Original article 29
Comparison of the Full Outline of Unresponsiveness
Score Coma Scale and the Glasgow Coma Scale in an
emergency setting population
Cenker Eken, Mutlu Kartal, Ayse Bacanli and Oktay Eray
Background The Glasgow Coma Scale (GCS) is the
most widely used tool for the evaluation of the level of
consciousness. The Full Outline of Unresponsiveness
(FOUR) Score is a new coma Scale that was developed
considering the limitations of the GCS, and has been found
to be useful in an intensive care setting. We aimed to
compare FOUR Score and GCS in the emergency setting.
Methods All patients older than 17 years who presented
with an altered level of consciousness, after any trauma to
the head or with neurological complaints were included in
this study. Three-month mortality, in-hospital mortality, and
poor outcome using a Modified Rankin Scale (MRS) of 3–6
points were used as the primary outcome measures.
Results A total of 185 patients were included in the study.
Area under the curve (AUC) values in predicting 3-month
mortality for GCS was 0.726 [P = 0.0001 and 95%
confidence interval (CI): 0.656–0.789] and 0.776 (P = 0.0001
and 95% CI: 0.709–834) for FOUR Score. AUC in predicting
hospital mortality for GCS was 0.735 (P = 0.0001 and
95% CI: 0.655–0.797) and 0.788 (P = 0.0001 and 95%
CI: 0.722–0.844) for FOUR Score. AUC in predicting poor
Introduction
Defining the level of conscious (LOC) is a core clinical
skill, which can be a challenge even for experienced
physicians. The Glasgow Coma Scale (GCS), defined by
Teasdale and Jennett in 1974 [1], remains the most
commonly used scoring system for LOC. Although the
GCS was created only for patients with head trauma, it
has become widely used for patients with other causes
of decreased LOC.
Although it has been commonly used and reported to be
a reliable tool in predicting the prognosis of patients with
altered mental status, there are some limitations to its
use. One of these limitations is the lack of consistent
interobserver agreement while using the GCS [2–4].
Furthermore, experienced staff tends to apply the GCS
better [5] and low interobserver agreement was reported
in evaluating patients with moderate Scores [6].
Another limitation for the GCS is that intubated patients
cannot manifest a verbal response. Withdrawal from pain,
which is easily misinterpreted as a flexion response to
pain, is another confounder for GCS. To enhance the
0969-9546 c 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
outcome (Modified Rankin Scale: 3–6) was 0.720 (P = 0.001
and 95% CI: 0.650–784) for GCS and 0.751 (P = 0.0001 and
95% CI: 0.682–0.812) for FOUR Score.
Conclusion The new coma Scale, FOUR Score, is not
superior to the GCS. However, the combination of the
eye and motor components of FOUR Score is a valuable
tool that can be used instead of either the FOUR Score
or GCS. European Journal of Emergency Medicine
16:29–36 c 2009 Wolters Kluwer Health | Lippincott
Williams & Wilkins.
European Journal of Emergency Medicine 2009, 16:29–36
Keywords: altered level consciousness, emergency population, Full Outline
of Unresponsiveness Score, Glasgow Coma Scale
Department of Emergency Medicine, Akdeniz University Medical Faculty,
Antalya, Turkey
Correspondence to Dr Cenker Eken, MD, Akdeniz University, Akdeniz Universitesi
Hastanesi, Acil Tip Anabilim Dali, 07059, Antalya, Turkey
Tel: + 90 242 249 6176; e-mail: cenkereken@akdeniz.edu.tr
Received 28 November 2007 Accepted 2 April 2008
validity of the GCS, many alternative scoring systems
evaluating consciousness by either using additional
physiological parameters or only using subunits of GCS
or different simple approaches have been developed.
Acute Physiology and Chronic Health Evaluation Score
[7], Mainz Emergency Evaluation Score [8], Reaction
Level Scale [9], Alert, response to Verbal stimulus,
response to Pain, Unresponsiveness Scale for trauma
patients [10], and Revised Trauma Score [11] are some
alternative scoring systems. Most of them were found to
be better or as good as the GCS in evaluating comatose
patients using the subunits of GCS. However, none of
them has been entirely accepted in the place of the GCS.
Wijdicks et al. [12] developed a new coma Scale, Full
Outline of Unresponsiveness (FOUR) Score, considering
the limitations of the GCS. Verbal response is not a
component of the FOUR Score. Brainstem reflexes and
respiratory pattern, which can be used in the evaluation
of patients with decreased LOC and not used in GCS,
were integrated into the FOUR Score. Withdrawal from
pain, which is a parameter for the motor component of
the GCS, was also removed in the FOUR Score. Widjicks
DOI: 10.1097/MEJ.0b013e32830346ab
 30 European Journal of Emergency Medicine 2009, Vol 16 No 1
et al. studied the FOUR Score in patients admitted in the
intensive care unit for nontraumatic medical conditions.
They suggested the FOUR Score to be superior to GCS
owing to the availability of brainstem reflexes, breathing
patterns, and the ability to recognize different stages of
