EXPLODING BACTERIAMed Decision Speed Tools
ED Decision Tools

Richmond Agitation-Sedation Scale (RASS)

Scores sedation depth from +4 (combative) to −5 (unarousable) — 0 is the target, and both directions away from it are bad.

Alert and calm
RASS 0 · the target for most patients
Ready for spontaneous awakening / breathing trials
RASS level — observe 30 s, then call the patient's name, then physically stimulate
Sessler CN, et al. Am J Respir Crit Care Med. 2002 · Assess in order — observe → voice → physical stimulation; do not jump to physical stimulation before trying voice. CAM-ICU is only valid at RASS ≥−3. Scale reproduced as published; scoring is invalid if the descriptors are reworded.