II. Criteria
- Behavior
- Score 3
- Lethargic or
- Cofused or
- Reduced pain response
- Score 2
- Irritable or agitated and not consolable
- Score 1
- Sleeping or
- Irritable but consolable
- Score 0
- Playing or
- Appropriate activity for the patient
- Score 3
- Cardiovascular
- Score 3
- Grey appearance or
- Capillary Refill Time 5 seconds or longer or
- Tachycardia with Heart Rate 30 beats above normal for age
- Bradycardia for age
- Score 2
- Capillary Refill Time 4 seconds or less
- Tachycardia with Heart Rate 20 beats above normal for age
- Score 1
- Pale or
- Capillary Refill Time 3 seconds or less
- Score 0
- Skin Pink or
- Capillary Refill Time 1-2 seconds
- Score 3
- Respiratory
- Score 3
- Respiratory Rate 5 breaths per minute below normal range or
- Supplemental Oxygen of FIO2 50% or higher to maintain adequate oxygenation
- Score 2
- Respiratory Rate 20 breaths per minute above normal range or
- Accessory Muscle use (neck retractions, intercostal retractions, abdominal breathing) or
- Supplemental Oxygen of FIO2 40-49% or 3 LPM or more to maintain adequate oxygenation
- Score 1
- Respiratory Rate 10 breaths per minute above normal range or
- Accessory Muscle use (neck retractions, intercostal retractions, abdominal breathing) or
- Supplemental Oxygen of FIO2 24-40% or 2 LPM or more to maintain adequate oxygenation
- Score 0:
- Respiratory Rate normal for age
- No retractions
- Score 3
- Modifiers
- Score 2:
- Frequent interventions (e.g. frequent suctioning, repositioning, Supplemental Oxygen changes) or
- Multiple IV attempts
- Score 2:
III. Interpretation
- Calculate total score
- Add score from each category (behavior, cardiovascular, respiratory and modifier)
- Parental concern regardless of score
- Rapid response evaluation
- Total score 7 or more
- Assess every 30 minutes
- Total score 6
- Assess every 1 hour
- Total score 5
- Assess every 1-2 hours
- Total score 4 or less
- Assess every 4 hours