herniation. They also found a higher probability of in-
hospital mortality using the lowest FOUR Score than the
lowest GCS.
We evaluated the hypotheses that the area under the
curve (AUC) for the FOUR Score would significantly
exceed the AUC for GCS Scores for the unfavorable
outcomes, in-hospital mortality, 3-month mortality, and a
low (3–6) Modified Rankin Scale (MRS).
Materials and methods
Study setting and design
This prospective observational study was performed in a
tertiary care hospital emergency department (ED), which
is also a level IV trauma center, with an annual census
of 55 000 from May to April in 2006. This study was
approved by the local ethics committee.
Selection of participants
All patients older than 17 years who presented with an
altered level of consciousness, after any trauma to the
head (whether or not LOC was altered), neurological
complaints of lateralizing motor, and/or sensory deficits,
dysarthria, dysphasia, or facial asymmetry were eligible
for inclusion in this study. A different study population
from the former studies comparing the coma Scales was
selected. The study population of the former studies only
consisted of patients with altered mental status. How-
ever, to calculate sensitivity, specificity, and a cut-off
value for two Scales, we preferred to enroll alert patients
who had the possibility of developing future adverse
events such as neurological deficit or death. Therefore, all
alert patients with head trauma and neurological deficit
were included in the study. Patients were excluded from
the study if they were intubated or if they had been
administered sedative or paralytic agents before their
presentation to the ED.
Data collection and processing
Before starting the study, all attending physicians and
residents in a 4-year residency program were trained on
the new coma Scale, FOUR Score, and also on the GCS
to standardize physicians’ definitions. Written definitions
of two Scales were included in the study form and
illustrative definitions of the FOUR Score were located in
various areas of the department. Patients were deemed
eligible for the study by attendees and residents who
filled out an enrollment form. The FOUR Score and GCS
of the patients were calculated before any invasive or
medical procedure. The enrollment form included
demographic features of the patients, presenting com-
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
plaints, GCS and FOUR Scores, 3-month mortality,
hospital mortality, and MRS. The final diagnoses of
patients were also recorded in the enrollment form.
However, final diagnoses of patients were displayed in the
manuscript after classifying them as:
1. Traumatic head injury: subarachnoid hemorrhage,
subdural hemorrhage, intraventricular hemorrhage,
skull fracture, and cerebral edema.
2. Stroke: ischemic or hemorrhagic.
3. Nontraumatic intracranial hemorrhage: aneurismal
subarachnoid hemorrhage, subdural hemorrhage, and
parenchymal or ventricular hemorrhage.
4. Central nervous system infections: meningitis and
encephalitis.
5. Metabolic encephalopathy: electrolyte disturbances,
hepatic or hypoxic encephalopathy, and hypoglycemia.
6. And the other diagnoses like brain tumor.
Description of the new coma Scale, FOUR Score,
and GCS
The FOUR Score differs from the GCS. The FOUR
Score consists of components that Score eye, motor,
brainstem reflex, and respiration patterns of the patients.
The FOUR Score and the GCS are detailed in Table 1.
Outcome measures
We selected three primary outcome measures; 3-month
mortality, hospital mortality, and 3-month morbidity using
an MRS [13]. The MRS can be defined briefly as; 0 = no
Table 1 Definition of FOUR score and Glasgow Coma Scale
FOUR Score Glasgow Coma Scale
Eye response Eye response
4 = eyelids open or opened, tracking, 4 = open spontaneously
or blinking to command
3 = eyelids open, but not tracking 3 = eye opening to verbal command
2 = eyelids closed, but open to loud 2 = eye opening to pain
voice
1 = eyelids closed, but open to pain 1 = no eye opening
0 = eyelids remain closed with pain
Motor response Motor response
4 = thumbs-up, fist, or peace sign 6 = obeys commands
3 = localizing to pain 5 = localizing to pain
2 = flexion response to pain 4 = withdrawal from pain
1 = extension response to pain 3 = flexion response to pain
0 = no response to pain or 2 = extension response to pain
generalized myoclonus status 1 = no motor response
Brainstem reflexes Verbal response
4 = pupil and corneal reflexes present 5 = oriented
3 = one pupil wide and fixed 4 = confused
2 = pupil or corneal reflexes absent 3 = inappropriate words
1 = pupil and corneal reflexes absent 2 = incomprehensible sounds
0 = absent pupil, corneal, and cough 1 = no verbal response
reflex
Respiration
4 = not intubated, regular breathing
pattern
3 = not intubated, Cheyne–Stokes
breathing pattern
2 = not intubated, irregular breathing
1 = breathes above ventilator rate
0 = breathes at ventilator rate or
apnea
FOUR, Full Outline of Unresponsiveness.
 FOUR Score and Glasgow Coma Scale Eken et al. 31

