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    FOUR (Full Outline of UnResponsiveness) Score

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

    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:

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    Next Steps
    Evidence
    Creator Insights
    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

    Are you Dr. Eelco F.M. Wijdicks? Send us a message to review your photo and bio, and find out how to submit Creator Insights!
    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
    Content Contributors
    • Victor Lin, MD
    Reviewed By
    • Rhonda Cadena, MD
    About the Creator
    Dr. Eelco F.M. Wijdicks
    Are you Dr. Eelco F.M. Wijdicks?
    Content Contributors
    • Victor Lin, MD
    Reviewed By
    • Rhonda Cadena, MD