Mental Health and ExDS

Question 1

What are the components of the RASS score?

Answer 1

Ranges from -5 to +4

• +4: Combative: Violent, Immediate danger to staff
• +3: Very Agitated: Pulls or removes tubes/catheters; aggessive
• +2: Agitated: Frequent non-purposeful movements; fights ventilator
• +1: Restless: Anxious, but movements not agressive, vigorous
• 0: Alert and Calm: Spontaneously pays attention to caregiver
• -1: Drowsy: Not alert, but sustained wakening to voice (>10s)
• -2: Light Sedation: Briefly awakes with eye contact to voice (<10s)
• -3:Moderate Sedation: Briefly opens eyes, without contact to voice (<10s)
• -4: Deep Sedation: No response to voice, but briefly opens eyes or responds to physical stimulation
• -5: Unarousable: Nada

Question 2

Which levels of the RASS are assessed by observation only?

Answer 2

0 to +4

Question 3

Which levels of the RASS involve and require a positive reponse to voice

Answer 3

-1 to -3

Question 4

Which levels of the RASS are assessed using touch?

Answer 4

-4 and -5

Question 5

What is the major difference between levels above -3, or -3 and lower on the RASS

Answer 5

Levels above -3 are able to make eye contact to voice, -3 and lower do not.

Question 6

What is the significance of not being able to make eye contct to voice with regards to sedation

Answer 6

RASS of -3 or lower indicates moderate or deep sedation, generally a deeper level of sedation than desired.

Question 7

Describe pharmaceutical management of extreme agitation and excited delirium using RASS targets

Answer 7

• RASS of +4
  
  • 4-5mg/kg IM Ketamine (MAX 500mg)
• RASS of +2 or +3
  
  • 2-5mg IV Midazolam
  • OR
  • 5-10mg IM Midazolam
• RASS of +1 or less
  
  • Don’t sedate! Are you crazy???

Question 8

What is YOUR threshold for defining someone as a RASS of +4 rather than +3 for purposes of emergent sedation?

Answer 8

RASS of +4 is defined as Combative, Violent, and Dangerous!

• Active violence that can not be rapidly de-escalated verbally
• Obvious threat of physical violence requiring hands-on intervention that can not be de-escalated verbally

RASS of +3 is defined as Very Agitated or Agressive

• Shouting is not the same as combative/violent! Consider the target of anger? Is agression directed towards staff? Is there an intention to harm?
• If agitation/agression is directionless, they are unlikely to be violent with mild sedation. Consider midazolam.