Neurocritical Care

, 10:50 | Cite as

Validation of a New Coma Scale, the FOUR Score, in the Emergency Department

  • Latha G. SteadEmail author
  • Eelco F. M. Wijdicks
  • Anjali Bhagra
  • Rahul Kashyap
  • M. Fernanda Bellolio
  • David L. Nash
  • Sailaja Enduri
  • Raquel Schears
  • Bamlet William
Original Article



Full Outline of Unresponsiveness (FOUR) score has previously been validated scale in the Neurosciences Intensive Care Unit. In this study, we sought to validate the use of FOUR score in the emergency department (ED) using non-neurology staff. We also compared its performance to the Glasgow Coma Scale (GCS) and correlated it to functional outcome at hospital discharge and overall survival.


We prospectively rated 69 patients with initial neurologic symptoms presenting to the ED. Three types of examiners performed the FOUR score: ED physician, ED resident, and ED nurse. Patients were followed through hospital discharge; functional outcome was measured using modified Rankin Score (mRS).


Interrater reliability for FOUR score and GCS was excellent (respectively, κw = 0.88 and 0.86). Both FOUR score and GCS predicted functional outcome, and overall survival with and without adjustment for age, sex, and alertness group.


The FOUR score can be reliably used in the ED by non-neurology staff. Both FOUR score and GCS performed equally well, but the neurologic detail incorporated in the FOUR score makes it more useful in management and triage of patients.


FOUR score Neurologic Glasgow Coma Scale Consciousness 


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Copyright information

© Humana Press Inc. 2008

Authors and Affiliations

  • Latha G. Stead
    • 1
    Email author
  • Eelco F. M. Wijdicks
    • 2
  • Anjali Bhagra
    • 3
  • Rahul Kashyap
    • 1
  • M. Fernanda Bellolio
    • 1
  • David L. Nash
    • 1
  • Sailaja Enduri
    • 1
  • Raquel Schears
    • 1
  • Bamlet William
    • 4
  1. 1.Department of Emergency MedicineMayo ClinicRochesterUSA
  2. 2.Division of Critical Care NeurologyMayo ClinicRochesterUSA
  3. 3.Department of Internal MedicineMayo ClinicRochesterUSA
  4. 4.Department of BiostatisticsMayo ClinicRochesterUSA

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