RICHMOND AGITATION-SEDATION SCALE (RASS) RICHMOND AGITATION-SEDATION SCALE (RASS)

STEP STEP
Sedation Assessment Sedation Assessment

Scale Label Description Scale Label Description

+4 COMBATIVE Combative, violent, immediate danger to staff +4 COMBATIVE Combative, violent, immediate danger to staff
+3 VERY AGITATED Pulls to remove tubes or catheters; aggressive +3 VERY AGITATED Pulls to remove tubes or catheters; aggressive
+2 AGITATED Frequent non-purposeful movement, fights ventilator +2 AGITATED Frequent non-purposeful movement, fights ventilator
+1 RESTLESS Anxious, apprehensive, movements not aggressive +1 RESTLESS Anxious, apprehensive, movements not aggressive
0 ALERT & CALM Spontaneously pays attention to caregiver 0 ALERT & CALM Spontaneously pays attention to caregiver
-1 DROWSY Not fully alert, but has sustained awakening to voice V -1 DROWSY Not fully alert, but has sustained awakening to voice V
(eye opening & contact >10 sec) O (eye opening & contact >10 sec) O
-2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec) I -2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec) I
C C
-3 MODERATE SEDATION Movement or eye opening to voice (no eye contact) -3 MODERATE SEDATION Movement or eye opening to voice (no eye contact)
E E

If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?) If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)
T T
-4 DEEP SEDATION No response to voice, but movement or eye opening -4 DEEP SEDATION No response to voice, but movement or eye opening
O O
to physical stimulation to physical stimulation
U U
-5 UNAROUSEABLE No response to voice or physical stimulation C -5 UNAROUSEABLE No response to voice or physical stimulation C
H H
If RASS is -4 or -5 STOP (patient unconscious), RECHECK later If RASS is -4 or -5 STOP (patient unconscious), RECHECK later

Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344 Ely, et al., JAMA 2003; 286, 2983-2991 Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344 Ely, et al., JAMA 2003; 286, 2983-2991

RICHMOND AGITATION-SEDATION SCALE (RASS) RICHMOND AGITATION-SEDATION SCALE (RASS)

STEP STEP
Sedation Assessment Sedation Assessment

Scale Label Description Scale Label Description

+4 COMBATIVE Combative, violent, immediate danger to staff +4 COMBATIVE Combative, violent, immediate danger to staff
+3 VERY AGITATED Pulls to remove tubes or catheters; aggressive +3 VERY AGITATED Pulls to remove tubes or catheters; aggressive
+2 AGITATED Frequent non-purposeful movement, fights ventilator +2 AGITATED Frequent non-purposeful movement, fights ventilator
+1 RESTLESS Anxious, apprehensive, movements not aggressive +1 RESTLESS Anxious, apprehensive, movements not aggressive
0 ALERT & CALM Spontaneously pays attention to caregiver 0 ALERT & CALM Spontaneously pays attention to caregiver
-1 DROWSY Not fully alert, but has sustained awakening to voice V -1 DROWSY Not fully alert, but has sustained awakening to voice V
(eye opening & contact >10 sec) O (eye opening & contact >10 sec) O
-2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec) I -2 LIGHT SEDATION Briefly awakens to voice (eyes open & contact <10 sec) I
C C
-3 MODERATE SEDATION Movement or eye opening to voice (no eye contact) -3 MODERATE SEDATION Movement or eye opening to voice (no eye contact)
E E

If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?) If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)
T T
-4 DEEP SEDATION No response to voice, but movement or eye opening -4 DEEP SEDATION No response to voice, but movement or eye opening
O O
to physical stimulation to physical stimulation
U U
-5 UNAROUSEABLE No response to voice or physical stimulation C -5 UNAROUSEABLE No response to voice or physical stimulation C
H H
If RASS is -4 or -5 STOP (patient unconscious), RECHECK later If RASS is -4 or -5 STOP (patient unconscious), RECHECK later

Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344 Ely, et al., JAMA 2003; 286, 2983-2991 Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344 Ely, et al., JAMA 2003; 286, 2983-2991
 Confusion Assessment Method for the ICU (CAM-ICU) Confusion Assessment Method for the ICU (CAM-ICU)
STEP STEP
DELIRIUM ASSESSMENT DELIRIUM ASSESSMENT

