ADULT TEWS CHART

3 2 1 0 1 2 3
STRETCHER /
Mobility WALKING WITH HELP Mobility
IMMOBILE
Respiratory
LESS THAN 9 9 - 14 15 - 20 21 - 29 MORE THAN 29
Rate RR
Heart Rate LESS THAN 41 41 - 50 51 - 100 101 - 110 111 - 129 MORE THAN 129 SR
Systolic BP LESS THAN 71 71-80 81 - 100 101 - 199 MORE THAN 199 Systolic BP
Temp COLD OR <35 35.1 - 38.4 HOT OR > 38.4 Temp
REACTS TO
AVPU CONFUSED ALERT REACTS TO PAIN Unresponsive AVPU
VOICE
Trauma NO YES Trauma
OLDER THAN 12 YEARS OR TALLER THAN 150 CM
COLOUR RED ORANGE YELLOW GREEN BLUE
TEWS 7 OR MORE 5-6 3-4 0-2 DEAD
Target Time
Immediate Less than 10 minutes Less than 60 minutes Less than 240 minutes
to Treat
Mechanism of
High - Energy transfer
Injury

Shortness of breath:
ACUTE
Coughing blood
Chest pains
Haemorrhage Haemorrhage
Uncontrolled Controlled
Seizure
Seizure : postictal
Current
Focal neurology - Acute
REDUCED
Level of Consciousness
Psychosis / Aggression
Threatened limb
Dislocation Dislocation DEAD
ALL OTHER PATIENTS
Presentation Other Joint Finger or Toe
Fracture Fracture
Compound (Open) Simple (Closed)
BURNS
> 20% Surface Area
Burns to Face Burns : Electrical BURNS - OTHER
or
Burns : Circumferential
Inhalational
Burns Burns : Chemical
Poisoning/overdose Abdominal Pain
Hypoglycemia Diabetic Diabetic
Gucose less Glucose over 11 mmol/l Glucose over 17 mmol/l
than 3mmol/l and ketonuria and NO ketonuria
Vomiting : fresh blood Vomting : Persistent
Pregnancy AND Pregnancy and Trauma
Abdominal Trauma / PAIN Pregnancy and PV Bleeding
Pain Severe Moderate Mild