ST ELIZABETH CATHOLIC GENERAL HOSPITAL,

SHISONG, KUMBO, CAMEROON

EARLY WARNING SCORE

This should be assessed on all admissions in the hospital, emergency cases, patients at risk of deterioration, once/day to hospitalised
patients and any patient you are concerned about. If score more than 4 in the wards follow appropriated protocol/flowchart. *If outside
this range call doctor immediately. The coma and pupils score monitor in unconscious or neurological cases.

Date of admission Name:

Consultant

Ward : Bed No: Registration No:

Date
Time
HR 30-180*
BP <60*
Resp rate 8-40*
Central Nerv System
Temp
Urine
Score
Call doctor Y/N
Glasgow coma scale
Pupils right size
reaction

left size
reaction

EARLY WARNING SCORE ADULTS

Score 3 2 1 0 1 2 3
HR per minute <40 41-50 51-100 101-110 111-129 >130
BP systolic <70 71-80 81-100 101-199 >200
Resp per min <8 9-14 15-20 21-29 >30
Central Nerv Alert Drowsy/rousable To pain Unresponsive
System to voice or newly
confused
Temperature <35 35.1-37.5 >37.5
Urine output Nil <20mls/2hrs or 20-50 ml/2hrs or >50ml/2hrs
has not voided has not voided
within 4hs of within 4 hrs of
admission admission

If the patient / child has a score of 4 or more follow the appropiated flowchart. Children physiological values at the back of this chart.

PEWA 0 1 2 3 Score
Behaviour Playing / Sleeping Irritable Lethargic/confused
appropriate Reduced response to pain
Cardiovascular Pink or capillary Pale or capillary Grey or capillary refill 4 seconds. Grey and mottled or capillary refill
refill 1-2 seconds refill 3 seconds Tachycardia of 20 above normal 5 seconds or above. Tachycardia of
rate 30 above normal rate or badycardia
Respiratory Within normal >10 above normal >20 above normal parameters with 5 below normal parameters with
parameters, no parameters using sternal recession, tracheal tug or sternal recession, thracheal tug or
recession or accessory muscles, grunting. 50% FiO2 or 8 l/min grunting. 50% FiO2 or 8 l/min
tracheal tug +30% O2 or 4l/min
Score 2 extra if child has persistent vomiting after surgery or does not improve after 15 mins Salbutamol steam
Modified Glasgow Coma Scale for verbal response in children