Wijdicks et al developed the Full Outline of UnResponsiveness (FOUR) score to assess a patient in coma. This has several advantages over the Glasgow Coma Score but is more complex to administer. The authors are from the Mayo Clinic.
Advantages over the Glasgow coma score:
(1) provides scoring for an intubated patient
(2) includes the brainstem reflexes
(3) recognizes the locked-in syndrome and possible vegetative state
(4) may be able to recognize different stages of herniation
Parameters:
(1) eye response
(2) motor response
(3) brainstem reflexes
(4) respirations
|
Response |
Findings |
Points |
|---|---|---|
|
eye response |
eyelids open and tracking, or blinking on command |
4 |
|
|
eyelids open but not tracking |
3 |
|
|
eyelids closed but open to loud voice |
2 |
|
|
eyelids closed but open to pain |
1 |
|
|
eyelids closed with pain |
0 |
|
motor response |
makes sign (thumbs-up, fist, other) |
4 |
|
|
localizing to pain |
3 |
|
|
flexion response to pain |
2 |
|
|
extension response to pain |
1 |
|
|
no response to pain |
0 |
|
|
generalized myoclonus status |
0 |
|
Pupil Reflexes |
Corneal Reflexes |
Cough |
Brainstem Points |
|---|---|---|---|
|
present |
present |
present |
4 |
|
one pupil wide and fixed |
present |
present |
3 |
|
absent |
present |
NA |
2 |
|
present |
absent |
NA |
2 |
|
absent |
absent |
present |
1 |
|
absent |
absent |
absent |
0 |
|
Intubation |
Breathing |
Respiratory Points |
|---|---|---|
|
not intubated |
regular |
4 |
|
not intubated |
Cheyne-Stokes |
3 |
|
not intubated |
irregular |
2 |
|
not intubated |
apnea |
0 |
|
intubated |
above ventilator rate |
1 |
|
intubated |
breathes at ventilator rate |
0 |
total score =
= SUM(points for all 4 parameters)
Interpretation:
• minimum score: 0
• maximum score: 16
• The lower the score the more severe the coma.
Performance:
• The inter-relater reliability was reported as good to excellent. Whether this extends to casual users needs to be determined.
• The curve for prediction of in-hospital death (Figure 3, page 592) shows better discrimination for the FOUR score. The curve for prediction of a Rankin score of 3-6 look fairly comparable.
Purpose: To evaluate a patient's level of coma using the Dull Outline of UnREsponsiveness (FOUR) score of Wijdicks et al.
Specialty: Neurology
Objective: severity, prognosis, stage
ICD-10: R40,
