Acute Medicine: The deteriorating patient

🩺 The deteriorating patient. Most in-hospital cardiac arrests are preceded by hours of warning signs -rising respiratory rate, falling blood pressure, new confusion -that were recorded but not acted on. The skill that saves lives is simple: spot deterioration early, assess with ABCDE, treat as you go, and call for help early. This page covers the generic approach; disease-specific emergencies are in each specialty's Emergencies chapter.
Your four questions for every unwell patient: How sick is this patient right now (ABCDE, NEWS2, your gut feeling)? What must I do in the next 5 minutes to keep them alive? Who do I need to call -and have I called them? What is the agreed ceiling of care, and does the patient know?

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Why Patients Deteriorate Unnoticed

• Deterioration is usually gradual -physiological changes often appear 6–24 hours before cardiac arrest, ICU admission or death.
• Common failures (national reports such as NCEPOD and the Royal College of Physicians):
  • Observations not done, not recorded, or not acted on.
  • Respiratory rate -the most sensitive early sign -often guessed or missed.
  • Junior staff not escalating, or seniors not responding.
  • Lack of a clear plan, ceiling of care or review time.
  • Poor handover, especially at night and weekends.
  • Normalising abnormal values ("she's always tachycardic").
  • Delays in antibiotics, fluids or imaging.
• Patients at higher risk -older and frail people, post-operative patients, sepsis, recent ICU discharge, those on opioids and sedatives, patients with learning disabilities or dementia (may not communicate symptoms), and those outlying on other specialty wards.
• Listen to concerns -of nurses ("I'm worried about her"), patients and families. In England, Martha's Rule gives patients and families a right to request an urgent independent review (critical care outreach) if they're worried about deterioration.

NEWS2 and Early Warning Scores

• National Early Warning Score 2 (NEWS2) (Royal College of Physicians, 2017) -the standard track-and-trigger system in UK hospitals and ambulances.
• Seven parameters, each scored 0–3:
  • Respiratory rate.
  • Oxygen saturation -Scale 1 (most patients) or Scale 2 (for patients with confirmed hypercapnic respiratory failure and a prescribed target of 88–92%).
  • Air or supplemental oxygen (oxygen scores 2).
  • Systolic blood pressure.
  • Pulse rate.
  • Level of consciousness -ACVPU -Alert, new Confusion, Voice, Pain, Unresponsive (any score other than A = 3).
  • Temperature.
• Response thresholds:

  NEWS2 score	Clinical risk	Response
  0	Low	Routine observations (at least 12-hourly)
  1–4	Low	Observations at least 4–6 hourly; nurse decides on escalation
  3 in any single parameter	Low–medium	Urgent ward-based review by a clinician (at least hourly observations)
  5–6	Medium	Urgent review by a clinician competent in acute illness (at least hourly observations); consider critical care outreach
  7 or more	High	Emergency response -senior clinician and critical care team; continuous monitoring

• NEWS2 and sepsis -a score of 5 or more (or 3 in one parameter) with suspected infection should prompt sepsis assessment (NICE NG51 uses NEWS2 to stratify risk).
• Limitations:
  • Doesn't apply to children (PEWS), pregnancy (MEOWS / national maternity early warning score), and some spinal or end-of-life patients.
  • Can be falsely reassuring -beta-blockers hide tachycardia; older people may not mount a fever; chronic hypoxia; "normal" BP may be low for a hypertensive person.
  • Trends matter -a rising score, even if low, is a warning.
  • Clinical concern overrides the score -escalate if worried, whatever the number.

