Comparative Analysis of Full Outline of Unresponsive Score and Glasgow Coma Scale Score for Outcomes Prediction in Children with Impaired Consciousness

 

 Buy Article Permissions and Reprints

Abstract

Objectives

This study aimed to compare two distinct consciousness evaluation scores (the pediatric Glasgow coma scale [GCS] scale and the full outline of unresponsive [FOUR] score) to predict outcomes for children admitted to the pediatric intensive care unit with impaired consciousness.

Methods

Children aged between 2 and 18 years who presented with impaired consciousness were included in this longitudinal study. The lead investigator evaluated the pediatric GCS score and the FOUR score. The first 3 days' score readings of both the scores were taken for analysis. The primary outcome of children was recorded as in-hospital mortality. The secondary outcome was functional outcome measured by the modified Rankin scale.

Results

A total of 78 children presented with impaired consciousness were eligible for statistical analysis. Survivors and nonsurvivors had significantly different FOUR and GCS scores at admission, 24 and 48 hours (p < 0.0001). The predictive accuracy of the FOUR scale at admission was slightly higher than GCS considering that the area under the curve (AUC) for the FOUR score was higher (AUC = 0.850; 95% confidence interval [CI]: 0.735–0.956) than GCS (AUC = 0.834; 95% CI: 0.735–0.934). The projected outcome based on the FOUR score and the actual patient outcomes were statistically significantly correlated (p = 0.021). Results showed that the FOUR scores had higher sensitivity (89%) specificity (84%), and negative predictive value (83%) than the GSC scale.

Conclusion

The FOUR at admission was a better predictor of the outcome as compared with the Glasgow coma scale. More sensitivity of the FOUR scores than GCS makes it an advisable predictive model for children with impaired consciousness.

Ethical Approval

This study was performed in line with the principles of the Declaration of Helsinki. Ethical approval was granted by the TMU Moradabad Institutional Ethics Committee India (TMU/IEC/2021–22, dated: June 29, 2022).

Clinical Trial Registration

The following in the manuscript clinical trial number is not applicable.

Consent to Participate

Written informed consent was obtained from the parents.

Data Availability Statement

The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author upon reasonable request.

Declaration of Artificial Intelligence (AI) in Scientific Writing

Artificial Intelligence is not used during paper writing.

Authors' Contributions

All authors contributed to the study's conception and design. Material preparation, data collection, and analysis were performed by M.H.F.M. and S.J. The first draft of the manuscript was written by B.K.G. and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Publication History

Received: 26 February 2025

Accepted: 03 June 2025

Article published online:
18 June 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