symptoms at all; 1 = no significant disability despite Table 2 Patient characteristics

symptoms, able to carry out all usual duties and activities; Variable No
2 = slight disability, unable to carry out some previous
Total number of patients 185
activities, but able to look after own affairs without Median age (range) 59 (18–97)
assistance; 3 = moderate disability, requiring some help, Sex
Male (%) 119 (64.3)
but is able to walk without assistance; 4 = moderately Female (%) 66 (35.7)
severe disability, unable to walk without assistance and Diagnosis (%)
unable to attend to own bodily needs without assistance; Stroke 66 (35.7)
Minor head trauma 43 (23.2)
5 = severe disability, bedridden, incontinent, and requir- Traumatic head injury 23 (12.4)
ing constant nursing and attention; and 6 = dead. Nontraumatic intracranial hemorrhage 16 (8.6)
Metabolic encephalopathy 11 (5.9)
Brain tumor 9 (4.9)
Primary data analysis Seizure 4 (2.2)
CNS infection 3 (1.6)
Data were analyzed by SPSS 15.0 for Windows (SPSS Nontraumatic brain edema 2 (1.1)
Inc., Chicago, Illinois, USA)and receiving operating Sepsis 2 (1.1)
characteristic (ROC) curve analyses were performed by Pneumonia 2 (1.1)
Traumatic intra-abdominal hemorrhage 1 (0.5)
Med Calc Version 9.2.0.1 (Frank Schoonjans, Mariakerke, Gastrointestinal system hemorrhage 1 (0.5)
Belgium). Continuous variables were expressed by Hypoxic encephalopathy 1 (0.5)
Altered mental status with unknown etiology 1 (0.5)
mean ± standard deviation, ordinal variables as median
and minimum–maximum, and frequent variables as rates. CNS, central nervous system.
Correlation between MRS and coma Scales was deter-
mined by Spearman’s correlation coefficient. Predictive
value of GCS and FOUR Score in predicting primary
outcome measures was established by ROC curve by
ROC curve was performed to predict the 3-month
calculating AUC values by 95% confidence intervals (CI).
mortality, in-hospital mortality, and poor outcome for
A binary logistic regression analysis was performed to
MRS (3–6). AUC values in predicting 3-month mortality
reveal the adjusted odds ratios of GCS and FOUR Scores
for GCS was 0.726 (P = 0.0001 and 95% CI: 0.656–0.789)
in predicting the primary outcome measures. This study
and 0.776 (P = 0.0001 and 95% CI: 0.709–834) for FOUR
had a 95% power of predicting the 3-month mortality,
Score. The cut-off values for GCS in predicting 3-month
which failed for a 3-month low (3–6) MRS; 288 patients
mortality was 5 (positive likelihood ratio = 11.7) and 9 for
were needed to detect the difference between FOUR
the FOUR Score (positive likelihood ratio = 11.7). AUC
Score and GCS in predicting the 3-month low (3–6) MRS
in predicting in-hospital mortality for GCS was 0.735
with an 80% power. All hypotheses were constructed two-
(P = 0.0001 and 95% CI: 0.655–0.797) and 0.788
tailed and P r 0.05 was considered significant.
(P = 0.0001 and 95% CI: 0.722–0.844) for FOUR Score.
AUC in predicting poor outcome (MRS: 3–6) was 0.720
(P = 0.001 and 95% CI: 0.650–784) for GCS and 0.751
Results (P = 0.0001 and 95% CI: 0.682–0.812) for FOUR Score.
A total of 188 patients were included in the study. Three However, the comparison of AUC values of total FOUR
of the eligible patients were excluded from the study Score and GCS lack statistical significance as the
because of not being able to be reached for telephone overlapping 95% CIs demonstrate (Table 3). ROC curves
follow-up at the end of the 3 months. The remaining 185 depicting the comparisons of FOUR Score and GCS in
patients composed the study population. The median age predicting primary outcome measures are displayed in
of the study patients was 59 years (range: 18–97 years) Figs 1–3. Figures 4 and 5 also display the frequency of
and 64.3% (n = 119) were men. Characteristics of the FOUR Score and GCS according to the patients’ assigned
study patients and the ultimate diagnosis are displayed Scores.
in Table 2. Five patients had blood alcohol levels over
10 mg/dl, the upper limit of the blood alcohol level, and The subunit analyses of FOUR Score and GCS revealed
three patients had hypoglycemia. that the eye and motor components of FOUR Score
had AUC values higher than GCS and lower than the
Forty-seven (25.4%) patients died at the end of the complete FOUR Score, but these differences lack
3 months and 55% (n = 26) of them died in the hospital. statistical significance. Furthermore, brainstem reflexes
Seventy-two patients (38.8%) had poor outcomes accord- and respiratory pattern had significantly lower AUC
ing to the MRS (MRS = 3–6). values than eye and motor components of the FOUR
Score (Table 3).
A moderate correlation was observed between the MRS
at the end of the 3 months both for GCS (r = – 0.430; To determine the predictive value of coma Scales in
P = 0.000) and FOUR Scores (r = – 0.483; P = 0.000). traumatic and nontraumatic patients, ROC was reperformed

