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    FOUR (Full Outline of UnResponsiveness) Score

    Grades coma severity; may be more accurate than the Glasgow Coma Scale.
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    INSTRUCTIONS

    Grade the best response in each category.

    When to Use
    Pearls/Pitfalls
    Why Use

    • Use in critically ill patients to assess coma severity.

    • More accurate than the Glasgow Coma Scale (GCS) in ventilated patients and in those with only brainstem reflexes.

    • Particularly useful in patients with the lowest GCS (i.e 3T).

    • Developed to address the shortcomings of the GCS in objectively quantifying coma severity.

    • The score is simpler to remember and to use in assessing patients (four categories, each with four possible points).

    • Can help clinicians identify impending neurological decline.

    • Can evaluate various states of impaired consciousness in ventilated and nonverbal patients.

    • Better assesses coma severity in patients with the worst GCS (3 points).

    • Inter-rater reliability among providers with different levels of training allows for accurate reassessment.

    • Sedating medications can artifactually lower the score.

    • Heavily weighted towards ocular components (extraocular movements, pupil, corneal).

    • Similar to the GCS, a lower FOUR Score suggests worse coma/mental status.
    • Allows for simple evaluation of neurological status in critically ill patients, in particular, in terms of assessing for impending neurological decline (i.e., brainstem herniation) as well as clearer differentiation between comatose states (e.g. minimal conscious state, locked-in syndrome).
    • At very low total scores (≤4), the FOUR Score has better predictive value of mortality and morbidity than does GCS (Wijdicks 2011).
    Eyelids open or opened, tracking, or blinking to command
    +4
    Eyelids open but not tracking
    +3
    Eyelids closed but open to loud voice
    +2
    Eyelids closed but open to pain
    +1
    Eyelids remain closed with pain
    0
    Thumbs-up, fist, or peace sign
    +4
    Localizing to pain
    +3
    Flexion response to pain
    +2
    Extension response to pain
    +1
    No response to pain or generalized myoclonus status
    0
    Pupil and corneal reflexes present
    +4
    One pupil wide and fixed
    +3
    Pupil OR corneal reflex absent
    +2
    Pupil AND corneal reflexes absent
    +1
    Absent pupil, corneal, and cough reflexes
    0
    Not intubated, regular breathing pattern
    +4
    Not intubated, Cheyne-Stokes breathing pattern
    +3
    Not intubated, irregular breathing
    +2
    Breathes above ventilatory rate
    +1
    Breathes at ventilator rate or apnea
    0

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Management

    • Clinical management decisions should not be based solely on the FOUR Score in the acute setting and should be used in conjunction with other clinical information.

    • Very low FOUR scores (≤4) are more predictive of in-hospital mortality as compared to the lowest GCS (3T).

    • Improvement in score of >2 is predictive of survival in cardiac arrest (Fugate 2010).

    • Each point increase in the FOUR Score is associated with decreased mortality and morbidity.

    Critical Actions

    • Abnormalities or decline in score should prompt reassessment and further evaluation for intracranial pathology.

    • While the FOUR Score may help suggest specific states of impaired consciousness, it is important to clearly identify the clinical criteria prior to making these diagnoses.

    Formula

    Addition of the selected points:

    Variable

    Points

    Eye response

    Eyelids open or opened, tracking, or blinking to command

    4

    Eyelids open but not tracking

    3

    Eyelids closed but open to loud voice

    2

    Eyelids closed but open to pain

    1

    Eyelids remain closed with pain

    0

    Motor response (upper extremities)

    Thumbs-up, fist, or peace sign

    4

    Localizing to pain

    3

    Flexion response to pain

    2

    Extension response to pain

    1

    No response to pain or generalized myoclonus status

    0

    Brainstem reflexes

    Pupil and corneal reflexes present

    4

    One pupil wide and fixed

    3

    Pupil OR corneal reflex absent

    2

    Pupil AND corneal reflexes absent

    1

    Absent pupil, corneal, and cough reflexes

    0

    Respiration pattern

    Not intubated, regular breathing pattern

    4

    Not intubated, Cheyne-Stokes breathing pattern

    3

    Not intubated, irregular breathing

    2

    Breathes above ventilatory rate

    1

    Breathes at ventilator rate or apnea

    0

    Facts & Figures

    Lower scores indicate higher coma severity.

    Evidence Appraisal

    The FOUR Score was originally developed to create an alternative to the GCS in evaluating patients with impaired consciousness and possible neurological injury. Given the categories included, the FOUR Score provides greater neurological information and includes key components of a basic neurological examination of a critically-ill patient. This was initially found to have good inter-rater reliability and prognostication in the neurological/neurosurgical intensive care unit (Wijdicks 2005).

    This score was then further assessed in other settings where neurological complications can arise, such as the medical intensive care unit and the emergency department. Even without specific neurological training, the inter-rater reliability remained high, allowing for consistent assessment of patients in these settings (Stead 2009, Iyer 2009).

    In summary, while the GCS is currently the most common score used both in the field and in the hospital, there are significant limitations in this score due to reliance on verbal responses. The FOUR Score eliminates this confounding factor and adds on objective information from a basic neurological coma examination that can provide both prognostic and clinical information to help guide management.

    Dr. Eelco F.M. Wijdicks

    From the Creator

    Why did you develop the FOUR Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

    The main reason to develop the FOUR Score was the major shortcomings of the Glasgow Coma Scale. When communicating the GCS, I always felt I remained uninformed and also noted poor use of its individual components with many physicians resorting to a handy sum score (i.e., GCS 3, GCS 8, GCS 14). The FOUR Score is easy to use and has been validated in numerous studies in numerous countries, and is rapidly becoming the most validated scale in neurology.

    What pearls, pitfalls and/or tips do you have for users of the FOUR Score? Do you know of cases when it has been applied, interpreted, or used inappropriately?

    The FOUR Score tests crucial brainstem reflexes and provides information about the severity of brainstem injury which are unavailable with the GCS. The FOUR Score recognizes a locked-in syndrome and a possible vegetative state. The FOUR Score includes signs suggesting brain herniation. Attention to respiratory patterns in the FOUR Score may not only indicate a need for intubation in comatose patients, but also provides information about the presence of a respiratory drive. The FOUR Score further characterizes the severity of the comatose state in patients with the lowest GCS scores of 3-4.

    What recommendations do you have for doctors once they have applied the FOUR Score? Are there any adjustments or updates you would make to the score based on new data or practice changes?

    Our experience over the last decade is that the FOUR Score has been greeted with great enthusiasm, not only physicians but all healthcare workers involved with the care of the comatose patient. The FOUR Score is working well and no modification has been needed.

    How do you use the FOUR Score in your own clinical practice? Can you give an example of a scenario in which you use it?

    We have fully implemented in our neurosciences ICU and it is available in our electronic medical record.

    Any other research in the pipeline that you’re particularly excited about?

    We are currently looking at its predictive value for deterioration in a number of ways.

    About the Creator

    Eelco F.M. Wijdicks, MD, PhD, is a professor and chief of neurology at the Mayo Clinic. He is also the founding editor of Neurocritical Care, the official journal of the Neurocritical Care Society. Dr. Wijdicks’ research focuses primarily on neurology and brain death.

    To view Dr. Eelco F.M. Wijdicks's publications, visit PubMed

    Content Contributors
    • Victor Lin, MD
    Reviewed By
    • Rhonda Cadena, MD
    About the Creator
    Dr. Eelco F.M. Wijdicks
    Content Contributors
    • Victor Lin, MD
    Reviewed By
    • Rhonda Cadena, MD