ABCDE Approach to Emergency Management

Introduction

https://geekymedics.com/abcde-approach/

The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps:

• Airway
• Breathing
• Circulation
• Disability
• Exposure

Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment.

The aim of the ABCDE approach is to improve the clinical outcome of unwell patients, regardless of the definitive diagnosis.

This guide provides a general overview that can be used for any unwell patient in a simulation setting; it may seem intimidating at first, but your patient is highly unlikely to need all of the investigations or interventions mentioned in this overview. More specific cases can be found in the emergency section of the site and are linked to throughout. This guide is written with final year medical students in mind – the assessments, investigations and interventions included are generally expected to be within the competencies of a junior doctor.

This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not intended to be relied upon for patient care.

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General tips

General tips for applying an ABCDE approach in an emergency setting include:

• Treat all problems as you discover them.
• Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
• Make use of the team around you by delegating tasks where appropriate.
• All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
• Clearly communicate how often would you like the patient’s observations relayed to you by other staff members.
• If you require senior input, call for help early using an appropriate SBARR handover structure.
• Review results as they become available (e.g. laboratory investigations).
• Make use of your local guidelines and algorithms in managing specific scenarios (e.g. acute asthma).
• Any medications or fluids will need to be prescribed at the time (in some cases you may be able to delegate this to another member of staff).
• Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical assessment, investigations and interventions.

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Initial steps

Acute scenarios typically begin with a brief handover from a member of the nursing staff including the patient’s name, age, background and the reason the review has been requested.

Introduction

Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.

Interaction

Introduce yourself to the patient including your name and role.

Ask how the patient is feeling as this may provide some useful information about their current symptoms.

Preparation

Make sure the patient’s notes, observation chart and prescription chart are easily accessible.

Ask for another clinical member of staff to assist you if possible.

If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.

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Airway

Clinical assessment

Can the patient talk?

Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.

No:

• Look for signs of airway compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
• Open the mouth and inspect: look for anything obstructing the airway such as secretions or a foreign object.

Causes of airway compromise

There is a wide range of possible causes of airway compromise including:

• Inhaled foreign body: symptoms may include sudden onset shortness of breath and stridor.
• Blood in the airway: causes include epistaxis, haematemesis and trauma.
• Vomit/secretions in the airway: causes include alcohol intoxication, head trauma and dysphagia.
• Soft tissue swelling: causes include anaphylaxis and infection (e.g. quinsy, necrotising fasciitis).
• Local mass effect: causes include tumours and lymphadenopathy (e.g. lymphoma).
• Laryngospasm: causes include asthma, gastro-oesophageal reflux disease (GORD) and intubation.
• Depressed level of consciousness: causes include opioid overdose, head injury and stroke.

Interventions

Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input.

Head-tilt chin-lift manoeuvre

Open the patient’s airway using a head-tilt chin-lift manoeuvre:

1. Place one hand on the patient’s forehead and the other under the chin.

2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.

3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to remove it.

Jaw thrust

If the patient is suspected to have suffered significant trauma with potential spinal involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre:

1. Identify the angle of the mandible.

2. With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.

3. Using your thumbs, slightly open the mouth by downward displacement of the chin.

Oropharyngeal airway (Guedel)

Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.

An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration.

To insert an oropharyngeal airway:

1. Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction.

2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.

3. Advance the airway until it lies within the pharynx.

4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for signs of breathing.

Nasopharyngeal airway (NPA)

A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA.

To insert a nasopharyngeal airway:

1. Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA.

2. Lubricate the NPA.

3. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.

4. If any obstruction is encountered, remove the tube and try the left nostril.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Other interventions

If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in our anaphylaxis guide.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Breathing

Clinical assessment

Observations

Review the patient’s respiratory rate:

• A normal respiratory rate is between 12-20 breaths per minute.
• Bradypnoea may be due to sedation, opioid toxicity, raised intracranial pressure (ICP) or exhaustion in airway obstruction (e.g. COPD).
• Tachypnoea may be due to airway obstruction, asthma, pneumonia, pulmonary embolism (PE), pneumothorax, pulmonary oedema, heart failure, or anxiety.

