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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