6.4 Management of the Deteriorating Patient & Emergency Care
Key Takeaways
- The Sepsis Six bundle must be fully delivered within 1 hour of recognition: 3 in (high-flow oxygen, blood cultures, IV broad-spectrum antibiotics) and 3 out (IV fluid challenge, serum lactate, strict hourly urine output).
- First-line emergency treatment for adult anaphylaxis is intramuscular (IM) adrenaline 1:1000 at a dose of 500 micrograms (0.5 mL) administered into the anterolateral thigh, repeatable every 5 minutes.
- Adult hypoglycaemia (CBG < 4.0 mmol/L) in conscious patients requires 15–20 g of rapid-acting carbohydrate orally, while unconscious patients require 150–200 mL of 10% IV glucose or 1 mg IM glucagon.
- Acute Coronary Syndrome (ACS) management requires a 12-lead ECG within 10 minutes and prompt administration of 300 mg dispersible aspirin (chewed) alongside GTN sublingual spray.
- Structure emergency handovers using the SBAR framework (Situation, Background, Assessment, Recommendation) when escalating deteriorating patients to the Medical Emergency Team (MET) via the internal 2222 emergency number.
6.4 Management of the Deteriorating Patient & Emergency Care
Early recognition of acute deterioration and swift, structured escalation are core competencies mandated by the NMC Code and Resuscitation Council UK (RCUK) standards. Registered nurses must maintain vigilance, utilize validated scoring tools such as the National Early Warning Score 2 (NEWS2), and execute immediate emergency bundles for life-threatening emergencies including sepsis, anaphylaxis, acute severe hypoglycaemia, and acute coronary syndromes.
Early Identification & Escalation of Deterioration
Systematic assessment following the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) remains the gold standard for detecting clinical decline. In the UK NHS, physiological parameters are aggregated using NEWS2, which evaluates six core physiological measurements alongside supplemental oxygen administration.
| Parameter | Normal Range | Trigger threshold for escalation |
|---|---|---|
| Respiration Rate | 12–20 breaths/min | ≤ 8 or ≥ 25 breaths/min (Score 3) |
| Oxygen Saturation (SpO2) | 96–100% (Scale 1) | ≤ 91% (Score 3) |
| Hypercapnic SpO2 (Scale 2) | 88–92% (target for COPD) | ≤ 83% (Score 3) |
| Systolic Blood Pressure | 111–219 mmHg | ≤ 90 mmHg or ≥ 220 mmHg (Score 3) |
| Pulse Rate | 51–90 beats/min | ≤ 40 or ≥ 131 beats/min (Score 3) |
| Consciousness (ACVPU) | Alert (A) | New Confusion (C), Voice (V), Pain (P), Unresponsive (U) (Score 3) |
| Temperature | 36.1–38.0 °C | ≤ 35.0 °C (Score 3) |
Escalation Protocols
- NEWS2 Score 1–4: Low-level risk; minimum 4-hourly monitoring by a registered nurse.
- NEWS2 Score 5–6 or single parameter score of 3: Medium-level risk; urgent review by a competent ward doctor within 30 minutes.
- NEWS2 Score 7 or more: High-level risk; emergency response by the Medical Emergency Team (MET) or Critical Care Outreach Team (CCOT) within 15 minutes.
- Cardiac Arrest / Life-Threatening Airway Compromise: Immediate internal emergency call via 2222 (UK NHS standard).
Sepsis Screening & The Sepsis Six Bundle
Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Any patient with a NEWS2 score of 5 or more, or meeting red-flag sepsis criteria (e.g., severe breathlessness, SpO2 < 92% on air, systolic BP ≤ 90 mmHg, pulse > 130 bpm, non-blanching rash, mottled skin, anuria for 18 hours), must be screened immediately.
NICE guidelines (NG51) mandate that the Sepsis Six Bundle must be fully initiated within 1 hour of recognition ("Golden Hour").
SEPSIS SIX BUNDLE (Within 60 Minutes)
┌─────────────────────────────────────────┐
│ 3 IN (DELIVER / ADMINISTER) │
├─────────────────────────────────────────┤
│ 1. High-flow oxygen (Target 94-98%; │
│ 88-92% if hypercapnic risk) │
│ 2. Broad-spectrum IV antibiotics │
│ 3. IV fluid resuscitation │
│ (30 mL/kg crystalloid bolus) │
└─────────────────────────────────────────┘
┌─────────────────────────────────────────┐
│ 3 OUT (MEASURE / TAKE) │
├─────────────────────────────────────────┤
│ 4. Take blood cultures (BEFORE Abx) │
│ 5. Measure serum lactate & full bloods │
│ 6. Measure strict hourly urine output │
│ (Indwelling urinary catheterization) │
└─────────────────────────────────────────┘
Note: Target urine output must be maintained at a minimum of 0.5 mL/kg/hour.
Emergency Anaphylaxis Management
Anaphylaxis is a severe, rapidly progressive, systemic hypersensitivity reaction characterized by airway obstruction, bronchospasm, and/or cardiovascular collapse.
Immediate Interventions (RCUK Guidelines)
- Remove exposure to the suspected allergen immediately.
- Call for immediate emergency help (Resuscitation Team via 2222).
- Position the patient: Lay the patient flat with legs elevated (unless airway compromise requires sitting up). Avoid sudden posture changes.
- Administer Intramuscular (IM) Adrenaline (Epinephrine):
- First-line dose: 500 micrograms (0.5 mL of 1:1000 solution) given IM into the anterolateral aspect of the middle third of the thigh.
- Repeat interval: Repeat after 5 minutes if symptoms do not resolve or if deterioration continues.
- High-flow Oxygen: Administer 15 L/min via a non-rebreathe reservoir mask.
- IV Fluid Resuscitation: Rapid bolus of 500–1000 mL crystalloid IV if hypotensive.
- Secondary Therapies (Post-Resuscitation): Non-sedating H1 antihistamines (chlorphenamine) and IV hydrocortisone may be administered following initial stabilisation.
Hypoglycaemia Protocol
Hypoglycaemia is defined as a capillary blood glucose (CBG) level < 4.0 mmol/L in adult patients with diabetes ("Four is the Floor").
| Clinical Status | First-Line Management | Follow-Up Action |
|---|---|---|
| Conscious, Oriented, Able to Swallow | 15–20 g rapid-acting oral carbohydrate (e.g., 4–5 glucotabs, 150–200 mL pure fruit juice, 4–5 jelly babies). | Recheck CBG after 15 minutes. Repeat up to 3 times if CBG remains < 4.0 mmol/L. |
| Conscious but Uncooperative / Impaired | 1–2 tubes of 40% oral glucose gel (GlucoGel) massaged into the buccal mucosa. | Recheck CBG in 15 minutes; prepare IV access if unresponsive. |
| Unconscious, Seizuring, or NPO | 150–200 mL of 10% IV Glucose over 15 minutes OR 1 mg Intramuscular (IM) Glucagon (if IV access unavailable). | Once CBG > 4.0 mmol/L and patient recovers, administer 20 g long-acting complex carbohydrate (e.g., 2 biscuits, 1 slice of toast, or meal). |
Acute Coronary Syndrome (ACS) Protocol
For patients presenting with acute onset central chest pain, radiation to the jaw or left arm, diaphoresis, or acute dyspnoea, initiate the ACS pathway immediately.
- Obtain a 12-lead ECG within 10 minutes of presentation to differentiate ST-elevation myocardial infarction (STEMI) from non-ST-elevation ACS (NSTEMI/Unstable Angina).
- Administer Aspirin: 300 mg dispersible aspirin, chewed or dissolved, to ensure rapid antiplatelet action (unless contraindicated).
- Glyceryl Trinitrate (GTN): Sublingual spray 400–800 micrograms (1–2 puffs) under the tongue. Hold if systolic blood pressure is < 90 mmHg.
- Analgesia: IV Morphine (2.5–5 mg) or Diamorphine titrated with an IV antiemetic (e.g., Metoclopramide 10 mg or Ondansetron 4 mg).
- Oxygen Therapy: Administer supplemental oxygen ONLY if SpO2 < 94% (or < 88% in COPD). Routine oxygen in non-hypoxaemic ACS causes coronary vasoconstriction.
- Second Antiplatelet: Administer loading dose of Ticagrelor 180 mg or Clopidogrel 300–600 mg as per local cardiology guidelines.
Structured Emergency Handover: SBAR Framework
When escalating a deteriorating patient to senior medical practitioners or the Medical Emergency Team, use the SBAR framework to ensure concise, unambiguous transfer of critical clinical information.
- Situation: State your name, role, ward location, patient identity, and the urgent problem (e.g., "I am Nurse Smith on Ward 4. I am calling about Patient John Doe who has a NEWS2 score of 8 and is acutely breathless.")
- Background: Provide relevant admission diagnosis, date of admission, key surgical/medical history, and baseline status.
- Assessment: Report current physiological vitals (ABCDE findings, latest NEWS2 parameters, lactate, capillary blood glucose, ECG findings).
- Recommendation: State clearly what action you require (e.g., "I require an immediate Medical Emergency Team review within 10 minutes and a prescription for IV fluid resuscitation.")
According to NICE guidelines and UK emergency standards, which action must be performed FIRST within the Sepsis Six bundle before administering intravenous antibiotics?
A nurse recognizes that an adult patient is suffering an acute anaphylactic reaction following an antibiotic infusion. What is the correct immediate first-line pharmacological treatment dose and route according to Resuscitation Council UK guidelines?
An adult patient with type 1 diabetes is found somnolent, uncooperative, and has a capillary blood glucose of 2.8 mmol/L. The patient has established peripheral IV access. What is the standard NHS first-line emergency intervention?
When escalating a deteriorating patient with a NEWS2 score of 9 to the Medical Emergency Team, which statement correctly illustrates the 'Recommendation' element of the SBAR handover tool?