Hrev_master [page 22] [Emergency Care Journal 2024; 20:12121] Emergency Care Journal 2024 volume 20:12121 Abstract The Glasgow Coma Scale (GCS) is a widely used clinical tool for assessing impaired consciousness, but concerns arise when applied to intubated patients or those receiving analgesics, sedati- ves, and paralytics because verbal scores are not evaluable. Furthermore, the GCS does not differentiate the neurological status of the patient once intubated, resulting in poor reliability in neuro- logical assessment, and clinical indicators that may reflect the severity of the coma are not included in the GCS. This study explo- res alternative tools for neurological assessment in Intensive Care Units (ICUs) when GCS is impractical. Conducting an integrative review of studies from 2018 to 2022, we identified seven relevant papers. Results indicate the FOUR score as a promising GCS alter- native, particularly in cases where the GCS is unavailable. Automated pupillometry also demonstrated the potential for moni- toring neurologically impaired ICU patients. These tools, indepen- dent of verbal responses and applicable to sedated patients, offer improved accuracy in assessing consciousness. The study empha- sizes the importance of adopting such alternatives, and addressing GCS limitations, and highlights the need for further research and implementation to enhance patient care in ICU settings. Introduction The alteration of the state of consciousness represents a very frequent neurological emergency in some contexts, including the intensive care unit but there is still no evidence that defines a uni- form way of evaluating this condition. Numerous behavioral scales have been validated and developed, both for rehabilitation and intensive settings, which allow to determine the level of conscious- ness and allow an accurate diagnosis of the type of alteration.1 The universal clinical scale used to evaluate altered consciousness is the Glasgow Coma Scale (GCS). It was created for the evaluation of patients with head trauma and then became the most widely used scale for the assessment of the state of consciousness of acute patients with both medical and traumatic pathologies.2 Despite widespread use, numerous concerns have been expressed about the accuracy of the GCS score in intubated patients and those receiv- ing analgesics, sedatives, and paralytics - as verbal scores cannot be evaluated. Furthermore, GCS does not differentiate the neuro- logical condition of the patient once intubated and is unreliable in neurological assessment.3 Therefore, it becomes necessary to find alternative tools, that can be used in Intensive Care Units, in case of the absence of the GCS score capable of evaluating and combin- ing the motor and ocular components and that do not depend on the verbal response. One of the alternative tools available for a correct and effective neurological and consciousness assessment, where the GCS score is poorly reliable or cannot be applied, is the Full Outline of UnResponsiveness score (FOUR)4 and the automated pupillometry.5 Assessment tools The pupillary reflex is one of the most used prognostic factors in the assessment of the severity of a head injury. The scores eval- uating the level of consciousness and the functions of the brain stem were used to create an extended index of clinical severity starting from the Glasgow Coma Scale Pupils Score (GCS-P) analysis. It aims to improve the accuracy of prognostic evaluation in traumatized patients by including the photomotor reflex among the parameters of GCS evaluation.6,7 Pupillary reflex was quanti- Correspondence: Gian Domenico Giusti, Nursing Bachelor Degree Course (School of Nursing), Department of Medicine and Surgery, Perugia University, Piazza Lucio Severi, 1 Edificio B - piano +1, 06132 Perugia, Italy. E-mail: giandomenico.giusti@unipg.it Key words: Glasgow Coma Scale, FOUR scale, automated pupil- lometry, impaired consciousness, neurological assessment. Contributions: AX, GdG, study design; AX, data collection; AX, NR, GdG, data analysis; NR, GdG, study supervision; AX, NR, GdG, manuscript writing; NR, GdG, critical revisions for important intellectual content. Conflict of interest: no conflict of interest has been declared by the authors. Funding: this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Ethics approval: ethical approval for this study was not required because it involved neither experimentation nor patient involvement in active data collection. Received: 22 November 2023. Accepted: 22 January 2023. Early view: 2 February 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Emergency Care Journal 2024; 20:12121 doi:10.4081/ecj.2024.12121 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Beyond the GCS: an integrative