Code Ready
Log inSign up free

Level 2 of 6Must-remember

Triage and clinical prioritisation

Assess, manage and stay safe — enough on its own

The card — assess, manage, caution

Assessment— look, ask, measure

  • Ask one question first — "What has brought you in?" — because the answer supplies the history, the level of consciousness, the speech pattern and the respiratory reserve at once.
  • Look before you touch a monitor: how does the patient look (alert and engaged, or grey, quiet, still, sweating, withdrawn), how are they breathing, and what is the skin doing — critically ill patients characteristically stop talking and stop moving, and agitation is equally ominous as an early cerebral sign of hypoxaemia or hypoperfusion.
  • Speech is the best bedside respiratory function test: full sentences, short phrases, single words, or none — a gradient that maps closely onto severity in asthma, heart failure, pneumonia and acidosis; also look for accessory muscle use, tracheal tug, inability to lie flat, paradoxical abdominal movement and the tripod position.
  • Capillary refill is assessed centrally over the sternum or forehead (peripheral refill is confounded by ambient temperature): longer than 3 seconds centrally in an adult, or 2 seconds in a child, implies significant hypoperfusion, and mottling extending proximally from the knee marks severe circulatory failure.
  • Count the respiratory rate for a full minute — it is the earliest and most sensitive marker of critical illness and the least often measured accurately; a rate counted for fifteen seconds and multiplied by four is the commonest way to lose a deteriorating patient.
  • Physiological danger signs — Airway: stridor, drooling, inability to speak, snoring or gurgling respiration, hoarseness, swelling of face, lips or tongue, soot or burns around the mouth.
  • Physiological danger signs — Breathing: respiratory rate below 8 or above 30/min, saturation below 90% on air, exhaustion, silent chest, inability to lie flat.
  • Physiological danger signs — Circulation: systolic pressure below 90 mmHg, heart rate below 40 or above 130/min, absent radial pulse, central capillary refill over 3 seconds, cold mottled peripheries, active major haemorrhage, haematemesis or melaena with pallor or tachycardia.
  • Physiological danger signs — Disability and Exposure: Glasgow Coma Scale 8 or less, new unresponsiveness, active seizure, new focal deficit, new confusion; urticaria with wheeze, stridor or hypotension; fever with a non-blanching purpuric rash.
  • Score NEWS2 on every adult: 0–4 is low risk; any single parameter scoring 3 is low–medium risk needing urgent review; 5–6 is medium risk needing urgent review within the hour; 7 or more is high risk needing immediate assessment, continuous monitoring and consideration of organ support.
  • Measure the capillary glucose within 5 minutes of altered consciousness, seizure, collapse, focal deficit or aggression — below 4.0 mmol/L (72 mg/dL) in an adult requires immediate treatment, and hypoglycaemia mimics stroke, seizure, psychosis and intoxication.
  • Record a 12-lead ECG within 10 minutes of chest pain, epigastric pain in the elderly or diabetic, syncope or unexplained breathlessness — a normal ECG excludes nothing, so repeat at 15–30 minutes and with every change in pain.
  • Use ACVPU for consciousness and record the Glasgow Coma Scale by component, the motor score carrying most of the prognostic weight; GCS 8 or less conventionally denotes an unprotected airway, and any reduction in conscious level mandates immediate glucose measurement before a neurological diagnosis is entertained.
  • In children use the Paediatric Assessment Triangle from the doorway — Appearance (tone, interactiveness, consolability, gaze, quality of cry), Work of Breathing (recession, nasal flaring, grunting, head bobbing, tracheal tug) and Circulation to Skin (pallor, mottling, cyanosis): abnormality in one limb means urgent assessment, in two or more means resuscitation.
  • Infant red flags carry unusual weight: refusal to feed, no wet nappy for 12 hours, a high-pitched or inconsolable cry, a bulging fontanelle, a floppy or unrousable infant, and any fever under three months of age — and grunting is the sound of a child generating their own positive end-expiratory pressure and is never benign.
  • Five complaint headings account for a disproportionate share of missed critical illness: chest or epigastric discomfort; breathlessness; abdominal or back pain; altered consciousness or collapse; and the undifferentiated "generalised weakness" or "unwell", which is the most dangerous heading in medicine because it has no organ attached to it.

