FOUR Score

Coma scale superior to GCS for intubated patients.

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Parameters

Eye Response (E)*

4 - Eyelids open or opened, tracking or blinking to command

3 - Eyelids open but not tracking

2 - Eyelids closed but open to loud voice

1 - Eyelids closed but open to pain

0 - Eyelids remain closed with pain

Motor Response (M)*

4 - Thumbs up, fist, or peace sign

3 - Localizing to pain

2 - Flexion response to pain

1 - Extension response to pain

0 - No response to pain or generalized myoclonus status

Brainstem Reflexes (B)*

4 - Pupil AND corneal reflexes present

3 - One pupil wide and fixed

2 - Pupil OR corneal reflexes absent

1 - Pupil AND corneal reflexes absent

0 - Absent pupil, corneal, and cough reflex

Respiration (R)*

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 Score Result

FormulaSum of Eye (0-4), Motor (0-4), Brainstem (0-4), and Respiration (0-4) scores.

Clinical Pearls

Captures brainstem reflexes and breathing patterns not evaluated in the GCS. It provides greater neurological detail, especially in patients intubated for airway protection.

Limitations

May be more complex for novice providers to learn and perform compared to the universally recognized GCS.

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