Role of Full Outline of Unresponsiveness (FOUR) Score and Glasgow Coma Scale (GCS) in critically ill children to predict outcome: A prospective observational study

OBJECTIVE: To evaluate the diagnostic value of the Outline of Unresponsiveness (FOUR) Score and Glasgow Coma Scale (GCS) to predict mortality in critically ill children with non-traumatic impaired consciousness. METHODS: In this single-center prospective observational study, children aged one month to 12 years admitted to the pediatric Intensive Care Unit (PICU) were included, and serial FOUR score and GCS at admission, 12th, and 24th hour were recorded. Children with PICU stay of <24 hours, with convulsion within the last hour, visual or motor impairment, or use of sedatives/ neuromuscular relaxants were excluded. Primary outcome: in-hospital mortality. Secondary outcome: requirement of intubation, and comparison of two scores for mortality. RESULTS: One hundred critically ill children were enrolled with a median (interquartile - IQR) age of 46.0 (10.0-84.0) months, and 53 children died during the hospital course. The GCS and FOUR scores were significantly higher among survivors (p<0.001). Both scores were independent predictors of mortality at admission and the 12th hour, but only the FOUR score was a statistically significant predictor of mortality at the 24th hour. The adjusted odds ratio (AOR) for mortality for FOUR24 was 0.505 (95% confidence interval - 95%CI 0.399-0.863) and for GCS24 score was 2.728 (95%CI 0.932-2.273). Sixty-three children needed intubation, with a median duration of 4.0 (1.0-7.0) days, and of these, 69.8% died. CONCLUSIONS: GCS and FOUR scores have comparable efficacy in predicting mortality during initial assessment. However, the FOUR score is better than GCS at the 24th hour and can hence be considered a prognostic tool.