Chapter 03. Recognising deterioration and preventing cardiorespiratory arrest

1. Importance of Early Recognition

• Clinical Deterioration: Most cardiac arrests in hospitals are preceded by observable signs of deterioration.
• Timely Intervention: Identifying and responding to these signs early improves survival rates.
• Failure to Rescue: Many cases of preventable deterioration occur due to delayed recognition, lack of monitoring, or inadequate clinical response.

2. Common Signs of Deterioration

• Changes in Consciousness: Reduced alertness, confusion, or unresponsiveness.
• Airway & Breathing Issues: Stridor, abnormal respiratory rates (<8 or >25 breaths/min), labored breathing.
• Circulatory Signs: Hypotension (systolic BP <90 mmHg), tachycardia (>130 bpm), cool/clammy skin.
• Oxygenation & Metabolic Changes: Low oxygen saturation (<90%), metabolic acidosis, lactate buildup.
• Other Warning Signs: Persistent pain, abnormal blood test results, poor urine output (<0.5 mL/kg/hr).

3. Systematic Assessment Using ABCDE Approach

A structured method for assessing and managing a deteriorating patient.

A – Airway

• Ensure a clear airway.
• Look for obstruction (e.g., swelling, foreign objects).
• Manage with airway positioning, suctioning, or advanced airway intervention.

B – Breathing

• Assess respiratory rate, effort, and oxygen saturation.
• Provide oxygen if necessary.
• Identify conditions like pneumonia, pulmonary edema, or pneumothorax.

C – Circulation

• Check pulse, blood pressure, capillary refill, and skin color.
• Manage shock with IV fluids, blood products, or vasopressors if needed.

D – Disability (Neurological Status)

• Use AVPU scale (Alert, Verbal response, Pain response, Unresponsive).
• Assess blood glucose levels.
• Consider causes such as stroke or sedation effects.

E – Exposure & Environment

• Look for hidden injuries, rashes, or infections.
• Maintain body temperature.

4. Monitoring Tools & Early Warning Scores

• Track & Trigger Systems: Use regular observations to track patient vitals and detect early signs of deterioration.
• Early Warning Score (EWS): A scoring system that assigns points based on abnormalities in vitals, triggering clinical intervention.
• National Early Warning Score (NEWS2): Standardized tool in the UK used to guide clinical response.

5. Escalation & Response Systems

• Rapid Response Teams (RRTs) or Medical Emergency Teams (METs): Specialized teams that intervene before full cardiac arrest occurs.
• SBAR Communication Tool: A structured way for healthcare professionals to communicate effectively:
  • S – Situation (What is happening?)
  • B – Background (Relevant history)
  • A – Assessment (What do you think is happening?)
  • R – Recommendation (What action is needed?)

6. Preventing Cardiorespiratory Arrest

• Continuous Monitoring: Frequent vital sign checks, bedside assessments.
• Timely Interventions: Addressing minor deterioration early to prevent worsening.
• Education & Training: Ensuring all healthcare staff recognize early warning signs.

Conclusion

Recognizing early deterioration is critical in preventing cardiac and respiratory arrest. A systematic approach (ABCDE), the use of early warning scores, and timely intervention by trained response teams significantly improve patient outcomes.