Review the patient’s oxygen saturation (SpO₂):

• A normal SpO₂ range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO₂ retention.
• Hypoxaemia may be seen in PE, aspiration, COPD, asthma and pulmonary oedema.

See our guide to performing observations/vital signs for more details.

General inspection

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology:

• Cyanosis: bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
• Shortness of breath: signs may include nasal flaring, pursed lips, use of accessory muscles, intercostal muscle recession and the tripod position which involves the patient sitting or standing whilst leaning forward and supporting their upper body with their hands on their knees or other surfaces. The inability to speak in full sentences is an indicator of significant shortness of breath.
• Cough: a productive cough can be associated with several respiratory pathologies including pneumonia, bronchiectasis, COPD and cystic fibrosis. A dry cough may suggest a diagnosis of asthma or interstitial lung disease.
• Stridor: a high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways. Stridor has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic).
• Cheyne-Stokes respiration: cyclical apnoeas, with varying depth of inspiration and rate of breathing. May be caused by stroke, raised intracranial pressure, pulmonary oedema, opioid toxicity, hyponatraemia or carbon monoxide poisoning.
• Kussmaul’s respiration: deep, sighing respiration associated with metabolic acidosis (e.g. diabetic ketoacidosis).

Tracheal position

Gently assess the position of the trachea, which should be central in healthy individuals:

• The trachea deviates away from tension pneumothorax and large pleural effusions.
• The trachea deviates towards lobar collapse and pneumonectomy.

Palpation of the trachea can be uncomfortable, so warn the patient and apply a gentle technique.

Chest expansion

Assess the patient’s chest expansion looking for evidence of reduced chest wall movement. Reduced chest expansion may indicate underlying pathology:

• Symmetrical: pulmonary fibrosis reduces lung elasticity, restricting overall chest expansion.
• Asymmetrical: pneumothorax, pneumonia and pleural effusion can all cause ipsilateral reduced chest expansion.

Percussion of the chest

Percuss the patient’s chest, listening to the resulting percussion note which should be resonant in healthy individuals. Abnormal findings on percussion include:

• Dullness: suggests increased tissue density (e.g. cardiac dullness, consolidation, tumour, lobar collapse).
• Stony dullness: typically caused by an underlying pleural effusion.
• Hyper-resonance: the opposite of dullness, suggestive of decreased tissue density (e.g. pneumothorax).

Auscultation

Auscultate the patient’s chest and identify any abnormalities such as:

• Bronchial breathing: harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal and there is a pause between. This type of breath sound is associated with consolidation.
• Quiet/reduced breath sounds: suggest reduced air entry into that region of the lung (e.g pleural effusion, pneumothorax).
• Wheeze: a continuous, coarse, whistling sound produced in the respiratory airways during breathing. Wheeze is often associated with asthma, COPD and bronchiectasis.
• Stridor: a high-pitched extra-thoracic breath sound resulting from turbulent airflow through narrowed upper airways. Stridor has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic).
• Coarse crackles: discontinuous, brief, popping lung sounds typically associated with pneumonia, bronchiectasis and pulmonary oedema.
• Fine end-inspiratory crackles: often described as sounding similar to the noise generated when separating velcro. Fine end-inspiratory crackles are associated with pulmonary fibrosis.

See our respiratory examination guide more for details.

Investigations and procedures

Arterial blood gas (ABG)

Take an ABG if indicated (e.g. low SpO₂).

See our guides for taking and interpreting an ABG for more details.

Chest X-ray

Order a portable chest X-ray if you suspect lung pathology (e.g. pneumonia, pneumothorax, pulmonary oedema).

See our chest X-ray interpretation guide for more details.

