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The deteriorating patient
A deteriorating patient is one who becomes acutely unwell in the hospital setting. This can occur at any stage of a patient's illness but is more common if the patient has been admitted as an emergency case, has undergone surgery or has spent time in a high-dependency or intensive care setting. Common causes for deterioration include urinary and chest sepsis, bleeding, myocardial infarction, hypoglycaemia and pulmonary embolism.
Early assessment and intervention are required, as these patients are at a high risk of cardiac arrest. Once this occurs, only 20% of patients survive up to hospital discharge.
Vital signs
Physiological observations that are routinely monitored in patients who are admitted to hospital include respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness. Additional monitoring may include urine output, pain assessment and blood glucose testing.
Early warning scores
Vital signs are recorded using track-and-trigger systems in the form of early warning scores designed to assess illness severity. Observations regularly recorded include respiratory rate, the level of oxygen therapy, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness, and scores are assigned for physiological derangement in each domain. The increased frequency of observations is recommended for patients with abnormal signs, and a rising total score triggers a graded response.
In the UK, there is a validated track-and-trigger system, the National Early Warning Score (NEWS2; Fig. 18.1 ). This system will trigger a graded response due to either an aggregated high score or a single severe physiological derangement, with the urgency and seniority of the team being summoned escalating as the score rises ( Box 18.1 ).
18.1
NEWS thresholds and triggers
From Royal College of Physicians. National Early Warning Score (NEWS) 2. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2 .
| NEWS score | Clinical risk | Response |
|---|---|---|
| Aggregate score 0–4 | Low | Ward-based response |
| A single red score (score of 3 in any individual parameter) |
Low-medium | Urgent ward-based response a |
| Aggregate score 5–6 | Medium | Key threshold for urgent response a |
| Aggregate score 7 or more | High | Urgent or emergency response b |
a Response by a clinician or team with competence in the assessment and treatment of acutely ill patients, in addition to recognising when the escalation of care to a critical care team is appropriate.
b The response team must also include staff with critical care skills, including airway management.
The early warning score is designed to complement clinical judgement. If you or your team are concerned about a patient, do not dismiss this instinct purely because the early warning score is low. A patient may just look unwell or feel cold to the touch and although these features are not captured by the early warning scoring systems, they may signify early deterioration, particularly in young patients with greater physiological reserve.
Initial assessment
When you review a deteriorating patient, a rapid assessment should replace the usual systematic history taking and physical examination, in order to identify abnormal physiology quickly and to administer immediate life-saving interventions to prevent further deterioration.
This assessment is time-critical. Thus attending to this patient should be prioritised; do not wait to finish other tasks. Make every effort to go and see the patient for yourself, as your immediate first impressions can provide much more information than can be obtained by lengthy discussion by telephone; if patients look sick, they probably are. Have a low threshold for calling for senior help.
Examination sequence
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Always ensure your own safety and use appropriate personal protective equipment.
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Approach the patient and assess their response by asking ‘Are you alright?’ Gently shake the patient by the shoulders and shout loudly into both ears if unresponsive. A normal response confirms that the airway is clear and there is perfusion of the brain.
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If the patient is unresponsive, check for a pulse and assess whether the patient is breathing. If in cardiac or respiratory arrest, ask a colleague to summon the cardiac arrest team and begin cardiopulmonary resuscitation in accordance with guidelines.
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Monitor the vital signs; attach a pulse oximeter, non-invasive blood pressure monitor and an electrocardiogram (ECG) monitor as soon as possible.
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Ensure that the patient has a patent intravenous cannula inserted.
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If the patient does not respond or looks unwell, seek senior help immediately.
The ABCDE approach
The ABCDE approach provides a standardised framework for simultaneously assessing and treating life-threatening problems in critically ill patients. This systematic approach will help you break down complex and stressful clinical situations into more manageable components.
A: Airway
If a patient is able to speak normally, the airway is patent. If there is no response or if the patient appears to have difficulty in breathing, perform a more detailed assessment. Airway obstruction is a medical emergency; call for expert help immediately.
Examination sequence
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Look for signs of airway obstruction. There may be use of the accessory muscles of respiration, supraclavicular or subcostal indrawing or paradoxical movements where the abdomen moves out as the chest moves in (‘seesaw’ breathing).
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Look in the mouth for foreign objects, blood, vomit or secretions. These can be removed by gentle suction with a Yankauer suction catheter, being careful not to cause airway trauma or to push obstructing material further into the airway.
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Listen for abnormal airway noises ( Box 18.2 ).
18.2Airway noisesNo noise (the ‘silent airway’)
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Implies complete airway obstruction and/or absence of, or minimal, respiratory effort
Stridor
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A harsh noise, usually loudest in inspiration, caused by partial obstruction in the trachea or larynx
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In febrile patients, consider supraglottitis
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Other causes are inhaled foreign bodies, laryngeal trauma, burns or tumours
Snoring/stertor
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Caused by partial upper airway obstruction from soft tissues of the mouth and oropharynx
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