Assessment of sedation most utilized in the ICU with the CAM-ICU scale. In the ED, may be useful for assessing severity of alcohol withdrawal or communicating severity of agitation / sedation to consultants.
- No response to voice or physical stimulation (-5)
- Movement to physical stimulation but not voice (-4)
- Eye opening to voice w/o eye contact (-3)
- Awakens to voice with eye opening < 10s (-2)
- Awakens to voice with eye opening > 10s (-1)
- Alert and calm (0)
- Anxious, apprehensive (1)
- Frequent nonpurposeful movements (2)
- Aggressive (pulling tubes / lines) (3)
- Combative, violent, danger to staff (4)
Sessler CN et al. Delerium in mechanically ventilated patients: validity and reliability in adult intensive care unit patients. Am J Resp Crit Care Med. 2002. 166(10):1338-44.