New tool is coming for neuro assessments

ED nurses often need to perform neurological assessments and may soon have a new tool to perform this task. Researchers at the Mayo Clinic in Rochester, MN, have created an assessment tool to assess neurological conditions called FOUR (Full Outline of UnResponsiveness) Score, which could replace the widely used Glasgow Coma Scale (GCS).

The score consists of four components — eye, motor, brainstem, and respiration — and each component has a maximum score of 4.

The FOUR score had a 20% higher predictive value for patients at risk for higher mortality for poor outcome than the GCS, according to a recent study's findings.1 The GCS fails to assess the verbal score in intubated patients and isn't able to test brainstem reflexes, note the study's authors.

"This score could replace the GCS. It is easy to learn, has very good inter-rater reliability, and provides a more accurate picture of the patient's status," says Lauren Brandt, RN, MSN, CNS, director of neurosciences for the Brain & Spine Center at Brackenridge Hospital in Austin, TX. "Another benefit is it can identify patients who are locked in or who meet some of the criteria for brain death."

What FOUR score offers

The FOUR score addresses the shortcomings of the GCS, says Brandt. Many of the patients who are comatose in the ED are intubated, she says. "This negates one-third of the GCS: the verbal section," Brandt says. "In addition, the FOUR score gives information on brainstem activity, respiratory pattern, and whether the patient may be locked in."

This additional information could give you more insight into the need for intubation and possible herniation, says Brandt.

ED nurses and physicians always had the sophistication to test patients in a more detailed way, says Eelco F.M. Wijdicks, MD, the study's principal investigator. "The GCS inventors assumed it was not possible to test brainstem reflexes and other important elements of the coma examination," he says. "We proved them wrong."

As a result, ED nurses get more information about the patient's neurological state, says Wijdicks. "More information impacts on care," he says. "The nurse will be aware of the need for ICP [intracranial pressure] management or possible neurosurgical intervention sooner."


  1. Wijdicks EFM, Bamlet WR, Maramattom BV, et al. Validation of a new coma scale: The FOUR score. Ann Neurol 2005; 58:585-593.


For more information about the Full Outline of UnResponsiveness (FOUR) score, contact:

  • Lauren Brandt, RN, MSN, CNS, Director of Neurosciences, Brain & Spine Center, Brackenridge Hospital, 601 E. 15th St., Austin, TX 78701. Telephone: (512) 324-7782. E-mail:
  • Eelco F. M. Wijdicks, MD, Mayo Clinic College of Medicine, Division of Critical Care Neurology, Mayo Clinic, 200 First St. S.W., Rochester, MN 55905. E-mail: