Introduction
Emergency departments treat all medical emergencies, critical illnesses, and injuries. Pain, delirium, agitation, and loss of responsiveness are commonly seen in patients requiring emergency care. Sedation and other pain-controlling therapies are used to manage such patients. Several scoring systems assess the depth of sedation to ensure an optimum level. The patient's responsiveness is assessed in certain emergencies, such as acute head or brain injuries and illnesses. Such neurological assessments or scoring systems help to decide the emergency management required for the patients. For instance, if the patient is severely impaired, emergency care, such as airway management and triage, is done to decide on patient transfer. In less severe cases, these scores help to decide if the patient requires admission, further imaging, or discharge. Serial assessments of the patient’s responsiveness are essential to monitoring the patient’s progress and making changes in the treatment if needed.
What Are Consciousness or Coma Scales?
In emergencies, it is vital to identify how awake, alert, or aware a critically ill or injured person is. Assessing the patient’s level of consciousness or degree of responsiveness guides the emergency physician in deciding on appropriate management. Abnormal or altered levels of consciousness, such as disorientation, confusion, delirium, slow response, and coma, often indicate a serious medical problem that can rapidly deteriorate. A person with a coma does not respond to stimuli, lacks gag reflex or pupillary response, and may require immediate airway and breathing assistance. Extreme blood loss, brain damage, and organ failure can cause reduced brain function and coma. Clinical scaling systems or coma scales are used to assess the patient’s consciousness during emergencies. This help analyzes the neurological status of severely ill or injured patients with head or brain injury and damage. There are several different coma scales used in the emergency room. Of these neurological assessments, the following are commonly used to assess the consciousness or responsiveness of emergency room patients:
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Glasgow coma scale (GCS).
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Full outline of unresponsiveness (FOUR) score.
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Assessment of pupils.
What Is Glasgow Coma Scale (GCS)?
The Glasgow coma scale (GCS) is used to assess the severity of consciousness impairment in critically ill or injured patients at the site of injury or in the emergency rooms and intensive care units. It is a reliable method to record the patient's initial and subsequent levels of consciousness. This scoring method provides a clear and communicable portrayal of the patient’s consciousness level as it assesses the three key aspects of responsiveness - the patient’s eye-opening, motor, and verbal responses. Each component of the scale gets a score, which can be aggregated to get the total Glasgow coma score that describes the overall severity of the patient. The total coma score has values between three (worst) and 15 (highest). The three parameters and their scoring criteria are as follows:
Patient’s Eye-Opening: Maximum score for the best response is four. The scoring is done as mentioned in the table below:
- One: Does not open eyes
- Two: Opens eye in response to pain
- Three: Opens eye in response to sound
- Four: Opens eye spontaneously
Patient’s Verbal Response: Maximum score for the best response is five. The scoring is done as mentioned in the table below:
- One: No response (verbal).
- Two: Response with indecipherable sounds.
- Three: Responds with inappropriate words.
- Four: Patient is confused.
- Five: Patient responds well verbally and is oriented.
Patient’s Motor Response: Maximum score for the best response is six. The scoring is done as mentioned in the table below:
- One: No response (motor).
- Two: Moves and makes abnormal movements that straighten the patient’s joints (extension) in response to pain.
- Three: Moves and makes abnormal movements that bend the patient’s joints (flexion) in response to pain.
- Four: The patient makes withdrawal movements from pain.
- Five: The patient can localize pain.
- Six: The patient can obey commands and give appropriate motor responses.
What Is the Full Outline of the Unresponsiveness (FOUR) Score?
Full outline of the unresponsiveness or FOUR scales assesses vital information that is not done by the Glasgow coma scale. It measures the brainstem reflexes and determines eye-opening, blinking, tracking, a wide range of motor responses, abnormal breath rhythms, and respiratory drive. It does not assess verbal response, so it is used generally to assess critically ill patients who are intubated. The four key components of the scaling system are given equal importance and weight. The elements of the FOUR score are the following:
- Eye response.
