Deteriorating patient and ICU triage

ABCDE approach to the deteriorating patient

Reviewed Nov 2026·4 references
New· views rounded down, updated weekly

Structured head-to-toe assessment that treats life threats as they are found, before a diagnosis is made.

Definition
ABCDE = Airway, Breathing, Circulation, Disability, Exposure. Assess and treat each step in order; reassess after every intervention and call for help early.

At the bedside

Timed steps
  1. 1

    Safety, response and help

    0 min

    Approach safely, ask 'Are you all right?'. If no response and not breathing normally, start CPR and call the code team (go to Cardiac arrest module). If responsive but sick, call for senior help early and attach monitoring (SpO2, ECG, NIBP).

  2. 2

    A - Airway

    0-1 min

    Look, listen, feel: talking = patent. Signs of obstruction: stridor, gurgling, see-saw breathing, silence with effort. Head tilt-chin lift / jaw thrust, suction, oro- or nasopharyngeal airway; give high-flow O2 15 L/min via non-rebreather. Anaphylaxis or burns: early anaesthetic help.

  3. 3

    B - Breathing

    1-3 min

    Count RR (normal 12-20), SpO2, work of breathing, chest expansion, trachea, percussion, auscultation. Treat: target SpO2 94-98% (88-92% if hypercapnic risk), nebulise bronchospasm, decompress tension pneumothorax, sit up. Send ABG.

  4. 4

    C - Circulation

    3-6 min

    HR, BP, CRT (> 2 s abnormal), skin colour and temperature, JVP, urine output. Two large-bore cannulae (16-18G), send bloods incl. lactate, cultures, cross-match. Hypotension: 250-500 mL crystalloid bolus and reassess; look for bleeding, sepsis, cardiac cause. 12-lead ECG.

  5. 5

    D - Disability

    6-8 min

    AVPU or GCS, pupils, capillary glucose (treat < 70 mg/dL), lateralising signs, seizures, drugs (opioids, sedatives). Protect the airway if GCS ≤ 8 or falling, unless rapidly reversible (e.g. hypoglycaemia, opioid).

  6. 6

    E - Exposure

    8-10 min

    Fully expose with dignity: temperature, rashes (meningococcal, dengue petechiae), wounds, drains, bleeding, calf swelling, pressure areas, bite marks (snakebite). Check charts, drug chart and fluid balance.

  7. 7

    Reassess, escalate, document

    10-15 min

    Repeat ABCDE after every intervention. Communicate with ISBAR to the senior/ICU, decide ceiling of care and destination (ward with closer monitoring, HDU, ICU). Write a timed note with NEWS2 and plan.

First treatment in A/B

Oxygen

Non-rebreather / nasal / Venturi
Dose
15 L/min non-rebreather if critically ill; then titrate to SpO2 94-98% (88-92% if hypercapnic risk)
Target
SpO2 94-98% or 88-92%

Fluid challenge in C

Balanced crystalloid (Ringer lactate / Plasma-Lyte)

IV
Dose
250-500 mL over 10-15 min, reassess
Worked example
70 kg with SBP 82 and cold peripheries: 500 mL RL over 15 min, recheck BP, HR, CRT, chest

Stop at signs of fluid intolerance; think early vasopressor if MAP < 65 mmHg persists.

Hypoglycaemia in D

Dextrose 25% (or 50%)

IV
Dose
25 g (100 mL 25% dextrose)
Target
Glucose > 70 mg/dL, recheck at 15 min

ABCDE quick reference

StepLook forImmediate actions
AStridor, gurgling, snoring, paradoxical movement, silenceAirway manoeuvres, suction, OPA/NPA, O2 15 L/min, call anaesthesia
BRR < 8 or > 25, SpO2 < 92%, accessory muscles, unequal air entryTitrated O2, nebulisers, sit up, needle decompression, ABG, CXR/ultrasound
CHR > 130 or < 40, SBP < 90, CRT > 2 s, mottling, oliguriaIV access x2, bloods + lactate, fluid bolus, ECG, stop bleeding
DGCS fall ≥ 2, glucose < 70 mg/dL, unequal pupils, seizureGlucose, naloxone if opioid, benzodiazepine for seizure, protect airway
EFever/hypothermia, rash, bleeding, wounds, bitesCultures, antibiotics if sepsis, warming/cooling, source search
Red flag · call your senior now
Airway obstruction, RR < 8 or > 30, SpO2 < 90% on oxygen, SBP < 90 mmHg, GCS drop ≥ 2 points or new seizure: call for senior/ICU help now.
Red flag
Silent chest in asthma, stridor in anaphylaxis or burns, and gurgling in a patient with low GCS are pre-arrest airway signs.
Pitfall
Moving to C before fixing A or B. A hypoxic patient needs oxygen before a CT scan.
Pitfall
Normal BP does not mean no shock: tachycardia, cold peripheries, rising lactate and oliguria come first, especially in young patients and those on beta-blockers.
Pitfall
Forgetting the capillary glucose in every confused or drowsy patient.
Pearl
Say findings aloud and delegate one task per person: one on airway, one on IV and bloods, one on monitoring and documentation.
Pearl
Ask 'What is the ceiling of care?' early. It shapes escalation and avoids non-beneficial ICU admission.

Calculators for this topic

NEWS2

National Early Warning Score 2 (SpO₂ scale 1).

Glasgow Coma Scale

Eye + Verbal + Motor (3-15). Record components, e.g. E3 V4 M5.

Shock index

Heart rate ÷ systolic BP.

Mean arterial pressure

(SBP + 2 × DBP) ÷ 3 (estimate; use the arterial line value when available).

References

  1. 1

    Resuscitation Council UK. The ABCDE approach (adult). London: RCUK; current version.

  2. 2

    Thim T, Krarup NH, Grove EL, Rohde CV, Lofgren B. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med 2012;5:117-21.

  3. 3

    Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial (MERIT). Lancet 2005;365:2091-7.

  4. 4

    Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007;35:1477-83.

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