FOUR score

Full Outline of UnResponsiveness

Eye response

  • E4: eyelids open or opened, tracking, or blinking to command
  • E3: eyelids open but not tracking
  • E2: eyelids closed but open to loud voice
  • E1: eyelids closed but open to pain
  • E0: eyelids remain closed with pain
  • Motor response

  • M4: thumbs-up, fist or peace sign
  • M3: localizing to pain
  • M2: flexion response to pain
  • M1: extension response to pain
  • M0: no response to pain or generalized myoclonus status
  • Brainstem reflexes

  • B4: pupil and corneal reflexes present
  • B3: one pupil wide and fixed
  • B2: pupil or corneal reflexes absent
  • B1: pupil and corneal reflexes absent
  • B0: absent pupil, corneal and cough reflex
  • Respiration pattern

  • R4: not intubated, regular breathing pattern
  • R3: not intubated, Cheyne-Stokes breathing pattern
  • R2: not intubated, irregular breathing
  • R1: breathes above ventilatory rate
  • R0: breathes at ventilator rate or apnea
  • Reference

    Iyer VN, Mandrekar JN, Danielson RD, Zubkov AY, Elmer JL, Wijdicks EFM. Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clin Proc 2009; 84:694-701.