Warning Signs Beyond the Score

• Respiratory rate over 25 -the single most important early warning sign (sepsis, metabolic acidosis, PE, heart failure, pain, anxiety -but never assume anxiety).
• New or increasing oxygen requirement.
• New confusion, agitation or drowsiness -delirium, hypoxia, hypercapnia, hypoglycaemia, sepsis, stroke, drugs.
• Falling urine output (under 0.5 mL/kg/hour) -an early sign of shock and AKI.
• Rising lactate (over 2 mmol/L -over 4 is severe).
• Mottled or cold peripheries, slow capillary refill (over 3 seconds).
• Tachycardia out of keeping, new arrhythmias (new AF in sepsis).
• Severe pain -out of proportion (ischaemic bowel, compartment syndrome, necrotising fasciitis).
• Laboratory clues -rising creatinine, falling platelets (sepsis, DIC), very high or low white cells, high glucose or ketones, low sodium or high potassium.
• The "worried" nurse, patient or relative -take seriously.
• Look again after treatment -has the patient improved, or are they still deteriorating?

Principles of ABCDE

• A systematic approach to any acutely unwell patient (Resuscitation Council UK) -assess and treat problems in the order they kill: Airway, Breathing, Circulation, Disability, Exposure.
• Key rules:
  • Safety first -personal protective equipment, environment, call for help early.
  • First impression -"Hello, how are you?" -a normal reply means a patent airway, adequate breathing and brain perfusion.
  • Treat each problem as you find it before moving on.
  • Reassess after every intervention and regularly -go back to A if the patient worsens.
  • Call for help early -don't wait until you've finished the assessment.
  • Communicate -use the team, assign tasks, use closed-loop communication.
  • Establish a plan and a ceiling of care; document everything.
• Look, listen, feel, measure at each stage, using monitoring (SpO₂, ECG, BP), blood gas and bedside tests.
• Cardiac arrest (unresponsive and not breathing normally) -call the arrest team and start CPR (see page 2).

Airway

• Look -is the patient talking? Signs of obstruction: paradoxical chest and abdominal movement ("see-saw"), use of accessory muscles, central cyanosis (late).
• Listen -stridor (upper airway), gurgling (fluid -secretions, vomit, blood), snoring (tongue or soft palate -reduced consciousness), wheeze (lower airway), silence (complete obstruction).
• Causes of obstruction -reduced consciousness (commonest -tongue falls back), vomit, blood, foreign body, anaphylaxis (angioedema), infection (epiglottitis, quinsy), trauma, burns, tumour, laryngospasm.
• Treat:
  • Head tilt–chin lift or jaw thrust (jaw thrust if neck injury possible).
  • Suction (rigid Yankauer) under direct vision.
  • Airway adjuncts -oropharyngeal airway (Guedel -only if no gag reflex; size from the incisors to the angle of the jaw) or nasopharyngeal airway (tolerated with a gag reflex; avoid with suspected base of skull fracture).
  • Recovery position if no spinal injury.
  • Anaesthetic help early for a threatened airway -supraglottic airway or intubation by trained staff.
• Oxygen -critically ill patients: 15 L/min via a non-rebreathe (reservoir) mask, then titrate to target saturations once stable (94–98%; 88–92% if at risk of hypercapnia).
• Specific treatments -anaphylaxis (IM adrenaline), choking (back blows and abdominal thrusts if conscious; CPR if unconscious).

Breathing

• Look -respiratory rate (count for a full 30–60 seconds), effort (accessory muscles, tripod position), chest movement (symmetry), cyanosis, ability to speak in sentences, sweating, conscious level.
• Measure -SpO₂, arterial blood gas (oxygenation, ventilation, acid–base, lactate).
• Feel -tracheal position (deviation -tension pneumothorax, collapse), chest expansion, percussion (dull -effusion or consolidation; hyper-resonant -pneumothorax).
• Listen -breath sounds, crackles (pulmonary oedema, pneumonia, fibrosis), wheeze (asthma, COPD, anaphylaxis, heart failure), bronchial breathing (consolidation), silent chest (life-threatening asthma).
• Treat:
  • Oxygen titrated to targets.
  • Tension pneumothorax -immediate needle or finger decompression, then chest drain.
  • Bronchospasm -nebulised salbutamol (oxygen-driven, except air-driven in COPD with hypercapnia), ipratropium, steroids.
  • Pulmonary oedema -sit up, oxygen, IV furosemide, consider nitrates and CPAP.
  • Respiratory depression -naloxone (opioids), bag–valve–mask ventilation.
  • Hypercapnic respiratory failure -controlled oxygen and NIV (e.g. pH under 7.35 and PaCO₂ over 6.5 kPa in COPD after initial treatment).
  • Type 1 respiratory failure with high oxygen needs -CPAP or high-flow nasal oxygen; critical care referral.
• Investigations -chest X-ray, ABG, ECG; CT pulmonary angiography if PE is suspected; bedside lung ultrasound if trained.

