In Patients with retinal detachments may present with “flashes,” “floaters,” or a
“curtain” over the visual field. Funduscopic findings may include a pale,
billowing parachute-like fundus, and a retina that appears partially out of focus.
In Patients with vitreous detachments often complain of “flashes” or “floaters.”
Visual loss may not be noted unless there is a retinal tear, vitreous hemorrhage,
or retinal detachment.
In Monocular maculopathy may prompt a loss of central vision, but peripheral
vision often is spared.
In Central retinal artery occlusion can be indicated by a pale retina with cherry-red
macula. These patients require emergent ophthalmologic evaluations and should
be assessed for embolic complications.
In A “blood and thunder” fundus is indicative of central venous artery occlusion,
which warrants urgent outpatient treatment.
In The most concerning etiology of amaurosis fugax is ischemia to the retinal
vessels or optic nerve from giant cell arteritis. These patients may or may not
present with classic temporal cephalalgia; ESR and CRP measurements should
be ordered in any elderly patient with a new headache.
Richmond Agitation Sedation Scale (RASS) * Score Term Description
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive
+2 Agitated Frequent non-purposeful movement, fights ventilator
+1 Restless Anxious but movements not aggressive vigorous
0 Alert and calm
-1 Drowsy Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice (>10 seconds)
-2 Light sedation Briefly awakens with eye contact to voice (<10 seconds)
-3 Moderate sedation Movement or eye opening to voice (but no eye contact)
-4 Deep sedation No response to voice, but movement or eye opening to physical stimulation
-5 Unarousable No response to voice or physical stimulation
Procedure for RASS Assessment
1. Observe patient a. Patient is alert, restless, or agitated. (score 0 to +4)
2. If not alert, state patient’s name and say to open eyes and look at speaker.
b. Patient awakens with sustained eye opening and eye contact. (score –1)
c. Patient awakens with eye opening and eye contact, but not sustained. (score –2)
d. Patient has any movement in response to voice but no eye contact. (score –3)
3. When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing sternum.
e. Patient has any movement to physical stimulation.(score –4)
f. Patient has no response to any stimulation. (score –5) *
Sessler CN, Gosnell M, Grap MJ, Brophy GT, O’Neal PV, Keane KA et al. The Richmond AgitationSedation Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med 2002; 166:1338-1344. * Ely EW, Truman B, Shintani A, Thomason JWW, Wheeler AP, Gordon S et al. Monitoring sedation status over time in ICU patients: the reliability and validity of the Richmond Agitation Sedation Scale (RASS). JAMA 2003; 289:2983-2991. Verbal Stimulation Physical S