review of new tools for neurological assessment in the intensive care unit for adult patients Alessia Xhaferri,1 Nicola Ramacciati,2 Gian Domenico Giusti3,4 1Hospice FARO Foundation, Torino; 2Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende (CS); 3Department of Medicine and Surgery, Perugia University, Perugia; 4Perugia Hospital, Perugia, Italy Non -co mmerc ial us e o nly fied to achieve the new assessment scale, introducing the concept of Pupil Reactivity Score (PRS). PSR can range from 0 to 2, the PRS is obtained by subtracting it from the GCS (range 3-15) to obtain the GCS-P (range 1-15) (Table 1). A new scale for state of consciousness assessment, the Full Outline of UnResponsiveness (FOUR), has recently been proposed.8 This scale introduces ele- ments that allow a more accurate neurological evaluation referring to four components: eye-opening, motor response, brain stem reflexes, and respiratory pattern.9 Each component is a 5-point scale, ranging from 0 to 4, with a combined FOUR score ranging from 0 to 16, where 16 indicates the highest level of consciousness, while the lowest score is zero, indicating brain death1 (Figure 1, Table 2). The FOUR score can be used in multiple intensive set- tings, it is easy to teach, learn, and administer, and it also provides essential information for accurate assessment of patients with impaired state of consciousness.4 In contrast to GCS, where abnor- mal reflexes of the brain stem are not included among the clinical indicators evaluated, in FOUR the reflexes of the brain stem exam- ined are: pupillary and corneal reflex.10 Aim of this review Specifically, this review aimed to answer the following ques- tion: is it possible to identify the limitations of the Glasgow Coma Scale and to find alternative assessment tools capable of assessing the consciousness of patients admitted to the Intensive Care Unit? Materials and Methods We chose to conduct an integrative review, based on Dhollande et al.11 Integrative reviews assimilate research data from various research designs to reach conclusions that are comprehensive and reliable.12 The search for bibliographical sources was conducted between March and October 2022, through PubMed, SCOPUS, Web Of Science, CINAHL, and Cochrane Library. The research strategy used is based on the P&PICO methodol- ogy (Table 3). Picos model (P) Population- subject of the question: adult male and female patients admitted to an intensive care unit with brain damage, who are in a coma or intubated. (I) Intervention - object of investigation: assessment of the state of consciousness through the use and comparison of GCS, Review Table 1. Pupil Reactivity Score (PRS). 2 No pupil shows the photomotor reflection 1 Only one pupil shows the photomotor reflex 0 Both pupils show the photomotor reflex Table 3. Question according to P&PICO methodology. Question according to the P&PICO methodology Population Problem Intervention Comparison Outcome Assisted adults hospitalized Poor Assessment of The use of GCS for the Highlight the GCS at ICU neurological, in a reliability of GCS the state of neurological assessment limits and suggest comatose state and/or intubated score in cases selected consciousness alternative tools of by FOUR and assessment pupillometer Search terms ICU Intensive care unit Adult Neurologic Examination Pupillometry Glasgow Coma Scale Neuro benefit FOUR GCS score Full Outline of Unresponsiveness score Table 2. Full Outline of UnResponsiveness Score (FOUR Score). Ocular response Action Score Open or open, tracer or flashing eyelids 4 Open but not tracer eyelids 3 Closed eyelids but open to verbal recall 2 Closed eyelids but open to painful stimulus 1 Eyelids remain closed even after painful stimulation 0 Motor response Action Score Thumb up, fist up or peace signal 4 Localization to pain 3 Flexion response to pain 2 Response in extension to pain 1 No pain response or generalized myoclonus state 0 Reflexes of the brain stem Action Score Presence of pupils and corneal reflexes 4 A wide and fixed pupil 3 No pupillary or corneal reflexes 2 No pupillary and corneal reflexes 1 Absence of pupillary, corneal and coughing reflex 0 Breathing Action Score Not intubated, regular breathing 4 Not intubated, Cheyne-Stokes breath 3 Not intubated, irregular breathing 2 Breathe over the ventilator frequency 1 Breathe at respiratory rate or apnea 0 [Emergency Care Journal 2024; 20:12121] [page 23] Non -co mmerc ial us e o nly FOUR score, and automated pupillometer. (C) Comparison - applicable alternative intervention: the alter- native intervention to GCS for the assessment of the state of con- sciousness is represented using FOUR scales and an automated pupillometer. (O) Outcome - result: highlight the limits of GCS in the assess- ment of the