Escalas Neurológicas e de Sedação

Glasgow Coma Scale

1 2 3 4 5 6

Opens eyes in
Does not Opens eyes in Opens eyes
Eye response to painful N/A N/A
open eyes response to voice spontaneously
stimuli

Utters Oriented,
Makes no Incomprehensible Confused,
Verbal inappropriate converses N/A
sounds sounds disoriented
words normally

Abnormal flexion
Extension to painful Flexion / Localizes
Makes no to painful stimuli Obeys
Motor stimuli (decerebrate Withdrawal to painful
movements (decorticate commands
response) painful stimuli stimuli
response)

JOUVET Scale

P R D V
Perceptivity Reactivity Pain Autonomic reactivity
1 No loss of consciousness, Positive orientation Normal response Autonomic responses to
neurologically normal reaction with eyes open painful stimuli are
and positive waking present
reaction if eyes are closed
2 Disoriented or unable to Eye opening but loss of Loss of facial and vocal Absence of autonomic
obey a written command orientation reaction with response to pain response to pain
but can obey a verbal one eyes open
3 A verbal command Loss of eye opening Only limb withdrawal
repeated many times to response
be obeyed, and even then
it is carried out slowly
4 Coma, only have blinking Absence of any response
reflex to pain
5 Absence of perception

As a rule: P ≥ R ≥ D ≥ V
FOUR Neurologic Score

Test Finding Score

Eye Response Eyelids open or opened, tracking, or blinking to command 4

Eyelids open but not tracking 3

Eyelids closed but open to loud voice 2

Eyelids closed but open to pain 1

Eyelids remain closed with pain 0

Motor response Makes sign (thumbs-up, fist, or peace sign) 4

Localizing to pain 3

Flexion response to pain 2

Extension response to pain 1

No response to pain or generalized myoclonus status 0

Brainstem reflexes Pupil and corneal reflexes present 4

One pupil wide and fixed 3

Pupil or corneal reflexes absent 2

Pupil and corneal reflexes absent 1

Absent pupil, corneal, and cough reflex 0

Respiration Not intubated, regular breathing pattern 4

Not intubated, cheyne-stokes breathing pattern 3

Not intubated, irregular breathing 2

Breathes above ventilator rate 1

Breathes at ventilator rate or apnea 0

RASS Sedation Scale

Score Classification (RASS)

4 Combative Overtly combative or violent; immediate danger to staff

3 Very agitated 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

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

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

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

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

-5 Unarousable No response to voice or physical stimulation

Ramsay Sedation Scale

Score (Ramsay)

1 Anxious, agitated, restless

2 Cooperative, oriented, tranquil

3 Responsive to commands only

4 Brisk response to light glabellar tap or loud auditory stimulus

5 Sluggish response to light glabellar tap or loud auditory stimulus

6 No response to light glabellar tap or loud auditory stimulus

Dr. Vitor Kawabata – UTI Adultos