Page 99 - ATP-P 11th Ed

Richmond Agitation Sedation Scale (RASS)
Score Term Description
+4 Combative Overtly combative, violent, immediate danger to staff. SECTION 1
+3 Very Pulls or removes tube(s) or catheter(s); aggressive.
Agitated
+2 Agitated Frequent non-purposeful movement, fights ventilator.
+1 Restless Anxious but movements not aggressive vigorous.
0 Alert, Calm
–1 Drowsy Not fully alert, but has sustained awakening
(eye-opening/eye contact) to voice (>10 seconds).
–2 Light Briefly awakens with eye contact to voice (<10 seconds). Verbal
Sedation Stimulation
–3 Moderate Movement or eye opening to voice (but no eye contact).
Sedation
–4 Deep No response to voice, but movement or eye opening to
Sedation physical stimulation. Physical
Stimulation
–5 Unarousable No response to voice or physical stimulation.
Procedure for RASS Assessment
1. Observe patient: Patient is alert, restless, or agitated. Score 0 to + 4
2. If not alert, state patient’s name and say to open eyes and look at speaker Score –1
a. Patient awakens with sustained eye opening and eye contact.
b. Patient awakens with eye opening and eye contact, but not sustained. Score –2
c. Patient has any movement in response to voice but no eye contact. Score –3
3. When no response to verbal stimulation, physically stimulate patient by
shaking shoulder and/or rubbing sternum.
a. Patient has any movement to physical stimulation. Score –4
b. Patient has no response to any stimulation. Score –5
*Sessler CN, Gosnell M. Grap MJ, Brophy GT, O’Neal PV, Keane KA et al. The Richmond Agitation-Sedation
Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med 2002; 166:1338–1344.
*Ely EW, Truman B, Shintani A., Thomason JWW, Wheeler AP, Gordon S et al. Monitoring sedation status over
time in ICU patients: the reliability and validity of the Richmond Agitation Sedation Scale (RASS). JAMA 2003;
289:2983–2991.

88 SECTION 1 TACTICAL TRAUMA PROTOCOLS (TTPs) ATP-P Handbook 11th Edition 89