Playing /
Appropriate

Sleeping

Irritable

Lethargic/
Confused OR
Reduced response to pain

Green = 0-2 Score

Pink or Capillary refill 1-2 seconds

Pale or Capillary refill 3 seconds

Grey or Capillary refill 4 seconds
OR
Tachycardia of 20 above normal rate

Grey and mottled or capillary refill 5 seconds or above
OR Tachycardia of 30 above normal rate or bradycardia.

Yellow = 3 Score

Within normal parameters, no retractions

> 10 above normal parameters, using accessory muscles OR 30+% FiO2
OR 3+ litres/min > 2 years; 2+ litres/min < 2 years (Nasal Cannula)

>20 above normal parameters
Retractions OR 40+% FiO2 or 6+ litres/min. (Facemask)

5 below normal parameters with retractions
Grunting OR 50% FiO2 or 8+ litres/min.

Orange = 4 Score

Red = 5-6 Score
OR > 7 Score

Green = 0-2 Score

Yellow = 3 Score

Orange = 4 Score

Red = 5-6 Score
OR > 7 Score

Score 2 extra for ¼ hourly nebulizers or persistent vomiting following surgery.

(Increase) Oxygen Requirements > 25%