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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:

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    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.

    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