FUNDAMENTAL PRINCIPLES

Recognizing the critically

ill patient

Learning objectives
After reading this article, you should be able to:
C
recall the abnormal clinical signs associated with a critically ill
patient and common patterns of presentation
C
describe a logical and systematic approach to the assessment
of an acutely unwell patient
C
discuss the clinical importance of the Chain of Response and
early warning systems in the recognition of the critically ill

Kathryn A Bennett
Laura C Robertson
Mohammed Al-Haddad

Abstract
Critical illness is a life-threatening multisystem process that can result
in signicant morbidity or mortality. In most patients, critical illness is
preceded by a period of physiological deterioration; but evidence suggests that the early signs of this are frequently missed. All clinical staff
have an important role to play in implementing an effective Chain of
Response that includes accurate recording and documentation of
vital signs, recognition and interpretation of abnormal values, patient
assessment and appropriate intervention. Early warning systems are
an important part of this and can help identify patients at risk of deterioration and serious adverse events. Assessment of the critically ill
patient should be undertaken by an appropriately trained clinician
and follow a structured ABCDE (airway, breathing, circulation,
disability and exposure) format. This facilitates correction of lifethreatening problems by priority and provides a standardized
approach amongst professionals. Good outcomes rely on rapid identication, diagnosis and denitive treatment and all doctors should
possess the skills to recognize the critically ill patient and instigate
appropriate initial management.

failure. Simple and preventative critical care is the most effective

approach, considering that up to 40% of intensive care unit (ICU)
admissions may be avoidable.1 Ineffective management or failure
to intervene in a timely fashion can lead to multi-organ failure
and mortality rises as the number of organ systems involved
increases.2 Ideal management involves prediction of at risk patients, proactive observation and timely intervention to prevent
deterioration. Occasionally, the onset of life-threatening illness is
acute and catastrophic. More commonly, however, the onset is
insidious. Studies have shown that early indicators of critical
illness are often missed by healthcare professionals.3 Signs and
symptoms can be subtle and patients may compensate for a long
time for abnormal changes in their physiology (Figure 1). Hence
the gradually deteriorating patient on a hospital ward may go
unnoticed until severe organ failure is established.
The Department of Health has recently published guidance on
recognizing critically ill patients and recommends that all
healthcare professionals are aware of the Chain of Response
and their role within it.4 The Chain of Response requires accurate recording and documentation of vital signs, recognition
and interpretation of abnormal values and appropriate patient
assessment and intervention. It should be conducted in an
effective, timely and seamless manner, aiming to ensure the right
patient receives the right treatment at the right time in response
to these abnormal values.
Use of early warning scoring systems can highlight subtle
physiological derangement (Table 1). The early warning scores
recorded are derived from routine physiological observations and
are linked to a pre-determined response for increasing the frequency of future monitoring and an escalation of care.5 An
abnormal score should prompt assessment by an appropriately
qualified professional or team, often called a medical emergency
team (MET) or critical care outreach service (CCOS). These
scoring systems are not intended to predict outcome but to
formulate a score which triggers a response.
Regardless of who assesses the patient, a systematic ABCDE
approach should be used. This facilitates assessment and
correction of life-threatening problems by priority, provides a
standardized approach amongst professionals, aids communication and reduces the risk of missing important details. In the
initial stages primary assessment, resuscitation and life-saving
interventions should be performed concurrently.

Keywords Assessment; CCOS; critical care outreach services; critical illness; early warning systems; medical emergency teams; MET;
outcomes; prediction; signs
Royal College of Anaesthetists CPD Matrix: This article correlates with the
following competencies from the RCOA 2010 curriculum:

Basic level training

RC_BS_01
Basic ICM e 1.1, 2.1, 2.2, 2.7
MK_BK_01-06
Intermediate level training
Intermediate ICM e 1.4, 12.9

Critical illness is a life-threatening process that, in the absence of

medical intervention, is expected to result in mortality or significant morbidity. It may be the product of one or more underlying pathophysiological processes leading to multisystem organ

Kathryn A Bennett MBChB FRCA is an Anaesthetic Registrar in the

West of Scotland, UK. Conicts of interest: none declared.
Laura Robertson MMBS FRCA is an Anaesthetic Registrar in the West
of Scotland, UK. Conicts of interest: none declared.

A e Assessment of airway

Mohammed Al-Haddad MBChB FRCA FFICM EDIC MSc Clinical Education is

a Consultant in Anaesthetics and Intensive Care Medicine at Queen
Elizabeth University Hospital, UK, Glasgow. Conicts of interest:
none declared.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:1

Complete airway obstruction is rare but recognized by silent but

exaggerated respiratory effort (see-saw breathing) until the point

2015 Elsevier Ltd. All rights reserved.

FUNDAMENTAL PRINCIPLES

Top five early and late signs of physiological deterioration with

the odds ratio (OR) for death
Early sign: OR (95% C.I.)

Late sign: OR (95% C.I.)

