FOUR Score Calculator (Full Outline of UnResponsiveness)
Evaluate consciousness in intubated patients. A more granular alternative to GCS, assessing Eye, Motor, Brainstem, and Respiration.
Eye Response (E)
Motor Response (M)
Brainstem Reflexes (B)
Respiration (R)
About
The Full Outline of UnResponsiveness (FOUR) Score is a neurological grading scale designed to assess patients with impaired consciousness. Unlike the Glasgow Coma Scale (GCS), the FOUR score does not rely on a verbal response, making it superior for intubated or aphasic patients. It provides greater neurological detail by explicitly evaluating brainstem reflexes and respiratory patterns, which aids in identifying the stages of herniation and locking-in syndrome.
neurology
coma scale
GCS alternative
intubated patients
brainstem
Formulas
The Total FOUR Score is the summation of four components:
Score = E + M + B + R
Maximum Score: 16 (Fully conscious).
Minimum Score: 0 (Deep coma/Brain death probable).
Reference Data
| Category | Score | Description |
|---|---|---|
| Eye | 4 | Eyelids open or opened, tracking, or blinking to command |
| 0 | Eyelids remain closed with pain | |
| Motor | 4 | Thumbs-up, fist, or peace sign |
| 0 | No motor response or generalized myoclonus | |
| Brainstem | 4 | Pupil and corneal reflexes present |
| 0 | Absent pupil, corneal, and cough reflex | |
| Respiration | 4 | Regular breathing pattern (not intubated) |
| 0 | Apnea or breathes at ventilator rate |
Frequently Asked Questions
GCS is limited in intubated patients because the "Verbal" component cannot be assessed. FOUR replaces Verbal with Respiration and Brainstem reflexes, providing a valid score for intubated patients without losing prognostic power.
A score of 0 indicates non-functioning brainstem and apnea, which is highly correlated with brain death. Immediate formal testing for brain death may be warranted.