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 32 European Journal of Emergency Medicine 2009, Vol 16 No 1

Table 3 Receiving operating characteristic curve analyses in predicting 3-month mortality, hospital mortality, and poor outcome for GCS,
FOUR score, and subunits of two scales
Variable Three-month mortality AUC (95% CI) Hospital mortality AUC (95% CI) Rankin Score 3–6 AUC (95% CI)

Total FOUR score 0.776 (0.709–0.834) 0.788 (0.722–0.844) 0.751 (0.682–0.812)

FOUR score
Eye 0.751 (0.682–0.812) 0.743 (0.674–0.805) 0.711 (0.640–0.775)
Motor 0.737 (0.667–0.799) 0.770 (0.703–0.829) 0.707 (0.635–0.771)
Brainstem reflexes 0.586 (0.512–0.658) 0.598 (0.523–0.669) 0.562 (0.487–0.634)
Respiration 0.572 (0.497–0.644) 0.585 (0.510–0.657) 0.567 (0.492–0.639)
Eye and motor responsesa 0.773 (0.706–0.831) 0.786 (0.720–0.843) 0.733 (0.633–0.795)
Total GCS 0.726 (0.656–0.789) 0.735 (0.655–0.797) 0.720 (0.650–0.784)
GCS
Eye 0.646 (0.573–0.715) 0.631 (0.557–0.701) 0.620 (0.546–0.690)
Motor 0.679 (0.606–0.745) 0.662 (0.589–0.730) 0.651 (0.578–0.720)
Verbal 0.701 (0.629–0.766) 0.705 (0.634–0.770) 0.720 (0.649–0.783)

AUC, area under the curve; CI, confidence interval; FOUR, Full Outline of Unresponsiveness; GCS, Glasgow Coma Scale.
a
Eye and motor responses of FOUR score combined because of having individually high AUC values whether a more simple approach could be established.

