has been in coma (ie, unresponsive) for >6 h.
• There are no spontaneous limb movements or localisation to painful stimuli in the initial stages.
• There is prolonged loss of pupillary responses (provided atropine has not been administered).
• There is sustained conjugate eye deviation (upgaze or downgaze).
• There are specific forms of abnormal eye movements (eg, upbeat and downbeat nystagmus, ping pong gaze or period alternating nystagmus).
• There are myoclonic seizures.
• Lower cranial nerve function is involved (eg, absent cough and gag reflexes).

FOUR score (Full Outline of UnResponsiveness)

Eye response	4	Eyelids open, tracking or blinking to command
	3	Eyelids open but not tracking
	2	Eyelids closed but open to a loud voice
	1	Eyelids closed but open to pain
	0	Eyelids remain closed with pain
Motor response	4	Thumbs-up, fist or peace sign
	3	Localising to pain
	2	Flexion response to pain
	1	Extension response to pain
	0	No response to pain, or generalised myoclonic status
Brainstem reflexes	4	Normal 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	4	Not intubated, regular breathing pattern
	3	Not intubated, Cheyne–Stokes breathing pattern
	2	Not intubated, irregular breathing pattern
	1	Breaths above ventilator rate
	0	Breaths at ventilator rate, or apnoea

http://pn.bmj.com/content/11/1/4.full#F2