The FOUR Score is a 16-point coma assessment scale designed to address the limitations of the GCS, particularly in intubated patients. It assesses four components each scored 0–4: Eye response, Motor response, Brainstem reflexes, and Respiration. Unlike GCS, it does not require a verbal response and directly assesses brainstem function and respiratory pattern.
inputs
✓ when to use
Use in neurocritical care, ICU, and ED settings for coma assessment, particularly when GCS is limited — most notably in intubated patients where the verbal component cannot be assessed. The FOUR score provides additional prognostic information through brainstem reflex and respiration assessment. A FOUR score of 0 may prompt consideration of brain death testing.
✗ when not to use
The FOUR score requires assessment of brainstem reflexes, which needs training. In settings where brainstem assessment is not routine (e.g., pre-hospital), GCS remains more practical. The FOUR score is more complex than GCS and requires more time to administer.
clinical pearls
The key advantage over GCS: the FOUR score works in intubated patients. GCS requires verbal response (V component), which is impossible in intubated patients — hence the common 'VT' notation. The FOUR score replaces verbal response with brainstem reflexes and respiration, both assessable in intubated patients.
A FOUR score of 0 (all components = 0) raises the possibility of brain death — absent brainstem reflexes and no respiratory drive above the ventilator. This should trigger formal brain death assessment protocols.
The eye component uses tracking/command-following rather than just opening, providing more information about cortical function than GCS eye opening alone.
The motor component uses specific hand signs (thumbs-up, fist, peace sign) to confirm command-following, which is more reliable than GCS 'obeys commands' for distinguishing voluntary from reflexive movement.
Like GCS, always report component scores (E3M2B4R1 = 10) in addition to the total. The total alone masks important clinical information.