Acutely Ill Critical care patient with High NEWS

🚨 Profoundly sick patient: Call for help early! Stay calm 😌, focus on ABCs, and work systematically - most crises become manageable when you stabilise physiology first and reassess repeatedly.

🧭 The Critically Ill Patient (A–E)

Critically ill patients are those with (or at imminent risk of) organ failure. The common final pathway is inadequate oxygen delivery (hypoxia, poor perfusion, anaemia) and/or impaired oxygen utilisation (e.g. sepsis-related cellular dysfunction). Early compensation (tachycardia, tachypnoea, vasoconstriction) can look “okay-ish” - but when it fails, deterioration is fast. Your priorities are: recognise ➝ stabilise ➝ treat the cause ➝ escalate early.

📖 Introduction

• ⏱️ Move quickly, but never randomly - treat what kills first: airway obstruction, respiratory failure, shock.
• 🔁 Reassess after each step - improvement (or not) tells you whether you’re on the right track.
• 🧠 Use physiology: tachycardia is often compensation; hypotension is often late.
• 🧩 Always consider multiple problems at once (e.g., sepsis + MI; asthma + pneumothorax; overdose + aspiration).
• 🔍 POCUS is invaluable: pneumothorax, tamponade, LV function, IVC/fluid status, AAA, RV strain.
• 🚽 If shocked/critically ill: catheterise to monitor urine output (target ~0.5 mL/kg/hr in many adults).

🧪 High-yield bedside tests (do early if safe)

• 🩸 ABG/VBG: oxygenation, CO₂, pH, lactate, glucose.
• 📈 ECG: ACS, arrhythmia, hyperkalaemia, PE strain patterns.
• 🫁 CXR: pneumonia, oedema, pneumothorax, effusion, line position.
• 🦠 Sepsis sampling: blood cultures (if no delay), urine dip/culture, sputum where relevant.
• 🧠 CT head if reduced consciousness/focal neurology once stabilised.

❓If the patient isn’t improving - always ask

• 🤔 Is the diagnosis wrong?
• 🧩 Is there more than one diagnosis?
• 🧯 Have I missed an immediate reversible killer (tension PTX, tamponade, anaphylaxis, hypoglycaemia, opioid toxicity, hyperkalaemia)?
• 📊 Do I need urgent tests (ABG, ECG, bedside echo, CXR)?
• ☎️ Should I escalate again now (registrar/consultant/ICU)?

🫁 Airway & breathing emergencies (recognise + act)

• 🚨 Stridor/epiglottitis: do not examine airway with a tongue depressor. High-flow O₂ and fast anaesthetics/ENT.
• 😮‍💨 Simple obstruction: suction, head tilt–chin lift/jaw thrust, remove visible debris, consider OPA/NPA.
• 💊 Opioid toxicity: ventilate first, then naloxone (repeat doses may be needed; monitor for re-sedation).
• ⚡ Tension pneumothorax: decompress immediately - do not wait for CXR.
• 💔 Acute LVF: crackles, severe dyspnoea, pink froth → sit up, O₂/CPAP, nitrates if BP allows, diuretics, treat trigger (often ACS).
• 🫀 Massive PE: hypoxia + shock → bedside echo/CTPA when stable; consider thrombolysis if haemodynamically unstable (local protocol).
• 😤 Acute severe asthma: silent chest/tiring/hypercapnia = peri-arrest → senior/ITU early.
• 🌪️ COPD exacerbation: controlled O₂ (target 88–92%), consider NIV if type 2 RF and pH low.

💨 Decompressing Tension Pneumothorax

🩸 Hypotension / Shock - a structured differential

🧠 Shock = inadequate tissue perfusion. Think in 4 types: 💧 hypovolaemic • 🦠 distributive • 💔 cardiogenic • 🧱 obstructive. Treat the physiology (fluids/vasopressors/oxygen) while fixing the cause.

• 💧 No clear cause: cautious fluid bolus (e.g., 250–500 mL crystalloid) + reassess (lungs, BP, cap refill, lactate).
• 🩸 Haemorrhagic shock: control bleeding, major haemorrhage protocol, blood products, TXA early when appropriate.
• 🦠 Septic shock: infection + hypotension and/or high lactate → Sepsis 6 + antibiotics early + fluids, escalate early.
• 💥 Leaking AAA: abdo/back pain + collapse → urgent vascular surgery, permissive hypotension per protocol.
• 👩‍🍼 Ectopic pregnancy: shocked fertile female + abdo pain → urgent gynae/surgery.
• 💔 Cardiogenic shock: post-MI/arrhythmia/myocarditis → ECG/echo, avoid over-fluiding, early cardiology/ICU.
• 🧩 Tamponade: hypotension + raised JVP + muffled HS (may be subtle) → urgent echo + pericardiocentesis.
• ⚡ Anaphylaxis: airway/breathing/circulation collapse → IM adrenaline 500 mcg + high-flow O₂ + IV fluids + adjuncts.
• 🩻 Dissection: tearing pain, pulse/BP asymmetry → CT aortogram once stable; avoid anticoagulation until excluded.
• ☣️ Meningococcal sepsis: purpura + shock → IV ceftriaxone + urgent ICU.
• 🌑 Addisonian crisis: shock + hyponatraemia ± hyperkalaemia → IV hydrocortisone + fluids.

