FOUR score

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The FOUR Score is a clinical grading scale designed for use by medical professionals in the assessment of patients with impaired level of consciousness. It was developed by Dr. Eelco F.M. Wijdicks and colleagues in Neurocritical care at the Mayo Clinic in Rochester, Minnesota.

"FOUR" in this context is an acronym for "Full Outline of UnResponsiveness."

The FOUR Score is a 17-point scale (with potential scores ranging from 0 - 16). Decreasing FOUR Score is associated with worsening level of consciousness. The FOUR Score assesses four domains of neurological function: eye responses, motor responses, brainstem reflexes, and breathing pattern.

The rationale for the development of the FOUR Score constituted creation of a clinical grading scale for the assessment of patients with impaired level of consciousness that can be used in patients with or without endotracheal intubation. The main clinical grading scale in use for patients with impaired level of consciousness has historically been the Glasgow Coma Scale (GCS), which cannot be administered to patients with an endotracheal tube (one component of the GCS is the assessment of verbal responses, which are not possible in the presence of an endotracheal tube.)

The FOUR score has been validated with reference to the Glasgow Coma Scale in several clinical contexts, including assessment by physicians in the Neurocritical Care Unit,[1] assessment by intensive care nurses,[2] assessment of patients in the medical intensive care unit (ICU),[3] and assessment of patients in the Emergency Department.[4] Comparison of the inter-observer reliability of the FOUR Score and the GCS suggests that the FOUR Score may have a modest but significant advantage in this particular measure of test function.[5]

Overall, FOUR score has better biostatistical properties than Glasgow Coma Scale in terms of sensitivity, specificity, accuracy and positive predictive value.[6]


  1. ^ Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL (2005). "Validation of a new coma scale: The FOUR score". Annals of Neurology. 58 (4): 585–93. doi:10.1002/ana.20611. PMID 16178024. 
  2. ^ Wolf CA, Wijdicks EF, Bamlet WR, McClelland RL (2007). "Further validation of the FOUR score coma scale by intensive care nurses". Mayo Clinic Proceedings. 82 (4): 435–438. doi:10.4065/82.4.435. PMID 17418071. 
  3. ^ Iyer VN, Mandrekar JN, Danielson RD, Zubkov AY, Elmer JL, Wijdicks EF (2009). "Validity of the FOUR score coma scale in the medical intensive care unit". Mayo Clinic Proceedings. 84 (8): 694–701. doi:10.4065/84.8.694. PMC 2719522Freely accessible. PMID 19648386. 
  4. ^ Stead LG, Wijdicks EF, Bhagra A, Kashyap R, Bellolio MF, Nash DL, Enduri S, Schears R, William B (2009). "Validation of a new coma scale, the FOUR score, in the emergency department". Neurocritical Care. 10 (1): 50–54. doi:10.1007/s12028-008-9145-0. PMID 18807215. 
  5. ^ Fischer M, Rüegg S, Czaplinski A, Strohmeier M, Lehmann A, Tschan F, Hunziker PR, Marsch SC (2010). "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. 14 (2): R64. doi:10.1186/cc8963. PMC 2887186Freely accessible. PMID 20398274. 
  6. ^ Khanal K, Bhandari SS, Shrestha N, Acharya SP, Marhatta MN(2016). "Comparison of outcome predictions by the Glasgow coma scale and the Full Outline of UnResponsiveness score in the neurological and neurosurgical patients in the Intensive Care Unit." Indian Journal of Critical Care Medicine 20 (8): 473-476 DOI: 10.4103/0972-5229.188199 PMID 27630460 PMCID: 4994128

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