Can FOUR Score replace GCS for assessing neurological

status of critically ill patients - An Indian Study

Anita Mercy S, Ramesh Thakur, Sandhya Yaddanapudi, Hemant Bhagat

Abstract Since its development in 1974, the Glasgow Coma Scale(GCS) has been the gold standard
for assessing the patients Level Of Consciousness(LOC) and acute changes in neurological status. Despite its
widespread use, the GCS has many limitations that are well documented. The Full Outline of
UnResponsiveness(FOUR) score is a new coma scale that was recently validated as a proposed alternative to
GCS. The main purpose of the study was to assess the reliability of the FOUR score in critically ill patients of
main ICU of PGIMER, Chandgiarh. In this study, scoring of GCS and FOUR score were performed by anesthetists
and nurses on 21 patients. In a total of 100 pair-wise ratings, the inter-rater agreement for both the FOUR score
(k = 0.65) and the GCS (k = 0.66) was good among nurse anesthetist pair. The internal consistency for both
the FOUR score ( = 0.97) and the GCS scale ( = 0.94) was excellent. A good correlation was found between
the FOUR score and the GCS ( = 0.94, p = 0.001). The predictive validity of the FOUR score [Area under the
receiver operating curve(AUROC)= 0.8] is slightly higher than the GCS (AUROC = 0.76) in this population.
But the results could not be concluded with the availability of very limited number of patients. Majority of the
raters strongly agreed that the FOUR score can be used as an alternative to the GCS scale, though there is no
significant difference in the raters opinion about both the scales. The study suggests that the new FOUR score
has precise clinical acumen in detecting subtle changes in neurological status as the GCS scale. Inclusion of
assessment of brainstem function along with the assessment of cortex function adds value to the new tool.

Keywords Introduction
Glasgow Coma Scale (GCS), Full Outline of
Consciousness is a state of general
UnResponsiveness score (FOUR),
Unconsciousness awareness of oneself and the environment
and includes the ability to orient towards new
Correspondance at stimuli.1 Despite advances in technology, a
thorough clinical assessment is still the key
Anita Mercy to identify subtle changes in a patients
MSc. Nursing 2nd yrs student (Oncology Nursing) neurological status and is fundamental to the
National Institute of Nursing Education (NINE), management of neuroscience patients. To
PGIMER, Chandigarh provide quality patient care, the bedside nurse
must therefore be able to accurately and

Nursing and Midwifery Research Journal, Vol-9, No.2, April 2013 63

consistently assess and communicate these response(E), motor response(M), brainstem
changes.2 reflexes(B), and respiration(R). In each of
these categories, a score of 0 indicates
Scales have been constructed to
nonfunctioning status, and a score of 4
improve communication among health care
represents normal functioning. The number
personnel.3 The most commonly used scale
of components and the maximal grade in each
is the GCS scale.3 GCS scale misses key
of the categories is four (E4, M4, B4, R4).3 In
essential elements of a comprehensive
contrast to the GCS, the FOUR score eye
neurological examination for comatose
response category assesses eye tracking in
patients.4 Failure to assess the verbal score in
addition to eye opening, which allows it to
intubated patients and inability to test brain
differentiate vegetative state from minimally
stem reflexes are shortcomings of GCS.5, 3, 6
conscious state (MCS) patients.2, 7, 12 The FOUR
The ability to assess the GCS motor score is
scale also more accurately and expeditiously
often impacted by the administration of
diagnose the locked in syndrome by
sedatives or neuromuscular blocking agents
specifically assessing voluntary eye
and the presence of confounders such as
movements. 7, 12 The motor assessment
spinal cord injury. The GCS is skewed toward
includes response to pain, ability to follow
motor assessment, with a maximum of 6
simple commands, and the presence of
points. This affects the ability to assign an
generalized myoclonus status epilepticus, a
accurate GCS to patients who are receiving
poor prognostic sign in comatose survivors
medications or who have injuries that interfere
after cardiac resuscitation.2, 3, 13 Brainstem reflex
with motor assessment. 2 Subsequent
category was created to assess the function
investigations of the GCS had revealed
of the mesencephalon, pons, and medulla,
disagreement among the raters, especially
which allows diagnosis of uncal herniation.2, 7
between experienced and inexperienced
Lower brainstem function is evaluated using
users.5, 7, 8, 9 Prior efforts to modify or replace
the respiration category to identify irregular
this scale have been unsuccessful because
breathing patterns, including Cheyne-Stokes
no scale could improve on its simplicity and
respirations.2
practical usefulness.
The FOUR score has been well received
To address the many limitations to the
in and outside the United States and has been
GCS, Wijdicks et al, at the Mayo Clinic
implemented at the Mayo Clinic Saint Marys
designed the FOUR score as a proposed
Hospital. The nursing staff too have
alternative in 2005. 7, 10, 11 The FOUR score has
enthusiastically embraced the new coma scale
been developed to assess the depth of coma
in the United States. Studies on its usefulness
in a more detailed manner than the GCS
outside the boundaries of the Neurological-
scale.11 The FOUR score assigns a value of 0
to 4 to each of four functional categories: eye Neurosurgical ICU are under way.11

