FOUR Score

Full Outline of UnResponsiveness — coma scale usable in intubated patients, 0 to 16

Eye response

4 — Eyelids open or opened, tracking or blinking to command

3 — Eyelids open but not tracking

2 — Eyelids closed, open to loud voice

1 — Eyelids closed, open to pain

0 — Eyelids remain closed with pain

Motor response

4 — Thumbs-up, fist or peace sign to command

3 — Localising to pain

2 — Flexion response to pain

1 — Extensor posturing

0 — No response to pain, or generalised myoclonus status

Brainstem reflexes

4 — Pupillary and corneal reflexes present

3 — One pupil wide and fixed

2 — Pupillary OR corneal reflex absent

1 — Pupillary AND corneal reflexes absent

0 — Absent pupillary, corneal and cough reflex

Respiration

4 — Not intubated, regular breathing pattern

3 — Not intubated, Cheyne-Stokes breathing

2 — Not intubated, irregular breathing

1 — Breathes above ventilator rate

0 — Breathes at ventilator rate or apnoea

Grade all four components to calculate

Evidence

Original publication

Wijdicks EFM, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: The FOUR score. Introduced the Full Outline of UnResponsiveness (Eye, Motor, Brainstem, Respiration; each 0–4). It had good inter-rater agreement and predicted in-hospital mortality, and a FOUR score of 0 discriminated the lowest GCS patients better than the GCS alone.

Annals of Neurology, 2005

Open source

Guideline

The FOUR score is recommended where the GCS verbal component cannot be assessed (intubation, aphasia). Lower totals track with higher in-hospital and long-term mortality and worse functional outcome; component scores of 0 (especially brainstem and respiration) carry particular weight.

Last reviewed: 2026-09

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MedScore is an educational and clinical decision-support tool. It does not provide a diagnosis, a treatment, or a drug-dosing recommendation, and it does not replace clinical judgement or local guidelines. Confirm every result against the original source before acting on it. The treating clinician remains responsible for all decisions.