Tutorial Week 4 Notes: Clinical Deterioration and Life Support
DRSABC
Basic Life Support (BLS)
Dangers?: Assess the surroundings for any potential hazards.
Responsive?: Check if the patient is responsive.
Send for help: Immediately call for assistance.
Open Airway: Ensure the airway is open and clear.
Normal Breathing?: Check if the patient is breathing normally.
Start CPR: If the patient is not breathing normally, begin cardiopulmonary resuscitation.
30 compressions: 2 breaths: Administer 30 chest compressions followed by 2 breaths.
Attach Defibrillator (AED):
As soon as available, follow prompts.
Continue CPR: Continue CPR until responsiveness or normal breathing returns.
Adult Advanced Life Support Algorithm
Assess Rhythm
Shockable: If the rhythm is shockable, administer a shock.
Continue CPR for 2 minutes.
30 compressions: 2 ventilations: Maintain a compression-to-ventilation ratio of 30:2.
Minimise interruptions: Avoid pauses during CPR.
Attach Defibrillator / Monitor.
Drugs
Adrenaline 1mg after 2nd shock, then every 2nd cycle.
Amiodarone 300mg after 3 shocks.
Non-Shockable: If the rhythm is non-shockable, continue CPR for 2 minutes.
During CPR:
Airway adjuncts (SGA or ETT).
Oxygen.
Waveform capnography.
IO or IV access.
Plan actions before interrupting CPR (e.g., charge defibrillator).
Drugs
Adrenaline 1mg immediately, then every 2nd cycle.
Consider and correct: Address reversible causes, including:
Hypoxia
Hypovolaemia
High or low electrolytes (K, Ca, Mg) & metabolic disorders
Hypothermia or hyperthermia
Tension pneumothorax
Tamponade
Toxins
Thrombosis (pulmonary or coronary)
Return of Spontaneous Circulation: Post Resuscitation Care
Post Resuscitation Care
Re-evaluate ABCDE.
12 lead ECG plus CXR.
Treat precipitating cause.
Aim for SpO_2 94-98%, normocapnia, normoglycaemia.
Temperature control.
Paediatric Basic Life Support (PBLS)
Steps:
Responsive?: Check for responsiveness.
Send for help: Call for assistance.
Open airway: Open the airway.
Normal breathing?: Check for normal breathing.
Give 2 breaths: If not breathing, give 2 breaths.
Check for signs of life +/- check pulse: Check for signs of life and pulse.
Start CPR: If no signs of life, start CPR.
15 compressions: 2 breaths: Administer 15 compressions followed by 2 breaths.
Attach defibrillator / monitor: Attach defibrillator/monitor.
Ensure help is coming: Make sure help is on the way.
Continue CPR: Continue CPR until responsiveness or normal breathing returns.
Differences from Adult BLS
Compression to ventilation ratio
Paediatric Acute Recognition and Response Observation Tool (Age 5-11 years)
General Instructions:
Include the parent/carer in determining what is normal for their child and what may have changed.
To obtain an Early Warning Score all observations must be recorded
Record the observation as a dot; connect to previous dot with a straight line to represent a graph
Any observation outside graph area or in a coloured area must be written as a number in allocated box
Always refer to local process
A full set of observations must be completed:
At time of initial presentation/admission to area and as appropriate for the patient's clinical condition
When a patient is experiencing, or at risk of experiencing, an episode of acute deterioration
When the clinician or family are worried about the patient.
If observation falls within coloured area:
A full set of observations must be completed
Refer to EWS Escalation or Sepsis Recognition Escalation Pathway for action plan, unless a modification has been made: refer to local process
Modification to Early Warning Score (EWS)
Acceptable parameters can be modified based on the patient's specific clinical, treatment and/or pre-existing conditions.
All modifications must adhere to local process and be reviewed frequently by the treating consultant.
Modifications must NEVER be used to normalise a clinically unstable patient.
Key Considerations:
Acknowledge parental concern - they know their child best
Increasing oxygen requirement
Changes in circulation (e.g. mottled/pallor)
Altered mental state
Involve the family
Engage with the parent/carer to agree a management plan and escalation criteria
Patients of concern include those with:
Greater than expected fluid loss
Reduced urine output (<1mL/kg/hr)
New, increasing or uncontrolled pain
Assessment of respiratory distress
If applicable assess observations with parent/carer to review parental concern
Blood glucose level <3mmol/L
Family or clinician worried
Changes to respiratory distress
Instructions for scoring:
Select the score related to the highest criteria obtained for the patient's clinical condition
Airway is assessed for stridor
Behaviour and feeding are assessed.
