FOUR score (Full Outline of UnResponsiveness)
- Category: General
- Version: v1.1.1
- Reviewed: Reviewed 6 Sep 2026
- Validation: Validation pending
Total = Eye + Motor + Brainstem + Respiration, each scored 0-4, giving a range of 0-16. Low is worse. There is no verbal component, which is why the score stays complete in an intubated patient, and every component has a true 0. This implements the adult instrument (Wijdicks 2005), not the modified Pediatric FOUR Score Scale (Czaikowski 2014).
STRUCTURAL CEILINGS, BUILT INTO THE INSTRUMENT. An INTUBATED patient can score at most 1 on respiration, capping the total at 13 — intubation is the split, not ventilator support, so a child on mask CPAP or high-flow is scored on rhythm like any unsupported patient; intubated and non-intubated totals are different rulers and are not comparable. Eye 4 and motor 4 require obeying an instruction, so a neurologically intact preverbal child caps at 14. That ceiling is reasoned from the item definitions; [NEEDS SOURCE] for a published youngest applicable age. BRAINSTEM READING TRAP: level 2 is exactly ONE of the pupillary/corneal pair lost; level 1 is BOTH lost with cough retained; level 0 is cough lost too. The or/and distinction is one point wide. Sedation and neuromuscular blockade make the eye and motor components uninformative. PAEDIATRIC STANDING: six studies, 571 children (Almojuela 2019): equivalent to the GCS in outcome prediction, reliably rated, superiority not established. The cohorts were mostly school-age (2-12 y), with neonates and infants effectively absent. Not interchangeable with the GCS, which has different components, ranges and floors. NO INTERPRETATION BANDS, DELIBERATELY. Wijdicks 2005 proposes none, and published cut-points are cohort- and outcome-specific and disagree, with values from 4 to 14 appearing for different populations and endpoints. Do not attach any of them to a computed result.
References
- Wijdicks EFM, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: The FOUR score. Ann Neurol. 2005;58(4):585-593.Derivation and validation in 120 adult ICU patients (Mayo Clinic); interrater kappa 0.82. Source of the four components, the sixteen levels this implementation paraphrases, and the 0-16 total.PMID 16178024DOI 10.1002/ana.20611
- Almojuela A, Hasen M, Zeiler FA. The Full Outline of UnResponsiveness (FOUR) Score and Its Use in Outcome Prediction: A Scoping Review of the Pediatric Literature. J Child Neurol. 2019;34(4):189-198.The paediatric evidence base assembled: 6 studies, 571 children. FOUR equivalent to GCS in outcome prediction in all six; interobserver reliability good to excellent; superiority over GCS NOT established.PMID 30630377DOI 10.1177/0883073818822359
- Cohen J. Interrater reliability and predictive validity of the FOUR score coma scale in a pediatric population. J Neurosci Nurs. 2009;41(5):261-267.First paediatric application, PICU. Weighted kappa 0.951 (FOUR) vs 0.738 (GCS). Excluded sedated and neuromuscularly blocked patients.PMID 19835239DOI 10.1097/JNN.0b013e3181b2c766
- Czaikowski BL, Liang H, Stewart CT. A pediatric FOUR score coma scale: interrater reliability and predictive validity. J Neurosci Nurs. 2014;46(2):79-87.The Pediatric FOUR Score Scale (PFSS) — a MODIFIED instrument for all paediatric ages including intubated/sedated children. Cited because its existence is the evidence that the adult scale needed adapting. This implementation is NOT the PFSS.PMID 24556655DOI 10.1097/JNN.0000000000000041
- Jamal A, Sankhyan N, Jayashree M, Singhi S, Singhi P. Full Outline of Unresponsiveness score and the Glasgow Coma Scale in prediction of pediatric coma. World J Emerg Med. 2017;8(1):55-60.63 children aged 5-12 y, paediatric ED. In-hospital mortality AUC 0.80 (FOUR) vs 0.83 (GCS), p=0.27 — no difference. Adult instrument applied unmodified.PMID 28123622DOI 10.5847/wjem.j.1920-8642.2017.01.010
- Khajeh A, Fayyazi A, Miri-Aliabad G, Askari H, Noori N, Khajeh B. Comparison between the Ability of Glasgow Coma Scale and Full Outline of Unresponsiveness Score to Predict the Mortality and Discharge Rate of Pediatric Intensive Care Unit Patients. Iran J Pediatr. 2014;24(5):603-608.200 children aged 2-12 y, PICU. Per-component kappa 0.72-0.82; cut-point 8; mean total 12.5 +/- 2.1 in survivors vs 5.1 +/- 2.8 in non-survivors. No DOI is registered for this article.PMID 25793069
