INTENSIVE CARE

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

Laura C Robertson
Mohammed Al-Haddad

Abstract
Critical illness is a life-threatening multisystem process that can result in
significant 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 life-threatening problems by
priority and provides a standardized approach between professionals.
Good outcomes rely on rapid identification, diagnosis and definitive treatment and all doctors should possess the skills to recognize the critically ill
patient and instigate appropriate initial management.

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. Simple, appropriate treatment can improve outcomes, for example early administration of
antibiotics in patients with an infective cause of critical illness (e.g.
meningitis, pneumonia, septic shock) improves chances of
recovery.
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
unreliable 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. Use of early-warning scoring systems can highlight
subtle physiological derangement (Table 1). 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).
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 between 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; MET, medical emergency teams; 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; however, the end result is a multisystem progression that ultimately involves respiratory, cardiovascular and neurological compromise. 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

A e Assessment of airway
Laura C Robertson MBBS FRCA is an Anaesthetic Registrar in the West of
Scotland, Scotland. Conflicts of interest: none declared.

Complete airway obstruction is silent but normally accompanied

by exaggerated respiratory effort (see-saw breathing) until the
point of cardio-respiratory collapse. Partial airway obstruction
results in noisy breathing (gurgling, snoring, etc). Stridor
suggests large airway obstruction and hoarseness implies
involvement of the vocal cords. Both are worrying signs and

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

a Consultant in Anaesthesia and Intensive Care at the Western Infirmary
of Glasgow, Scotland. Conflicts of interest: none declared.

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INTENSIVE CARE

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 7.3 but 7.2:
29.0 (3.1268.3)

pH 7.2:
116.1 (7.11906.1)

Base deficit 5 to 8 mmol/litre:

40.2 (7.7208.8)

Base deficit 8 mmol/litre:

29.0 (3.1268.3)

Drain fluid loss expected:

30.1 (6.1148.9)

Urine output 200ml in

24 hours:
188.6 (30.11179.8)
Anuric:
29.0 (3.1268.3)

Adapted from the SOCCER study

Figure 1

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 risk of cervical spine injury manual in-line stabilization 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. Early
request for senior help can be life saving. Infectious (e.g.

Example of an early-warning scoring system

The modified 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 five-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 qualified professional.
Score

Systolic blood pressure

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

<45% Y
d
d
d
e

30% Y
<40
<9
<35
e

15% Y
41e50
d
d
e

Normal for patient

51e100
9e14
35.0e38.4
Alert

15% [
101e110
15e20
d
Voice

30% [
111e129
21e29
>38.5
Pain

>45% [
>130
>30
d
Unresponsive

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

Table 1

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INTENSIVE CARE

Medicine 2010; 11(12): 509e511. The causes of shock can be

broadly categorized as pump failure (cardiogenic shock) or
peripheral circulatory failure (see Ischaemic Cardiogenic Shock,
Anaesthesia & Intensive Care Medicine 2010; 11(12): 519e522).
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, for example young,
fit adults, pregnant women or patients on b-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 valuable information: a decrease in
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. Hyperlactataemia is a marker of critical illness and
associated with increased morbidity and mortality.5 Early
measurement of lactate with continued monitoring and treatment
aimed at active reduction may improve clinical outcomes.6
In all shocked patients large-bore intravenous 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
readings. Invasive monitoring can aid diagnosis and guide fluid
administration. Central venous access is also of value in patients
who fail to response to adequate ventricular filling and require
inotropic support.

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.

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. 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 kPa (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, non-invasive, or invasive ventilation. This should be
discussed with a senior clinician.

D and E e Assessment of disability and exposure

The patients neurological status should be assessed using the
Glasgow Coma Scale. 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, for example those with trauma, on anticoagulation,
with focal neurological deficits or papillary abnormalities or 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.7 The patient should be fully exposed and examined,
while avoiding hypothermia and maintaining patient dignity.
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

C e Assessment of circulation
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
Causes and Investigation of Shock, Anaesthesia & Intensive Care

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5 Nichol A, Bailey M, Egi M, et al. Dynamic lactate indices as predictors

of outcome in critically ill patients. Crit Care 2011; 15: R242.
6 Jansen TC, van Bommel J, Schoonderbeek FJ, et al. LACTATE Study
Group. Early lactate-guided therapy in intensive care unit patients:
a multicenter, open-label, randomized controlled trial. Am J Respir Crit
Care Med 2010; 182: 752e61.
7 Jurkovich GJ, Greiser WB, Luterman A, Curreri PW. Hypothermia in
trauma victims: an ominous predictor of survival. J Trauma 1987; 27:
1019e24.

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

REFERENCES
1 McQillan P, Pilkington S, Allan A, et al. Confidential enquiry into
quality of care before admission to intensive care. Br Med J 1998;
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2 Zimmerman JE, Knaus WA, Sun X, Wagner DP. Severity stratification
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World J Surg 1996; 20: 401e5.
3 McGloin H, Adam SK, Singer M. Unexpected deaths and referrals to
intensive care of patients on general wards: are some cases potentially avoidable? J R Coll Physicians Lond 1999; 33: 255e9.
4 Department of Health. Competencies for recognising and responding to
acutely ill patients in hospital, http://www.dh.gov.uk/publications; 2009.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 14:1

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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