Cam Icu Pocketcards.pdf 2l4r5i
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VERY AGITATED
AGITATED
RESTLESS
ALERT & CALM
DROWSY
LIGHT SEDATION
MODERATE SEDATION Movement or eye opening to voice (no eye )
+3
+2
+1
0
-1
-2
-3
No response to voice or physical stimulation
Ely, et al., JAMA 2003; 286, 2983-2991
VERY AGITATED
AGITATED
RESTLESS
ALERT & CALM
DROWSY
LIGHT SEDATION
MODERATE SEDATION Movement or eye opening to voice (no eye )
+3
+2
+1
0
-1
-2
-3
UNAROUSEABLE
-5
No response to voice or physical stimulation
No response to voice, but movement or eye opening to physical stimulation
Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344
Ely, et al., JAMA 2003; 286, 2983-2991
If RASS is -4 or -5 STOP (patient unconscious), RECHECK later
DEEP SEDATION
If RASS is ≥ -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)
Briefly awakens to voice (eyes open & <10 sec)
Not fully alert, but has sustained awakening to voice (eye opening & >10 sec)
Spontaneously pays attention to caregiver
Anxious, apprehensive, movements not aggressive
Frequent non-purposeful movement, fights ventilator
Pulls to remove tubes or catheters; aggressive
Combative, violent, immediate danger to staff
COMBATIVE
+4
Description
Label
Sedation Assessment
-4
T O U C H
V O I C E
T O U C H
V O I C E
RICHMOND AGITATION-SEDATION SCALE (RASS)
Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344
Scale
STEP
UNAROUSEABLE
-5
No response to voice, but movement or eye opening to physical stimulation
If RASS is -4 or -5 STOP (patient unconscious), RECHECK later
DEEP SEDATION
-4
If RASS is ≥ -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)
Briefly awakens to voice (eyes open & <10 sec)
Not fully alert, but has sustained awakening to voice (eye opening & >10 sec)
Spontaneously pays attention to caregiver
Anxious, apprehensive, movements not aggressive
Frequent non-purposeful movement, fights ventilator
Pulls to remove tubes or catheters; aggressive
Combative, violent, immediate danger to staff
COMBATIVE
+4
Description
Label
Sedation Assessment
RICHMOND AGITATION-SEDATION SCALE (RASS)
Scale
STEP
-5
-4
-3
-2
-1
0
+1
+2
+3
+4
Scale
STEP
-5
-4
-3
-2
-1
0
+1
+2
+3
+4
Scale
STEP
Briefly awakens to voice (eyes open & <10 sec)
Not fully alert, but has sustained awakening to voice (eye opening & >10 sec)
Spontaneously pays attention to caregiver
Anxious, apprehensive, movements not aggressive
Frequent non-purposeful movement, fights ventilator
Pulls to remove tubes or catheters; aggressive
Combative, violent, immediate danger to staff
Description
No response to voice or physical stimulation
No response to voice, but movement or eye opening to physical stimulation
Briefly awakens to voice (eyes open & <10 sec)
Not fully alert, but has sustained awakening to voice (eye opening & >10 sec)
Spontaneously pays attention to caregiver
Anxious, apprehensive, movements not aggressive
Frequent non-purposeful movement, fights ventilator
Pulls to remove tubes or catheters; aggressive
Combative, violent, immediate danger to staff
No response to voice or physical stimulation
No response to voice, but movement or eye opening to physical stimulation
Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344
Ely, et al., JAMA 2003; 286, 2983-2991
If RASS is -4 or -5 STOP (patient unconscious), RECHECK later
UNAROUSEABLE
DEEP SEDATION
If RASS is ≥ -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)
MODERATE SEDATION Movement or eye opening to voice (no eye )
LIGHT SEDATION
DROWSY
ALERT & CALM
RESTLESS
AGITATED
VERY AGITATED
Description
Sedation Assessment
COMBATIVE
Label
Ely, et al., JAMA 2003; 286, 2983-2991
T O U C H
V O I C E
T O U C H
V O I C E
RICHMOND AGITATION-SEDATION SCALE (RASS)
Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344
If RASS is -4 or -5 STOP (patient unconscious), RECHECK later
UNAROUSEABLE
DEEP SEDATION
If RASS is ≥ -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)
MODERATE SEDATION Movement or eye opening to voice (no eye )
LIGHT SEDATION
DROWSY
ALERT & CALM
RESTLESS
AGITATED
VERY AGITATED
COMBATIVE
Label
Sedation Assessment
RICHMOND AGITATION-SEDATION SCALE (RASS)
DELIRIUM ASSESSMENT
YES
RASS = zero
DELIRIUM ASSESSMENT
RASS = zero
Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved
Command: “Hold up this many fingers” (Hold up 2 fingers) “Now do the same thing with the other hand” (Do not demonstrate) OR “Add one more finger” (If patient unable to move both arms)
1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail?