Interventions

If the patient is short of breath, they should be sat upright in the bed if possible to aid inspiration.

Oxygen

Administer oxygen to all critically unwell patients during your initial assessment. This typically involves the use of a non-rebreathe mask with an oxygen flow rate of 15L. You can then trial titrating oxygen levels downwards after your initial assessment.

In COPD, target SpO₂ levels accordingly (88-92%) and consider using a Venturi mask: 24% (4L) or 28% (4L). Consider discussing non-invasive ventilation (NIV) with a senior in acute exacerbations of COPD where there is evidence of type 2 respiratory failure.

If the patient is conscious, sit them upright as this can also help with oxygenation.

See our guide to airway equipment and non-invasive ventilation for more details.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Acute severe asthma

The acute management of asthma may involve interventions such as oxygen, nebulisers, steroids and other agents (e.g. magnesium sulphate, aminophylline).

See our guide to the acute management of asthma for more details.

Acute exacerbation of COPD

The acute management of an exacerbation of COPD may involve interventions such as oxygen, nebulisers, steroids and antibiotics.

See our guide to the acute management of COPD for more details.

Other pathology

Other pathologies which may be identified during the assessment of breathing include pneumonia and pneumothorax. Each problem should be treated as it is identified.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Circulation

Clinical assessment

Observations

Review the patient’s heart rate:

• A normal resting heart rate (HR) can range between 60-99 beats per minute.
• Causes of tachycardia (HR>99) include hypovolaemia, arrhythmia, infection, hypoglycaemia, thyrotoxicosis, anxiety, pain and drugs (e.g. salbutamol).
• Causes of bradycardia (HR<60) include acute coronary syndrome (ACS), ischaemic heart disease, electrolyte abnormalities (e.g. hypokalaemia) and drugs (e.g. beta-blockers).

Review the patient’s blood pressure:

• A normal blood pressure (BP) range is between 90/60mmHg and 140/90mmHg but you should review previous readings to gauge the patient’s usual baseline BP.
• Causes of hypertension include hypervolaemia, stroke, Conn’s syndrome, Cushing’s syndrome and pre-eclampsia (in pregnant females). Severe hypertension (systolic BP > 180 mmHg or diastolic BP > 100 mmHg) may present with confusion, drowsiness, breathlessness, chest pain and visual disturbances.
• Causes of hypotension include hypovolaemia, sepsis, adrenal crisis and drugs (e.g. opioids, antihypertensives, diuretics).

Extremes of heart rate or blood pressure with other concerning features such as syncope, pre-syncope, shortness of breath or evidence of myocardial ischaemia require urgent senior and/or critical care input.

See our guide to performing observations/vital signs for more details.

Fluid balance assessment

Calculate the patient’s fluid balance:

• Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts.
• Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult.
• Causes of oliguria include dehydration, hypovolaemia, reduced cardiac output and acute kidney injury.

General inspection

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology:

• Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage, chronic disease) or poor perfusion (e.g. congestive cardiac failure).
• Oedema: typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites) and may indicate underlying heart failure.

Palpation

Place the dorsal aspect of your hand onto the patient’s to assess temperature:

• In healthy individuals, the hands should be symmetrically warm, indicating adequate perfusion.
• Cool hands indicate poor peripheral perfusion (e.g. congestive cardiac failure, acute coronary syndrome).
• Cool and sweaty/clammy hands are typically associated with acute coronary syndrome.

Measure capillary refill time (CRT):

• In healthy individuals, the initial pallor of the area you compressed should return to its normal colour in less than two seconds.
• A CRT that is greater than two seconds suggests poor peripheral perfusion (e.g. hypovolaemia, congestive heart failure) and the need to assess central capillary refill time.