1. Acute Change or Fluctuating Course of Mental Status: 1. Acute Change or Fluctuating Course of Mental Status:
NO CAM-ICU negative NO CAM-ICU negative
Is there an acute change from mental status baseline? OR Is there an acute change from mental status baseline? OR
Has the patients mental status fluctuated during the past 24 hours?
NO DELIRIUM Has the patients mental status fluctuated during the past 24 hours?
NO DELIRIUM

YES YES
2. Inattention: 2. Inattention:
Squeeze my hand when I say the letter A. 0-2 Squeeze my hand when I say the letter A. 0-2
Read the following sequence of letters: S A V E A H A A R T CAM-ICU negative Read the following sequence of letters: S A V E A H A A R T CAM-ICU negative
ERRORS: No squeeze with A & Squeeze on letter other than A Errors NO DELIRIUM ERRORS: No squeeze with A & Squeeze on letter other than A Errors NO DELIRIUM
If unable to complete Letters Pictures If unable to complete Letters Pictures

> 2 Errors > 2 Errors

3. Altered Level of Consciousness RASS other 3. Altered Level of Consciousness RASS other
Current RASS level (think back to sedation assessment in Step 1) than zero CAM-ICU positive Current RASS level (think back to sedation assessment in Step 1) than zero CAM-ICU positive
DELIRIUM Present DELIRIUM Present
RASS = zero RASS = zero

4. Disorganized Thinking: 4. Disorganized Thinking:

1. Will a stone float on water? > 1 Error 1. Will a stone float on water? > 1 Error
2. Are there fish in the sea? 2. Are there fish in the sea?
3. Does one pound weigh more than two? 3. Does one pound weigh more than two?
4. Can you use a hammer to pound a nail? 4. Can you use a hammer to pound a nail?
0-1 0-1
Command: Hold up this many fingers (Hold up 2 fingers) Error Command: Hold up this many fingers (Hold up 2 fingers) Error
Now do the same thing with the other hand (Do not demonstrate) CAM-ICU negative Now do the same thing with the other hand (Do not demonstrate) CAM-ICU negative
OR Add one more finger (If patient unable to move both arms) NO DELIRIUM OR Add one more finger (If patient unable to move both arms) NO DELIRIUM
Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved

Confusion Assessment Method for the ICU (CAM-ICU) Confusion Assessment Method for the ICU (CAM-ICU)
STEP STEP
DELIRIUM ASSESSMENT DELIRIUM ASSESSMENT

1. Acute Change or Fluctuating Course of Mental Status: 1. Acute Change or Fluctuating Course of Mental Status:
NO CAM-ICU negative NO CAM-ICU negative
Is there an acute change from mental status baseline? OR Is there an acute change from mental status baseline? OR
Has the patients mental status fluctuated during the past 24 hours?
NO DELIRIUM Has the patients mental status fluctuated during the past 24 hours?
NO DELIRIUM

YES YES
2. Inattention: 2. Inattention:
Squeeze my hand when I say the letter A. 0-2 Squeeze my hand when I say the letter A. 0-2
Read the following sequence of letters: S A V E A H A A R T CAM-ICU negative Read the following sequence of letters: S A V E A H A A R T CAM-ICU negative
ERRORS: No squeeze with A & Squeeze on letter other than A Errors NO DELIRIUM ERRORS: No squeeze with A & Squeeze on letter other than A Errors NO DELIRIUM
If unable to complete Letters Pictures If unable to complete Letters Pictures

> 2 Errors > 2 Errors

3. Altered Level of Consciousness RASS other 3. Altered Level of Consciousness RASS other
Current RASS level (think back to sedation assessment in Step 1) than zero CAM-ICU positive Current RASS level (think back to sedation assessment in Step 1) than zero CAM-ICU positive
DELIRIUM Present DELIRIUM Present
RASS = zero RASS = zero

4. Disorganized Thinking: 4. Disorganized Thinking:

1. Will a stone float on water? > 1 Error 1. Will a stone float on water? > 1 Error
2. Are there fish in the sea? 2. Are there fish in the sea?
3. Does one pound weigh more than two? 3. Does one pound weigh more than two?
4. Can you use a hammer to pound a nail? 4. Can you use a hammer to pound a nail?
0-1 0-1
Command: Hold up this many fingers (Hold up 2 fingers) Error Command: Hold up this many fingers (Hold up 2 fingers) Error
Now do the same thing with the other hand (Do not demonstrate) CAM-ICU negative Now do the same thing with the other hand (Do not demonstrate) CAM-ICU negative
OR Add one more finger (If patient unable to move both arms) NO DELIRIUM OR Add one more finger (If patient unable to move both arms) NO DELIRIUM
Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved