Level 1 of 6Core
Triage and clinical prioritisation
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- Look before you touch a monitor: critically ill patients characteristically stop talking and stop moving, and agitation is equally ominous; speech is the best bedside respiratory function test — full sentences, short phrases, single words, or none.
- Count the respiratory rate for a full minute — the earliest and most sensitive marker of critical illness; capillary refill is assessed centrally over the sternum or forehead — over 3 seconds in an adult (2 in a child) means significant hypoperfusion.
- Physiological danger signs mandate immediate assessment: stridor or drooling; RR below 8 or above 30/min; SpO₂ below 90% on air; SBP below 90 mmHg; HR below 40 or above 130/min; GCS 8 or less; active seizure; fever with a non-blanching purpuric rash; urticaria with wheeze, stridor or hypotension.
- Score NEWS2 on every adult: 0–4 low risk; any single parameter scoring 3 needs urgent review; 5–6 urgent review within the hour; 7 or more needs immediate assessment, continuous monitoring and consideration of organ support — a low score in a patient who looks unwell is a reason to distrust the score.
- Two tests must not wait: capillary glucose within 5 minutes of altered consciousness, seizure, collapse, focal deficit or aggression (below 4.0 mmol/L needs immediate treatment); 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, repeat at 15–30 minutes.
- In children use the Paediatric Assessment Triangle from the doorway (Appearance, Work of Breathing, Circulation to Skin): one abnormal limb = urgent assessment, two or more = resuscitation; infant red flags — refusal to feed, no wet nappy for 12 hours, bulging fontanelle, any fever under three months — and grunting is never benign.
Manage now— do this, in order
- Correct physiology before the diagnosis is reached: open the airway, give oxygen, correct the glucose, restore perfusion and relieve pain — these interventions are diagnosis-agnostic and reversible.
- Hypoxaemia (SpO₂ below 94%): oxygen by reservoir mask at 15 L/min targeting 94–98% (same in children); in known or suspected chronic type 2 respiratory failure use a 28% Venturi mask or nasal cannulae 1–2 L/min, target 88–92%, with a blood gas at 30 minutes.
- Hypoglycaemia with IV access: 100 mL of 20% glucose IV over 10–15 minutes (or 150–200 mL of 10%), recheck at 10 minutes, then long-acting carbohydrate; child 10% glucose 2 mL/kg IV/IO. No access: glucagon 1 mg IM (0.5 mg if under 25 kg or under 8 years) — oral gel only in a fully conscious patient.Doctor / Nurse
- Hypotension without haemorrhage: crystalloid 500 mL over 15 minutes, reassessing after each bolus — 250 mL in heart failure or age over 75; child 10 mL/kg over 10–20 minutes.Doctor / Nurse
- Anaphylaxis: adrenaline 1:1000 IM into the anterolateral thigh — 500 micrograms in an adult, repeated at 5 minutes (children: 150 micrograms under 6 years, 300 micrograms at 6–12, 500 micrograms over 12) — never wait for tryptase.
- Opioid toxicity (pinpoint pupils, RR below 8): naloxone 400 micrograms IV every 2–3 minutes to a total of 2 mg, titrated to respiratory rate and not to consciousness (start at 100 micrograms in known dependence); child 10 micrograms/kg IV, maximum 400 micrograms per dose.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; child lorazepam 0.1 mg/kg IV (max 4 mg) or buccal midazolam 0.3 mg/kg (max 10 mg).Doctor / Nurse
- Suspected sepsis: cultures, then a broad-spectrum antibiotic with fluid and lactate, within 1 hour of recognising septic shock (weight-based in a child).Doctor / NurseNot available at your setup — Blood culture.
- Reassess on a clock and 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 arrival, new drowsiness or agitation, worsening pain, or a relative's statement that the patient is not right — when hesitating between two categories, always take the higher one.
The five categories and their clocks
| Level | Descriptor | Target time | Reassessment |
|---|---|---|---|
| 1 | Immediate | 0 min | Continuous |
| 2 | Very urgent | ≤ 10 min | 15-minutely |
| 3 | Urgent | ≤ 60 min | 30-minutely |
| 4 | Standard | ≤ 120 min | Hourly |
| 5 | Non-urgent | ≤ 240 min | 2-hourly |
Refer / escalate
Assign level 1 and call for immediate senior and resuscitation-team help for any airway threat, RR below 8 or above 30, SpO₂ below 90% on air, SBP below 90 mmHg, HR below 40 or above 130, GCS 8 or less, active seizure, anaphylaxis, major haemorrhage or NEWS2 of 7 or more — when hesitating between two categories, always take the higher one.
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