state of consciousness and propose alternative tools that combine the ocular and motor components. (S) Study design: includes simultaneous assessment of con- sciousness by two scales: the FOUR and GCS scales and neurolog- ical assessment with automated pupillometer, based on strict crite- ria of inclusion and exclusion. The query strings used in the databases were constructed using the keywords with the appropriate boolean operators. For this review, we chose to focus our search on 2018-2022. These dates were selected to capture the most up-to-date trends in this context as it is broadly accepted that research currency spans 3-5 years. Only publications in English with abstract and full-text availability have been examined, the selection criteria used for the studies are described in Table 4. Results and Discussion From the first research, 139 citations were identified. After reading the title and abstracts, 32 publications were relevant to the topic. After the retrieval of the full texts and the full reading of the articles, 7 articles met the criteria of inclusion and exclusion of the revision (Figure 2). These studies included a more complete neurological assess- ment in the assisted with traumatic brain injury (TBI), a synopsis of the selected studies is shown in Table 5. The results of the research showed that to date, several studies have been conducted for the evaluation of the usefulness and reli- ability of the FOUR score compared to GCS, with the aim of including the FOUR score among the clinical evaluation tools, especially in the absence of the GCS score. Over the years many limitations have emerged regarding the use of the Glasgow Coma Scale: inconsistent inter-observer reliability, the impossibility of testing the verbal component in intubated patients, in those receiv- ing paralytic, analgesic, and sedative, absence of evaluation of brain stem reflexes and poor correlation between outcome and low GCS index.3 Moreover, the withdrawal response in the motor com- ponent of GCS can be mistaken for a flexor response, leading to a score error. The study conducted by Brennann and colleagues7 ana- Review Table 4. Inclusion and exclusion criteria for studiesQuestion according to the P&PICO methodology Inclusion criteria Exclusion criteria Adult population Paediatric population Patients admitted to general ICU or neurological ICU Patients admitted in non-intensive settings Peer-reviewed scientific papers Discussions papers, editorial and opinions, dissertations thesis Years from 2018 to 2022 Articles published prior to 2018 and after 2022 English language Articles with full text and abstract available [page 24] [Emergency Care Journal 2024; 20:12121] Figure 1. Description of Full Outline of UnResponsivenes (FOUR) score) (adapted from Iyer et al. 2009;4 reproduction permission has been requested and granted by the author). Non -co mmerc ial us e o nly lyzed data from 15,900 patients from the CRASH and IMPACT studies, the two largest studies in patients with TBI, to evaluate whether the combination of GCS and photomore reflex could pro- vide more accurate information on the outcome of patients com- pared to the two factors taken individually. From the study emerges that the simple addition of the photomore reflex to the GCS allows obtaining a score that combines the easy applicability necessary in the traumatological field to the greater prognostic pre- cision useful in the correct management of the patient, with results similar to those obtained with more complex assessment scales. The FOUR score has several advantages: it is not complex to use, it distinguishes various states of unconsciousness between them, provides important details on brain stem reflexes, and requires minimal need for neurological testing in states of impaired consciousness.12,13 The assessment of the state of consciousness, using FOUR, can be carried out in all patients, including patients with tracheostomy. Through the application of the FOUR scale, it is possible to detect the presence of an uncal hernia, locked-in syn- drome, and the beginning of a vegetative state - all conditions in which the GCS score does not provide much information.14 The FOUR score adds additional information to the GCS eye-opening, including eye tracking, so that mesencephalic and pontine functions are included in the assessment of the state of consciousness. The final category of the FOUR score refers to the different respiratory models. Respiration is evaluated as spontaneous regular or irregular, Cheyne-Stokes breath, intubat- ed but independent of ventilation, dependent ventilation, or absent breath. The assessment of the state of consciousness, with the use of FOUR, can be performed in all patients, including those with an endotracheal tube and