Full Outline of Unresponsiveness score and the Glasgow Coma Scale in prediction of pediatric coma

doi:10.5847/wjem.j.1920-8642.2017.01.010

Abstract

Abstract:

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.

Key words: Altered sensorium, Neuro-intensive care, Neuro-monitoring, Neuroinfection, Tropical neurology

Atahar Jamal, Naveen Sankhyan, Murlidharan Jayashree, Sunit Singhi, Pratibha Singhi. Full Outline of Unresponsiveness score and the Glasgow Coma Scale in prediction of pediatric coma[J]. World Journal of Emergency Medicine, 2017, 8(1): 55-60.

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References 13

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Variables	Survived (n=43)	Died in hospital (n=20)	P value
Age (years)	7.4±2.1	7.4±2	0.9
Male sex, n (%)	23 (53.4)	10 (50)	1
Fever, n (%)	25 (58.1)	17 (85)	0.046
Vomiting, n (%)	23 (53.5)	15 (75)	0.16
Seizure, n (%)	25 (58.1)	9 (45)	0.41
Headache, n (%)	8 (18.6)	2 (10)	0.48
Cough, n (%)	5 (11.6)	5 (25)	0.26
Shock, n (%)	3 (7)	8 (40)	0.003
Meningeal signs, n (%)	5 (11.6)	3 (15)	0.07
Non-reactive or sluggish pupils, n (%)	0	7 (35)	<0.001
Hepatomegaly, n (%)	8 (18.6)	8 (40)	0.18
Intubated, n (%)	37 (86)	16 (80)	0.7
Duration of ventilation (days)	3.8±4.7	3.5±4.5	0.8

Coma score/Subscore	Survived (n=43)	Died in hospital (n=20)	P value
GCS
Subscore eye response	2.4±0.9	1.3±0.6	<0.001^*
Subscore verbal response	2.4±1.3	1.2±0.4	0.002
Subscore motor response	4.2±1.0	3.2±1.3	<0.001^*
Total	9.1±2.5	5.8±1.9	<0.001
FOUR score
Subscore eye response	1.7±1.3	0.6±1.1	0.001
Subscore motor response	2.4±0.8	1.7±0.9	0.007
Subscore brainstem reflexes	3.9±0.15	3.4±1.1	0.054^*
Subscore respiration	3.7±0.7	3.0±1.1	0.017^*
Total score	11.8±2.2	8.8±3.0	<0.001

Variable compared	GCS (95%CI)	FOUR score (95%CI)	Differences in AUC (95%CI)	Z statistic	Significance level
In-hospital mortality	0.83 (0.73 to 0.92)	0.80 (0.69 to 0.91)	0.0250 (0.0192 to 0.0692)	1.109	P=0.2674
Three-month mortality	0.78 (0.67 to 0.90)	0.74 (0.62 to 0.87)	0.0399 (0.00907 to 0.0889)	1.597	P=0.1102
Poor outcome at 3 months outcome on POPC scale	0.82 (0.72 to 0.93)	0.79 (0.68 to 0.90)	0.0294 (0.0194 to 0.0782)	1.181	P=0. 2377

Author; Year of publication	Number	Population studied	Raters and setting	Prediction of death by GCS	Prediction of death by FOUR score
Kochar et al; 2014^[8]	70	5-18 years, non traumatic coma	Pediatric neurology, fellow, ward and ICU	0.916	0.940
Büyükcam et al; 2012^[3]	100	2-17 year, traumatic coma	Physicians and residents, emergency	0.965	0.975
Khajehet et al; 2014^[7]	200	Mean age 4.4 years, children, non trauma PICU	ICU	-	-
Cohen et al; 2009^[12]	-	-	Critical care nurse, ICU	0.77	0.81
Current study	63	5-12 years	Pediatric resident trainee, emergency room	0.83	0.80