• References

• 1 Brown KL, Agrawal S, Kirschen MP. et al. The brain in pediatric critical care: unique aspects of assessment, monitoring, investigations, and follow-up. Intensive Care Med 2022; 48 (05) 535-547
  PubMedSearch in Google Scholar
• 2 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2 (7872): 81-84
  CrossrefPubMedSearch in Google Scholar
• 3 Stead LG, Wijdicks EF, Bhagra A. et al. Validation of a new coma scale, the FOUR score, in the emergency department. Neurocrit Care 2009; 10 (01) 50-54
  PubMedSearch in Google Scholar
• 4 Iyer VN, Mandrekar JN, Danielson RD, Zubkov AY, Elmer JL, Wijdicks EF. Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clin Proc 2009; 84 (08) 694-701
  CrossrefPubMedSearch in Google Scholar
• 5 Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: the FOUR score. Ann Neurol 2005; 58 (04) 585-593
  CrossrefPubMedSearch in Google Scholar
• 6 Seifu A, Eshetu O, Tafesse D, Hailu S. Admission pattern, treatment outcomes, and associated factors for children admitted to pediatric intensive care unit of Tikur Anbessa specialized hospital, 2021: a retrospective cross-sectional study. BMC Anesthesiol 2022; 22 (01) 13
  PubMedSearch in Google Scholar
• 7 Wang G, Gao Y, Fu Y. et al. A simple nomogram for predicting the mortality of PICU patients with sepsis-associated encephalopathy: a multicenter retrospective study. Front Neurol 2024; 15: 1418405
  PubMedSearch in Google Scholar
• 8 Labelle A, Juang P, Reichley R. et al. The determinants of hospital mortality among patients with septic shock receiving appropriate initial antibiotic treatment. Crit Care Med 2012; 40 (07) 2016-2021
  PubMedSearch in Google Scholar
• 9 Leteurtre S, Duhamel A, Salleron J, Grandbastien B, Lacroix J, Leclerc F. Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP). PELOD-2: an update of the PEdiatric logistic organ dysfunction score. Crit Care Med 2013; 41 (07) 1761-1773
  CrossrefPubMedSearch in Google Scholar
• 10 Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated pediatric risk of mortality score. Crit Care Med 1996; 24 (05) 743-752
  CrossrefPubMedSearch in Google Scholar
• 11 Straney L, Clements A, Parslow RC. et al; ANZICS Paediatric Study Group and the Paediatric Intensive Care Audit Network. Paediatric index of mortality 3: an updated model for predicting mortality in pediatric intensive care. Pediatr Crit Care Med 2013; 14 (07) 673-681
  CrossrefPubMedSearch in Google Scholar
• 12 Matics TJ, Sanchez-Pinto LN. Adaptation and validation of a pediatric sequential organ failure assessment score and evaluation of the sepsis-3 definitions in critically ill children. JAMA Pediatr 2017; 171 (10) e172352
  CrossrefPubMedSearch in Google Scholar
• 13 Ramazani J, Hosseini M. Comparison of full outline of unresponsiveness score and Glasgow coma scale in medical intensive care unit. Ann Card Anaesth 2019; 22 (02) 143-148
  CrossrefPubMedSearch in Google Scholar
• 14 Almojuela A, Hasen M, Zeiler FA. The full outline of unresponsiveness (FOUR) score and its use in outcome prediction: a scoping systematic review of the adult literature. Neurocrit Care 2019; 31 (01) 162-175
  PubMedSearch in Google Scholar
• 15 Almojuela A, Hasen M, Zeiler FA. The full outline of unresponsiveness (FOUR) score and its use in outcome prediction: a scoping review of the pediatric literature. J Child Neurol 2019; 34 (04) 189-198
  PubMedSearch in Google Scholar
• 16 Ahmadi S, Sarveazad A, Babahajian A, Ahmadzadeh K, Yousefifard M. Comparison of Glasgow coma scale and full outline of unresponsiveness score for prediction of in-hospital mortality in traumatic brain injury patients: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2023; 49 (04) 1693-1706
  CrossrefPubMedSearch in Google Scholar
• 17 Khanal K, Bhandari SS, Shrestha N, Acharya SP, Marhatta MN. Comparison of outcome predictions by the Glasgow coma scale and the full outline of unresponsiveness score in the neurological and neurosurgical patients in the intensive care unit. Indian J Crit Care Med 2016; 20 (08) 473-476
  CrossrefPubMedSearch in Google Scholar
• 18 Bodien YG, Barra A, Temkin NR. et al; TRACK-TBI Investigators. Diagnosing level of consciousness: the limits of the Glasgow coma scale total score. J Neurotrauma 2021; 38 (23) 3295-3305
  CrossrefPubMedSearch in Google Scholar
• 19 Quinn TJ, Dawson J, Walters M. Dr John Rankin; his life, legacy and the 50th anniversary of the Rankin stroke scale. Scott Med J 2008; 53 (01) 44-47
  PubMedSearch in Google Scholar
• 20 Mittal K, Kaushik JS, Dwivedi KD. Predictive value of full outline of unresponsiveness (FOUR) score and Glasgow coma scale (GCS) in outcome of children aged 1–14 years admitted with altered sensorium. J Pediatr Crit Care 2020; 7: 14-21
  PubMedSearch in Google Scholar
• 21 Kochar GS, Gulati S, Lodha R, Pandey R. Full outline of unresponsiveness score versus Glasgow coma scale in children with nontraumatic impairment of consciousness. J Child Neurol 2014; 29 (10) 1299-1304
  PubMedSearch in Google Scholar
• 22 Jamal A, Sankhyan N, Jayashree M, Singhi S, Singhi P. Full outline of unresponsiveness score and the Glasgow coma scale in prediction of pediatric coma. World J Emerg Med 2017; 8 (01) 55-60
  PubMedSearch in Google Scholar
• 23 Khajeh A, Fayyazi A, Miri-Aliabad G, Askari H, Noori N, Khajeh B. Comparison between the ability of Glasgow coma scale and full outline of unresponsiveness score to predict the mortality and discharge rate of pediatric intensive care unit patients. Iran J Pediatr 2014; 24 (05) 603-608
  PubMedSearch in Google Scholar
• 24 Cohen J. Interrater reliability and predictive validity of the FOUR score coma scale in a pediatric population. J Neurosci Nurs 2009; 41 (05) 261-267 , quiz 268–269
  PubMedSearch in Google Scholar
• 25 Büyükcam F, Kaya U, Karakılıç ME, Cavuş UY, Turan Sönmez F, Odabaş O. Predicting the outcome in children with head trauma: comparison of FOUR score and Glasgow coma scale. Ulus Travma Acil Cerrahi Derg 2012; 18 (06) 469-473
  CrossrefPubMedSearch in Google Scholar
• 26 Assa NP, Wati DK, Subanada IB, Soetjiningsih S, Kardana M, Sukmawati M. Full outline of unresponsiveness score as a predictor of outcomes in critically ill pediatric patients. Paediatr Indones 2020; 60 (02) 77-82
  PubMedSearch in Google Scholar
• 27 Eken C, Kartal M, Bacanli A, Eray O. Comparison of the full outline of unresponsiveness score coma scale and the Glasgow coma scale in an emergency setting population. Eur J Emerg Med 2009; 16 (01) 29-36
  PubMedSearch in Google Scholar