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Overview :
The Triage Early
Warning System (TEWS) can be used to triage an emergency patient. It is a
physiological score based on the MEWS (Medical Early Warning
System).
Patient
selection: adult (age > 12 years, > 150 cm)
Parameters from
MEWS:
(1) respiratory
rate
(2) heart
rate
(3) systolic
blood pressure
(4)
temperature
(5)
consciousness as AVPU = alert, verbal, pain,
unconsciousness
Additional
parameters:
(6)
mobility
(7)
trauma
|
Parameter |
Finding |
Points |
|
respiratory
rate |
< 9
breaths per minute |
2 |
|
|
9 - 14
breaths per minute |
0 |
|
|
15 - 20
breaths per minute |
1 |
|
|
21 - 29
breaths per minute |
2 |
|
|
>= 30
breaths per minute |
3 |
|
heart
rate |
< 41
beats per minute |
2 |
|
|
41 - 50
beats per minute |
1 |
|
|
51 - 100
beats per minute |
0 |
|
|
101 - 110
beats per minute |
1 |
|
|
111 - 129
beats per minute |
2 |
|
|
>= 130
beats per minute |
3 |
|
systolic
blood pressure |
< 71 mm
Hg |
3 |
|
|
71 - 80 mm
Hg |
2 |
|
|
81 - 100
mm Hg |
1 |
|
|
101 - 199
mm Hg |
0 |
|
|
>= 200
mm Hg |
2 |
|
temperature |
<
35°C |
2 |
|
|
35 -
38.4°C |
0 |
|
|
>=
38.5°C |
2 |
|
consciousness |
alert |
0 |
|
|
responds
to voice |
1 |
|
|
responds
to pain |
2 |
|
|
unresponsive |
3 |
|
mobility |
walking |
0 |
|
|
with
help |
1 |
|
|
immobile,
requires stretcher |
2 |
|
trauma |
absent |
0 |
|
|
present |
1 |
where:
• Trauma probably refers to significant
trauma.
• A patient who has decreased
consciousness should be listed as immobile on the mobility
scale.
total score
=
= SUM(points for
all 7 items)
Interpretation:
• minimum score:
0
• maximum score:
17
• The higher the
score the more serious the patient's condition.
| References: | |
Wallis LA, Gottschalk SB, et al (Cape
Triage Group). The Cape Triage Score - a triage system for South Africa. SAMJ.
2006; 96: 53-56.
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