Immediate survival depends on urgent attention to the safety of the critically ill patient – the Airway, the Breathing, the Circulation. Subsequent progress depends on a more comprehensive assessment – by measuring Disability and Exposing the patient for detailed examination. This plan of immediate action based on the mnemonic ‘ABCDE’ is a recurring theme in the book – emphasising the critical importance of urgent and effective resuscitation. Urgent initial treatment may have to proceed in the absence of a definite diagnosis. However, a detailed assessment will be necessary to make a comprehensive diagnosis and to plan subsequent management; to do this requires a history, examination and an understanding of the underlying medical conditions. Each chapter therefore emphasises both the immediate safety of the patient and the nature, mechanisms and management of the underlying disease. The challenge for the nurse is to integrate this very technically demanding work with a humane and caring approach, combining modern clinical expertise with traditional nursing skills.

The first chapter gives an overview of the initial assessment and the early management which will be necessary to ensure the patient’s immediate survival. Fig. 1.1 provides a summary of the most urgent nursing observations – matched with the corrective interventions that may be necessary – and page references to relevant sections in the book. Detailed descriptions of resuscitation in specific conditions appear in later chapters.

It is important to develop a structured and systematic approach to immediate resuscitation. The focus should be on two fundamental issues: getting oxygen into the blood (Airway and Breathing) and getting blood (Circulation) to the brain and kidneys. The format for the initial assessment (→Fig. 1.1) is based on the primary survey performed by first response teams such as the ambulance crew, and is founded on the standard ABCDE system in which the most important observations are performed first and the problems that are identified are rectified before moving on to the next stage. The primary survey is repeated when the patient is admitted to the ward; its structure ensures that the immediate safety of the patient continues to be addressed.

Subsequent progress is monitored from a number of basic physiological measurements obtained using standard nursing observations (the ‘vital signs’):

In response to criticisms that critically ill medical patients are not recognised soon enough and that resuscitative measures are delayed, inadequate, or both, a number of tools have been developed that utilise the observation of vital signs to identify patients who are at risk. These tools, sometimes known as ‘Track and Trigger’ systems, are used to monitor progress (track) and to provide specific criteria which, when met, trigger a call for assistance with a view to urgent corrective intervention.

The aim is to prevent any patient passing through an unrecognised yet potentially reversible period of instability and deterioration. The most common events preceding a cardiac arrest or transfer to ITU are a falling blood pressure and a reduction in the level of consciousness.

The most common system in use scores each observation according to its value. For example, in the Modified Early Warning Score (MEWS), a urine output of less than 0.5ml/kg per hour scores 2 points, whereas between 1 and 3ml/kg per hour scores 0. Scores from each observation are added up, and the total used to determine the level of action. Depending on the total score, this will vary from a simple increase in the frequency of observations to an urgent review by middle-grade medical staff. It is important that there is an explicit protocol to match the score with the action that is required. As the score increases there should be an appropriate escalation of the response. The nature of the protocol will depend on local circumstances: in some Units, for example, the nurses are authorised to order tests and initiate treatments once a certain level of score is reached, whereas in others the response may simply be based on calling for escalating levels of assistance. In many Units, an important and effective development has been the availability of nurseled Critical Care Outreach Teams which can react rapidly to deteriorating warning scores by advising and initiating early interventions and liaising with the High Dependency Unit and Intensive Therapy Unit. Once the staff have responded and a management plan is in place, the assessment tools are used to monitor improvement and to provide a mechanism to ensure that patients who fail to improve are identified and re-assessed within explicit time-frames.

It is important, therefore, that any Early Warning protocol should have a time element within it. When every staff member is hard pressed and there are competing clinical priorities, it is vital that there is a clear and mutual understanding of the expected response times; in one system, for example, the maximum response time for a doctor is 1h for an oxygen saturation of 90% and a systolic blood pressure of 90mmHg, but 15min when both values are only 80. Another system specifies the following maximum time intervals: patient first triggering a response and the attendance of the doctor, 25min for an SHO; if the patient continues to trigger despite intervention, 70min for the registrar; if there is continuing concern, 120min for discussion with the on-call consultant.