FOUR Score Calculator (Full Outline of UnResponsiveness Coma Scale)
Score coma with the FOUR score — eye response, motor response, brainstem reflexes and respiration, 0–4 each for a total of 0–16 — a coma scale that works in intubated patients.
How it works
FOUR = eye (0–4) + motor (0–4) + brainstem reflexes (0–4) + respiration (0–4); total 0–16. Each component has five fixed descriptors; 4 is normal and 0 is the worst response.
The Full Outline of UnResponsiveness (FOUR) score was developed at the Mayo Clinic by Wijdicks and colleagues (Annals of Neurology 2005) as an alternative to the Glasgow Coma Scale. Unlike the GCS it has no verbal component, so it can be scored fully in intubated patients, and it adds brainstem reflexes and breathing pattern, which can recognize a locked-in syndrome, herniation or a vegetative state. Lower totals indicate deeper coma and higher in-hospital mortality; a total of 0 should prompt formal brain death evaluation according to local criteria.
Worked example
An intubated patient opens the eyes and tracks the examiner’s finger (E4), localizes to pain (M3), has intact pupil and corneal reflexes (B4) and triggers breaths above the set ventilator rate (R1): FOUR = 4 + 3 + 4 + 1 = 12 / 16.
Sources: Wijdicks EFM et al. Validation of a new coma scale: the FOUR score. Ann Neurol 2005;58:585–593
Frequently asked questions
Why use the FOUR score instead of the GCS?
The FOUR score can be completed in intubated patients because it has no verbal item, and it tests brainstem reflexes and respiration, which the GCS does not. It is used mainly in intensive care and neurocritical care.
What is a normal FOUR score?
A fully alert patient breathing normally scores 16 (4 in each component). There are no formal severity bands; lower scores mean deeper coma.
What does a FOUR score of 0 mean?
No eye opening, no motor response, absent pupil, corneal and cough reflexes and apnea or breathing only at the ventilator rate. It should prompt evaluation for brain death, which has its own formal criteria.
How is eye tracking tested?
If the eyes are open, ask the patient to track your finger or to blink twice on command. If the eyelids are closed, open them and test tracking; a patient who opens the eyes but cannot track scores 3.
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Clinical decision tool for education and for use by trained clinicians alongside clinical judgement — not a diagnosis and not a substitute for medical assessment. Scores and cut-offs come from the cited validation studies and may not apply to every patient; follow local protocols.