- Pandwar U, Navindana, Ramteke S, Motwani B, Agrawal A. Comparison of Full Outline of Unresponsiveness Score and Glasgow Coma Scale for Assessment of Consciousness in Children With Acute Encephalitis Syndrome. Indian Pediatr. 2022;59(12):933-935.150 children with acute encephalitis syndrome; FOUR and GCS strongly correlated (r=0.82) and comparable.PMID 36511207
- Foo CC, Loan JJM, Brennan PM. The Relationship of the FOUR Score to Patient Outcome: A Systematic Review. J Neurotrauma. 2019;36(17):2469-2483.37 studies. Good-to-excellent prognostication of in-hospital mortality (AUC >0.80); motor and eye components more prognostic than the brainstem component; closes by calling for further standardised research across populations — the basis for shipping no interpretation bands.PMID 31044668DOI 10.1089/neu.2018.6243
Reproduction rights
Freely reproducible.The scoring math is an ordinal sum of four integers (E+M+B+R, 0-16) — under 17 USC 102(b) a procedure or method of operation, not copyrightable expression — and the numeric levels and total range are facts. The DESCRIPTOR PROSE is a different matter: the scale was developed at the Mayo Clinic (Wijdicks) and the derivation and validation papers are publisher-copyrighted, and the developer is reported to have fielded several hundred requests for permission to use the scale. No explicit reproduction restriction on the scale text was located, and no explicit grant was either. This implementation therefore reproduces NONE of it: every option label is this project's own paraphrase of what the level represents, per the binding constraint in ADR-tier-b-ip.md third addendum (2026-08-02), with Wijdicks 2005 attributed here, in references, in formula and in notes (four-score.md IP status).
Independent clinical validation: pending
Two independent clinical validators will be named here once review is complete.
- 2026-08-10v1.0.0Initial releaseInitial published text.
- 2026-09-03v1.1.0Formula correctionCorrects three option labels that had drifted from the published instrument, each worth points on a scale where low is worse. RESPIRATION now splits on INTUBATION rather than on ventilator support, which is what the source splits on: a child on mask CPAP, BiPAP or high-flow is not intubated and is scored on breathing rhythm alone, where the old wording sent them to level 1 and cost up to three points. The mirror ran the other way, letting an intubated patient on a T-piece reach 16 where the instrument allows 13. MOTOR level 2 now covers any flexion response to pain, pulling away from it as well as the decorticate pattern; this scale collapses what the Glasgow Coma Scale separates, and naming only decorticate flexion left a child who withdraws without localising matching no level, so raters reached for level 3 and scored a point high. EYE level 4 now counts eyes OPENED by the examiner, not only eyes already open, so lids held shut by periorbital swelling no longer put the top level out of reach. Every label remains this project own paraphrase rather than the source descriptors. Found 2026-09-03 by an independent recompute of every calculator against its published source.
- 2026-09-06v1.1.1ClarificationAdded a one-line description for the catalogue card and shortened field guidance to fit an info toggle. No rule, threshold or reference changed.
Other general scores
- APLS age-based weight estimateAge-based weight estimate for when a child cannot be weighed
- Body surface areaBody surface area from height and weight, for mg/m² dosing and cardiac index
- Corrected QT intervalHeart-rate-corrected QT interval by Bazett and Fridericia
- Ideal body weightIdeal body weight from height, by four published methods side by side
- Pediatric Glasgow Coma ScaleAge-adapted Glasgow Coma Scale for infants and children
Important. For use by qualified health professionals as an informational and educational aid. It supports clinical judgment and does not replace it. Verify every result independently before making a clinical decision. This is not a medical device.