Pulses and blood pressure

Assess the patient’s radial and brachial pulse to assess rate, rhythm, volume and character:

• An irregular pulse is associated with arrhythmias such as atrial fibrillation.
• A slow-rising pulse is associated with aortic stenosis.
• A pounding pulse is associated with aortic regurgitation as well as CO₂ retention.
• A thready pulse is associated with intravascular hypovolaemia (e.g. sepsis).

Jugular venous pressure (JVP)

Inspect for evidence of a raised JVP which may be caused by:

• Right-sided heart failure: commonly caused by left-sided heart failure (e.g. secondary to fluid overload). Pulmonary hypertension is another cause of right-sided heart failure, often occurring due to chronic obstructive pulmonary disease or interstitial lung disease.
• Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease.
• Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.

Auscultation

Auscultate the patient’s precordium to assess heart sounds:

• An ejection systolic murmur is associated with aortic stenosis.
• An early diastolic murmur is associated with aortic regurgitation.
• A mid-diastolic murmur is associated with mitral stenosis.
• A pan-systolic murmur is associated with mitral regurgitation.
• A murmur of recent onset may suggest recent myocardial infarction (e.g. papillary muscle rupture) or endocarditis.
• A pericardial rub or muffled heart sounds may indicate underlying pericarditis.
• A third heart sound is typically associated with congestive heart failure.

Ankles and sacrum

Assess the patient’s ankles and sacrum for evidence of oedema which is typically associated with heart failure.

Investigations and procedures

Intravenous cannulation

Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.

See our intravenous cannulation guide for more details.

Blood tests and blood cultures

Request FBC, U&Es and LFTs for all patients regardless of their presentation and consider additional blood tests such as:

• Sepsis: CRP, lactate and blood cultures
• Haemorrhage or surgical emergency: coagulation and cross-match
• Acute coronary syndrome: troponin
• Arrhythmia: calcium, magnesium, phosphate, TFTs, coagulation
• Pulmonary embolism: D-dimer (if appropriate based on Well’s score)
• Overdose: toxicology screen (e.g. paracetamol levels)
• Anaphylaxis: consider serial mast cell tryptase levels

See our blood culture, blood bottle and investigation panel guides for more details.

ECG

Record a 12-lead ECG if appropriate (e.g. if the patient has chest pain, arrhythmia, a murmur, or suspected electrolyte imbalance).

Consider continuous ECG monitoring for critically unwell patients (e.g. myocardial infarction, severe electrolyte abnormalities requiring replacement).

See our guides to recording and interpreting an ECG for more details.

Bladder scan

Perform a bladder scan in suspected urinary retention or obstruction.

Urine pregnancy test

Perform a urine pregnancy test in any female of childbearing age presenting with clinical evidence of shock, abdominal pain or gynaecological symptoms.

Other cultures/swabs

Ask the nursing staff to collect and send other appropriate cultures (e.g. sputum, urine, line cultures).

Fluid output/catheterisation

Ask the nursing staff to initiate a strict fluid balance if not already in place.

Consider catheterisation to allow accurate monitoring of urine output or to relieve urinary retention where appropriate.

See our guide to catheterisation for more details.

Interventions

Hypovolaemia

Hypovolaemic patients require fluid resuscitation (the below guidelines are for adults):

• Administer a 500ml bolus Hartmann’s solution or 0.9% sodium chloride (warmed if available) over 15 mins.
• Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure).

After each fluid bolus, reassess for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).

Repeat administration of fluid boluses up to four times (e.g. 2000ml or 1000ml in patients at increased risk of fluid overload), reassessing the patient each time.

Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn’t responding adequately to repeated boluses (e.g. persistent hypotension).

See our fluid prescribing guide for more details on resuscitation fluids.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Acute coronary syndrome (ACS)

The management of suspected ACS can involve interventions such as pain relief (e.g. morphine), nitrates, aspirin, clopidogrel and oxygen.

See our ACS guide for more details.