Circulation

• Look -colour (pale, mottled), sweating, distended neck veins (raised JVP -heart failure, tamponade, tension pneumothorax), bleeding (drains, wounds, melaena, haematemesis), urine output (catheter if needed in critical illness).
• Feel -peripheral temperature, capillary refill time (press the fingertip for 5 seconds at heart level -over 2–3 seconds is prolonged), pulse rate, rhythm and volume (central and peripheral).
• Measure -blood pressure (compare with baseline; a "normal" BP can be low for this patient), heart rate, 12-lead ECG.
• Listen -heart sounds, murmurs, pericardial rub, muffled sounds (tamponade).
• Treat:
  • IV access -two large-bore cannulas (or intraosseous if IV fails); take bloods -FBC, U&E, LFTs, CRP, clotting, glucose, lactate, group and save or crossmatch, blood cultures if infection suspected.
  • Fluid challenge if hypovolaemic or septic -500 mL crystalloid over under 15 minutes (smaller -250 mL -in heart failure or frailty); reassess after each bolus.
  • Haemorrhage -stop the bleeding, major haemorrhage protocol, blood products, tranexamic acid where indicated, reverse anticoagulants.
  • Arrhythmias -follow peri-arrest algorithms (page 2).
  • Chest pain -ECG, aspirin (if ACS likely), consider PE and aortic dissection.
  • Persistent hypotension despite fluids -vasopressors in critical care (sepsis, cardiogenic shock -see page 3).

Disability

• Conscious level -ACVPU for quick assessment; Glasgow Coma Scale for detail:

  Eyes (E)	Verbal (V)	Motor (M)
  4 -spontaneous	5 -orientated	6 -obeys commands
  3 -to sound	4 -confused	5 -localises to pain
  2 -to pressure	3 -words	4 -normal flexion (withdraws)
  1 -none	2 -sounds	3 -abnormal flexion
  	1 -none	2 -extension
  		1 -none

• GCS 8 or less -the patient may not protect their airway -call anaesthetics.
• Pupils -size, equality, reaction (pinpoint -opioids, pontine lesion; unequal and dilated -third nerve compression; bilateral dilated -anticholinergics, sympathomimetics, severe hypoxia).
• Capillary glucose -always check ("Don't Ever Forget Glucose") -treat hypoglycaemia (under 4 mmol/L).
• Other checks -limb movements (lateralising signs -stroke), seizures, neck stiffness, signs of head injury, drug chart (opioids, sedatives -reverse if needed), temperature.
• Common causes of reduced consciousness -hypoxia, hypercapnia, hypotension, hypoglycaemia, sepsis, drugs and alcohol, stroke, seizures, head injury, metabolic (sodium, calcium, uraemia, liver failure) -see page 5.
• Treat -airway protection, glucose, naloxone if opioid toxicity, treat seizures, CT head if focal signs, head injury or unexplained coma.

Exposure and Everything Else

• Expose the patient fully (maintaining dignity and warmth) -look for rashes (non-blanching purpuric rash -meningococcal sepsis), bleeding, wounds, surgical sites, drains, swollen or tender limbs (DVT, cellulitis, compartment syndrome, necrotising fasciitis), pressure areas, injection sites, patches (fentanyl).
• Temperature -fever or hypothermia (sepsis, environmental, drugs).
• Abdomen -tenderness, distension, peritonism, bladder (retention), aortic aneurysm.
• Then:
  • Full history -from the patient, nurses, notes, family; AMPLE (Allergies, Medications, Past history, Last meal, Events).
  • Review notes, charts (observations trend, fluid balance, drug chart -missed or new drugs), and results.
  • Further investigations and imaging.
  • Make a plan -diagnosis or differentials, treatment, monitoring frequency, review time, ceiling of care, who to call if worse.
  • Document clearly and communicate with the patient, family and team.

