12/24/23, 9:32 AM The Four Score: A Revolution in Coma Grading

Coma Whisperer
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The Four Score: A Revolution in Coma Grading

December 24, 2023

By Sherry Phipps

Coma grading is a critical aspect of neurological assessment, providing vital

information about a patient’s condition and prognosis. Traditionally, the Glasgow

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12/24/23, 9:32 AM The Four Score: A Revolution in Coma Grading

Coma Scale (GCS) has been the gold standard for this purpose. However, a new
tool, the Four Score, is gaining recognition for its comprehensive and nuanced
approach to coma grading.

What is the Four Score?

The Four Score is a clinical grading scale developed by renowned neurologist Dr.
Ronald Wijdicks and his team at the Mayo Clinic. It assesses four key aspects of a
patient’s neurological function: eye response, motor response, brainstem reflexes, and
respiration. Each category is scored from 0 to 4, with a total score ranging from 0 (deep
coma) to 16 (fully conscious).

Advantages of the Four Score

The Four Score offers several advantages over traditional coma grading scales:

1. Comprehensive Assessment: The Four Score provides a more detailed

neurological assessment by evaluating brainstem reflexes and respiration,
aspects not covered by the GCS.

2. Increased Sensitivity: The Four Score has been shown to be more sensitive in
detecting subtle changes in a patient’s neurological status, allowing for timely
intervention.

3. Reduced Observer Variability: The Four Score’s detailed criteria reduce

observer variability, leading to more consistent and reliable assessments.

4. Prognostic Value: Studies have shown that the Four Score has a strong
prognostic value, helping clinicians predict patient outcomes more accurately.

Promoting the Use of the Four Score

Given these advantages, it’s clear that the Four Score can play a pivotal role in
improving patient care in the neuro-intensive care unit. However, its adoption requires
concerted efforts:

Education and Training: Clinicians need to be educated about the Four Score
and trained in its use. This can be achieved through workshops, seminars, and
inclusion in medical curricula.

Clinical Guidelines: Incorporating the Four Score into clinical guidelines can
help standardize its use across different healthcare settings.

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Research and Validation: Continued research is needed to further validate the

Four Score and explore its potential applications.

The Four Score represents a significant advancement in coma grading. It introduces

simplicity and uniformity that no other coma grading scale has accomplished. By
promoting its use, we can enhance neurological assessment, improve patient care, and
ultimately, save lives.

As a caregiver whose love one once received three vastly different coma grades from
three different doctors in one day, I cannot over emphasize the necessity and potential
impact of this new coma grading system.

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