Nursing and Midwifery Research Journal, Vol-9, No.2, April 2013 64

 Wijdicks et al (2005) and other
investigators, have conducted validation of
FOUR score in different clinical settings like
medical ICU, neurology ICU and emergency
department of Mayo Clinic involving different
group of raters including experienced and
inexperienced nurses and neuro physicians.
Validation of FOUR score has also been done
in different group of patients including stroke
patients,15 pediatric population,2 critically ill
patients11, 14 and neuroscience patients6, 11, 16 in
different settings by various groups of raters
in other places outside the Mayo Clinic. No
studies related to FOUR score have been done
in India. It is very important to have a simple
and reliable clinical scale system to determine
the level of consciousness in our clinical
settings with which both the nurses and
doctors are comfortable.
In this preview, the present study was
planned to assess the reliability and feasibility
of the FOUR score in critically ill patients
admitted in main Intensive Care Unit.
Materials and Methods
This study was conducted at main ICU
of Nehru hospital, PGIMER, Chandigarh, a
premier institution of medical education and
research in India which has been functioning
as a tertiary care hospital. The main ICU is a
12 bedded multi-specialty ICU under the
Department of Anesthesia and Intensive Care,
which caters to medical, neurological,
surgical, gynecological, and other intensive
and critical care conditions. The target
population of the study was critically ill patients
Nursing and Midwifery Research Journal, Vol-9, No.2, April 2013
and the raters (nurses and anesthetists) and
the accessible population was critically ill
patients admitted in main ICU of PGIMER,
Chandigarh and the raters (nurses and
anesthetists) of the same unit. Patients were
selected by purposive sampling i.e.) all
critically ill patients of four different categories
(alert, drowsy, stuporous and comatose)
admitted in main ICU, patients with age >12
yrs during 16th July till 31st august 2011 and
21 patients were included in the study. All
patients who were on neuromuscular
blocking agents were excluded from the study.
Raters were selected by purposive sampling
i.e.) all nurses and anesthetists who were on
duty were included in the study and 32 raters
were included in the study. All raters who were
not willing to participate were excluded from
the study. The sample size was determined
before the study and a total of 100 pair-wise
ratings of FOUR score and GCS were included
in the study. The tools used for data collection
were demographic proforma of the patients
and the raters, the FOUR score, the GCS scale
and the raters opinionnaire.
GCS scale & four score were
standerised tools and other tools were
prepared by thorough literature review and
experts opinion and validated by different
experts of the medical and nursing field.
Ethical approval for the study was obtained
from the Ethics Committee of the institution.
A written permission was obtained from the
HOD, Department of Anesthesia and main ICU,
PGIMER. Sister-in-charge of main ICU was
informed about the study. The anonymity and
confidentiality of the participants (raters) in
65
relation to findings was protected while
repor ting the study. The period of data
collection was from 16th July to 31st August
2011. The techniques of data collection
followed were observation and records.
Scoring on each patient was performed at the
first possible admittance by the researcher for
predictive validity analysis. Raters were
oriented to the FOUR score by a teaching
session using PowerPoint presentation on
FOUR score along with demonstration on
actual patients. Return demonstration was
also taken from the raters. Posters on FOUR
score was put up on walls of each cubical of
main ICU. Written instructions about the FOUR
score were given to each evaluator at the time
of rating. Raters pair were nurse-nurse,
anesthetistnurse and anesthetist
anesthetist. Paired observations were made
by the raters on each patient and each patient
was observed by different pair of raters at
different timings. Within the same hour, each
evaluator in the pair recorded a FOUR score
and a GCS score for the patient. At the end of
data collection, raters were given opinionnaire
on GCS and FOUR score and the responses
were taken by 5-point Likert scale. The data
was analyzed using both descriptive and
inferential statistics. Calculation was carried
out manually using a calculator and with the
help of Microsoft excels (2007) and Statistical
Package for Social Science (SPSS)
programme version 16.
Results
During the study period of 6 weeks,
100 observations were done on 21 pateints.
Nursing and Midwifery Research Journal, Vol-9, No.2, April 2013
Among 100 observations, 29 were done by
nurse nurse pair, 41 by nurse anesthetist
pair and 30 anesthetist anesthetist pair. In
total, 31 raters were enrolled in the study.
Among 21 patients, 9 (42.9%) belong
to the middle adulthood (41 65 Yrs) group
and the mean age of the patients was 44.4
1.9 years (range 17- 78 years). Among the
21 patients, 14 (66.7%) were males and 7
(33.3%) were females, 11 (52.4%) were
intubated using orotracheal tube and 10
(47.6%) were intubated using tracheostomy
and 8 (38.1%) died in ICU and 13 (61.9%)
were alive and got transferred from ICU.
Among 21 patients, 6(28.6%) were admitted
with head injury.
Among 32 raters, 12(37.5%) were
holding Diploma in Nursing (GNM), 13(40.6%)
were B. Sc Nursing (Nsg) holders, 6(18.8%)
had professional qualification as
M. B. B. S, currently undergoing M.D and
1(3.1%) had M. D as qualification. The mean
professional experience of the raters was 4.6
5.5 years (range 2 months - 23 years). The
mean experience of the raters in ICU was 2.7
2 years (range 2 months - 6 years & 8
months).
Internal consistency of the FOUR score and
the GCS
Internal consistency of the FOUR score
and the GCS was analyzed using Cronbachs
and spearmans correlation coefficient.
value of 0.5 or less is considered
unacceptable, values between 0.5 and 0. 6
are considered poor, values between 0. 6 and
0.7 are considered questionable, values
between 0.7 and 0.8 are considered
66
acceptable, values between 0. 8 and 0.9 are are shown in table. 1. Cronbachs for the
considered good and values above 0.9 are FOUR score (0.95) and the GCS (0. 94)
considered excellent internal consistency.6,18 indicate excellent internal consistency for both
values for both the FOUR score and the GCS the scores.
Table. 1: Internal consistency of the FOUR score and the GCS N = 100

