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, undergone surgery or spent time in a high-dependency or intensive care setting. Common causes for deterioration include sepsis, bleeding, myocardial infarction, hypoglycaemia and pulmonary embolism.
Early assessment and intervention is required, as these patients are at high risk of cardiac arrest; once this occurs, fewer than 20% of patients survive to hospital discharge.
Vital signs
Physiological observations are monitored routinely in patients who are admitted to hospital. The vital signs that are measured include heart rate, blood pressure, respiratory rate, oxygen saturations, 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. Measurements are made of the patient’s respiratory rate, the use of oxygen therapy, oxygen saturation, temperature, heart rate, blood pressure and level of consciousness, and points are assigned for physiological derangement in each organ system. Increased frequency of observations is recommended for patients with abnormal signs, and a rising score triggers a graded response.
In the UK there is a validated track-and-trigger system, the National Early Warning Score (NEWS; 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 ). For example, a NEWS score of between 1 and 4 is escalated to the nurse in charge of the ward, a score of 5 or 6 (or a single observation scoring 3) is escalated to the doctor covering the ward, and a score of 7 should be escalated to a senior doctor and discussed with the supervising consultant, with consideration of referral to a critical care team.
| Early warning score | Response |
|---|---|
| Normal | Carry out minimum 12-hourly observations |
| Low |
|
| Medium |
|
| High |
|
The early warning score is designed to complement clinical judgement. If you or another member of your team is 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 are reviewing 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 and death.
The approach to the acutely deteriorating patient is time-critical and attending to this patient should be prioritised; do not wait to finish other tasks or ward rounds. 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 several minutes of discussion by telephone; if patients look sick, they probably are.
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Always ensure your own safety and use the 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 an electrocardiogram (ECG) monitor, a non-invasive blood pressure monitor and a pulse oximeter as soon as possible. Ensure the patient has an 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 to break down complex and stressful clinical situations into more manageable components.
A: Airway
If a patient is able to speak normally, you can be confident that 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.
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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). Cyanosis is a late sign.
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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 ( Fig. 18.2 ).
Fig. 18.2
Yankauer suction catheter.
This may have a small hole to control airflow. If this is present, occlude it with your thumb to generate suction.
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Listen for abnormal airway noises ( Box 18.2 ).
18.2
Airway noises
No 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 around the larynx
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In febrile patients, consider supraglottitis
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Other causes are 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
Gurgling
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Caused by fluids (secretions, blood or vomit) in the oropharynx
Grunting
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A grunt during expiration is a sign of respiratory muscle fatigue. It may be present after chest-wall trauma with a flail segment. Grunting improves gas exchange by slowing expiration and preventing alveolar collapse by creating positive end-expiratory pressure.
Wheeze
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A ‘musical’ noise, best heard on auscultation
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When loudest in expiration, relates to intrathoracic obstruction of the small bronchi and bronchioles; most often occurs in asthma and chronic obstructive pulmonary disease
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Open the airway with a chin-lift or jaw-thrust manœuvre ( Figs 18.3 and 18.4 ).
Fig. 18.3
Chin lift for opening the airway.
Fig. 18.4
Jaw thrust for opening the airway.
Place your fingers behind the angle of the patient’s jaw, and then lift it to open the airway.
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In patients with altered consciousness it may be necessary to maintain the airway by insertion of an oropharyngeal (Guedel) or nasopharyngeal airway adjunct ( Fig. 18.5 ), or by tracheal intubation, which must be performed by an experienced clinician.
Fig. 18.5
Airway adjuncts.
Guedel airway (top) and nasopharyngeal airway (bottom). Note the ‘safety pin’, which prevents migration of the proximal end of the airway beyond the nasal orifice.
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Administer high-concentration oxygen via a non-rebreather mask at a flow rate of 15 L/minute ( Fig. 18.6 ).
Fig. 18.6
Administering high-concentration oxygen using a non-rebreather mask with a reservoir bag.
Oxygen should be delivered at a rate of 15 L/minute.
Aim for an oxygen saturation of 94–98% except in patients at risk of type 2 (hypercapnic) respiratory failure such as chronic obstructive pulmonary disease; in this case use a lower target of 88–92%.
B: Breathing
It is vital to identify and treat hypoxia, as it can lead rapidly to cardiac arrest and death. Perform a thorough assessment, looking for life-threatening respiratory compromise due to conditions such as acute severe asthma, pulmonary oedema or tension pneumothorax.
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Attach a pulse oximeter to assess peripheral oxygenation. Be alert to circumstances in which this measurement may be unreliable ( Box 18.3 ).
18.3
Situations in which pulse oximetry may give misleading values
Inadequate waveform
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Hypoperfusion – ear-lobe sensor may be better than finger probe if poor hand perfusion
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Hypothermia
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Movement artefact
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Rapid irregular pulse – e.g. atrial fibrillation
Falsely normal or high reading
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Abnormal haemoglobins:
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Carboxyhaemoglobin (e.g. carbon monoxide poisoning)
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Methaemoglobin a
a Depending on the levels of methaemoglobin or sulphaemoglobin, pulse oximetry may underestimate or overestimate the true arterial oxygen saturation (usually low).
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Sulphaemoglobin a
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High levels of HbA 1c
Falsely low reading
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Abnormal haemoglobins:
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Severe anaemia
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Nail varnish, false fingernails
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Skin pigmentation
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Excessively dirty fingers
HbA 1c , haemoglobin A 1c , glycated haemoglobin.
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