Validation of a new coma scale, the four score, in the emergency department

Latha G. Stead, Eelco F.M. Wijdicks, Anjali Bhagra, Rahul Kashyap, M. Fernanda Bellolio, David L. Nash, Sailaja Enduri, Raquel Schears, Bamlet William

Research output: Contribution to journalArticlepeer-review

79 Scopus citations


Objective: 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. Methods: 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). Results: 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. Conclusion: 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.

Original languageEnglish (US)
Pages (from-to)50-54
Number of pages5
JournalNeurocritical care
Issue number1
StatePublished - Feb 1 2009


  • Consciousness
  • Four score
  • Glasgow coma scale
  • Neurologic

ASJC Scopus subject areas

  • Clinical Neurology
  • Critical Care and Intensive Care Medicine


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