The Full Outline of Unresponsiveness (Four)

Fundamental Review 17-4

The Full Outline of Unresponsiveness (Four)

Researchers at the Mayo Clinic designed the FOUR score coma scale, which has been proposed as an alternative to the Glasgow Coma Scale (GCS). The FOUR score assigns a value of 0 to 4 to each of the four functional categories: eye response, motor response, brainstem reflexes, and respiration. In each of these categories, a score of 0 indicates nonfunctioning status, and a score of 4 represents normal functioning. The FOUR score may provide greater neurologic detail than the GCS due to its ability to evaluate brainstem reflexes and to recognize changes in breathing patterns and stages of brain herniation (Hickey & Strayer, 2020; Kocak et al., 2012). The FOUR score is used in conjunction with other neurologic assessments and vital sign measurement to evaluate a patient's status.

Eye response (E):	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
Motor response (M):	M4 = demonstrated thumbs-up, fist, or peach sign to command
	M3 = localizing to pain
	M2 = flexion response to pain
	M1 = extensor posturing
	M0 = no response to pain or generalized myoclonus status epilepticus (prolonged repetitive epileptic myoclonic [involuntary twitching of a muscle] activity)
Brainstem reflexes (B):	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 (R):	R4 = not intubated, regular breathing
	R3 = not intubated, Cheyne-Stokes breathing pattern
	R2 = not intubated, irregular breathing pattern
	R1 = breathes above ventilator rate
	R0 = breathes at ventilator rate or apnea

Source:Wijdicks, E. F., Bamlet, W. R., Maramattom, B. V., Manno, E. M., & McClelland, R. L. (2005). Validation of a new coma scale: The FOUR score. Annals of Neurology, 58(4), 585-593. Used with permission of Mayo Foundation for Medical Education and Research. All rights reserved.

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Fundamental Review 17-4