it is a good predictor in the prognosis of critically ill clients.4 Whereas eye and motor com- ponents of the GCS represent the global impact of the neurotrau- ma on the brain, the brainstem and respiratory pattern compo- nents of the FOUR score are perhaps assessing more specific brainstem injury, hence the variation seen between patients with different severities of TBI.15 Review Figure 2. PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only. [Emergency Care Journal 2024; 20:12121] [page 25] Non -co mmerc ial us e o nly Review [page 26] [Emergency Care Journal 2024; 20:12121] Ta bl e 5. S tu di es a na ly ze d in th e re vi ew . A ut ho r/ Ye ar A im s T yp e of st ud y S ub je ct s i nc lu de d C on cl us io ns Br en na n et al .,7 20 18 As se ss if th e c om bi na tio n of G CS P ro sp ec tiv e s tu dy D ata an aly sis o f 1 5,9 00 in di vi du als fr om Th e a dd iti on o f t he p ho to m or e r ef lex to th e G CS al lo ws to o bt ain a nd p ho to m ot or re fle cti on ca n pr ov id e m or e a cc ur ate C RA SH an d IM PA CT , t he tw o lar ge st TB I s tu di es a s co re th at co m bi ne s t he ea sy ap pl ica bi lit y ne ce ss ar y in th e in fo rm ati on o n th e o ut co m e o f p ati en ts co m pa re d tra um ato lo gi ca l f iel d to th e g re ate r p ro gn os tic p re cis io n us ef ul in t o th e t wo fa cto rs tak en in di vi du all y t he co rre ct m an ag em en t o f t he p ati en t, wi th re su lts si m ila r t o t ho se o bt ain ed w ith m or e c om pl ex as se ss m en t s ca les Ba yr ak tar et a l., 19 20 19 S tu dy ai m to as se ss in g th e r eli ab ili ty P ro sp ec tiv e s tu dy W er e r ec ru ite d 79 p er so ns b etw ee n th e a ge s T he co ns ist en cy d em on str ate d by th e s co re s a ttr ib ut ed o f F OU R an d GC S sc or es b y co m pa rin g of 1 8 an d 65 w ho w er e t re ate d fo r a t l ea st 24 h ou rs by tw o di ffe re nt p ro fe ss io na ls fo r t he sa m e p ati en t d em on str ate s t he v alu es as sig ne d by sp ec ial ist s t o as sis ted in IC U an d wh o di d no t r ec eiv e s ed ati on th e e as e o f a pp lic ati on o f G CS an d FO UR . H ow ev er, d ue to th e p er so ns i n an ae sth es ia an d re an im ati on ad di tio na l p ar am ete rs of F OU R, th e l att er is m or e e ffe cti ve a nd n eu ro su rg ica l I CU i n ev alu ati ng th e s ub jec t w ho is u nc on sc io us o r d ep en de nt o n m ec ha ni ca l v en til ati on Ol se n et al .,2 0 20 20 E va lu ate h ow F OU R sc or e a nd au to m ate d P ro sp ec tiv e o bs er va tio na l P ati en ts ad m itt ed to a Ne ur oi nt en siv e U ni t T he tr ain in g of n ur sin g sta ff in th e u se o f F OU R sc or e a nd p up ill om etr y ad d m ea ni ng an d cli ni ca l i nf or m ati on s tu dy a ut om ate d pu pi llo m ete r i s a g oo d str ate gy to im pl em en t f re qu en t i n an in ten siv e c ar e c on tex t, co m pa rin g it wi th G CS m on ito rin g in n eu ro in ten siv e u ni ts. B ot h as se ss m en t t oo ls s co re an d m an ua l p up il as se ss m en t pr ov id e m or e c lin ica l i nf or m ati on th an G CS an d th e s tu dy d em on str ate s h ow F OU R sc or e i s a b ett er p re di cto r o f o ut co m es , p ro gn os is an d m or tal ity th an G CS Ra m az an i e t a l., 23 20 19 E va lu ate F OU R sc or e a nd G CS ab ili ty in p re di cti ng Ob se rv ati on al an d 30 0 pa tie nt s a dm itt ed to m ed ica l I CU . B ot h FO UR sc or e a nd G CS ar e v alu ab le sc ale s f or p re di cti ng t he o ut co m es (S ur vi vo rs, n on su rv iv or s) in M ed ica l p ro sp ec tiv e s tu dy E xc lu de d fro m th e s tu dy p op ul ati on w er e o ut co m es in p ati en ts ar e a dm itt ed to th e M IC U; h ow ev er, th e I nt en siv e C ar e U ni t ( M IC U) p ati en ts wi th a len gt h of IC U sta y <2 4 h an d br ain F OU R sc or e s ho we d be tte r d isc rim in ati on an d ca lib ra tio n th an de ath at th e t im e o f a dm iss io n G CS , s o it is su pe rio r t o GC S in p re di cti ng o ut co m es in th is p ati en ts po pu lat io n Te m iz et al .22 (2 01 8) T o ev alu ate th e e ffe cti ve ne ss an d th e u se o f C ro ss -se cti on al stu dy 47 p ati en ts ca lcu lat ed w ho w er e a dm itt ed to th e Co nc or da nc e b etw ee n nu rse s w as fo un d hi gh b ot h fo r G CS an d G las go w Co m a S co re (G CS ) a nd F ul l O ut lin e o f i nt en siv e c ar e u ni t f or cr an ial su rg er y or h ea d tra um a F OU R. T he F OU R sc or e i s a s e ffe cti ve as G CS o n th e f ol lo w- up U nr es po ns iv en es s ( FO UR ) s co re b y nu rse s i n th e of p ati en ts wh o ar e m an ag ed in th e n eu ro su rg ica l i nt en siv e c ar e f ol lo w- up an d ev alu ati on o f p ati en ts ad m itt ed to th e un its . ne ur os ur gi ca l i nt en siv e c ar e u ni t f or cr an ial s