ADD-ONS / SCALES

Created 13/01/2023, last revision 13/01/2023

• the test assesses the quantitative component of consciousness and the level of psychomotor activity
  • mostly it is used in mechanically ventilated patients in order to avoid over and under-sedation
• timing is important; reduce sedation 1-2h before testing
• start with observing the patient
  • patient is alert, in the normal state (0)
    
  • patient is hyperactive (score +1 to +4)
• if not alert, state the patient’s name and ask him/her to open eyes and look at the speaker
  • patient awakens with sustained eye opening and eye contact (score –1)
  • patient awakens with eye opening and eye contact, but not sustained (score –2)
  • patient has any movement in response to voice but no eye contact (score –3)
  • grades -1 to -3 correspond to somnolence of varying degrees, the patient responds to verbal stimulus and can potentially be further tested for delirium
• when no response to verbal stimulation, physically stimulate the patient by shaking the shoulder and/or rubbing the sternum
  • any movement to physical stimulation (score –4)
  • no response to any stimulation (score –5)
  • grades -4 and -5 correspond to a more profound disturbance of consciousness (sopor – coma) and the patient cannot be further tested for delirium