Management— do this, in order

  • Correct physiology before the diagnosis is reached: open the airway, give oxygen, correct the glucose, restore perfusion and relieve pain before anyone knows what is wrong — these interventions are diagnosis-agnostic and reversible.
  • Hypoxaemia with SpO₂ below 94%: oxygen by reservoir mask at 15 L/min, targeting SpO₂ 94–98% (the same 15 L/min and target in children).
  • Known or suspected chronic type 2 respiratory failure: controlled oxygen by 28% Venturi mask or nasal cannulae at 1–2 L/min, target SpO₂ 88–92%, with a blood gas at 30 minutes.Not available at your setup — Arterial blood gas.
  • Hypoglycaemia with access: 100 mL of 20% glucose IV into a large vein over 10–15 minutes (or 150–200 mL of 10%), recheck at 10 minutes, then give long-acting carbohydrate; in a child 10% glucose 2 mL/kg IV/IO, and 2.5 mL/kg in a neonate.Doctor / Nurse
  • Hypoglycaemia with no access: glucagon 1 mg IM in an adult (0.5 mg IM if under 25 kg or under 8 years, 1 mg if larger), with oral gel only in a fully conscious patient.
  • Hypotension without haemorrhage: crystalloid 500 mL over 15 minutes, reassessing after each bolus — 250 mL in heart failure or age over 75; in a child 10 mL/kg over 10–20 minutes, using 10 mL/kg aliquots in ketoacidosis, malnutrition and cardiac disease and 20 mL/kg in septic shock where intensive support is available.Doctor / Nurse
  • Opioid toxicity (pinpoint pupils, respiratory rate below 8): naloxone 400 micrograms IV every 2–3 minutes to a total of 2 mg, titrated to respiratory rate and not to consciousness, starting at 100 micrograms in known dependence; in a child 10 micrograms/kg IV to a maximum of 400 micrograms per dose.Doctor / Nurse
  • Anaphylaxis: adrenaline 1:1000 intramuscularly into the anterolateral thigh, 500 micrograms (0.5 mL) in an adult, repeated at 5 minutes — in children 150 micrograms under 6 years, 300 micrograms at 6–12 years, 500 micrograms over 12 years — and never wait for tryptase.
  • Pain 1–7/10: paracetamol 1 g orally or IV 6-hourly to a maximum of 4 g in 24 hours (15 mg/kg if under 50 kg) with or without ibuprofen 400 mg orally 8-hourly; in a child paracetamol 15 mg/kg 6-hourly to a maximum of 60 mg/kg/24 h and ibuprofen 10 mg/kg 8-hourly.
  • Pain 8–10/10: titrated intravenous opioid with continuous monitoring — morphine 2 mg IV every 5 minutes to effect (usual total about 0.1 mg/kg); in a child morphine 0.1 mg/kg IV slowly, or intranasal fentanyl 1.5 micrograms/kg where access is difficult.Doctor / Nurse
  • Seizure lasting more than 5 minutes: a benzodiazepine repeated once after 10 minutes — lorazepam 4 mg IV, midazolam 10 mg buccal or IM, or diazepam 10 mg rectally; in a child lorazepam 0.1 mg/kg IV (maximum 4 mg) or buccal midazolam 0.3 mg/kg (maximum 10 mg).Doctor / Nurse
  • Suspected sepsis: cultures, then a broad-spectrum antibiotic against the likely pathogens, with fluid and lactate, within 1 hour of recognising septic shock (within 1 hour and weight-based in a child).Doctor / NurseNot available at your setup — Blood culture. If cultures cannot be obtained quickly, give the antibiotic without them — cultures must never delay the first dose.
  • Position by physiology: upright for respiratory distress and pulmonary oedema; supine with legs elevated for hypovolaemia; left lateral tilt in late pregnancy to relieve aortocaval compression; recovery position for the unconscious patient with an intact airway.
  • Establish intravenous access early — two large-bore cannulae, 16G or 18G in an adult, where haemorrhage is suspected — since access becomes harder as shock deepens, and take the allergy and drug history at once, asking specifically about anticoagulants, beta-blockers, insulin, corticosteroids and over-the-counter or herbal preparations.Doctor / Nurse
  • Where airborne infection is plausible — cough over two weeks with weight loss, night sweats or haemoptysis, or fever with a new rash or after travel — put a surgical mask on the patient and separate them from a crowded waiting area; pulmonary tuberculosis spreads by droplet nuclei that remain suspended in poorly ventilated air for hours.
  • Reassess on a clock: continuous observation at level 1, 15-minutely at level 2, 30-minutely at level 3, hourly at level 4 and two-hourly at level 5, with reassessment after every intervention, and physically re-examine any patient who has waited beyond their target time.
  • Up-triage immediately for a rise in NEWS2 of 2 or more points, a new oxygen requirement, a fall in systolic pressure of more than 20 mmHg from the arrival value, new drowsiness or agitation, worsening pain, or a relative's statement that the patient is not right.

