16
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16
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16
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16
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100
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The FOUR Score (Full Outline of UnResponsiveness) is a modern clinical scale for assessing the level of consciousness that was developed by Dr. Eelco Wijdicks and colleagues at the Mayo Clinic in 2005 to address key limitations of the traditional Glasgow Coma Scale. The FOUR Score evaluates four components — Eye response, Motor response, Brainstem reflexes, and Respiration — each scored from 0 to 4, yielding a total score ranging from 0 to 16.
The FOUR Score offers several significant advantages over the GCS. Most importantly, it can be used in intubated patients because it does not include a verbal component — a major limitation of the GCS in ICU settings where many patients are mechanically ventilated. Additionally, it incorporates brainstem reflex testing (pupillary light reflex, corneal reflex) and respiratory patterns, providing crucial information about brain function that the GCS does not capture. These components help detect early signs of brainstem herniation and can differentiate between various levels of severe coma.
The FOUR Score has been validated in multiple clinical settings including neuroscience ICUs, medical ICUs, surgical ICUs, and emergency departments. Studies have demonstrated that it has comparable or superior predictive accuracy for in-hospital mortality and functional outcomes compared to the GCS, with the additional advantage of detecting locked-in syndrome and vegetative states that may score identically on the GCS. A FOUR Score of 0 (all components at zero) suggests loss of all brainstem function and may prompt evaluation for brain death.
This calculator enables standardized FOUR Score assessment at the bedside, particularly valuable in intensive care settings where intubated patients cannot be fully assessed with the traditional GCS. It supports clinical decision-making regarding level of care, prognostication, and identification of patients who may need brain death evaluation.
The FOUR Score evaluates four components, each scored 0–4:
Eye Response (E): 0 = Eyelids remain closed with pain; 1 = Eyelids closed, open to pain; 2 = Eyelids closed, open to loud voice; 3 = Eyelids open, not tracking; 4 = Eyelids open, tracking or blinks to command
Motor Response (M): 0 = No response or generalized myoclonus status; 1 = Extension; 2 = Flexion; 3 = Localizing to pain; 4 = Thumbs-up, fist, or peace sign to command
Brainstem Reflexes (B): 0 = Absent pupil, corneal, and cough reflexes; 1 = Pupil and corneal reflexes both absent; 2 = Pupil or corneal reflex absent; 3 = One pupil wide and fixed; 4 = Pupil and corneal reflexes present
Respiration (R): 0 = Breathes at ventilator rate or apnea; 1 = Breathes above ventilator rate; 2 = Not intubated, irregular breathing; 3 = Cheyne-Stokes breathing; 4 = Regular breathing
Total = E + M + B + R (range 0–16).
A FOUR Score of 16 indicates full consciousness with intact brainstem function and normal respiration. Scores of 12–15 suggest moderate impairment but preserved brainstem reflexes. Scores of 7–11 indicate significant neurological compromise. Scores of 1–6 indicate severe impairment with likely brainstem dysfunction. A score of 0 suggests absent brainstem function and should prompt evaluation for brain death when appropriate.
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FOUR Score 13 — patient intubated but alert, following commands, intact brainstem reflexes.
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FOUR Score 2 — deep coma with minimal brainstem function, breathing at ventilator rate.
FOUR stands for Full Outline of UnResponsiveness. It is a 4-component coma scale (Eye, Motor, Brainstem, Respiration) with each component scored 0–4, totaling 0–16 points.
The FOUR Score replaces the verbal component (unusable in intubated patients) with brainstem reflex and respiration assessments, making it applicable in ICU settings. It also better detects locked-in syndrome and brainstem herniation.
Yes, this is one of its primary advantages. Unlike the GCS, which cannot score the verbal component in intubated patients, all FOUR Score components can be assessed regardless of intubation status.
A FOUR Score of 0 indicates absent eye response, motor response, brainstem reflexes, and respiratory drive — all four components at zero. This suggests absent brainstem function and may warrant brain death evaluation.
Yes. Locked-in syndrome patients may score low on GCS due to inability to speak or move, but the FOUR Score can detect eye tracking (E4) and preserved brainstem reflexes, distinguishing it from coma.
Studies show excellent inter-rater reliability for the FOUR Score, comparable to or better than the GCS, across different types of healthcare providers including nurses, residents, and attending physicians.
Multiple studies show the FOUR Score has comparable or slightly superior predictive accuracy for mortality and functional outcomes compared to GCS, with the added advantage of applicability in intubated patients.
The FOUR Score tests the pupillary light reflex, corneal reflex, and cough reflex. These reflexes test the function of cranial nerves II, III, V, VII, IX, and X, providing comprehensive brainstem assessment.
Breathing at the ventilator rate or apnea scores 0; breathing above ventilator rate scores 1; irregular breathing scores 2; Cheyne-Stokes pattern scores 3; regular breathing pattern scores 4.
The FOUR Score is increasingly recommended as a complement or alternative to GCS, particularly in ICU settings. However, GCS remains the most widely known scale, and many protocols and guidelines still reference it.
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