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.
Purpose: To evaluate an adult using the Triage Early Warning System (TEWS) for an adult.
Specialty: Surgery, orthopedic, Emergency Medicine, Critical Care, Surgery, general
Objective: clinical diagnosis, including family history for genetics, criteria for diagnosis, severity, prognosis, stage, public health
ICD-10: T14,