4. Disorganized Thinking:
3. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1)
> 2 Errors
• If unable to complete Letters Pictures
• “Squeeze my hand when I say the letter ‘A’.” Read the following sequence of letters: S A V E A H A A R T ERRORS: No squeeze with ‘A’ & Squeeze on letter other than ‘A’
YES
• Is there an acute change from mental status baseline? OR • Has the patient’s mental status fluctuated during the past 24 hours?
2. Inattention:
0-1 Error
> 1 Error
RASS other than zero
0-2 Errors
CAM-ICU negative NO DELIRIUM
CAM-ICU positive DELIRIUM Present
CAM-ICU negative NO DELIRIUM
CAM-ICU negative NO DELIRIUM
0-1 Error
> 1 Error
RASS other than zero
0-2 Errors
NO
CAM-ICU negative NO DELIRIUM
CAM-ICU positive DELIRIUM Present
CAM-ICU negative NO DELIRIUM
CAM-ICU negative NO DELIRIUM
Confusion Assessment Method for the ICU (CAM-ICU)
1. Acute Change or Fluctuating Course of Mental Status:
STEP
Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved
Command: “Hold up this many fingers” (Hold up 2 fingers) “Now do the same thing with the other hand” (Do not demonstrate) OR “Add one more finger” (If patient unable to move both arms)
1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail?
4. Disorganized Thinking:
3. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1)
> 2 Errors
• If unable to complete Letters Pictures
• “Squeeze my hand when I say the letter ‘A’.” Read the following sequence of letters: S A V E A H A A R T ERRORS: No squeeze with ‘A’ & Squeeze on letter other than ‘A’
2. Inattention:
• Is there an acute change from mental status baseline? OR • Has the patient’s mental status fluctuated during the past 24 hours?
NO
Confusion Assessment Method for the ICU (CAM-ICU)
1. Acute Change or Fluctuating Course of Mental Status:
STEP DELIRIUM ASSESSMENT
YES
RASS = zero
DELIRIUM ASSESSMENT
RASS = zero
Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved
Command: “Hold up this many fingers” (Hold up 2 fingers) “Now do the same thing with the other hand” (Do not demonstrate) OR “Add one more finger” (If patient unable to move both arms)
1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail?
4. Disorganized Thinking:
3. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1)
> 2 Errors
• If unable to complete Letters Pictures
• “Squeeze my hand when I say the letter ‘A’.” Read the following sequence of letters: S A V E A H A A R T ERRORS: No squeeze with ‘A’ & Squeeze on letter other than ‘A’
YES
• Is there an acute change from mental status baseline? OR • Has the patient’s mental status fluctuated during the past 24 hours?
2. Inattention:
0-1 Error
> 1 Error
RASS other than zero
0-2 Errors
CAM-ICU negative NO DELIRIUM
CAM-ICU positive DELIRIUM Present
CAM-ICU negative NO DELIRIUM
CAM-ICU negative NO DELIRIUM
0-1 Error
> 1 Error
RASS other than zero
0-2 Errors
NO
CAM-ICU negative NO DELIRIUM
CAM-ICU positive DELIRIUM Present
CAM-ICU negative NO DELIRIUM
CAM-ICU negative NO DELIRIUM
Confusion Assessment Method for the ICU (CAM-ICU)
1. Acute Change or Fluctuating Course of Mental Status:
STEP
Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved
Command: “Hold up this many fingers” (Hold up 2 fingers) “Now do the same thing with the other hand” (Do not demonstrate) OR “Add one more finger” (If patient unable to move both arms)
1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail?
4. Disorganized Thinking:
3. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1)
> 2 Errors
• If unable to complete Letters Pictures
• “Squeeze my hand when I say the letter ‘A’.” Read the following sequence of letters: S A V E A H A A R T ERRORS: No squeeze with ‘A’ & Squeeze on letter other than ‘A’
2. Inattention:
• Is there an acute change from mental status baseline? OR • Has the patient’s mental status fluctuated during the past 24 hours?