Sepsis

If any clinical signs of sepsis are present, you should commence the sepsis 6 pathway which includes the following investigations and interventions:

1. Oxygen
2. Blood cultures
3. IV antibiotics
4. IV fluids
5. Serial lactates
6. Ongoing monitoring of urine output

See our sepsis guide for more details.

Haemorrhage

The management of haemorrhage involves interventions such as the replacement of intravascular volume with fluid and blood products as well as measures to slow or stop bleeding.

See our post-operative bleeding guide and upper gastrointestinal bleeding guide for more details.

Fluid overload

The management of fluid overload typically involves interventions such as the administration of diuretics (e.g. furosemide) and strict fluid balance monitoring.

See our pulmonary oedema guide for more details.

Atrial fibrillation (AF)

The management of acute atrial fibrillation involves interventions to control heart rate and rhythm.

See our atrial fibrillation guide for more details.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Disability

Clinical assessment

Consciousness

Assess the patient’s level of consciousness using the AVPU scale:

• Alert: the patient is fully alert, although not necessarily orientated.
• Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt).
• Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure).
• Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain.

If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS).

Causes of depressed consciousness

Acute deterioration in a patient’s level of consciousness may be due to a number of causes including:

• Hypovolaemia
• Hypoxia
• Hypercapnia
• Metabolic disturbance (e.g. hypoglycaemia)
• Seizure
• Raised intracranial pressure or other neurological insults (e.g. stroke)
• Drug overdose
• Iatrogenic causes (e.g. administration of opiates)

Pupils

Assess the patient’s pupils:

• Inspect the size and symmetry of the patient’s pupils (e.g. pinpoint pupils in opioid overdose, dilated pupils in tricyclic antidepressant overdose). Asymmetrical pupillary size may indicate intracerebral pathology (e.g. stroke, space-occupying lesion, raised intracranial pressure).
• Assess direct and consensual pupillary responses which may reveal evidence of intracranial pathology (e.g. stroke).

Drug chart review

Review the patient’s drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives, anxiolytics).

Investigations and procedures

Blood glucose and ketones

Measure the patient’s capillary blood glucose level to screen for abnormalities (e.g. hypoglycaemia or hyperglycaemia). The normal reference range for capillary blood glucose is 4.0-11.0 mmol/L.

A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).

If the blood glucose is elevated, check ketone levels which if also elevated may suggest a diagnosis of diabetic ketoacidosis (DKA).

See our blood glucose measurement, hypoglycaemia and diabetic ketoacidosis guides for more details.

Imaging

Request a CT head if intracranial pathology is suspected after discussion with a senior.

See our guide on interpreting a CT head for more details.

Interventions

Maintain the airway

Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient’s airway as explained in the airway section of this guide.

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Opioid toxicity

If opioid toxicity is suspected as the cause for the patient’s reduced level of consciousness (e.g. pinpoint pupils) interventions such as naloxone should be considered.

See our opioid toxicity guide for more details.

Hypoglycaemia

The management of hypoglycaemia involves the administration of glucose (e.g. oral or intravenous).

See our hypoglycaemia guide for more details.

Diabetic ketoacidosis (DKA)

The management of DKA involves interventions such as intravenous fluids and insulin.

See our DKA guide for more details.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Exposure

It may be necessary to expose the patient during your assessment: remember to prioritise patient dignity and conservation of body heat. 

Clinical assessment

Begin by asking the patient if they have pain anywhere, which may be helpful to guide your assessment.

Inspection

Inspect the patient’s skin for evidence of rashes (e.g. adverse drug reaction, meningococcal sepsis), bruising (e.g. coagulation disorders, trauma, surgery) and signs of infection (e.g. cellulitis).

Review any in situ intravenous lines for evidence of surrounding erythema or discharge.

Assess the patient’s calves for erythema, swelling and tenderness which may suggest a deep vein thrombosis.

Review any surgical wounds for evidence of haematoma, active bleeding or infection (e.g. purulent discharge).

