Validation of a New Coma Scale, the FOUR Score, in the Emergency Department
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ORIGINAL ARTICLE
Validation of a New Coma Scale, the FOUR Score, in the Emergency Department Latha G. Stead Æ Eelco F. M. Wijdicks Æ Anjali Bhagra Æ Rahul Kashyap Æ M. Fernanda Bellolio Æ David L. Nash Æ Sailaja Enduri Æ Raquel Schears Æ Bamlet William
Published online: 20 September 2008 Ó Humana Press Inc. 2008
Abstract Objective Full Outline of Unresponsiveness (FOUR) score has previously been validated scale in the Neurosciences Intensive Care Unit. In this study, we sought to validate the use of FOUR score in the emergency department (ED) using non-neurology staff. We also compared its performance to the Glasgow Coma Scale (GCS) and correlated it to functional outcome at hospital discharge and overall survival. Methods We prospectively rated 69 patients with initial neurologic symptoms presenting to the ED. Three types of examiners performed the FOUR score: ED physician, ED resident, and ED nurse. Patients were followed through hospital discharge; functional outcome was measured using modified Rankin Score (mRS). Results Interrater reliability for FOUR score and GCS was excellent (respectively, jw = 0.88 and 0.86). Both FOUR score and GCS predicted functional outcome, and
L. G. Stead (&) R. Kashyap M. F. Bellolio D. L. Nash S. Enduri R. Schears Department of Emergency Medicine, Mayo Clinic, Generose G 410, 200 First Street, Rochester, MN 55905, USA e-mail: [email protected] E. F. M. Wijdicks Division of Critical Care Neurology, Mayo Clinic, Rochester, MN, USA A. Bhagra Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA B. William Department of Biostatistics, Mayo Clinic, Rochester, MN, USA
overall survival with and without adjustment for age, sex, and alertness group. Conclusion The FOUR score can be reliably used in the ED by non-neurology staff. Both FOUR score and GCS performed equally well, but the neurologic detail incorporated in the FOUR score makes it more useful in management and triage of patients. Keywords FOUR score Neurologic Glasgow Coma Scale Consciousness
Introduction Coma scales have been created to improve communication between providers and have been used to triage patients with impaired consciousness in and out of the Emergency Department (ED). The Glasgow Coma Scale (GCS) was originated in a Neurosurgical Intensive Care Unit, but found its way elsewhere, and became a standard scale used in the field by first responders, emergency physicians, and neuroscience specialists [1]. Over the years, considerable limitations have been identified on this scale: crucial parts of the neurologic examination of a patient with impaired consciousness were not included (e.g., brainstem reflexes and eye movements) and language evaluation—largely an assessment of orientation rather than consciousness— became useless in intubated patients. More concerning, the performance of the GCS in the ED has mixed results. Recently, pre-hospital GCS scores were compared with its assessment in the ED, and poor agreement was found in patients with traumatic head injury and GCS sum scores
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