NO
Confusion Assessment Method for the ICU (CAM-ICU)
1. Acute Change or Fluctuating Course of Mental Status:
STEP
AGITATED
RESTLESS
ALERT & CALM
DROWSY
LIGHT SEDATION
MODERATE SEDATION Movement or eye opening to voice (no eye )
+3
+2
+1
0
-1
-2
-3
No response to voice or physical stimulation
Ely, et al., JAMA 2003; 286, 2983-2991
VERY AGITATED
AGITATED
RESTLESS
ALERT & CALM
DROWSY
LIGHT SEDATION
MODERATE SEDATION Movement or eye opening to voice (no eye )
+3
+2
+1
0
-1
-2
-3
UNAROUSEABLE
-5
No response to voice or physical stimulation
No response to voice, but movement or eye opening to physical stimulation
Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344
Ely, et al., JAMA 2003; 286, 2983-2991
If RASS is -4 or -5 STOP (patient unconscious), RECHECK later
DEEP SEDATION
If RASS is ≥ -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)
Briefly awakens to voice (eyes open & <10 sec)
Not fully alert, but has sustained awakening to voice (eye opening & >10 sec)
Spontaneously pays attention to caregiver
Anxious, apprehensive, movements not aggressive
Frequent non-purposeful movement, fights ventilator
Pulls to remove tubes or catheters; aggressive
Combative, violent, immediate danger to staff
COMBATIVE
+4
Description
Label
Sedation Assessment
-4
T O U C H
V O I C E
T O U C H
V O I C E
RICHMOND AGITATION-SEDATION SCALE (RASS)
Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344
Scale
STEP
UNAROUSEABLE
-5
No response to voice, but movement or eye opening to physical stimulation
If RASS is -4 or -5 STOP (patient unconscious), RECHECK later
DEEP SEDATION
-4
If RASS is ≥ -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)
Briefly awakens to voice (eyes open & <10 sec)
Not fully alert, but has sustained awakening to voice (eye opening & >10 sec)
Spontaneously pays attention to caregiver
Anxious, apprehensive, movements not aggressive
Frequent non-purposeful movement, fights ventilator
Pulls to remove tubes or catheters; aggressive
Combative, violent, immediate danger to staff
COMBATIVE
+4
Description
Label
Sedation Assessment
RICHMOND AGITATION-SEDATION SCALE (RASS)
Scale
STEP
-5
-4
-3
-2
-1
0
+1
+2
+3
+4
Scale
STEP
-5
-4
-3
-2
-1
0
+1
+2
+3
+4
Scale
STEP
Briefly awakens to voice (eyes open & <10 sec)
Not fully alert, but has sustained awakening to voice (eye opening & >10 sec)
Spontaneously pays attention to caregiver
Anxious, apprehensive, movements not aggressive
Frequent non-purposeful movement, fights ventilator
Pulls to remove tubes or catheters; aggressive
Combative, violent, immediate danger to staff
Description
No response to voice or physical stimulation
No response to voice, but movement or eye opening to physical stimulation
Briefly awakens to voice (eyes open & <10 sec)
Not fully alert, but has sustained awakening to voice (eye opening & >10 sec)
Spontaneously pays attention to caregiver
Anxious, apprehensive, movements not aggressive
Frequent non-purposeful movement, fights ventilator
Pulls to remove tubes or catheters; aggressive
Combative, violent, immediate danger to staff
No response to voice or physical stimulation
No response to voice, but movement or eye opening to physical stimulation
Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344
Ely, et al., JAMA 2003; 286, 2983-2991
If RASS is -4 or -5 STOP (patient unconscious), RECHECK later
UNAROUSEABLE
DEEP SEDATION
If RASS is ≥ -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)
MODERATE SEDATION Movement or eye opening to voice (no eye )
LIGHT SEDATION
DROWSY
ALERT & CALM
RESTLESS
AGITATED
VERY AGITATED
Description
Sedation Assessment
COMBATIVE
Label
Ely, et al., JAMA 2003; 286, 2983-2991
T O U C H
V O I C E
T O U C H
V O I C E
RICHMOND AGITATION-SEDATION SCALE (RASS)
Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344
If RASS is -4 or -5 STOP (patient unconscious), RECHECK later
UNAROUSEABLE
DEEP SEDATION
If RASS is ≥ -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)
MODERATE SEDATION Movement or eye opening to voice (no eye )
LIGHT SEDATION
DROWSY
ALERT & CALM
RESTLESS
AGITATED
VERY AGITATED
COMBATIVE
Label
Sedation Assessment
RICHMOND AGITATION-SEDATION SCALE (RASS)
DELIRIUM ASSESSMENT
YES
RASS = zero
DELIRIUM ASSESSMENT
RASS = zero
Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved
Command: “Hold up this many fingers” (Hold up 2 fingers) “Now do the same thing with the other hand” (Do not demonstrate) OR “Add one more finger” (If patient unable to move both arms)
1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail?
