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Sarnat Scoring Tool: Normal/Mild Moderate HIE Severe HIE

The Sarnat scoring tool is used to assess the severity of hypoxic-ischemic encephalopathy (HIE) in infants. It evaluates six areas: level of consciousness, spontaneous activity, posture, tone, primitive reflexes, and autonomic system function. Scores range from 1 to 3, with 1 being normal/mild, 2 being moderate HIE, and 3 being severe HIE. A score of 3 in any category indicates the infant is experiencing severe or abnormal findings in that area. The tool provides a standardized way to evaluate HIE severity across multiple domains of an infant's neurological function.

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Billy Wijaya
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399 views

Sarnat Scoring Tool: Normal/Mild Moderate HIE Severe HIE

The Sarnat scoring tool is used to assess the severity of hypoxic-ischemic encephalopathy (HIE) in infants. It evaluates six areas: level of consciousness, spontaneous activity, posture, tone, primitive reflexes, and autonomic system function. Scores range from 1 to 3, with 1 being normal/mild, 2 being moderate HIE, and 3 being severe HIE. A score of 3 in any category indicates the infant is experiencing severe or abnormal findings in that area. The tool provides a standardized way to evaluate HIE severity across multiple domains of an infant's neurological function.

Uploaded by

Billy Wijaya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SARNAT SCORING TOOL

Normal/Mild Moderate HIE Severe HIE

1. Level of Consciousness Code 2: Lethargic: delayed but Code 3: stupor/coma: infant is not
Code 1: arouses to wakefulness, complete response to external stimuli arousable and is non-responsive to external
responds to external stim, or appears (start with mild stimuli first then stimuli; may have a delayed but incomplete
hyperalert or inconsolable/irritable proceed to more noxious stimuli) response to stimuli

2. Spontaneous Activity 2 = Decreased activity Code 3: no activity


Code 1: infant is active Code 2: activity is decreased

3. Posture 2 = Distal flexion, complete extension Code 3 if decerebrate with or without stimulation
Code 1: if infant is moving around and does Code 2 if strong distal flexion,
not maintain one posture, should have complete extension or “frog-legged”
flexion of lower extremity at hip and/or position (complete abduction)
knees

4. Tone 2a = Hypotonia (focal or general) Code 3:


Code 1 if there is normal resistance 2b = Hypertonia 3a if flaccid (like a rag doll)
Code 2: 3b if rigid (stiffness or inflexibility)
2a if hypotonic or floppy either focal
or generalized
2b if increased tone noted

5. Primitive Reflexes Code 2 if suck is weak or if infant has a Code 3 = Suck is Absent
bite Code 3 = Absent
* Suck
Code 1 if the infant vigorously sucks the
examiners finger or the ET tube
Code 2 if incomplete Code 3 if absent
*Moro
Code 1 if, with stimulus, there is
extension of limbs, opening of hands
extension with abduction of UE

6. Autonomic System Code 2 if bradycardia (< 100/min) Code 3 if heart rate is not constant
with only occasional increases to and varies widely between <100 and
*Heart rate >120/min > 120
Code 1 if >100 per min or consistent
tachycardia Code 3 if apnea or requiring ventilator
Code 2 if periodic breathing associated support:
*Respiration with desaturations (SpO2 < 80%) ± •3a if spontaneous breaths above the ventilator
Code 1 if breathing spontaneously or if supplemental O2 •3b if no spontaneous breaths above the vent
periodic breathing without desaturation
Code 3 if skew deviation of eyes, pupils
Code 2 if constricted and reacting to are dilated or non-reactive to light
*Pupils light •If pupils asymmetric, assign 3
Code 1 if normal in size and reactive to light Code 3 if skew deviation of eyes,
pupils are

Refer to Power Point Slides for visual clarification: Screening Neurologic Exam for
Therapeutic Hypotherma @ http://hopefn3.org

Adapted from: A Phase II Multi-site Study of Autologous Cord Blood Cells for Hypoxic
Ischemic Encephalopathy (HIE)

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