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The FOUR Score Predicts Mortality, Endotracheal Intubation and ICU Length of Stay After Traumatic Brain Injury

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Abstract

Background

The Glasgow Coma Scale (GCS) is the most widely accepted scale for assessing levels of consciousness, clinical status, as well as prognosis of traumatic brain injury (TBI) patients. The Full Outline of UnResponsiveness (FOUR) score is a new coma scale developed addressing the limitations of the GCS. The aim of this prospective cohort study was to compare the performance of the FOUR score vs. the GCS in predicting TBI outcomes.

Methods

From April to July 2011, 60 consecutive adult patients with TBI admitted to the Alexandria Main University Hospital intensive care units (ICU) were enrolled in the study. GCS and FOUR score were documented on arrival to emergency room. Outcomes were in-hospital mortality, unfavorable outcome [Glasgow outcome scale extended (GOSE) 1–4], endotracheal intubation, and ICU length of stay (LOS).

Results

Fifteen (25 %) patients died and 35 (58 %) had unfavorable outcome. When predicting mortality, the FOUR score showed significantly higher area under receiver operating characteristic curve (AUC) than the GCS score (0.850 vs. 0.796, p = 0.025). The FOUR score and the GCS score were not different in predicting unfavorable outcome (AUC 0.813 vs. 0.779, p = 0.136) and endotracheal intubation (AUC 0.961 vs. 0.982, p = 0.06). Both scores were good predictors of ICU LOS (r 2 = 0.40 [FOUR score] vs. 0.41 [GCS score]).

Conclusions

The FOUR score was superior to the GCS in predicting in-hospital mortality in TBI patients. There was no difference between both scores in predicting unfavorable outcome, endotracheal intubation, and ICU LOS.

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References

  1. World Health Organization. Traumatic brain injuries. In: Neurological disorders: public health challenges. Geneva: World Health Organization; 2006. p. 164–75.

  2. Lingsma HF, Roozenbeek B, Steyerberg EW, Murray GD, Maas AI. Early prognosis in traumatic brain injury: from prophecies to predictions. Lancet Neurol. 2010;9:543–54.

    Article  PubMed  Google Scholar 

  3. Matis G, Birbilis T. The Glasgow Coma Scale—a brief review. Past, present, future. Acta Neurol Belg. 2008;108:75–89.

    PubMed  Google Scholar 

  4. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma. 1989;29:623–9.

    Article  CAS  PubMed  Google Scholar 

  5. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma. 1987;27:370–8.

    Article  CAS  PubMed  Google Scholar 

  6. Champion HR, Copes WS, Sacco WJ, et al. Improved predictions from a severity characterization of trauma (ASCOT) over Trauma and Injury Severity Score (TRISS): results of an independent evaluation. J Trauma. 1996;40:42–8.

    Article  CAS  PubMed  Google Scholar 

  7. Perel P, Edwards P, Wentz R, Roberts I. Systematic review of prognostic models in traumatic brain injury. BMC Med Inform Decis Mak. 2006;6:38.

    Article  PubMed Central  PubMed  Google Scholar 

  8. Perel P, Arango M, Clayton T, et al. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ. 2008;336:425–9.

    Article  PubMed  Google Scholar 

  9. Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008;5:e165.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: the FOUR score. Ann Neurol. 2005;58:585–93.

    Article  PubMed  Google Scholar 

  11. Fischer M, Rüegg S, Czaplinski A, et al. Inter-rater reliability of the Full Outline of UnResponsiveness score and the Glasgow Coma Scale in critically ill patients: a prospective observational study. Crit Care. 2010;14:R64.

    Article  PubMed Central  PubMed  Google Scholar 

  12. Idrovo L, Fuentes B, Medina J, et al. Validation of the FOUR Score (Spanish Version) in acute stroke: an interobserver variability study. Eur Neurol. 2010;63:364–9.

    Article  PubMed  Google Scholar 

  13. Kramer AA, Wijdicks EF, Snavely VL, et al. A multicenter prospective study of interobserver agreement using the Full Outline of Unresponsiveness score coma scale in the intensive care unit. Crit Care Med. 2012;40:2671–6.

    Article  PubMed  Google Scholar 

  14. Marcati E, Ricci S, Casalena A, Toni D, Carolei A, Sacco S. Validation of the Italian version of a new coma scale: the FOUR score. Intern Emerg Med. 2012;7:145–52.

    Article  PubMed  Google Scholar 

  15. Menon DK, Schwab K, Wright DW, Maas AI. Position statement: definition of traumatic brain injury. Arch Phys Med Rehabil. 2010;91:1637–40.

    Article  PubMed  Google Scholar 

  16. Baker SP, O’Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187–96.

    Article  CAS  PubMed  Google Scholar 

  17. Marshall LF, Marshall SB, Klauber MR, et al. The diagnosis of head injury requires a classification based on computed axial tomography. J Neurotrauma. 1992;9:S287–92.

    PubMed  Google Scholar 

  18. Teasdale GM, Pettigrew LE, Wilson JT, Murray G, Jennett B. Analyzing outcome of treatment of severe head injury: a review and update on advancing the use of the Glasgow Outcome Scale. J Neurotrauma. 1998;15:587–97.

    Article  CAS  PubMed  Google Scholar 

  19. Ray P, Le Manach Y, Riou B, Houle TT. Statistical evaluation of a biomarker. Anesthesiology. 2010;112:1023–40.

    Article  PubMed  Google Scholar 

  20. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988;44:837–45.

    Article  CAS  PubMed  Google Scholar 

  21. Qualls M, Pallin DJ, Schuur JD. Parametric versus nonparametric statistical tests: the length of stay example. Acad Emerg Med. 2010;17:1113–21.

