FOUR Score Coma Scale in Medical Intensive Care

Summary and Comment |
October 20, 2009

FOUR Score Coma Scale in Medical Intensive Care

  1. David M. Greer, MD, MA

This relatively new coma assessment scale performed well in predicting outcome in medical intensive care, but it needs further validation.

  1. David M. Greer, MD, MA

For several decades, clinicians have struggled to find the most useful and reliable coma assessment scale. The Glasgow Coma Scale (GCS) is widely used and accepted but gives relatively limited information about brainstem function, eye opening and tracking, and respiratory patterns. Its usefulness is substantially limited for intubated patients, realistically the population to which coma scales are most appropriately applied. A group at the Mayo Clinic have developed and validated the FOUR (Full Outline of UnResponsiveness) score, a tool that provides significantly more information about brainstem function than the GCS and maintains usefulness for intubated patients. To date, the FOUR score has been used primarily by those trained in the neurosciences and applied primarily to patients in the neurocritical care unit.

Now, researchers have compared the predictive abilities of the FOUR score and the GCS as applied by nonneuroscience personnel to 100 patients in a nonneuroscience setting, the medical intensive care unit. The predictive power of the FOUR score for poor outcome had an area under the receiver operating characteristic curve of 0.75, compared with 0.76 for the GCS score. The mortality rate was higher in patients with the worst FOUR score (89%) than in those with the worst GCS score (71%). The FOUR score was performed reliably, consistently, and with excellent interrater reliability.


I am hopeful that this study will provide additional traction for the FOUR score to gain acceptance for common use for coma assessment in any intensive care unit. The main problem this score faces is that it has not been validated outside the Mayo Clinic, and thus its ability to supplant the GCS outside the Mayo Clinic remains hindered. However, given the ease of performance and high reliability of the FOUR score, and its vast superiority in giving more-detailed information about brainstem function, it is easy to imagine that it will be appropriately embraced by intensive care units in the future.

Dr. Greer is Assistant in Neurology, Massachusetts General Hospital, and Associate Professor of Neurology, Harvard Medical School, Boston.


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