Respiratory rate pattern
Work of breathing is assessed
Level of Consciousness (AVPU)
ALERT: Awake and alert
VOICE: Responds to verbal stimuli
PAIN: Responds to painful stimuli
UNRESPONSIVE: No response to stimuli
Level of Sedation (UMSS-University of Michigan Sedation Scale)
ONLY complete if sedation administered as per local policy
0 = Awake and alert
1 = Minimally sedated: may appear tired/sleepy, responds to verbal conversation and/or sound
2 = Moderately sedated: somnolent/sleeping, easily roused with tactile stimulation or simple verbal command
3 = Deep sedation: deep sleep, rousable only with deep or physical stimulation
4 = Unrousable
Pain Scales Used:
FLACC
FPS-R
Numeric
Early Warning Score (EWS) Escalation Pathway
Score and Clinical Response:
1-3: Remain vigilant, complete a full set of observations, notify nurse in charge, optimise treatment. A plan must be documented. Reassess EWS after interventions. Consider transfer to higher care. Responders to ensure patient team are aware of deterioration
4-5: Timely Medical Review - Request treating medical team/RMO to review within 30 mins. Reassess observations within 30 mins, of Medical Review
6-7: Urgent Treating Team Review - Request Senior Medical or Consultant to review within 15 mins. Consider Emergency Telehealth Service/Critical Care referral/transfer of care. Reassess observations within 15 mins. of Urgent Medical Review
8+: Rapid Response Review/MET - Request Senior Medical/Consultant review within 5 mins. Assess the patient and initiate appropriate clinical care. If no response within 5 mints, or if clinically concerned place a Medical Emergency Call/ Code Blue
Immediate Medical Emergency Call/Code Blue:
Emergency response team with APLS equipment and skills
Initiate BLS and/or APLS as required
Emergency Call for any of the following:
Severe respiratory distress
Airway threat
Cardiac or respiratory arrest
Apnoea or cyanosis
Seizure/prolonged convulsion
Major bleeding
Any observation in the purple zone
You are worried about the patient
Assessment Parameters:
Respiratory Rate: Documented in breaths/minute.
O₂ saturations: Documented in percentage.
O₂ therapy: Mode of O₂ delivery and litres/minute.
Heart rate: Documented in beats/minute.
Blood pressure: Documented in mmHg.
Capillary refill time: Documented in seconds.
Level of consciousness: Using AVPU scale
Temperature: Documented in °C, If suspected infection or temperature <36°C consider sepsis.
Pain scale: Documented and consider review for unrelieved or unexpected pain.
Sepsis Recognition Escalation Pathway
When to Use:
If suspected infection OR abnormal temperature (<36°C or >38°C)
Consider sepsis, bacterial infection and need for antibiotics.
*If sepsis recognition prompt not triggered, respond as per early warming score.
High-Risk Patients (lower threshold for medical review):
Infants less than 3 months
Immunosuppression, chemotherapy, long-term steroids or asplenia
Invasive devices
Recent surgery, burn or wound
Unimmunised/incomplete immunisation
Rural, remote or low socioeconomic status
Re-presentation or delayed presentation
Sepsis recognition prompt:
EWS 6-7 OR any of the following
Mottled, CRT >3 or cold peripheries
Non-blanching rash
Drowsy or confused
Unexplained pain
Lactate 2-4 mmol/L
Family and/or clinician concern is continuing or increasing
EWS 8+ OR any of the following
Any observation in red Zone
AVPU score P
Lactate >4 mmol
BSL <3 mmol/L
Clinical Response:
Urgent Medical Review
Request treating medical team or Registrar review within 15 mins
State sepsis review required
Refer to local paediatric sepsis guideline
Reassess observations within 15 mins. Consider Emergency Telehealth Service/Critical Care referral or transfer to higher level of care
Rapid Response Review
Request senior medical or consultant review within 5 mins
State sepsis review required
Refer to local paediatric sepsis guideline
Assess the patient and initiate appropriate clinical care
Action is per local process
Adult Deterioration Detection System (ADDS)
If any observation is in a shaded area, add up the Total ADDS Score and take the action required for that score.
Emergency call if:
Any observation is in a purple area
Airway threat
Respiratory of cardiac arrest
New drop in saturation < 90%
Sudden fall in level of consciousness
Seizure
You are seriously worried about the patient but they do not fit the above criteria
Actions Required
Total ADDS Score 1-3
Increase frequency of
observations [specify frequency]
Inform senior nurse and/or Team
Leader
Total ADDS Score 4
Senior nurse and/or junior medical
officer review within 30 minutes
e SS
Total ADDS Score E
Senior medical officer review
(registrar or above) within 30
minutes
Request re@ew and note on the
back of this for
Total ADDS Score
Place Emergency call
Begin initial life support
interventions (support airway,
breathing coulation)
Advanced life support provider to
attend patient immediately
e