Variable Cronbach s alpha () p value

FOUR score 0.97 <0.001**
GCS 0.94 <0.001**
**
Internal consistency is significant at the 0.01 level
Spearman correlation coefficient was used
to analyze the correlation of the FOUR score 12.50

and the GCS for 200 observations. A highly

positive correlation of = 0.94 between the 10.00
FOURscore

FOUR score and the GCS score (Figure. 1) 7.50

Inter-rater agreement of the FOUR score and 5.00

the GCS
Inter-rater agreement of the FOUR 2.50
R Sq Linear = 0.871

score and the GCS was analyzed using 0.00

Cohens kappa. A kappa value of 0.4 or less 2.00 4.00 6.00

GCSscore
8.00 10.00 12.00

is considered poor, values between 0.4 and

0.6 are considered fair to moderate, values
between 0.6 and 0.8 are considered good and
values above 0.8 are considered excellent
agreement.5, 2, 6
Kappa statistics of the FOUR score is
shown in table-2 and kappa statistics of the
GCS is shown in table-3. In 29 pair-wise
ratings, the two nurses agreed exactly in
51.7% of the observations of the total FOUR
score [k = 0.47(fair to moderate observer
agreement)] and in 68.9% of the observations
of the total GCS score [(k = 0.65(good
observer agreement)], in 41 pair wise
ratings the nurse agreed exactly with the
Figure 1. Correlation between the GCS
score and the FOUR score
anesthetist in 68. 3% of the observations of
the total FOUR score (k = 0.65) and in 71%
of the observations of the total GCS score (k
= 0.66) which shows that the degree of
agreement between Nurse Anesthetist pair
is higher than that of other pairs (Nurse
Nurse pair and Anesthetist Anesthetist pair),
for FOUR score, k = 0.65(good observer
agreement) and for GCS, k = 0.66 (good
observer agreement), in 30 pair wise ratings
the two anesthetists agreed exactly in 53. 3%
of the observations of the total FOUR score

Nursing and Midwifery Research Journal, Vol-9, No.2, April 2013 67

(k = 0. 48) and in 53.3% of the observations
of the total GCS score [k = 0.46(fair to
moderate agreement)] Overall among 100 pair
wise ratings the two group of raters agreed
exactly in 59% of the observations of the total
FOUR score (k = 0. 55) and in 65% of the
observations of the total GCS score (k = 0.6)
which shows that there is fair to moderate
agreement among all pairs.

