Full Outline of UnResponsivenes (FOUR) score. Eye response: 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; E0 = eyelids remain closed with pain. Motor response: M4 = thumbs-up, fist, or peace sign; M3 = localizing to pain; M2 = flexion response to pain; M1 = extension response to pain; M0 = no response to pain or generalized myoclonus status. Brainstem reflexes: 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 pattern: R4 = not intubated, regular breathing pattern; R3 = not intubated, Cheyne-Stokes breathing pattern; R2 = not intubated, irregular breathing; R1 = breathes above ventilatory rate; R0 = breathes at ventilator rate or apnea.
The FOUR score can be used in a variety of ICU settings. It is easily taught, is simple to administer, and provides essential neurologic information that allows an accurate assessment of patients with altered consciousness. The FOUR score accurately predicts which patients will have a poor outcome and can detect the occurrence of brain death in a critically ill patient. In addition, the FOUR score can diagnose a locked-in syndrome mimicking coma and can test the vigilance of the patient by using simple hand signals. In contrast, the GCS cannot assess these conditions because it uses only eye opening and motor response to pain as measures of impaired consciousness in intubated patients. The FOUR score has the potential to become an important measure in prospective clinical studies.
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