Review the output of the patient’s catheter and any surgical drains for blood loss, fluid loss and evidence of infection (e.g. pus).

Bleeding

If active bleeding is identified:

• Estimate the total blood loss and the rate of blood loss.
• Re-assess for signs of hypovolaemic shock (e.g. hypotension, tachycardia, pre-syncope, syncope).

Temperature

Review the patient’s body temperature:

• A normal body temperature range is between 36°c – 37.9°c.
• A temperature of >38°c is most commonly caused by infection (e.g. sepsis).
• A temperature < 36°c may also be caused by sepsis or cold exposure (e.g. drowning, inadequate clothing outside).
• Consider warming (e.g. Bair Hugger™) in hypothermia (seek senior input).

Investigations and procedures

Cultures/swabs

Ask the nursing staff to take relevant swabs/samples of any potential infection source (e.g. line tip culture).

Interventions

Haemorrhage

If the patient is actively bleeding seek urgent senior input (e.g. surgical registrar, anaesthetics) and consider the need for blood products (e.g. packed red cells, platelets).

Large-bore intravenous access (x2) should be established and relevant blood tests should be sent (e.g. FBC, U&Es, coagulation studies, group and crossmatch) if not done so already.

In severe haemorrhage, consider initiating the major haemorrhage protocol (with senior approval).

See our post-operative bleeding, upper gastrointestinal bleeding and blood transfusion guides for more details.

Infection

If an infection is suspected (e.g. a surgical wound is leaking pus) re-assess the patient for clinical evidence of sepsis and perform the sepsis 6 if appropriate.

Consult local guidelines and/or microbiology advice to guide appropriate antibiotic treatment.

See our sepsis guide for more details.

Deep vein thrombosis (DVT)

If a DVT is suspected, calculate the patient’s Well’s score and manage as per guidelines (e.g. arranging USS, commencing anticoagulation).

CPR

If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.

Re-assessment

Make sure to re-assess the patient after any intervention.

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Re-assessment and seeking help

Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.

Deterioration should be recognised quickly and acted upon immediately.

Seek senior help if the patient shows no signs of improvement or if you have any concerns.

Support

You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate.

You may need further help or advice from a senior staff member and you should not delay seeking help if you have concerns about your patient.

Use an effective SBARR handover to communicate the key information effectively to other medical staff.

Examples of who you may be able to contact

If a patient is critically unwell (e.g. peri-arrest, cardiac arrest) the cardiac arrest team should be alerted (the team typically consists of an anaesthetist, medical registrar and junior doctors).

Airway problems:

• On-call anaesthetist

Breathing problems:

• Medical registrar on call
• Critical care team

Circulation problems:

• Medical registrar on call
• Critical care team
• Other specialists depending on the suspected pathology (e.g. microbiologist, cardiologist, surgeon, gastroenterologist)

Disability problems:

• Medical registrar on call
• Anaesthetist on call if the airway is threatened (e.g. GCS<8)
• Other specialists depending on the suspected pathology (e.g. neurosurgeon, endocrinologist, neurologist)

Exposure problems:

• Medical registrar on call
• Other specialists depending on the suspected pathology (e.g. surgeon, dermatologist, microbiologist)

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Next steps

Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do…

Take a history

Take a thorough history to help narrow the differential diagnosis.

See our history taking guides for more details.

Review

Review the patient’s notes, charts and recent investigation results.

Review the patient’s current medications and check any regular medications are prescribed appropriately.

Document

Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.

See our documentation guides for more details.

Discuss

Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover.

Questions which may need to be considered include:

• Are any further assessments or interventions required?
• Does the patient need a referral to HDU/ICU?
• Does the patient need reviewing by a specialist?
• Should any changes be made to the current management of their underlying condition(s)?

Handover

The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated.

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References

1. Resuscitation Council (UK): ABCDE Approach. Available from: [LINK].
2. Resuscitation Council (UK): Peri-arrest arrhythmias. Available from: [LINK].