Caution— what harms

  • A normal blood pressure does not exclude shock: a young adult, an athlete or a pregnant woman may lose 30–40% of circulating volume before the systolic pressure falls at all, and when it falls it falls abruptly, because compensation is a plateau, not a slope.
  • Oxygen saturation changes late and then catastrophically: the dissociation curve is flat above a partial pressure of about 8 kPa, so large falls in arterial oxygen tension produce trivial changes in saturation until, below roughly 90%, the curve becomes steep — the oximeter reassures until the patient is at the edge of the cliff.
  • Do not trust the oximeter in poor perfusion, carbon monoxide poisoning (carboxyhaemoglobin is read as oxyhaemoglobin, giving a falsely high value), methaemoglobinaemia (readings tend towards 85%) or deeply pigmented skin, where occult hypoxaemia is more frequent.
  • A falling respiratory rate in an exhausted patient is pre-arrest, not improvement, and the chest falls silent because insufficient air moves to generate a wheeze; a normal or rising pCO₂ in acute severe asthma signifies exhaustion and impending arrest.
  • Bradycardia in a sick child is a pre-arrest rhythm — hypoxia and acidosis depress the sinus node — and hypotension in a child is pre-terminal; the child who has gone quiet is deteriorating, not settling.
  • Never name a neurological diagnosis before measuring the glucose: hypoglycaemia imitates stroke, seizure, psychosis, aggression and intoxication and is reversible in minutes.
  • A normal ECG excludes nothing in ongoing chest pain, a normal chest radiograph may occur in the first hours of pneumonia especially if dehydrated or neutropenic, haemoglobin is normal in the first hours of acute haemorrhage, a normal white cell count does not exclude sepsis, and early infarction is often invisible on CT.
  • qSOFA has poor sensitivity — it identifies those already deteriorating and misses many who will still die, and must not be used to exclude sepsis; SIRS is sensitive and very non-specific.
  • NEWS2 is not validated in pregnancy or in children, over-scores patients with chronic hypoxaemia unless SpO₂ Scale 2 is applied and under-scores them if Scale 2 is applied inappropriately, and under-performs in acute neurological illness — a low score in a patient who looks unwell is a reason to distrust the score.
  • Uncontrolled high-concentration oxygen precipitates hypercapnic acidosis in chronic type 2 respiratory failure, but hypoxaemia is never left uncorrected out of concern for carbon dioxide.
  • Do not over-fill: fluid overload follows over-enthusiastic boluses in cardiogenic shock, heart failure and the frail elderly, and beyond approximately 30 mL/kg of crystalloid further boluses harm as often as they help.
  • Excessive naloxone precipitates withdrawal; opioids cause respiratory depression; concentrated glucose extravasation causes skin necrosis, so never give 25% or 50% glucose peripherally in a child; and a single glucose bolus in sulphonylurea toxicity produces rebound hypoglycaemia.
  • Withholding opioid in undifferentiated abdominal pain to avoid masking the signs is not supported by evidence — adequate analgesia improves the reliability of abdominal examination, and untreated severe pain inflates the respiratory rate and heart rate about to be scored, corrupting the triage decision itself.
  • Beware the labels that kill: "indigestion", "gastroenteritis", "drunk", "anxiety", "mechanical back pain", "simple faint", "viral illness", "off legs" and "asthma but he has settled" each conceal a lethal condition; a positive urine dipstick is a leading cause of premature closure in the confused older patient, in whom asymptomatic bacteriuria is common.

Refer / escalate

Assign level 1 and call for immediate senior and resuscitation-team help for any airway threat, respiratory rate below 8 or above 30, SpO₂ below 90% on air, systolic pressure below 90 mmHg, heart rate below 40 or above 130, GCS 8 or less, active seizure, anaphylaxis, major haemorrhage or NEWS2 of 7 or more — and when hesitating between two categories, always take the higher one.

PreviousNext

Read the full lesson free

Create a free account to unlock every page, the level exams, and progress tracking.

Sign up freeLog in