The FOUR score provides superior neurological granularity in patients with impaired consciousness, effectively distinguishing between coma and locked-in states.
Consciousness Sentinel Probe
Complete all four neurological domains to quantify the depth of unresponsiveness and assess brainstem reflex integrity.
Guidelines & Evidence
Clinical Details
Section 1
When to Use
When to Use
Superior alternative to GCS in the ICU setting.
Assessing intubated patients (eliminates the "Verbal NT" problem).
Detailed monitoring for impending brainstem herniation.
Detecting "locked-in" syndrome via eye-tracking evaluation.
Section 2
Formula & Logic
Four Pillars of Assessment
Component
Score Range
Key Assessment
Eye (E)
0–4
Blinking, tracking, and response to loud voice
Motor (M)
0–4
Command following (thumbs up/fist) vs. pain
Brainstem (B)
0–4
Pupillary, corneal, and cough reflexes
Respiration (R)
0–4
Breathing pattern vs. ventilator trigger
Range
Total score 0–16. Higher is better.
Section 3
Pearls/Pitfalls
The "Locked-In" Check
The FOUR score Eye component specifically awards the highest points (4) for tracking or blinking to command. This is a critical safety check for Locked-In syndrome, which is frequently missed by the standard GCS assessment.
Section 4
Evidence Appraisal
Primary Reference
Validation of a new coma scale: The FOUR score
Wijdicks EF et al. • Ann Neurol. 2005;58(4):585-593