Fig. 1 Fig. 2

100 100

80 80

60 60
Sensitivity
Sensitivity

40 40

20 20 Total FOUR Score

Total FOUR Score
Total GCS Total GCS

0 0
0 20 40 60 80 100 0 20 40 60 80 100

100-Specificity 100-Specificity

Receiving operating characteristic curves comparing Full Outline of Receiving operating characteristic curves comparing Full Outline of
Unresponsiveness (FOUR) score and Glasgow Coma Scale (GCS) Unresponsiveness (FOUR) score and Glasgow Coma Scale (GCS)
in predicting 3-month mortality. in predicting hospital mortality.

using MRS as the dependent variable. We did not
use mortality as the dependent variable because of
insufficient mortality in the trauma group.
AUC for GCS in trauma patients was 0.776 (P = 0.0045
and 95% CI: 0.657–0.869) and 0.786 (P = 0.0024 and 95%
CI: 0.668–0.876) for the FOUR Score. In nontraumatic
patients, AUC for the GCS was 0.655 (P = 0.0026 and
95% CI: 0.562–0.740) and 0.713 (P = 0.0001 and 95% CI:
0.623–0.793) for the FOUR Score. No statistical differ-
ence was observed between the AUC values of total
FOUR Score and GCS. The AUC values with 95% CI are
displayed in Table 4.
A logistic regression analysis including age, sex, systolic
and diastolic blood pressures, respiration rate, alcohol,
hypoglycemia, and trauma revealed both the FOUR Score
and GCS as independent variables in predicting 3-month
mortality. The adjusted odds ratios for FOUR Score and
GCS were 0.638 (95% CI: 0.511–0.796; P = 0.000) and
0.796 (95% CI: 0.695–0.911; P = 0.001), respectively.
Discussion
The FOUR Score has been developed to overcome
certain limitations of the GCS, imposed by the need to
characterize a verbal response. Furthermore, the authors

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 FOUR Score and Glasgow Coma Scale Eken et al. 33

Fig. 3 Fig. 5

100 100

80
80

Frequency
60
60
Sensitivity

40

40
20

20 Total FOUR Score 0

Total GCS 2.50 5.00 7.50 10.00 12.50 15.00
GCS Score
0
Frequency of Glasgow Coma Scale (GCS) (range: 3–15) among study
0 20 40 60 80 100 population.
100-Specificity

Receiving operating characteristic curves comparing Full Outline of

Unresponsiveness (FOUR) score and Glasgow Coma Scale (GCS) in Table 4 Receiving operating characteristic curve in predicting poor
predicting poor outcome (Modified Rankin scale: 3–6). outcome in patients with and without trauma
Patients without trauma Patients with trauma
Variable MRS from 3 to 6 MRS from 3 to 6

Total FOUR score 0.713 (0.623–0.793) 0.786 (0.668–0.876)

FOUR score
Fig. 4 Eye 0.674 (0.582–0.758) 0.776 (0.657–0.869)
Motor 0.652 (0.559–0.738) 0.810 (0.695–0.895)
Brainstem reflexes 0.565 (0.471–0.656) 0.508 (0.383–0.632)
100 Respiration 0.561 (0.467–0.653) 0.611 (0.484–0.728)
Total GCS 0.655 (0.562–0.740) 0.776 (0.657–0.869)
GCS
Eye 0.594 (0.500–0.684) 0.679 (0.553–0.787)
80
Motor 0.597 (0.503–0.686) 0.706 (0.582–0.811)
Verbal 0.646 (0.553–0.732) 0.782 (0.664–0.873)
Frequency

60 FOUR, Full Outline of Unresponsiveness; GCS, Glasgow Coma Scale; MRS,

modified Rankin Scale.

40
indicates that brainstem and respiratory components of
the FOUR Score had much lower AUC numerical values
20
than did the eye and motor components of the FOUR
Score. This demonstrates that brainstem reflexes and
0 respiratory pattern do not provide the expected benefit
0.00 5.00 10.00 15.00 to using the eye and motor components; contrary to
FOUR Score what the authors of the FOUR Score anticipated. The
developers of the FOUR Score also did not state the AUC
Frequency of Full Outline of Unresponsiveness (FOUR) score (range: values of brainstem reflexes and respiratory pattern. They
0–16) among study population.
only found a significant odds ratio for the brainstem
component, but not for respiratory pattern in predicting
in-hospital mortality when adjusted for confounding
who developed the FOUR Score anticipated that it would variables in the logistic regression analysis.
be more easily remembered than the GCS, because the
FOUR Score assigns all Scores within the same 0–4 range, Although the AUC values of the FOUR Score were
unlike the GCS. Also, the FOUR Score adds the slightly better than the GCS in predicting all primary
evaluation of brainstem reflexes and respiratory patterns outcome measures not only for the whole study popula-
rather than a verbal response Score. However, this study tion, but also for nontraumatic and traumatic patient