❤️ Chest pain - sick vs not sick

• 🫀 ACS: ECG + troponin, aspirin, treat pain; activate PCI pathway for STEMI.
• 🩻 Aortic dissection: CT aortogram; avoid anticoagulation until excluded.
• 🫁 PE: CTPA (or bedside echo if unstable), anticoagulate if appropriate; thrombolysis if massive PE per protocol.
• 🪠 Boerhaave/oesophageal rupture: severe pain after vomiting → surgical emergency.

🧠 Reduced consciousness / coma - don’t miss the reversibles

• 🍬 Hypoglycaemia: treat immediately (IV glucose), then find the cause.
• 💊 Opioids: ventilate + naloxone (monitor for recurrence).
• ⚡ Seizure/NCSE: treat convulsive seizures early; consider EEG if persistent reduced GCS.
• 🧠 Stroke/SOL: CT head once stable; protect airway if GCS low.
• 🦠 Meningitis/encephalitis: treat early if suspected (antibiotics/aciclovir per local guidance).
• 🍷 Toxins/intoxication: supportive care + antidotes where relevant.

⚡ Arrhythmias - the exam rule

• 📉 Bradycardia + shock/syncope/chest pain/HF: atropine then pacing per ALS.
• 📈 Tachycardia + hypotension/ischemia/HF/altered mental state: synchronised cardioversion.
• 📊 Always get a 12-lead ECG and follow ALS algorithms.

🤕 Abdominal pain emergencies

• 💥 Leaking AAA → shock + abdo/back pain → vascular emergency.
• 🔥 Pancreatitis → severe epigastric pain ± Grey-Turner/Cullen signs.
• 🕳️ Perforated viscus → rigid abdomen + free air → urgent surgery.
• 👩‍🍼 Ectopic pregnancy → shocked fertile female → urgent gynae.
• 🩸 GI bleed → resuscitate, bloods/crossmatch, endoscopy once stabilised.

🧩 Mini-cases (ABCDE thinking)

• Case 1 - Sepsis from pneumonia 🌡️: RR 32, BP 85/50, SpO₂ 86% RA, confusion. Actions: O₂ to target, IV access, lactate/ABG, fluids, cultures (no delay), antibiotics within 1 hr, escalate early.
• Case 2 - Acute severe asthma 😮‍💨: cannot complete sentences, PEFR 25%, tachycardia. Actions: O₂, nebs (salbutamol + ipratropium), steroids, MgSO₄, watch for tiring/hypercapnia, senior/ITU early.
• Case 3 - Acute pulmonary oedema 💔: frothy sputum, severe hypoxia, hypertension, crackles. Actions: sit up, O₂/CPAP, nitrates if BP allows, diuretics, ECG/CXR, treat trigger.
• Case 4 - Anaphylaxis 🐝: stridor/wheeze + hypotension + rash. Actions: IM adrenaline 0.5 mg, high-flow O₂, IV fluids, airway help early.
• Case 5 - Hypoglycaemia 🍬: GCS 8, glucose 1.9. Actions: IV glucose now, airway protection if needed, monitor response, investigate cause.
• Case 6 - Upper GI bleed 🩸: haematemesis, BP 85/50, HR 140. Actions: 2 large-bore cannulas, crossmatch, fluids/blood as needed, senior + endoscopy once stabilised.
• Case 7 - Tension pneumothorax ⚡: trauma + hypotension + absent breath sounds + tracheal deviation. Actions: immediate decompression, then chest drain, O₂, monitor.
• Case 8 - Hyperkalaemia ⚡: ECG changes (peaked T waves/widened QRS). Actions: IV calcium, insulin+dextrose, salbutamol, monitor, dialysis planning if needed.

Teaching Commentary 🧠

This is a pattern-recognition + physiology skill. Use ABCDE to identify immediate threats, and treat as you go - do not wait for tests if the patient is collapsing. Breathing failure kills quickly, but shock is often the hidden driver (especially sepsis or bleeding), so measure lactate and urine output early as markers of perfusion. Repeated reassessment is what separates a checklist from safe practice: every intervention (oxygen, fluids, bronchodilators, glucose, naloxone) should produce a measurable physiological response. Escalation is not a weakness - in UK practice, early senior/ICU outreach involvement prevents arrests and reduces harm.