Abstract
The Glasgow Coma Scale (GCS) is the most widely accepted tool for the evaluation of consciousness, despite several reported shortcomings. A new coma scale, named Full Outline of UnResponsiveness (FOUR) score, is now available. The aim of the present study is to provide and validate the Italian version of the FOUR score. The Italian version of the FOUR score was developed according to a standardized protocol, and thereafter validated in a series of patients with acute neurological illness. For each patient, the FOUR and the GCS scores were recorded by two physicians randomly selected. The inter-rater agreement for the FOUR and the GCS scores was evaluated using the weighted kappa (κw). The receiving operating characteristic curve was also calculated to determine the ability of the scales to predict outcome. Eighty-seven consecutive patients with an acute brain injury were enrolled. The inter-rater agreement was excellent both for the FOUR (κw = 0.953; P < 0.0001) and the GCS (κw = 0.943; P < 0.01). The area under the curve for mortality was 0.935 for the FOUR and 0.953 for the GCS. The FOUR score provides greater neurological details than the GCS. Our data indicate that the Italian version of the FOUR score is a valid predictor of outcome, yielding reproducible findings across raters independent of their expertise.
Similar content being viewed by others
References
Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84
Wijdicks EFM, Bamlet WR, Maramattom BV, Manno EM, McClelland RL (2005) Validation of a new coma scale: the FOUR score. Ann Neurol 58:585–593
Balestreri M, Czosnyka M, Chatfield DA, Steiner LA, Schmidt EA, Smielewski P, Matta B, Pickard JD (2004) Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry 75:161–162
Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE (1981) APACHE—acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 9:591–597
Stanczak DE, White JG 3rd, Gouview WD, Moehle KA, Daniel M, Novack T, Long CJ (1984) Assessment of level of consciousness following severe neurological insult. A comparison of the psychometric qualities of the Glasgow Coma Scale and the Comprehensive Level of Consciousness Scale. J Neurosurg 60:955–960
Starmark JE, Stalhammar D, Holmgren E (1988) The Reaction Level Scale (RLS85). Manual and guidelines. Acta Neurochir 91:12–20
Benzer A, Mitterschiffthaler G, Marosi M, Luef G, Puhringer F, De La Renotiere K, Lehner H, Schmutzhard E (1991) Prediction of non-survival after trauma: Innsbruck Coma Scale. Lancet 338:977–978
Gill M, Martens K, Lynch EL, Salih A, Green SM (2007) Inter-rater reliability of 3 simplified neurologic scales applied to adults presenting to the emergency department with altered levels of consciousness. Ann Emerg Med 49:403–407
Wijdicks EFM, Varelas PN, Gronseth GS, Greer DM (2010) Quality Standards Subcommittee of the American Academy of Neurology. Neurology 74:1911–1918
Lombardi F, Gatta G, Sacco S, Muratori A, Carolei A (2007) The Italian version of the Coma Recovery Scale-Revised (CRS-R). Funct Neurol 22:47–61
Schnakers C, Giacino J, Kalmar K, Piret S, Lopez E, Boly M, Malone R, Laureys S (2006) Does the FOUR score correctly diagnose the vegetative and minimally conscious states? Ann Neurol 60:744–745
Eken C, Kartal M, Bacanli A, Eray O (2009) Comparison of the Full Outline of UnResponsiveness Score Coma Scale and the Glasgow Coma Scale in an emergency setting population. Eur J Emerg Med 16:29–36
Stead LG, Wijdicks EFM, Bhagra A, Kashyap R, Bellolio MF, Nash DL, Enduri S, Schears R, William B (2009) Validation of a new coma scale, the FOUR score, in the emergency department. Neurocrit Care 10:50–54
Iyer VN, Mandrekar JN, Danielson RD, Zubkov AY, Elmer JL, Wijdicks EFM (2009) Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clin Proc 84:694–701
Wolf CA, Wijdicks EFM, Bamlet WR, McClelland RL (2007) Further validation of the FOUR score coma scale by intensive care nurses. Mayo Clin Proc 82:435–438
Weiss N, Mutlu G, Essardy F, Nacabal C, Sauves C, Bally C, Houbert M, Lecorre C, Germack V, Demeret S, Pierrot-Deseilligny C, Bolgert F (2009) The French version of the FOUR score: a new coma score. Rev Neurol (Paris) 165:796–802
Idrovo L, Fuentes B, Medina J, Gabaldón L, Ruiz-Ares G, Abenza MJ, Aguilar-Amat MJ, Martínez-Sánchez P, Rodríguez L, Cazorla R, Martínez M, Tafur A, Wijdicks EF, Diez-Tejedor E (2010) Validation of the FOUR Score (Spanish Version) in acute stroke: an interobserver variability study. Eur Neurol 63:364–369
Sacco S, Carolei A (2010) The FOUR Score: a reliable instrument to assess the comatose stroke patient. Eur Neurol 63:370–371
Ropper AH (1986) Lateral displacement of the brain, level of consciousness in patients with an acute hemispheral mass. N Engl J Med 314:953–958
Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174
Acknowledgments
We are grateful to Angelo G. Blasetti, Renato Galzio, Tullio Pozone, Gustavo Spadetta and all their staff for kindly supporting the study.
Conflict of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Marcati, E., Ricci, S., Casalena, A. et al. Validation of the Italian version of a new coma scale: the FOUR score. Intern Emerg Med 7, 145–152 (2012). https://doi.org/10.1007/s11739-011-0583-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11739-011-0583-x