E — Eye Response

E4 — Eyelid tracking or blinking to command (follow a finger or blink on request)+4E3 — Eyelids open spontaneously but NOT tracking (no purposeful gaze)+3E2 — Eyelids open to loud voice only+2E1 — Eyelids open to pain only (supraorbital or nailbed pressure)+1E0 — Eyelids remain closed even with pain (or periorbital edema prevents assessment)+0

M — Motor Response

M4 — Follows commands: thumbs up, fist, or peace sign on request+4M3 — Localizing to pain (hand moves above clavicle toward painful stimulus)+3M2 — Flexion posturing to pain (decorticate — arm flexion, leg extension)+2M1 — Extension posturing to pain (decerebrate — arm and leg extension, internal rotation)+1M0 — No motor response to pain OR generalized myoclonus status epilepticus+0

B — Brainstem Reflexes

B4 — Pupil AND corneal reflexes both present bilaterally+4B3 — One pupil wide and fixed (CN III compression) OR corneal reflex unilaterally absent+3B2 — Pupil AND corneal reflexes both absent (pontine/midbrain dysfunction)+2B1 — Pupil, corneal, AND cough reflex all absent (absent midbrain, pontine, and medullary reflexes)+1B0 — Absent pupil, corneal, AND cough reflexes (consistent with brain death criteria)+0

R — Respiration Pattern

R4 — Not intubated: regular breathing pattern+4R3 — Not intubated: Cheyne-Stokes breathing (crescendo-decrescendo cycles with apneic pauses)+3R2 — Not intubated: irregular breathing (variable rate, depth, or both)+2R1 — Intubated: breathing above set ventilator rate (has some respiratory drive)+1R0 — Intubated: breathing only at ventilator rate OR apnea (no spontaneous respiratory effort)+0

FOUR Score (Full Outline of UnResponsiveness)

FOUR Score (Full Outline of UnResponsiveness)