Ashok Kumar Nayak1, Srikanta Das2, Prafullachandra Hoogar3
BACKGROUND
Traumatic head injury is one of the most common causes of mortality all over
the world. Substantial initial assessment of head injury and its intensity in these
patients is the primary goal for medical treatment. Hence, there is a necessity for
a score better than GCS for the assessment of head injury patients. FOUR score,
a new coma scale was published by Wijdicks in 2005. It included 4 components,
motor response, eye response, brainstem reflex, and respiration. It precisely
assesses the neurological activity as it includes the brain stem reflexes and
eliminates the verbal component and identifies locked-in syndromes, temporal
lobe herniations and third nerve dysfunctions which GCS fails to do so. We
wanted to evaluate the correlation between FOUR score and GCS in evaluating
the level of consciousness in patients with head injuries and evaluate the interobserver
reliability of both the above-mentioned scores.
METHODS
This is an observational prospective study conducted on 92 patients with isolated
traumatic head injury admitted to Department of General Surgery, VIMSAR,
Burla, from November 2018 to October 2020. The parameters that were
evaluated were clinical examination at the time of admission, were blood
pressure (BP), temperature, pulse, and respiratory rate at the time of admission.
Assessment of GCS and FOUR score at the time of admission, at 6th hour, 24th
hour and daily assessment till discharge.
RESULTS
A total of 92 isolated traumatic head injury patients were included in the study.
Number of females (19.5 %) were significantly less when compared to males.
The Pearson correlation coefficient between FOUR score and GCS was calculated
to be 0.945, 0.962 and 0.951 respectively at the time of presentation, after 6
hours and isolated traumatic head injury. After 24 hours in patients with isolated
traumatic head injury, Cohen’s weighted Kappa of GCS and FOUR score inter
reliability was 0.956 and 0.985 respectively. Area under receiver operating
characteristic curve (ROC) for GCS and FOUR score with Modified Rankins Score
was 0.951 and 0.951. Area under ROC for mortality for GCS and FOUR score was
0.974 and 0.997 respectively.
CONCLUSIONS
As per our results, there is an excellent correlation between GCS and FOUR score
in head injury patients. The FOUR score aims to overcome these shortcomings
with a scale that is both simple to use and comprehensive in its overall
neurologic assessment of the isolated traumatic head injury patients. FOUR score
might prove to be a better tool to evaluate the consciousness of head injury
patients and help in detection and stratification of these patients and in
monitoring the efficiency of ongoing treatment.