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 34 European Journal of Emergency Medicine 2009, Vol 16 No 1
subgroups, according to the results of this study, this
difference was not statistically significant, which can
be seen by analyzing the overlapped 95% CIs in Table 3.
The critical question here is whether the FOUR Score
replaces the GCS in clinical practice. As previously
mentioned, the coma Scales that were developed instead
of GCS have not been accepted commonly in the clinical
practice of emergency medicine. Some suggest that the
Alert Verbal Painful Unresponsive Scale as an alternative,
although this was not found to be as valuable as GCS.
The findings of this study show the total FOUR Score
cannot replace the GCS Score although, interobserver
reliability and the ease-of-use of the FOUR Score in EDs
are still unknown.
An interesting finding in this study was that the eye
and motor components of FOUR Score had higher AUC
values than the total GCS, and these components were
also close to the total FOUR Score although, these
differences lacked statistical significance. Studies com-
paring the predictive values of components of the GCS
with the total GCS showed insignificant differences
according to the AUC values in the ROC analysis in
predicting unfavorable outcomes [14,15]. As this study
demonstrated high predictive values of the eye and motor
components of FOUR Score, an additional ROC analysis
was performed by combining these two components to
determine whether the predictive value would be
enhanced. This process slightly augmented the AUC
value, but did not constitute a statistically significant
difference than the total FOUR Score. Actually, these
findings are in concordance with previous studies and
should be interpreted as a summary of the literature.
Even though the predictive values of the subunits of
the GCS are close to the GCS, combining them does
not increase their predictive values as expected. Never-
theless, the close AUC value of the combined eye and
motor responses, which are easier to remember than both
the entire GCS and FOUR Score, may be the most useful
predictor of 3-month mortality, in-hospital mortality, and
a final Rankin Score of 3–6.
As the GCS is not only used for traumatic brain injuries,
but also for all patients with altered conscious, many
researchers have developed coma Scales by adding
physiological parameters to the GCS to take into
consideration their affects on the prognosis of comatose
patients. Acute Physiology and chronic health evaluation
and the Revised Trauma score are two of those that are
widely known. However, studies comparing these Scores
with the GCS have not shown the expected enhance-
ment when compared with the predictive value of GCS
both in patients with and without trauma [16–19]. These
disappointing results regarding the physiological para-
meters may be interpreted as physiological abnormalities
that are serious to be able to cause altered LOC and are
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
expected to result with an unfavorable outcome. In this
instance, the level of altered consciousness may naturally
be expected to be related to the poor outcome. Hence,
including only the patients with altered LOC, as
practiced in the previous studies, may cause referral bias.
Studies investigating the value of simpler coma Scales
compared with the GCS that have reported close
predictive values to the GCS may support the conclusion
that complex coma Scores are not necessarily better. The
findings of this study on brainstem reflexes and
respiratory pattern in predicting unfavorable outcomes
also support the results stated in the previous literature.
However, a dilemma has developed after these studies
were performed because of the simple methods, as
aforementioned, have not replaced the GCS. This
dilemma is still a challenge in the development of new
coma Scales other than the GCS. As aforementioned, eye
and motor components of FOUR Scores either alone or
in combination demonstrated high AUC values, which
were not statistically different from total FOUR Score
and GCS. The motor subunit of the FOUR Score does
not include the component ‘withdrawal from pain’. The
eye component classifies a patient with open eyes
according to the ability to track. These findings may be
attributed to the changes in the eye and motor
components of FOUR Score.
One of the aims of the authors in developing the FOUR
Score was to eliminate the limitations caused by the
evaluation of verbal response in intubated patients.
Verbal response does not help the evaluation of the eye
and motor components. It can also be predicted from the
eye and motor Scores of GCS as reported by Rutledege
et al. [20]. A recent study by Marmarou et al. [21], which
combined the results of multiple studies with a total
number of 8721 patients, reported the entire eye, verbal,
and motor components of GCS and one or two unreactive
pupils individually were all strongly associated with
unfavorable outcomes. In this study, the advantage of
the FOUR Score over the GCS seems to arise from the
changes in eye and motor components more than
excluding the verbal response.
The developers of the FOUR Score also aimed to
construct a more practical Scale than the GCS. They
assigned the components of FOUR Score from 0 to 4.
The interrater reliability of the FOUR Score and GCS
among nurses, residents, and neurointensivists was also
investigated in their study. They reported an overall k
value of 0.82 both for total GCS and total FOUR Score.
The interrater reliability among nurses was found to be
lower than that among residents and neurointensivists.
Although the previous studies stated that experienced
nurses have been found to have higher agreement rates
than inexperienced ones in scoring GCS [5], a close
agreement between emergency physicians and parame-