ur ge ry o r h ea d tra um a Fo o et al .,15 20 19 Sy ste m ati c r ev iew P ati en ts ad m itt ed to d ed ica ted n eu ro sc ien ce ce nt er s F OU R sc or e o ve ra ll ha s a cl os e r ela tio ns hi p to in -h os pi tal m or tal ity an d po or fu nc tio na l o ut co m e i n pa tie nt s w ith im pa ire d c on sc io us ne ss . F ur th er co m pa ris on o f F OU R sc or e a nd G CS , a nd w ith G CS -P , m ay , i n su bg ro up s o f p ati en ts, id en tif y re lat iv e m er its o f F OU R sc or e Al m oj ue la et al .,2 1 20 19 To p er fo rm a sc op in g sy ste m ati c r ev iew o n th e S ys tem ati c r ev iew T he F OU R sc or e h as b ee n sh ow n to b e a u se fu l o ut co m e a va ila bl e l ite ra tu re fo r F OU R sc or e a nd o ut co m e p re di cto r i n m an y pa tie nt s w ith d ep re ss ed le ve l o f c on sc io us ne ss . p red ict ion in cr iti ca lly il l p ati en ts It dis pla ys go od in ter -ra ter re lia bil ity am on g p hy sic ian s a nd nu rse s Non -co mmerc ial us e o nly The literature shows the ease of application of GCS and FOUR, however, due to the additional parameters of FOUR, the second one is more effective in evaluating the unconscious subject or dependent on mechanical ventilation16-18 since it has a better cor- relation and a higher predictive value with the need for ventilation, the stay in ICU and the GOS score compared to GCS, in patients with traumatic brain injury.19 The reliability of the FOUR score is excellent and the agreement between the evaluators is similar to GCS. The probability of intrahospital death is higher for the lower FOUR’s total score. The FOUR score provides more details related to neurological status than GCS8,10 and can be used as an alterna- tive to the GCS scale as there is no significant difference in evalu- ators, it has a satisfactory prognostic value, good specificity, and sensitivity.18 It also emerged that the new FOUR score is an insightful clinical tool in detecting subtle changes in neurological status as well as GCS, the prognosis of mortality for patients with altered sensory was similar to GCS19 but the evaluation of cortical function and brain stem gave additional value to FOUR, this score provides more neurological information compared to GCS and can be used by any intensive care nurse, even by those who have less experience.20 It has been studied in a wide variety of critically ill patients, both with and without neurologic pathology in predicting mortality and functional outcomes. It displays good inter-rater reli- ability among physicians and nurses.21 Also, GCS and FOUR scores were compared in patients with brain tumors or TBI at the intensive care unit and the FOUR score was found to be just as effective and reliable as GCS. FOUR and GCS scores have been found to have a high interclass correlation coefficient between practitioners. The correlation for both scales is quite strong. This conclusion is thought to help decrease mistakes when evaluating intensive care unit patients and a more accurate evaluation can be made.22 In a study recently conducted to evaluate the FOUR score and the ability of GCS to predict the outcomes (survivors, non-survivors) in a medical intensive care unit (MICU), both scores were found to be reliable Scales and showed acceptable discrimination power but the FOUR score showed bet- ter discrimination and calibration than GCS for predicting out- comes in hospitalized MICU patients. The higher accuracy of the FOUR score compared to the GCS makes it an advisable predic- tive model for patients who are admitted to the medical ICU23 (Table 6). New technologies were also adopted to support the med- ical staff in assessing neurological status. The pupillometer is an automated portable device, easy to use and economical, and has the advantage of making accurate and reproducible quantitative measurements and evaluations.6 Automated pupillometry evaluates the pupillary reflex in light, or photomotor reflex, the diameter, the shape of the pupil, the latency time, the rate of constriction and dilation, and the percentage of amplitude reduction.24 The values calculated by the pupillometer are displayed on the screen showing an algorithm that takes into account all these variables as input to obtain a composite score that defines the pupillary response index (Neurological Pupil Index) 25 (Figure 3 and 4). Review Figure 3. NPi-300 Automated Pupillometry® (From: NeurOptics’ NPi-300 Automated Pupillometer, US (reproduction permission has been requested and granted by the author). Figure 4. NPi-300 Automated Pupillometry® (From: NeurOptics’ NPi-300 Automated Pupillometer, US (reproduction permission has been requested and granted by the author). Table 6. Comparison between Glasgow Coma Scale (GCS) and Full Outline of