The eye response (E) is graded as: eyelids remain closed with pain (0), eyelids closed but opens to pain (1), eyelids closed but opens to loud voice (2), eyelids open but not tracking (3), and eyelids open or opened, tracking or blinking to command (4). All components have five subscores from zero to four. The FOUR score has four testable components (E, eye responses M, motor responses B, brainstem reflexes and R, respiration). Wijdicks and colleagues in 2005 proposed a new coma scale named the FOUR score.

This study aimed to compare the predictive ability of FOUR score and Glasgow Coma Scale (GCS) in 5 to 12-year-old children admitted in the pediatric emergency with impaired consciousness. It still needs to generate more data on the use of FOUR score in children, especially those with non-traumatic coma. The FOUR score has been evaluated in children with altered consciousness in only a few studies. In a pooled analysis of prospectively studied patients with traumatic and non-traumatic coma, the predictive ability of FOUR score was reported to be as good as that of GCS. It has been shown to have good inter-rater reliability and predictive ability comparable to GCS. It has been used by trainees, nurses, ICU staff and neurologists. Over the last ten years or so it has been demonstrated to be useful in adults with stroke, trauma and non-traumatic coma. The “FOUR score” was first validated in the neurological-neurosurgical ICU and showed favourable characteristics. The main highlights of this 16-point score are the exclusion of the verbal component of GCS, and the inclusion of brainstem reflexes and respiratory pattern. However, a recently validated new coma scale the “Full Outline of Unresponsiveness (FOUR) score” has generated interest worldwide. Newer scales have not been met with wide acceptance. It has limitations in inter-observer agreement it is hard to use in non-verbal or intubated patients it lacks brainstem reflexes the sub-scores are not equally represented in the total scores and there are concerns regarding its predictive abilities. Several limitations of the GCS have been encountered on its use.

It was designed to assess individuals with head trauma, but it’s increasingly being used in patients with non-traumatic coma as well. The Glasgow Coma Scale (GCS) is by far the most widely used and popular scoring system for this purpose. Clinicians frequently rely upon clinical scores or scales to record the level of consciousness. There is no objective measure to communicate and document the severity of coma as distinct from vital signs. Evaluation of altered consciousness in children is a challenge and an important aspect of emergency care.

Pediatric glasgow coma scale