FOUR Score Eye Response 4 Eyelids open or opened, ‘racking or blinking to command {3 Eyelids open but not tracking, 2 Eyelids closed but opens to loud voice Lyell closed but opens to pain 0 Eyelids remain closed with pain Motor Response 4 Thumb up, fist, oF peace sign to command 8 Localzing to pain 2 Fexion response to pain 1 Extensor posturing 0 No response to pain or generalized myoctonus status epllepticus Brainstem Reflex 4 Pupll and comeat reflexes present 8 One pupil wide and fixed 2 Pupil or comeal reflexes ‘absent 41 Pupll and comeat reflexes absent 0 Absent pupil, comeal, and cough reflex Respiration 4 Not intubated, regular breathing pattern breathing pattern 2 Not intubated, regia breathing pattern 11 Breathes above ventilator rate 0 Breathes at ventilator rte or apnea Instructions for the Assessment of the Individual Categories of the FOUR Score Eye Response (E) ‘ade the best possible response after atleast 3 tas in an attempt to chet the bos evel of elertness, A score of E8 indicates a least {3 voluntary excursions. eyes are closed, the examiner should open ‘hem and examine tracking ofa ger of abject. Trecking withthe open- ing oft eyelid wil suffice in cases of eyelid edema or faa aura. ‘rocking is absent horzontally, examine vertical tracking, Atomasiely [ins on command shoul be dooumente. This wil ecognize @ Teokodin syndrome (ptint i uly aware). A coor of ES incicates tho sbsence of voluntary tracking with open ejes. A score of E2 indicates ‘ehds opening to loud voice. A score of EL incicateseyelcs open to pain stimulus. A score of EO indicates no eylds opening to pain. Motor response (M) ‘Grade the best possible response ofthe arms. A score of M4 inicates ‘hat the patient cemonstated at least 1 of 3 hand postions (thumbs. up, fst, or peace sign) wit eter hand, A score of M3 indicates that ‘he pationt touched the examiners hand after a painful stimulus com pressing the temperomandibuar joint orsuprenrbial nerve (localize tion). A score of M2 indicates any tesion movement oF the upper lime. A score of MA indioatas extensor posturing, A score of MO indicates no motor response or nyocionus status epilepticus. Brainstem reflexes (8) ‘Gade the best possible response. Examine pupillary ard comeal reflexes. Preferably, cornea reflexes are tested by instiling 23 drops ‘of stenie saline on the comea ftom a distance of 4-6 inches (ts ‘minimizes comeal trauma from repeated examinations), Cotton swabs. an algo be used. The cough reflex to tracheal suctioning is tested ‘only when both of these reflves are absont. A soore of 84 indicates pupil and cornea reflaxes are present. A score of B3 incieates one Dupl wide and fed. A score of Bz Indicates either pupt or cornea fefleyes ae absent, BL indicates both pupl nl cornea reflexes sre absent an 9 score of BO indicates pul, comes and cough reiex [using tracheal suctioning) are sent Respiration (R} Determine spontaneous breathing pattern n a nonintubated patent, and grade simply as regular Ra. irregular R2, oF CheyneStokes R3 breathing. In mechericaly vantiated patents, assess the pressure ‘waveform of spontaneous respiratory pattern or the patent tragering {ofthe ventilator Ra. Tha ventiater moniter displaying respiratory i used to identity the patient generated breaths onthe c-No adjusunents are mede to the venuator whe tne Patent is graded, br gading Is done preferably wth PECO? within ‘normal mits, A standard apnea (oxgenaitusion) test may be ‘needed when pationt breathes at venblator rate RO. gy MAYO CLINIC In patsiasw TORT Roches, Minnesota S305 omuanayodnicone Smut ahha ar une