4. Disorganized Thinking:
3. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1)
> 2 Errors
• If unable to complete Letters Pictures
• “Squeeze my hand when I say the letter ‘A’.” Read the following sequence of letters: S A V E A H A A R T ERRORS: No squeeze with ‘A’ & Squeeze on letter other than ‘A’
YES
• Is there an acute change from mental status baseline? OR • Has the patient’s mental status fluctuated during the past 24 hours?
2. Inattention:
0-1 Error
> 1 Error
RASS other than zero
0-2 Errors
CAM-ICU negative NO DELIRIUM
CAM-ICU positive DELIRIUM Present
CAM-ICU negative NO DELIRIUM
CAM-ICU negative NO DELIRIUM
0-1 Error
> 1 Error
RASS other than zero
0-2 Errors
NO
CAM-ICU negative NO DELIRIUM
CAM-ICU positive DELIRIUM Present
CAM-ICU negative NO DELIRIUM
CAM-ICU negative NO DELIRIUM
Confusion Assessment Method for the ICU (CAM-ICU)
1. Acute Change or Fluctuating Course of Mental Status:
STEP
Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved
Command: “Hold up this many fingers” (Hold up 2 fingers) “Now do the same thing with the other hand” (Do not demonstrate) OR “Add one more finger” (If patient unable to move both arms)
1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail?
4. Disorganized Thinking:
3. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1)
> 2 Errors
• If unable to complete Letters Pictures
• “Squeeze my hand when I say the letter ‘A’.” Read the following sequence of letters: S A V E A H A A R T ERRORS: No squeeze with ‘A’ & Squeeze on letter other than ‘A’
2. Inattention:
• Is there an acute change from mental status baseline? OR • Has the patient’s mental status fluctuated during the past 24 hours?
NO
Confusion Assessment Method for the ICU (CAM-ICU)
1. Acute Change or Fluctuating Course of Mental Status:
STEP DELIRIUM ASSESSMENT
YES
RASS = zero
DELIRIUM ASSESSMENT
RASS = zero
Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved
Command: “Hold up this many fingers” (Hold up 2 fingers) “Now do the same thing with the other hand” (Do not demonstrate) OR “Add one more finger” (If patient unable to move both arms)
1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail?
4. Disorganized Thinking:
3. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1)
> 2 Errors
• If unable to complete Letters Pictures
• “Squeeze my hand when I say the letter ‘A’.” Read the following sequence of letters: S A V E A H A A R T ERRORS: No squeeze with ‘A’ & Squeeze on letter other than ‘A’
YES
• Is there an acute change from mental status baseline? OR • Has the patient’s mental status fluctuated during the past 24 hours?
2. Inattention:
0-1 Error
> 1 Error
RASS other than zero
0-2 Errors
CAM-ICU negative NO DELIRIUM
CAM-ICU positive DELIRIUM Present
CAM-ICU negative NO DELIRIUM
CAM-ICU negative NO DELIRIUM
0-1 Error
> 1 Error
RASS other than zero
0-2 Errors
NO
CAM-ICU negative NO DELIRIUM
CAM-ICU positive DELIRIUM Present
CAM-ICU negative NO DELIRIUM
CAM-ICU negative NO DELIRIUM
Confusion Assessment Method for the ICU (CAM-ICU)
1. Acute Change or Fluctuating Course of Mental Status:
STEP
Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved
Command: “Hold up this many fingers” (Hold up 2 fingers) “Now do the same thing with the other hand” (Do not demonstrate) OR “Add one more finger” (If patient unable to move both arms)
1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail?
4. Disorganized Thinking:
3. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1)
> 2 Errors
• If unable to complete Letters Pictures
• “Squeeze my hand when I say the letter ‘A’.” Read the following sequence of letters: S A V E A H A A R T ERRORS: No squeeze with ‘A’ & Squeeze on letter other than ‘A’
2. Inattention:
• Is there an acute change from mental status baseline? OR • Has the patient’s mental status fluctuated during the past 24 hours?
NO
Confusion Assessment Method for the ICU (CAM-ICU)
1. Acute Change or Fluctuating Course of Mental Status:
STEP
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