Table. 2: Kappa values for the inter-rater agreement of the FOUR score N = 100
Kappa value (k)
Rater Pair Total Eye Motor Brainste Respiration
n Score response response reflexes Score
Score Score Score
Nurse Nurse 29 0.47 0.58 0.74 0.74 0.90
Nurse Doctor 41 0.65 0.70 0.64 0.86 0.78
Doctor- Doctor 30 0.48 0.69 0.59 0.78 0.32 `
Overall 100 0.55 0.67 0.66 0.80 0.69

Table. 3: Kappa values for the inter-rater agreement of the GCS score N = 100
Kappa value (k)
Rater Pair n Total Eye response Motor response ROC Curve

Score Score 1.0

Score
Nurse - Nurse 29 0.65 0.79 0.8
0.75
Nurse - Doctor 41 0.66 0.81 0.69
Sensitivity

30 0.46 0.77 0.61

0.6
Doctor- Doctor
Overall 100 0.6 0.8 0.4
0.69
Predictive value of the FOUR score and the GCS 0.2

ICU mortality status prediction using the FOUR score was analyzed using ROC curve
0.0
0.0 0.2 0.4 0.6 0.8 1.0
1 - Specificity

Diagonal segments are produced by ties.

------------ GCS score

Reference Line

FOUR score

Figure 2. Predictive value of the GCS and the FOUR score for ICU Mortality

Nursing and Midwifery Research Journal, Vol-9, No.2, April 2013 68

 Figure 2. shows the predictive value of
the GCS (AUROC is 0.76, 95% confidence
interval 0.55 0.96, p = 0.55) and the
predictive value of the FOUR score (AUROC is
0.8, 95% CI: 0.6 1, p = 0.25). Out of 8
patients who died in ICU, 1 (12.5%) got the
minimum GCS score of 3 and 1 (12.5%) got
the minimum FOUR score of 2.
Practical feasibility of the FOUR score
The descriptive statistics of the raters
opinion about the practical feasibility of the
GCS is shown in table. 4. Among 31 raters,
18(58.1%) agreed to the statement that GCS
is reliable, 20(64.5%) agreed to the statement
that GCS is easy to use, 19(29%) agreed to
the statement that GCS is reproducible,
16(51.6%) agreed to the statement that GCS
gives more clinical information and 16(51.6%)
agreed to the statement that GCS takes less
time to perform.

Table. 4: Raters opinion on practical feasibility of the GCS N = 31

Statements regarding Strongly Disagree No opinion Agree Strongly
GCS Disagree agree
n % n % n % N % n %
GCS is reliable 1 03.2 7 22.6 18 58.1 5 16.1
GCS is easy to use 1 03.2 20 64.5 10 32.3
GCS is reproducible 2 06.5 16 51.6 19 29.0 4 12.9
GCS gives more clinical 1 3.2 5 16.1 8 25.8 16 51.6 1 03.2
information
GCS takes less time to 3 9.7 1 03.2 2 06.5 16 51.6 9 29.0
perform

The descriptive statistics of the raters
opinion about the practical feasibility of the
FOUR score is shown in table. 5. Among 31
raters, 20(64.5%) agreed to the statement that
FOUR score is reliable, 20(64.5%) agreed to
the statement that FOUR score is easy to use,
13(41.9%) agreed to the statement that FOUR
score is reproducible, 20(64.5%)agreed to the
statement that FOUR score gives more clinical
information, 16(51.6%) agreed to the
statement that FOUR score takes less time to
perform & 13(41.9%) agreed & 10(32.3%)
strongly agreed to the statement that FOUR
score can be used as an alternative to GCS.
Very few among both the raters group
were disagreeing that FOUR score can be used
as an alternative to GCS. Most of the raters
expressed that they find difficulty in eliciting
withdrawal response to pain and often face
confusion between withdrawal response to
pain and flexion response to pain in GCS.
Some of them verbalized difficulty in
assessing the motor component of GCS in
quadriplegic patients. Raters felt that the
addition of brain stem reflexes in FOUR score
would give them more clinical information.