- Motor response.
- Brainstem reflexes (these give a complete and accurate assessment of how deep the coma is).
- Respiration pattern.
What Are the Common Sedation Scales?
Sedatives (sleep-inducing or calming medicines) and pain medications are given to patients in the emergency room. This helps the patient tolerate unpleasant medical procedures. Administering sedatives calms the patient, reduces intervention time, reduces the risk of injury, and ensures quality emergency care. The level of sedation, such as minimal, moderate, deep, or complete, depends on the patient’s condition and the intervention required. There are various scoring systems to assess the depth of sedation. These sedation scales guide the doctors to adjust the pain medications and sedation therapies to provide the optimum level of sedation for the critically ill or injured. There are various sedation scales. The most commonly used sedation scales include the following:
- Ramsey sedation scale.
- Richmond agitation sedation scale (RASS).
- Sedation agitation scale.
What Is the Ramsay Sedation Scale?
Ramsey sedation scale is one of the most commonly used tools for assessing sedation. The patient’s level of sedation is divided into six categories, from agitation to coma. Though it is frequently used in the emergency room, it has many drawbacks. When used in complex cases, the patients seem to conform to more than one sedation level per the scale. The scoring criteria used in the scale are highlighted in the table below:
- One: Restless or agitated, anxious, or both.
- Two: Oriented, cooperative, and calm.
- Three: Only responds to commands.
- Four: Briskly responds to loud noise or a light tap on the forehead between the eyebrows.
- Five: Lightly responds to loud noise or a light tap on the forehead between the eyebrows.
- Six: No response.
What Is Richmond Agitation Sedation Scale (RASS)?
Richmond agitation sedation scale (RASS) is a scoring system to assess the level of alertness and agitation in critically ill or injured patients. This system can be used for any patient to assess their sedation level but is generally used for patients under mechanical ventilation to prevent over or under-sedation. This method is user-friendly and is the most reliable. However, this scoring system cannot be used for patients with severe hearing or vision problems. The scoring criteria used in the scale are highlighted in the table below:
- Combative (+4): Violent, immediate danger to staff.
- Very Agitated (+3): Aggressive (pulls or removes tubes or catheters).
- Agitated (+2): Frequent movements without a purpose and fighting ventilator
- Restless (+1): Anxious but not aggressive.
- Alert and calm (0): Calm and responsive.
- Drowsy (-1): Not alert but responds to voice.
- Light Sedation (-2): Briefly awakes in response to voice.
- Moderate Sedation (-3): Opens eye or moves in response to the voice without eye contact.
- Deep Sedation (-4): Does not respond to voice. Opens the eye or moves on physical stimulation.
- Unarousable (-5): No response to voice or physical stimulation.
What Is Sedation Agitation Scale?
The sedation agitation scale (SAS) categorizes seven levels of agitation and sedation. It thoroughly describes the patient’s condition and behavior, from severe, dangerous agitation to complete sedation. The scoring criteria used in the scale are highlighted in the table below:
- Seven: Dangerous, violent, pulling out tubes and catheters are of immediate danger to staff.
- Six: Very agitated and requiring restraint.
- Five: Is agitated and anxious but calms down on talking to them.
- Four: Calm, cooperative, and follow commands.
- Three: Sedated and difficult to keep awake but responds to voice or physical stimulation.
- Two: Very sedated. Does not wake up to voice or follow commands. Responds to physical stimulation.
- One: Minimal or no response to any stimuli.
Conclusion
It is vital to identify how awake, alert, or aware a critically ill or injured person is in case of an emergency. Glasgow coma scale and a full outline of the unresponsiveness (FOUR) scales are the commonly used scoring systems in emergency rooms to assess the patient’s consciousness. The scores obtained guide emergency physicians in deciding on the appropriate patient management. The sedation scales assess and help to ensure the optimum level of sedation for the critically ill or injured for quality emergency care.