dics was also stated for GCS by Menegazzi et al. [6],
k values were 0.66 for emergency physicians and 0.63
for paramedics. And a recent study by Wolf et al. [22]
reported an excellent agreement both for FOUR Score
(weighted k: eye, 0.84; motor, 0.73; brainstem, 0.89; and
respiration, 0.92) and GCS (weighted k: eye, 0.85; motor,
0.74; and verbal, 0.89) among intensive care nurses,
unlike data from Widjicks et al. The high agreement rates
stated in the study by Widjicks et al. for the total GCS and
its verbal components (weighted k: total GCS, 0.82 and
verbal, 0.88) were not similar to the studies investigating
the interrater agreement of GCS among emergency
physicians. Gill et al. [2] reported lower agreement rates
for total GCS and verbal response than motor and eye
components among emergency physicians (k: eye, 0.57;
motor, 0.54; verbal, 0,44; and total GCS, 0.32). In another
study by Gill et al. [3], verbal components and total GCS
were found to have lower weighted k values than motor
and eye components, despite intubated patients which
were assigned with the same Scores. The interrater
agreement of the FOUR Score among emergency
physcians was not investigated in this study. This should
be investigated in future studies.
The cut-off values in this study were 5 for the GCS and
9 for the FOUR Score in predicting mortality, but if the
hospital mortality was used as the outcome measure, both
the cut-off values for the GCS and FOUR Scores were
found to be 4. However, Wijdikcs et al. reported cut-off
values of 7 for GCS and 9 for FOUR Score in predicting
hospital mortality. These differences may be as a result of
the statistical techniques used in determining the cut-off
values and the differences between study populations.
Wijdicks et al. used the maximum sum of sensitivity and
specificity, which is similar to Youden Index (sensitivi-
ty + specificity – 1). However, we used the positive
likelihood ratio to determine the cut-off values. Cho
and Wang [17] stated a cut-off value of 5 for GCS in
predicting hospital mortality.
Limitations
The population of this study has a composition different
from the former studies. We also enrolled the patients
with neurological deficits who did not have an altered
level of consciousness. We thought that all of these
patients would not have a GCS of 15 and FOUR Score
of 16 and they all had high risks of mortality and
neurological disability, which was evaluated with MRS.
We also included the patients with head trauma without
altered mental status. GCS has been used in the clinical
practice not only for patients with a Score of under 15,
but also for patients without any neurological deficits.
The level of mental status of these patients is usually
defined as having a GCS of 15, particularly for patients
presenting with trauma to the ED. These patients also
have a risk of mortality and morbidity even though their
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
FOUR Score and Glasgow Coma Scale Eken et al. 35
GCS Score is 15, which could be a limitation of this study.
Another limitation to this study was the low mortality
rate in trauma patients and that only MRS was used as
the outcome measure for the subgroup analysis. Studies
with bigger sample sizes are needed for more accurate
subgroup analyses. The number of potentially eligible
patients who were not enrolled in this study is not known.
The interrater reliability was also not investigated in
this study. Further studies are needed to determine the
interrater reliability of FOUR Score among emergency
physicians.
Conclusion
The new coma Scale, FOUR Score, developed to
overcome the limitations of GCS, had slightly higher
AUC values than the GCS in predicting 3-month
mortality, in-hospital mortality, and low (3–6) MRS, but
this lacked statistical and clinical significance. However,
the combination of the eye and motor components of
the FOUR Score should be a valuable tool instead of
either the FOUR Score or the GCS, which is also easy to
remember. Brainstem reflexes and respiration pattern do
not provide additional benefits in predicting the unfavor-
able outcomes as expected. The interobserver reliability
of FOUR Score among emergency physicians and
paramedics should also be a studied further.
Acknowledgement
This study was supported by Akdeniz University
Foundation and great thanks to Dr Feras Khan for his
contributions to the syntax of the article.
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