Nursing and Midwifery Research Journal, Vol-9, No.2, April 2013 69

Table. 5: Raters opinion on practical feasibility of the FOUR score N = 31
Statements regarding Strongly Disagree No opinion Agree Strongly
FOUR score Disagree agree
n % n % n % n % n %
FOUR score is reliable 2 6.5 20 64.5
FOUR score is easy to use 1 3.2 4 12.9 20 64.5 6 19.4
FOUR score is reproducible 3.2 12 38.7 13 41.9 5 16.1
FOUR score gives more 3 3 20 64.5 8 25.8
clinical information
FOUR takes less time to 3 9.7 4 12.9 5 16.1 16 51.6 3 9.7
perform
FOUR score can be used 1 3.2 1 3.2 6 19.4 13 41.9 10 32.3
as an alternative to GCS
Discussion Studies have been conducted among
Neurological disturbances pose a different group of patients (stroke patients,15
greater challenge in the critically ill patients and pediatric population,2 critically ill patients11,14
patients with neurological disorders. The GCS and neuroscience patients6, 11, 16). This is the
has been the gold standard for assessing the first study to evaluate this newly validated
LOC in patients with significant brain injury FOUR score in India for its application in
since it was developed in 1974.2 The GCS is critically ill patients. Wijdicks et al (2005) and
widely used and accepted but gives relatively other investigators, have conducted validation
limited information about brainstem function, of FOUR score in different clinical settings like
eye opening and tracking, and respiratory medical ICU, neurology ICU and emergency
patterns.13 Since its introduction in 2005, FOUR department of Mayo Clinic involving different
score has been refined in clinical use, and its group of raters including experienced and
usefulness has been confirmed by hundreds inexperienced nurses and neuro
of neurosurgical patients and dozens of physicians.2,3,5,6 This study involved nurses
doctors.7 FOUR score maintains simplicity and and anesthetists of diverse experience and
provides far better information, particularly for different qualification.
intubated patients. The FOUR score is a good Study results demonstrated that the
predictor of the prognosis of critically ill predictive value of the FOUR score for ICU
patients and has important advantages over mortality is slightly on the higher side than
the GCS in the ICU setting.14 The FOUR score the GCS as Cohen et al (2009) found a higher
has been developed to assess the depth of predictive value for the FOUR score than the
coma in a more detailed manner than the GCS. 2 The study also demonstrated an
GCS.11 excellent internal consistency for both GCS and

