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Full Outline of Unresponsiveness score and the Glasgow Coma Scale in prediction of pediatric coma
Atahar Jamal1, Naveen Sankhyan1, Murlidharan Jayashree1
1Department of Pediatrics, Advance Pediatric Center, Post-graduate Institute of Medical Education and Research, Chandigarh, India.
Insights
The Full Outline of Unresponsiveness (FOUR) score and Glasgow Coma Scale (GCS) effectively predict outcomes in children with impaired consciousness. Both scores demonstrated comparable accuracy in predicting mortality and functional outcomes.
Area of Science:
- Pediatric Neurology
- Clinical Neuroscience
- Medical Assessment Tools
Background:
- Impaired consciousness in children requires accurate prognostic tools.
- The Glasgow Coma Scale (GCS) is widely used, but its effectiveness in pediatric populations is debated.
- The Full Outline of Unresponsiveness (FOUR) score is a newer alternative for assessing neurological status.
Purpose of the Study:
- To compare the predictive accuracy of the admission FOUR score versus the GCS for outcomes in children with impaired consciousness.
- To evaluate both scores' ability to predict in-hospital mortality and 3-month mortality and functional outcomes.
- To assess the inter-rater reliability of the FOUR score and GCS in this pediatric cohort.
Main Methods:
- An observational study included children aged 5-12 years with impaired consciousness for less than 7 days.
- Exclusion criteria included traumatic brain injury, sedative use, and specific pre-existing neurological conditions.
- Receiver operating characteristic (ROC) curve analysis was used to compare the area under the curve (AUC) for mortality and functional outcomes.
Main Results:
- The AUC for in-hospital mortality was comparable for GCS (0.83) and FOUR score (0.80).
- At 3 months, AUCs for mortality (GCS: 0.78, FOUR: 0.74) and poor functional outcome (GCS: 0.82, FOUR: 0.79) were also similar between the two scales.
- Inter-rater reliability was high for both scales, with the FOUR score showing slightly better reliability (0.98 vs. 0.96 for GCS).
Conclusions:
- The FOUR score is as effective as the GCS in predicting in-hospital and 3-month mortality in children with impaired consciousness.
- Both scales demonstrated comparable predictive accuracy for functional outcomes at 3 months.
- The FOUR score exhibits good inter-rater reliability, making it a viable alternative to the GCS.
Background:
This study was done to compare the admission Full Outline of Unresponsiveness (FOUR) score and Glasgow Coma Scale (GCS) as predictors of outcome in children with impaired consciousness.
Methods:
In this observational study, children (5-12 years) with impaired consciousness of <7 days were included. Children with traumatic brain injury, on sedatives or neuromuscular blockade; with pre-existing cerebral palsy, mental retardation, degenerative brain disease, vision/hearing impairment; and seizure within last 1 hour were excluded. Primary outcomes: comparison of area under curve (AUC) of receiver operating characteristic (ROC) curve for in-hospital mortality. Secondary outcomes: comparison of AUC of ROC curve for mortality and poor outcome on Pediatric Overall Performance Category Scale at 3 months.
Results:
Of the 63 children, 20 died during hospital stay. AUC for in-hospital mortality for GCS was 0.83 (CI 0.7 to 0.9) and FOUR score was 0.8 (CI 0.7 to 0.9) [difference between areas -0.0250 (95%CI 0.0192 to 0.0692), Z statistic 1.109, P=0.2674]. AUC for mortality at 3 months for GCS was 0.78 (CI 0.67 to 0.90) and FOUR score was 0.74 (CI 0.62 to 0.87) (P=0.1102) and AUC for poor functional outcome for GCS was 0.82 (CI 0.72 to 0.93) and FOUR score was 0.79 (CI 0.68 to 0.9) (P=0.2377), which were also comparable. Inter-rater reliability for GCS was 0.96 and for FOUR score 0.98.
Conclusion:
FOUR score was as good as GCS in prediction of in-hospital and 3-month mortality and functional outcome at 3 months. FOUR score had a good inter-rater reliability.
