🚨 The Deteriorating Patient requires rapid recognition, structured assessment, and timely escalation.
Failure to act early can lead to cardiac arrest, ICU admission, or death — hence the importance of NEWS2, ABCDE, and early senior help.
🔎 Initial Recognition & Assessment
- Early Warning Signs (NEWS2):
- 📈 Abnormal vitals: HR, BP, RR, SpO₂, Temp.
- 🧠 Altered mental state (AVPU or GCS).
- 🚽 Oliguria, 💧 mottled/cyanosed skin.
- ABCDE Primary Survey:
- 🅰️ Airway: Open? Obstructed? Use head-tilt/chin-lift or airway adjuncts.
- 🅱️ Breathing: Rate, effort, SpO₂; give O₂ (target 94–98%, 88–92% if COPD).
- 🅲️ Circulation: HR, BP, cap refill, IV access, fluids if hypotensive.
- 🅳 Disability: GCS/AVPU, check glucose, pupils, seizures?
- 🅴 Exposure: Full exam (rash, trauma, sepsis signs), maintain dignity & warmth.
📢 Escalation of Care
- 📞 Call for help: Activate MET/CCOT/2222 early.
- 📋 SBAR: Structured communication = Situation, Background, Assessment, Recommendation.
- 👩⚕️ Senior input: Escalate to registrar/consultant early.
💉 Immediate Medical Interventions
- 🅰️ Airway: Reposition, suction, airway adjuncts → consider intubation if failing.
- 🅱️ Breathing: O₂ therapy, nebulisers, NIV (CPAP/BiPAP) or intubation if resp failure.
- 🅲️ Circulation: IV access, crystalloid bolus (500 ml–1 L), monitor for response. Vasopressors (e.g. noradrenaline) if refractory shock. Treat arrhythmias.
- 🅳 Disability: Correct hypoglycaemia (IV glucose), treat seizures (IV lorazepam). Consider naloxone if opioid overdose.
- 🅴 Exposure: Sepsis 6 (ABx within 1 hr), thrombolysis/PCI for ACS, anticoagulate PE if suspected.
📈 Monitoring & Reassessment
- 📊 Continuous obs: HR, BP, RR, SpO₂, Temp, urine output.
- 🔄 Repeat ABCDE after each intervention — assess response.
- 📝 Document interventions, times, and patient response carefully.
🏥 Definitive Management & Higher Care
- ⚖️ Stabilise based on cause (HF, sepsis, arrhythmia, PE, etc.).
- 🚑 Transfer to HDU/ICU if ongoing organ failure or invasive monitoring needed.
- 🤝 Multidisciplinary approach: involve intensivists, cardiology, respiratory, surgery as appropriate.
🩺 Post-Crisis Care & Follow-Up
- 📑 Case review: What triggered deterioration? Missed early signs?
- 📌 Ongoing plan: Clear monitoring & escalation instructions.
- 🧠 Psychological support: For patient & family. Consider chaplaincy, psychology, or palliative team if needed.
💡 Key Clinical Pearls
- NEWS2 score ≥5 = red flag → urgent review.
- Always treat hypoxia and hypoglycaemia first — both rapidly reversible.
- ABCDE is iterative → reassess after each intervention.
- Never delay escalation — better to call early than too late.