Nursing and Midwifery Research Journal, Vol-9, No.2, April 2013 70

FOUR score and good correlation between
GCS and FOUR score. High degree of internal
consistency for both GCS and FOUR score and
good correlation between GCS and FOUR
score were also elicited in 2 studies
conducted by Wijdicks et al (2005)3 and Iyer
VN et al (2009).14
The study conducted by Wolf et al
(2007) found that the inter-rater agreement
among experienced and inexperienced
neuroscience ICU nurses was good to
excellent with the FOUR score and the GCS6
but in this present study only fair to moderate
agreement was found for the FOUR score and
GCS among all 100pairs of raters and at the
same time, good inter-rater agreement existed
between Nurse Anesthetist pair for the FOUR
score. In other pairs (Nurse-nurse pair and
anesthetist-anesthetist pair) the inter-rater
agreement was fair to moderate.
Majority of the raters of this present
study agreed and 10 of them strongly agreed
that the FOUR score can be used as an
alternative to the GCS.
The FOUR score and the GCS were
almost equally able to predict mortality in this
population. The excellent internal consistency
and good level of inter-rater agreement among
Nurse Anesthetist pair suggests that the new
scale is consistent and reliable and that nurses
with differing levels of experience and
expertise are more likely to correctly assess
the patient and assign the same score using
the FOUR score. The FOUR score has the
potential to become an important measure in
prospective clinical studies. However, the ease
Nursing and Midwifery Research Journal, Vol-9, No.2, April 2013
of use and global acceptance raises the
potential of GCS scoring in the critical care
neurological assessment, provided one keeps
in mind its limitations.
The raters agreed that Four score is
reliable, easy to use, reproducible gives more
clinical information and takes less time to
perform and can be used as alternate to GCS.
The study findings recommend that the
Four score can replace the GCS scale since
the inter-rater agreement between nurse-nurse
pair and anesthetist-anesthetist pair was fair
to moderate and the inter-rater agreement
between nurse-anesthetist pair was good in
total FOUR score. It is also recommended that
the health care team need to be trained and
made proficient in using the FOUR score before
its implementation in the clinical settings and
a similar study can be replicated with large
sample size involving more number of patients
of different population for a longer period of
time to confirm the usability and reliability of
the FOUR score.
References:
1. Hickey JV. The clinical practice of
neurological and neurosurgical nursing. 4th ed.
Philadelphia: Lippincott; 1997.134-7
2. Cohen J. Interrater reliability and
predictive validity of the FOUR score coma scale
in a pediatric population. Journal of neuroscience
nursing 2009 Oct; 41(5): 261-7
3. Wijdicks EF, Bamlet WR, Maramattom BV,
Manno EM, McClelland IR. Validation of a new
coma scale: The FOUR score. Annals of neurology
2005; 58: 585- 93
71
 11.
4. Murthy TVSP. A new score to validate
coma in emergency department FOUR score.
Indian journal of neurotrauma. 2009; 6(1):59-62
5. Fischer M, Regg S, Czaplinski A, 12.
Strohmeier M, Lehmann A, Tschan F, 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. Critical care 2010;14(2): R64
13.
6. Wolf CA, Wijdicks EFM, Bamlet WR,
McClelland LR. Further validation of the FOUR
score coma scale by intensive care nurses. Mayo
clinic proceedings. 2007 Apr; 82(4):435-8
7. Ankavipat P. Endorsement of the FOUR 14.
score for consciousness assessment in
neurosurgical patients. Neurolgia Medico-
Chirurgica 2009 Dec; 49(12): 565-71
8. Balestreri M et al. Predictive value of
Glasgow coma scale after brain trauma: change 15.
in trend over the past ten years. Journal of
Neurology Neurosurgery Psychiatry (2004); 75:
161, 162
9. Rowley G, Fielding K. Reliability and
accuracy of the Glasgow Coma Scale with 16.
experienced and inexperienced users. Lancet.
1991; 337:535 38
10. SoRelle Ruth. FOUR score challenges
Glasgow Coma Scale. Emergency Medicine
News [online] August 2006; 28(8): 50-55.
Available from: URL: http://journals.lww.com/
em-news/Fulltext/2006/08000/
FOUR_Score_Challenges_
Glasgow_Coma_Scale.2.aspx [accessed
January 2012]
Nursing and Midwifery Research Journal, Vol-9, No.2, April 2013
Wijdicks EFM, Bamlet WR, Maramattom
BV, Manno EM, McClelland RL. Does the JFK
Revised Coma Recovery Complement the FOUR
Score? Annals of neurology 2006 Dec; 60(6): 745
Schnakers C, Giacino J, Kalmar K, Piret
S, Lopez E, Boly M, et al. Does the Four Score
Correctly Diagnose the Vegetative and Minimally
Conscious States? Annals of neurology 2006 Dec;
60(6): 746
Wijdicks EFM, Kokmen E, OBrien PC.
Measurement of impaired consciousness in the
neurological intensive care unit: a new test.
Journal of neurology neurosurgery psychiatry.
1998; 64:117 - 19
Iyer VN, Mandrekar NJ, Danielson RD,
Zubkov AY, Elmer JL, Wijdicks EFM. Validity of
the FOUR score coma scale in the medical
intensive care. Mayo clinic proceedings 2009
August; 84(8): 694-701
Idrovo L, Fuentes B, Medina J, Gabaldn
L, Ruiz-Ares G, Abenza MJ, et al. Validation of the
FOUR score (Spanish Version) in acute stroke:
An interobserver variability Study. European
Neurology 2010; 63: 364-69
Ledoux D, Bruno M, Jonlet S, Choi P,
Schnakers C, Damas F, et al. Full Outline of
Unresponsiveness compared with Glasgow
coma scale assessment and outcome prediction
in coma. Critical Care. 2009;13(1): 107
72