Escalation and SBAR

• Escalate early -it is never wrong to ask for help with a sick patient; delayed escalation is a common cause of avoidable death.
• Who to call -your registrar or consultant, critical care outreach, the medical emergency team (MET) or cardiac arrest team (2222 in UK hospitals), specialty teams (surgeons for an acute abdomen, anaesthetics for an airway).
• SBAR -a structured way to communicate:
  • Situation -who you are, who the patient is, what the problem is ("I'm calling about Mr Smith, 72, on ward 8, who has a NEWS2 of 8 and BP 78/40").
  • Background -admission reason, relevant history, treatment so far.
  • Assessment -ABCDE findings, what you think is happening ("I think he has septic shock from a urinary source").
  • Recommendation -what you need ("I need you to come and see him in the next 10 minutes" / "Should I start noradrenaline?").
• Be clear and direct -state your concern, the urgency and what you want.
• Graded assertiveness -if not heard, escalate your concern ("I'm worried -I need you to come now") or go higher (consultant).
• Document who you called, when, and the advice given.

Critical Care Outreach and ICU Referral

• Critical care outreach teams -experienced nurses and doctors who support ward staff with deteriorating patients, provide follow-up after ICU discharge, and help decide on ICU referral.
• Levels of care (Intensive Care Society):
  • Level 0 -normal ward care.
  • Level 1 -ward patients at risk of deterioration, needing outreach support.
  • Level 2 (high dependency) -single organ support (e.g. NIV, single vasoactive drug), or more detailed monitoring.
  • Level 3 (intensive care) -advanced respiratory support (invasive ventilation) or support of two or more organs.
• Organ support in critical care -invasive ventilation, NIV and high-flow oxygen, vasopressors and inotropes, renal replacement therapy, invasive monitoring (arterial line, central line), sedation.
• When to refer -persistent hypotension or high lactate despite fluids, rising oxygen requirement or respiratory failure, reduced consciousness (GCS 8 or less), multi-organ dysfunction, severe metabolic derangement, need for close monitoring.
• ICU decisions -senior-to-senior discussion; consider whether the patient is likely to benefit (reversibility of illness, frailty, comorbidities, patient wishes); decisions should be made early, not at the point of crisis.
• After ICU -"post-intensive care syndrome" -weakness, cognitive problems, anxiety, PTSD; rehabilitation and follow-up.

Ceilings of Care and Treatment Escalation Plans

• Treatment escalation plan -an advance decision (ideally on admission) about which treatments would be appropriate if the patient deteriorates -e.g. ward-based treatment only, NIV but not intubation, full escalation including ICU and CPR.
• ReSPECT forms in many UK hospitals record the focus of care and CPR recommendation (see the Older Person chapter).
• Making decisions -senior clinician, considering the illness, reversibility, frailty (Clinical Frailty Scale), comorbidities and the patient's wishes and values; involve the patient (and family or LPA if the patient lacks capacity).
• "Not for escalation" does not mean "not for treatment" -continue antibiotics, fluids, oxygen and symptom control, and review regularly.
• When the ceiling is reached -focus on comfort; recognise dying; involve palliative care; communicate with family.
• DNACPR -only about CPR; inform the patient (Tracey case); review on transfer.
• Out of hours -check for existing plans before calling the arrest team or ICU; if none and the situation is uncertain, start appropriate treatment and escalate to a senior.

Human Factors and Teamwork

• Human factors -how people, teams and systems interact; most errors in emergencies arise from communication, situational awareness and workload rather than knowledge.
• Good team behaviours (crisis resource management):
  • Clear leadership -one leader, hands-off where possible, with an overview.
  • Role allocation -airway, compressions, drugs, scribe.
  • Closed-loop communication -"Give 1 mg adrenaline IV" -"1 mg adrenaline IV given".
  • Situational awareness -step back, summarise ("So far we have…"), ask for input.
  • Speak up -everyone, at any level, should voice concerns (e.g. using "PACE" -Probe, Alert, Challenge, Emergency).
  • Use cognitive aids -algorithms, checklists.
  • Avoid fixation errors -"what else could this be?"
• Debrief after emergencies -learning, wellbeing (hot and cold debriefs).
• Look after yourself -fatigue, hunger and stress impair performance; take breaks; ask for support.