Unresponsive to voice:
34.8 (10.7113.0)

Partial airway obstruction:

38.7 (3.964.4)

Poor peripheral circulation:

34.4 (6.8174.0)
pH<7.3but>7.2:
29.0 (3.1268.3)

pH 7.2:
116.1 (7.11906.1)
Base deficit 8 mmol/litre:
29.0 (3.1268.3)

Base deficit 5 to 8 mmol/litre:

40.2 (7.7208.8)

Urine output 200ml in

24 hours:
188.6 (30.11179.8)

Drain fluid loss expected:

30.1 (6.1148.9)

Anuric:
29.0 (3.1268.3)

Adapted from the SOCCER study

Figure 1

of cardiorespiratory collapse. Partial airway obstruction is more

common and often occurs as a result of reduced conscious level. It
results in noisy breathing (gurgling, snoring, etc.) and evidence of
increased work of breathing. Stridor suggests large airway
obstruction and hoarseness implies involvement of the vocal
cords. Both are worrying signs and warrant immediate action by
an experienced anaesthetist and/or ear, nose and throat surgeon.

A fast, simple way of assessing the airway is to ask the patient

a question, such as how are you? A clear, coherent answer
implies a patent airway, sufficient respiratory capacity to permit
speech and adequate cerebral perfusion for cognitive processing.
A more thorough airway assessment should use the look, listen,
feel approach which is described in standard textbooks. If there
is a risk of cervical spine injury, manual in-line stabilization

Example of an early warning scoring system

The modied early warning score (MEWS) system is employed in many UK hospitals to assist in the early detection of patients with
physiological impairment. It is a ve-component scoring system based on four bedside physiological parameters and an assessment
of neurological state using the AVPU (alert, voice, pain, unresponsive) score. A score of 5 or more is associated with increased
likelihood of death or admission to the intensive care unit. Abnormal scores should prompt an escalating response, varying from
increasing the frequency of observations to urgent review by an appropriately qualied professional.
Score

Systolic blood pressure

Heart rate (BPM)
Respiratory rate (RPM)
Temperature ( C)
AVPU

<45% Y
e
e
e
e

30% Y
<40
<9
<35
e

15% Y
41e50
e
e
e

Normal for patient

51e100
9e14
35.0e38.4
Alert

15% [
101e110
15e20
e
Voice

30% [
111e129
21e29
>38.5
Pain

>45% [
>130
>30
e
Unresponsive

Subbe CP, Kruger M, Gemmel L. Validation of a modied Early Warning Score in medical admissions. Quarterly Journal of Medicine 2001; 94; 521e6.

Table 1

ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:1

2015 Elsevier Ltd. All rights reserved.

FUNDAMENTAL PRINCIPLES

C e Assessment of circulation

should be maintained and in the acute setting high-flow oxygen

should be administered to all patients and titrated to achieve an
SpO2 94e98%.
Airway obstruction must be corrected immediately. Simple
manoeuvres (such as jaw thrust or chin lift) or use of an airway
adjunct (oropharyngeal or nasopharyngeal airway) can relieve
the obstruction temporarily but early request for senior help and
definitive management can be life-saving. Infectious (e.g. epiglottitis) and inflammatory (e.g. burns, anaphylaxis) causes of
airway obstruction are less common but can be rapidly progressive and life-threatening. If conscious, the patient will often
adopt the best position to maintain their airway (usually sitting
upright and leaning forward). Do not attempt to lay such a patient flat as this may precipitate complete obstruction. Involve an
experienced anaesthetist early.

Shock occurs when the oxygen supply to organs or tissue is

inadequate to meet their metabolic demands. Adequate perfusion
requires the presence of an appropriate circulating volume of
blood with a sufficient amount of pressure to reach the vital
organs.
For a full description of the different patterns of shock see
Anaesthesia & Intensive Care Medicine 2014; 15(2): 64e67. The
causes of shock can be broadly categorized as pump failure
(cardiogenic shock) or peripheral circulatory failure. Peripheral
circulatory failure may represent absolute hypovolaemia (e.g. in
haemorrhage, burns or excess gastrointestinal loss) or relative
hypovolaemia due to vasodilatation and distributive shock (e.g.
in sepsis, anaphylaxis or neurogenic shock). The signs of shock
vary depending on aetiology and are frequently masked in
certain patient groups (e.g. young fit adults, pregnant women or
patients on beta-blockers). Hypoperfusion can occur despite a
normal blood pressure and hypotension is frequently a late and
worrying sign. Despite this, the blood pressure can provide
useful information: a decrease in the diastolic blood pressure can
indicate vasodilatation in early distributive shock and narrowing
of the pulse pressure is a sign of arterial vasoconstriction
designed to maintain perfusion in the setting of reduced cardiac
output or hypovolaemia. Other subtle signs of end organ hypoperfusion should be actively sought, for example, delayed
capillary refill, tachypnoea, confusion, agitation and oliguria.
Hyperlactaemia is a marker of critical illness and associated
with increased morbidity and mortality.6 Early measurement of
lactate with continued monitoring and treatment aimed at active
reduction may improve clinical outcomes.7 In all shocked patients, large-bore venous access should be secured and a fluid
challenge considered in all but those with cardiogenic shock. The
response to this must be assessed as trends in clinical parameters
are far more valuable than isolated reading. Invasive monitoring
can aid diagnosis and guide fluid administration. Central venous
access is also of value in patients who fail to respond to adequate
ventricular filling and require vasopressor or inotropic support.

