SEPT 13 Built from the handwritten pages you uploaded on 13 September 2026.

Sedation & delirium: RASS and CAM-ICU

The Richmond Agitation–Sedation Scale, the targets for different patients, and how it gates the delirium screen.

The Richmond Agitation–Sedation Scale

Ten points from +4 to −5. Observe first; then use voice for −1 to −3, and physical stimulation only if there is no response to voice.

Score	Term	What you see
+4	Combative	Violent; an immediate danger to staff
+3 · MCQ	Very agitated	Pulls at or removes tubes and catheters; aggressive
+2 · MCQ	Agitated	Frequent non-purposeful movement; fights the ventilator
+1	Restless	Anxious, but movements are not aggressive or vigorous
0	Alert and calm	—
−1	Drowsy	Not fully alert, but sustained eye opening and eye contact to voice (> 10 s)
−2	Light sedation	Briefly awakens to voice, eye contact < 10 s
−3	Moderate sedation	Movement or eye opening to voice, but no eye contact
−4	Deep sedation	No response to voice; moves or opens eyes to physical stimulation
−5	Unrousable	No response to voice or physical stimulation

+2 fights the ventilator; +3 pulls the tube out. The tube is the dividing line.
−1 vs −2 is the 10-second eye contact rule. −3 is movement without eye contact. −4 needs touch.
Positive scores fit hyperactive delirium; negative scores fit hypoactive delirium — the commoner and more often missed type.

Patient	Target RASS	Why
Most ventilated ICU patients	0 to −1 (light)	Less delirium, shorter ventilation and ICU stay. Current guidance accepts 0 to −2
Head injury / raised ICP	−3 to −4 (deep)	Reduces cerebral metabolic rate and ICP; tolerates the ventilator for tight CO₂ control
Also deep	−4 to −5	Severe ARDS on neuromuscular blockade or proning, status epilepticus

The sheet says "RASS is done in intubated patients only" — that is not right. RASS is validated in both ventilated and non-ventilated ICU patients.

RASS is step one. You cannot assess attention in someone who cannot respond to voice.

1
Score the RASS
−4 or −5 → STOP, and recheck later. −3 or above → proceed to the CAM-ICU. (Your sheet's column prints the cut-off near −2; the CAM-ICU manual uses −3 — patients who open their eyes to voice.)
F1
Acute onset or fluctuating course
A change from baseline mental state, or fluctuation over the past 24 h.
F2
Inattention
Squeeze my hand on every "A" in SAVEAHAART — more than 2 errors is positive.
F3
Altered level of consciousness
Any RASS other than 0.
F4
Disorganised thinking
Yes/no questions ("Will a stone float on water?") and a two-step command.

+3 pulls tubes

+2 fights ventilator

10 s −1 vs −2

0 / −1 usual target

−3 to −4 head injury

−4 / −5 no CAM-ICU

1+2+(3/4) delirium