Richmond Agitation Sedation Scale (RASS)
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Indications
- recognition of altered states of consciousness in the emergency department
- recognition of delirium in emergency department[3]
Procedure
- observe the patient
- if the patient is not alert
- state the patient's name
- ask the patient to open their eyes & look at you
- physically stimulate patient by
| score | vigilance | behavior |
|---|---|---|
| +4 | combative | violent |
| +3 | very agitated | removes tubes, catheters; aggressive |
| +2 | agitated | non purposeful movements |
| +1 | restless | anxious, apprehensive |
| 0 | altert & calm | pays attention |
| -1 | drowsy | > 10 seconds of eye contact to voice |
| -2 | light sedation | < 10 seconds of eye contact to voice |
| -3 | moderate sedation | does not awaken; but responds to voice |
| -4 | deep sedation | no response to voice, movement to contact |
| -5 | unrousable | no response to voice or contact |
More general terms
References
- ↑ Medical Knowledge Self Assessment Program (MKSAP) 15, 18. American College of Physicians, Philadelphia 2009, 2018.
- ↑ Wikipedia: Richmond Agitation-Sedation Scale https://en.wikipedia.org/wiki/Richmond_Agitation-Sedation_Scale
- ↑ Jump up to: 3.0 3.1 Han JH, Vasilevskis EE, Schnelle JF, et al. The diagnostic performance of the Richmond Agitation Sedation Scale for detecting delirium in older emergency department patients. Acad Emerg Med. 2015;22(7):878-882 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26113020 Free PMC Article