UnResponsiveness Score (FOUR score). GCS FOUR score Three major components: Four components (E4, M4, B4, R4) with maximum score of 4 points each: • Eye 4 points • Eye response • Motor 6 points • Motor response • Verbal 5 points • Brainstem reflexes • Respiratory pattern Limited utility in intubated patients and children with limited language development Includes testing for intubated patients and brainstem reflexes Key component of other ICU severity of illness scales Useful in dececting patients with locked-in-syndrome and VSs Widely used and validated for more than 30 years Multicenter trials and validation are pending [Emergency Care Journal 2024; 20:12121] [page 27] Non -co mmerc ial us e o nly A study has recently been conducted to study the relationship between GCS and dilation rate (DV) through 42,229 observations in patients with brain damage and an average age of 58.9 years, of which 49.11% are female. The study showed that higher GCS is associated with faster DV, and that automated pupillometry can be a biomarker of injury where neurological examination is limited.26 In 2019 a systematic review was published to evaluate the spe- cific results associated with the use of the automated pupillometer in the monitoring of critical patients with neurological impairment receiving assistance in an intensive care environment.27 The study also aims to examine whether the use of the pupillometer in this population has any effect on outcomes and to assess potential lim- itations to a wider adoption of automated pupillometry. It has emerged as a crucial tool in neurocritical care, allowing the detec- tion of elevated intracranial pressure and imminent neurological deterioration at an early stage.28-30 At the moment there are no guidelines approving the routine use of automated pupillometry in an intensive care environment despite has received more attention in recent years as a predictive tool for delirium in ICU through evaluation of the pupillary reflex of both eyes immediately after hospitalization through the use of a portable infrared pupillometer31 being an effective triage tool in brain trauma patients.32 However, the increase in research and studies supports the usefulness of automated pupillometry because of the greater accuracy and reliability compared to manual pupil- lary examination, in detecting pupillary changes indicating an increase in intracranial pressure and detecting the level of sedation and analgesia, it also offers a more accurate and objective assess- ment, with only one-third of non-reactive pupils28,33-36 and half of anisocoria cases detected.37 Limitations The integrative review consists of different empirical sources and, therefore, no particular criterion for assessing the quality of the studies exists,38 but the strict inclusion criteria in the review can be evaluated not only as a strength but also as a limitation that might have resulted in relevant studies being excluded. Therefore, the study might have reporting bias, since, for example, only English-language studies with at least an abstract available were included. Conclusions The purpose of this integrative review is to describe tools capa- ble of making complete assessments of the neurological status of patients admitted to intensive care units and that are better predic- tors of mortality and morbidity in head injury. Two primary evalu- ation tools are proposed and analyzed: FOUR score and automated pupillometry, capable of exceeding the limits of GCS for a more calibrated and complete assessment of the neurological state and consciousness of the patient in the ICU. The FOUR score is not higher than GCS but the combination of visual and motor compo- nents is essential for an even more complete neurological assess- ment. The FOUR score can be used in multiple intensive settings, is easy to teach, learn, and administer, and also provides essential information for accurate assessment of patients with impaired states of consciousness. In contrast to GCS, where abnormal reflexes of the brain stem are not included among the clinical indi- cators evaluated, FOUR also includes pupillary and corneal reflex evaluation. The score showed a prognostic value comparable to that provided by GCS but offers indisputable advantages: it can be used in intubated patients, can distinguish vegetative states from minimally responsive states, and detect the “locked-in syndrome”. References 1. Giusti GD, Mistraletti G. Neurological, Pain, Sedation, and Delirium Assessment. In: Nursing in Critical Care Setting. Springer, Cham. 2018. 2. Teasdale G, Jennett B. Assessment of coma and impaired con- sciousness. A practical scale. Lancet 1974;2:81-4. 3. Balestreri M, Czosnyka M, Chatfield DA, et al. 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