Handover and the Night Shift

• Handover is a high-risk moment -structured, face-to-face where possible, with written documentation.
• Structures -SBAR, or ISBAR (Identify), and electronic handover lists.
• Include -sick and deteriorating patients, those with NEWS2 rising, outstanding jobs (results to chase, reviews), ceilings of care and DNACPR status, patients with no plan, and expected admissions.
• The night shift:
  • Prioritise -sick patients first (ABCDE), then urgent tasks (prescriptions, blood results), then routine tasks.
  • Use the hospital at night team and outreach; triage bleeps (ask the right questions -NEWS2, what has changed).
  • Don't prescribe over the phone without enough information; review the patient if unwell.
  • Hand over at the end of the shift, including what you've done and what needs following up.
• Common night-time calls -falls, chest pain, breathlessness, low BP, high temperature, confusion and agitation, low urine output, high or low glucose, abnormal results (high potassium), pain, cannula and fluid prescriptions, verification of death.

The Deteriorating Patient at a Glance

Step	Look for	Immediate action
Airway	Stridor, gurgling, snoring, see-saw breathing	Head tilt–chin lift, jaw thrust, suction, adjuncts, anaesthetics
Breathing	RR, SpO2, effort, trachea, percussion, breath sounds	Oxygen; treat pneumothorax, bronchospasm, oedema; ABG; NIV
Circulation	HR, BP, CRT, JVP, urine output, bleeding	IV access, bloods, 500 mL fluid bolus, ECG, stop bleeding
Disability	ACVPU or GCS, pupils, glucose, seizures	Glucose, naloxone, airway protection if GCS 8 or less
Exposure	Rash, temperature, abdomen, limbs, wounds	Look for source; keep warm
NEWS2 5–6	Medium risk	Urgent clinical review
NEWS2 7+	High risk	Emergency response; critical care
SBAR	Situation, Background, Assessment, Recommendation	Clear escalation
Ceiling of care	Treatment escalation plan, ReSPECT	Decide early with the patient

Spot the Problem

Clue	Problem or action
Snoring breathing in a drowsy patient	Partial airway obstruction -head tilt–chin lift or jaw thrust
Gurgling after vomiting	Fluid in the airway -suction
See-saw chest and abdomen movement	Airway obstruction
Stridor and facial swelling after IV antibiotics	Anaphylaxis -IM adrenaline
RR 32 with SpO2 96% on air in a post-operative patient	Early warning sign -look for sepsis, PE, acidosis
Tracheal deviation, hypotension and absent breath sounds on one side	Tension pneumothorax -decompress
Raised JVP, low BP and quiet heart sounds after cardiac surgery	Cardiac tamponade
NEWS2 of 4 with HR 50 on bisoprolol and lactate 5	Falsely reassuring score -shock
New confusion only (ACVPU "C")	Scores 3 -urgent review
GCS 7 after an overdose	Airway at risk -anaesthetic help
Drowsy, glucose 2.1	Hypoglycaemia -IV glucose
Pinpoint pupils and RR 7 on a PCA	Opioid toxicity -stop PCA, naloxone
Non-blanching rash and fever	Meningococcal sepsis -antibiotics now
Nurse says "I'm just worried about him", NEWS2 2	Review anyway -clinical concern overrides score
Family request an urgent second opinion about deterioration	Martha's Rule -outreach review

Exam-style Scenarios

1. You are the FY1 on nights. A nurse bleeps you about a 68-year-old man, day 2 after a bowel resection. NEWS2 is 7: RR 28, SpO₂ 93% on 2 L, HR 118, BP 92/58, temperature 38.4°C, new confusion.
Answer: Acutely deteriorating patient -likely sepsis (possible anastomotic leak).

