A structured approach to stabilising

the deteriorating patient

Session Objectives
Provide a framework for the management of the

deteriorating patient
Introduce an assessment tool to assist you with the

management of the deteriorating patient

How do you prioritise patient

information?
A patient in the post-surgical ward
Post operative orders?
Is the patient bleeding?
How many days post surgery ?
Complications?
RR 32
Allergies?
HR 104
History of COPD?
Intravenous cannula?
SpO2 91%
Oxygen?
Coughing?
Discharge plan?
Conscious state?
NIBP 90/50
What should I do?????

Basic Approach

Identify any life threatening issues

Make the patient as safe as possible

Then look for the underlying cause and treat

What are the likely problems?

Respiratory:
the sats are low
the patient has difficulty breathing

Cardiovascular:
the patient has a low blood pressure
the patient has chest pain

Neurological:
the patient is becoming drowsy/ has a worsening GCS
the patient is unresponsive

How do we go about figuring out

WHAT the problem is?
A

Airway

Breathing

Circulation

Disability

How do we go about figuring out

WHAT the problem is?

A&B

Airway & Breathing

Circulation

Disability

Airway & Breathing:

Is there a life threatening
problem?
Unlikely: Pt talking OK, normal chest movement, pink

sats>92%,
Possibly : Decreased GCS, stridor, noisy breathing,

wheeze, accessory muscle usage,

paradoxical breathing, no chest movement,
RR<5 or >20, sats <92%,

What to do if possibly life

threatening?
CALL FOR HELP!
If patient not breathing and not responsive: CPR
Otherwise apply 15l/min oxygen via hudson mask or

reservoir mask
Ensure patent upper airway by performing airway

manoeuvres
Head tilt, jaw thrust & chin lift,
Consider an oropharyngeal or nasopharyngeal airway

Consider using a bag and mask

Bag and Mask

Applying this (without bagging) will deliver much

higher concentration O2 than a normal mask (100%

v 60%)
Can also be used to manually support ventilation

i.e. time your bag compressions with the patients

own breath

Now what?

Only once satisfied that the patient is breathing

supplemental oxygen do you move on to

assessing the circulation

Circulation:
Is there a life threatening
problem?
Unlikely: Pt. talking and feeling OK, pink and well

perfused, systolic >100

Possibly : Pt. feeling unwell/ dizzy/ faint, chest pain,

decreased GCS , systolic <100, pulse <50 or

>100 or irregular

What to do if possibly life

threatening?
CALL FOR HELP!
Feel pulse
Attach BP cuff and measure
Attach ECG / Defib
Obtain IV access
Then consider if the problem is : pressure or rate/rhythm

and attempt to optimise

Optimising Pressure or
Rate/Rhythm
If it is a blood pressure problem i.e. systolic <100:
Administer a fluid bolus initially

500ml crystalloid or 250 ml colloid (Gelfusine)

If systolic <90 then consider:

Metaraminol (aramine) 0.5mg IV

If it is a rate/ rhythm problem:

Wait for senior help to arrive

Assessing the Disability?

Awake

Responds to verbal commands ( 11-10)

Responds to painful stimuli (9-5)

Unresponsive (4-3)

(GCS 15-12)

Aim for at least

O2 saturation 90%
Systolic BP 90

And then start to figure out why the

problem exists

So in practice
Confirm and optimise any life threatening problems

Further investigation once safe to do so

Definitive treatment depending on cause while continuing

supportive measures

So remember
Sort A & B, C then D.
And youre off to a very good start!