Using the Richmond Agitation Sedation Scale in Postintubation Management of RSI

After a patient has undergone an emergency rapid sequence intubation and has been placed on a mechanical ventilator, “long term sedation almost always is indicated. Use of a sedation scale, such as the Richmond Agitation Sedation Scale, to optimize patient comfort helps to guide decision making regarding the necessity of neuromuscular blockade. Sedation and analgesia are administered to reach the desisired level, and neuromuscular blockage is used only if the patient then requires it for management. Use of a sedation scale prevents the use of neuromuscular blockage for patient control when the cause of patient’s agitation is inadequate sedation.” (1)


Score Term Description

+4  Combative: Overtly combative or violent; immediate danger to staff

+3 Very agitation: Pulls on or removes tube(s) or catheter(s) or has aggressive behavior
toward staff

+2 Agitated: Frequent nonpurposeful movement or patient–ventilator dyssynchrony

+1 Restless: Anxious or apprehensive but movements not aggressive or vigorous

0 Alert and calm

-1 Drowsy: Not fully alert, but has sustained (more than 10 seconds) awakening,
with eye contact, to voice

-2 Light sedation: Briefly (less than 10 seconds) awakens with eye contact to voice

-3 Moderate sedation: Any movement (but no eye contact) to voice

-4 Deep sedation: No response to voice, but any movement to physical stimulation

-5 Unarousable No response to voice or physical stimulation


1. Observe patient. Is patient alert and calm (score 0)?
Does patient have behavior that is consistent with restlessness or agitation (score 1 to 4 using the criteria listed above, under DESCRIPTION)?

2. If patient is not alert, in a loud speaking voice state patient’s name and direct patient to open eyes and look at speaker. Repeat once if necessary. Can prompt patient to continue looking at speaker.
Patient has eye opening and eye contact, which is sustained for more than 10 seconds (score  -1).
Patient has eye opening and eye contact, but this is not sustained for 10 seconds (score -2).
Patient has any movement in response to voice, excluding eye contact (score -3).

3. If patient does not respond to voice, physically stimulate patient by shaking shoulder and then rubbing sternum if there is no response to shaking shoulder.
Patient has any movement to physical stimulation (score  -4).
Patient has no response to voice or physical stimulation (score -5).

For information on how to use the RASS to titrate sedative medication, please see  “Postintubation Management Protocol Using the Richmond Agitation Sedation Scale in an upcoming article on this site.

(1) Manual of Emergency Airway Management, 4th ed, 2012, RM Walls and MF Murphy

(2) The Richmond Agitation–Sedation Scale: Validity and Reliability in Adult Intensive Care Unit Patients Am J Respir Crit Care Med Vol 166. pp 1338–1344, 2002 available at [This link is no longer valid. See reference 3 for another reference on the topic.]

(3) Critical Care 2008 Volume 12 Supplement 3: Analgesia and sedation in the intensive care unit


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