• Attend immediately; ABCDE -oxygen to target, IV access, bloods (including lactate, cultures, crossmatch), 500 mL fluid bolus, catheter and urine output, ECG.
• Sepsis Six -IV antibiotics within 1 hour per local policy (intra-abdominal source).
• Escalate -call the surgical registrar (anastomotic leak -CT abdomen) and critical care outreach using SBAR; check the ceiling of care; reassess regularly.

2. An 82-year-old woman admitted with pneumonia becomes drowsy. RR 10, SpO₂ 99% on 15 L/min via a reservoir mask, GCS 10. She has COPD.
Answer: Possible hypercapnic respiratory failure from excess oxygen (or other causes of drowsiness).

• ABCDE; airway support; urgent ABG.
• Reduce oxygen to a target of 88–92% (Venturi mask) -don't stop it abruptly; check glucose and drug chart (opioids, sedatives).
• If pH under 7.35 with raised PaCO₂ -NIV (if within ceiling of care); escalate to senior and outreach.

3. A 45-year-old man on the ward is found with snoring respirations and GCS 6, an hour after receiving IV morphine for pain. His pupils are pinpoint, RR 6.
Answer: Opioid-induced respiratory depression.

• Airway -head tilt–chin lift or jaw thrust, airway adjunct; bag–valve–mask ventilation with oxygen; call for help.
• Naloxone IV (e.g. 400 micrograms, titrated) until breathing adequately; check glucose.
• Monitor closely (re-sedation); review opioid prescribing, kidney function and other sedatives; incident report if a dosing error.

4. You assess a patient with NEWS2 of 6 and are worried, but your registrar is busy in ED and says to "give fluids and call back if worse".
Answer: Escalation when not getting the response needed.

• Continue ABCDE treatment and reassess frequently; use SBAR to state your concern and what you need clearly.
• If still worried -call critical care outreach or the medical emergency team, or the on-call consultant (graded assertiveness).
• Document your assessment, actions and who you contacted.

5. A 90-year-old man with advanced dementia (CFS 8) from a nursing home deteriorates with aspiration pneumonia. There is no treatment escalation plan.
Answer: Urgent ceiling-of-care decision.

• Start appropriate treatment (oxygen, antibiotics, fluids) and contact a senior to make an escalation decision.
• Check for an LPA, advance decision or ReSPECT form; speak with the family about his wishes and what treatments are likely to help (best interests).
• Record the plan (e.g. ward-based treatment, not for ICU or CPR); ensure symptom control and comfort; involve palliative care if he continues to deteriorate.

Key Points

• Deterioration is usually preceded by hours of abnormal observations -act on them.
• Respiratory rate is the most sensitive early warning sign -count it properly.
• NEWS2 -5–6 urgent review; 7 or more emergency response; 3 in one parameter needs urgent review.
• New confusion scores 3 on NEWS2.
• Clinical concern overrides the score; beta-blockers and frailty can hide shock.
• ABCDE -treat as you find; reassess after every intervention; call for help early.
• Critically ill -15 L/min oxygen via reservoir mask, then titrate to target.
• Fluid challenge -500 mL crystalloid over under 15 minutes, then reassess.
• Always check glucose; GCS 8 or less means the airway may be at risk.
• Escalate with SBAR -be clear about urgency and what you need.
• Agree ceilings of care early with the patient; "not for escalation" is not "not for treatment".
• Good teamwork -clear leader, roles, closed-loop communication, speak up.
• Structured handover, especially for sick patients and night shifts.

Guidelines and Further Reading

• Royal College of Physicians: National Early Warning Score (NEWS) 2
• Resuscitation Council UK: The ABCDE approach; Immediate Life Support and ALS manuals
• NICE CG50: Acutely ill adults in hospital -recognising and responding to deterioration
• NCEPOD: "Time to Intervene?" and related reports
• Intensive Care Society: Levels of adult critical care
• NHS England: Martha's Rule
• Resuscitation Council UK: ReSPECT process
• NHS Improvement: SBAR communication tool
• BNF -for current doses