II. Indications

  1. Intensive care monitoring of Sedation
  2. Delirium evaluation in the Emergency Department
    1. Score other than 0, has a Test Sensitivity of 64% and Test Specificity of 93% for Delirium in ED
    2. Han (2015) Acad Emerg Med 22(7): 878-82 [PubMed]

III. Scoring

  1. Score +4: Combative
    1. Combative or violent
    2. Danger to care team
  2. Score +3: Very Agitated
    1. Pulls or removes tubes or catheters
    2. Aggressive
  3. Score +2: Agitated
    1. Frequent non-purposeful movements
    2. Fights Ventilator
  4. Score +1: Restless
    1. Anxious or apprehensive
    2. Not aggressive
  5. Score 0: Alert and calm
  6. Score -1: Slightly Drowsy
    1. Awakens to voice (e.g. eye opening with eye contact) >10 sec
  7. Score -2: Moderately Drowsy
    1. Light Sedation
    2. Briefly awakens to voice (e.g. eye opening with eye contact) <10 sec
  8. Score -3: Severely Drowsy
    1. Moderate Sedation
    2. Movement or eye opening to voice
    3. No eye contact
  9. Score -4: Arousable to pain only
    1. Deep Sedation
    2. No response to voice
    3. Movement or eye opening to physical stimulation
  10. Score -5: Unarousable
    1. Unarousable
    2. No response to voice or physical stimulation

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