Full outline of unresponsiveness score

The full outline of unresponsiveness score (FOUR score) is a grading scale for assessing the level of consciousness.

Scoring

This scale assesses four domains of neurological function:

• eye responses (E)

• motor responses (M)

• brainstem reflexes (B)

• respiratory (R)

Each is graded from 1 to 4 and the grades are added together so the lowest score is 0 and highest is 16.

Eye responses (E)

• eyelids open: 4 points

• eyelids open but voluntary tracking is absent: 3 points

• eyelids closed but will open to loud voice: 2 points

• eyelids closed but will open after pain stimulus: 1 point

• eyelids remain closed in responding to the pain stimulus: 0 points

Motor responses (M)

• obeys commands, e.g. for example patient can show "OK" sign, victory sign, show number by his/her fingers: 4 points

• localizes to pain: 3 points

• upper limbs will be flexed after pain stimulus: 2 points

• extensor posturing after pain stimulus: 1 point

• unresponsive to pain stimulus: 0 points

Brainstem reflex (B)

• pupil and corneal reflexes are present: 4 points

• one pupil is nonreactive and is dilated: 3 points

• either the pupil reflex or corneal reflex is absent: 2 points

• both pupil and corneal reflexes are absent but cough reflex during tracheal suctioning is present: 1 point

• all reflexes such as the pupil, corneal and cough reflex are absent: 0 points

Respiratory (R)

• not intubated and can breathe spontaneously and regularly: 4 points

• not intubated but breathing pattern is abnormal - rate and depth of breath is changeable and abnormal and also breathing pattern is apneustic: 3 points

• not intubated but breathing pattern is irregular: 2 points

• intubated and ventilated by ventilator but the rate of patient breath is more than the set rate (rate of breathing in ventilator setting): 1 point

• intubated and rate of breathing is equal to the set rate: 0 points

Interpretation

FOUR score is thought to provide more neurological detail than the Glasgow Coma Scale (GCS).