    Article  PubMed  Google Scholar 

  22. Hyam JA, Welch CA, Harrison DA, Menon DK. Case mix, outcomes and comparison of risk prediction models for admissions to adult, general and specialist critical care units for head injury: a secondary analysis of the ICNARC Case Mix Programme Database. Crit Care. 2006;10:S2.

    Article  PubMed Central  PubMed  Google Scholar 

  23. Hoffmann M, Lefering R, Rueger JM, et al. Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. Br J Surg. 2012;99:122–30.

    Article  PubMed  Google Scholar 

  24. Vivien B, Yeguiayan JM, Le Manach Y, et al. The motor component does not convey all the mortality prediction capacity of the Glasgow Coma Scale in trauma patients. Am J Emerg Med. 2012;30:1032–41.

    Article  PubMed  Google Scholar 

  25. Sadaka F, Patel D, Lakshmanan R. The FOUR score predicts outcome in patients after traumatic brain injury. Neurocrit Care. 2012;16:95–101.

    Article  PubMed  Google Scholar 

  26. McNett M, Amato S, Gianakis A, et al. The FOUR Score and GCS as predictors of outcome after traumatic brain injury. Neurocrit Care. 2014 Jan 10 [Epub ahead of print]. doi:10.1007/s12028-013-9947-6.

  27. Roozenbeek B, Maas AI, Menon DK. Changing patterns in the epidemiology of traumatic brain injury. Nat Rev Neurol. 2013;9:231–6.

    Article  PubMed  Google Scholar 

  28. Marmarou A, Lu J, Butcher I, et al. Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J Neurotrauma. 2007;24:270–80.

    Article  PubMed  Google Scholar 

  29. Chamoun RB, Robertson CS, Gopinath SP. Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation. J Neurosurg. 2009;111:683–7.

    Article  PubMed Central  PubMed  Google Scholar 

  30. Demetriades D, Kuncir E, Velmahos GC, Rhee P, Alo K, Chan LS. Outcome and prognostic factors in head injuries with an admission Glasgow Coma Scale score of 3. Arch Surg. 2004;139:1066–8.

    Article  PubMed  Google Scholar 

  31. Chen B, Grothe C, Schaller K. Validation of a new neurological score (FOUR Score) in the assessment of neurosurgical patients with severely impaired consciousness. Acta Neurochir (Wien). 2013;155:2133–9.

    Article  PubMed  Google Scholar 

  32. Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia. Lancet. 1996;348:123–4.

    Article  CAS  PubMed  Google Scholar 

  33. Frontera JA, de los Reyes K, Gordon E, et al. Trend in outcome and financial impact of subdural hemorrhage. Neurocrit Care. 2011;14:260–6.

    Article  PubMed  Google Scholar 

  34. Kim YJ. The impact of time from ED arrival to surgery on mortality and hospital length of stay in patients with traumatic brain injury. J Emerg Nurs. 2011;37:328–32.

    Article  PubMed  Google Scholar 

  35. Knaus WA, Wagner DP, Zimmerman JE, Draper EA. Variations in mortality and length of stay in intensive care units. Ann Intern Med. 1993;118:753–61.

    Article  CAS  PubMed  Google Scholar 

  36. Gruenberg DA, Shelton W, Rose SL, Rutter AE, Socaris S, McGee G. Factors influencing length of stay in the intensive care unit. Am J Crit Care. 2006;15:502–9.

    PubMed  Google Scholar 

  37. Singh B, Murad MH, Prokop LJ, et al. Meta-analysis of Glasgow coma scale and simplified motor score in predicting traumatic brain injury outcomes. Brain Inj. 2013;27:293–300.

    Article  PubMed  Google Scholar 

  38. Wisborg T, Montshiwa TR, Mock C. Trauma research in low- and middle-income countries is urgently needed to strengthen the chain of survival. Scand J Trauma Resusc Emerg Med. 2011;19:62.

    Article  PubMed Central  PubMed  Google Scholar 

  39. Sitsapesan HA, Lawrence TP, Sweasey C, Wester K. Neurotrauma outside the high-income setting: a review of audit and data-collection strategies. World Neurosurg. 2013;79:568–75.

    Article  PubMed  Google Scholar 

  40. Agrawal D, Joshua SP, Gupta D, Sinha S, Satyarthee GD. Can glasgow score at discharge represent final outcome in severe head injury? J Emerg Trauma Shock. 2012;5:217–9.

    Article  PubMed Central  PubMed  Google Scholar 

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Conflict of Interest

Ahmed Said Okasha, Akram Muhammad Fayed, and Ahmad Sabry Saleh declare that they have no conflict of interest.

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None.

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Authors and Affiliations

  1. Department of Anesthesia & Surgical Intensive Care, Faculty of Medicine, Alexandria University, Alexandria, Egypt

    Ahmed Said Okasha

  2. Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt

    Akram Muhammad Fayed

  3. Intensive Care Unit, Kom el-Shoqafa Chest Hospital, Khufu Street, Karmoz, 21572, Alexandria, Egypt

    Ahmad Sabry Saleh

Authors
  1. Ahmed Said Okasha
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  2. Akram Muhammad Fayed
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Corresponding author

Correspondence to Ahmad Sabry Saleh.

Additional information

This article is dedicated to the memory of the late professor Hassan Abou-Khabar, former chair of the Critical Care Medicine Department, Faculty of Medicine, Alexandria University.

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Okasha, A.S., Fayed, A.M. & Saleh, A.S. The FOUR Score Predicts Mortality, Endotracheal Intubation and ICU Length of Stay After Traumatic Brain Injury. Neurocrit Care 21, 496–504 (2014). https://doi.org/10.1007/s12028-014-9995-6

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