B e Assessment of breathing
Adequate respiratory function requires an intact central respiratory
drive, respiratory muscle activity, sufficient surface area for alveolar
gas exchange and adequate pulmonary circulation. Impairment of
any of these can cause respiratory embarrassment. Clinical assessment using a look, listen, feel approach is advocated. Tachypnoea
can imply respiratory pathology but is also a sensitive early indicator
of acute illness, occurring as the body attempts to correct metabolic
acidosis secondary to poor tissue perfusion. Other signs of increased
respiratory effort include inability to complete sentences, accessory
muscle use and cyanosis. Peripheral oxygen saturations should be
recorded, but pulse oximetry can be unreliable, falsely reassuring
and does not indicate adequate ventilation. Arterial blood gas
analysis should be performed if time allows.
Differentiating between the two types of respiratory failure
can aid diagnosis and management. Type I failure (PaO2 <8 kPa
(60 mmHg) with low/normal PaCO2) is normally due to V/Q
mismatch. The cause can be lung areas that are perfused but not
ventilated (e.g. in pneumonia, atelectasis, pulmonary oedema) or
ventilated but not perfused (e.g. pulmonary embolus). As a
consequence of this mismatch, simply increasing the FiO2 may
not resolve the hypoxaemia. In severe cases type I respiratory
failure may progress to type II failure as muscle weakness develops due to fatigue, hypoxia and acidosis. This requires urgent
intervention and consideration of invasive ventilation. Type II
respiratory failure represents a decrease in alveolar ventilation,
causing hypoxaemia (PaO2 <8 kPa (60 mmHg)) with hypercarbia
(PaCO2 >6 TPa (45 mmHg)). This can be due to central causes
(e.g. intracranial haemorrhage, opiate drugs), chest wall abnormalities (e.g. kyphoscoliosis, trauma, obesity), neurological or
muscular disorders. Patients with advanced chronic obstructive
pulmonary disease often display chronic type II respiratory failure, with compensation of hypercarbia through renal bicarbonate
retention. In these patients arterial acidaemia is a more sensitive
marker of acute deterioration than absolute PaCO2 value. In type
II respiratory failure increasing the FiO2 will improve
hypoxaemia but correction of hypercarbia requires an increase in
alveolar ventilation and management of the underlying cause.
Critically ill patients who do not improve with simple increases
in FiO2 may benefit from continuous positive airway pressure,
noninvasive, or invasive ventilation. This should be discussed
with a senior clinician.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:1

D and E e Assessment of disability and exposure

The patients neurological status should be assessed using the
Glasgow Coma Scale or AVPU scale (Alert, responds to Voice,
responds to Pain, Unresponsive). Relevant neurological examination also includes identification of focal and localizing signs,
pupillary response and signs of menigism. In the critically ill
patient, multiple factors may contribute to depression of the
conscious level, for example hypoxia, hypercarbia, hypothermia,
electrolyte abnormalities, sepsis or metabolic derangement.
These should be corrected as they are identified. Exclude hypoglycaemia and consider the influence of alcohol, drugs and other
toxins. Primary neurological conditions (e.g. intracranial haemorrhage, ischaemia, infection) should be considered and
actively excluded in at risk patients. These include patients with
trauma, on anticoagulation, with focal neurological deficits or
pupillary abnormalities or those who fail to respond to resuscitative treatment. Core temperature should be recorded and
actively managed. Hypothermia can indicate severe sepsis and is
a negative predictor of survival in trauma.8 The patient should be

2015 Elsevier Ltd. All rights reserved.

FUNDAMENTAL PRINCIPLES

fully exposed and examined, whilst avoiding hypothermia and

maintaining patient dignity.
4

Conclusion
At each stage of the assessment interventions to treat lifethreatening conditions should be undertaken prior to moving
on. This may require the involvement of clinicians with specialist
skills, for example, to facilitate intubation and invasive ventilation, or movement to a different clinical area, such as the operating theatre for haemorrhage control. In all cases early
involvement of senior staff is mandatory. Once the patient has
been stabilized, the primary survey should be followed by a full
secondary survey, including thorough history, case note and
chart review, detailed clinical examination and targeted investigation. Good outcomes rely on rapid identification of critical
illness, accurate diagnosis and definitive management. Simple
measures performed well can prevent irreversible deterioration
and save lives.
A

6
7

FURTHER READING
National Institute for Health and Clinical Excellence. Acutely ill patients
in hospital: recognition of and response to acute illness in adults in
hospital (NICE guideline no. 50). London: National Institute for
Health and Clinical Excellence, 2007.
National Patient Safety Agency. Recognising and responding appropriately to early signs of deterioration in hospitalised patients. Ref
no. 0683. London: National Patient Safety Agency, 2007.
Smith GB, Osgood VM, Crane S. ALERT e a multiprofessional
training course in the care of the acutely ill adult patient. Resuscitation 2002; 52: 281e6.

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ANAESTHESIA AND INTENSIVE CARE MEDICINE 17:1

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