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Target exams

Red flags

• In-hospital cardiac arrest is rarely sudden — approximately 80 per cent of patients show documented physiological deterioration in the hours before arrest, and the respiratory rate is the vital sign most often abnormal and most often missed
• A rising respiratory rate with falling oxygen saturation is the single earliest and most reliable marker of deterioration; a normal heart rate and blood pressure do not exclude it, because they are late-failing compensatory mechanisms
• NEWS2 of 7 or more is a clinical emergency mandating an emergency assessment by a clinician with critical care competencies within minutes, not hours — and a score of 5 or 6 requires urgent ward-based review
• Altered mental state in a deteriorating ward patient is a late sign of shock or sepsis until proven otherwise — a new confusion or reduced GCS is a MET-call criterion in its own right
• The patient whose Early Warning Score is rising on consecutive observations is deteriorating regardless of where the absolute score sits — the trend is more informative than any single value
• A systolic blood pressure that appears acceptable may be masking decompensation in a chronically hypertensive patient — a systolic of 110 in someone whose baseline is 170 is a 60 mmHg drop and represents significant shock
• Oxygen saturation is a lagging indicator — by the time SpO2 falls, the patient has already exhausted respiratory reserve; respiratory rate and effort are the leading indicators
• Never intubate a patient you cannot oxygenate and ventilate with a bag-valve-mask — call for senior airway help at the first sign that basic airway manoeuvres are failing