Synopsis
Build a defensible sequence of immediate treatment, focused assessment and escalation when a surgical patient becomes acutely unwell, and communicate the working diagnosis without waiting for certainty.
- Identify the immediate physiological threat before deciding which abdominal diagnosis best explains it.
- Assess and treat airway, breathing and circulation sequentially while colleagues obtain observations, access and relevant records.
- Establish the procedure performed, postoperative day, trajectory and treatments already given; a change from baseline may be more informative than one value.
Key red flags
New confusion, worsening perfusion or a rising oxygen requirement after surgery warrants urgent reassessment even when the abdomen is initially soft.
Observe whether the patient can speak, the work of breathing, skin perfusion and engagement with the surroundings. Ask the bedside nurse what prompted the call. If the patient is unexpectedly drowsy after an opioid, assess ventilation and airway protection immediately rather than assuming normal postoperative sleep. A pulse oximeter can look reassuring during supplemental oxygen despite inadequate ventilation.
Reasoning priorities
Define the physiological problem and identify reversible causes without leaving the bedside.
Record respiratory rate, saturation with oxygen delivery, pulse, blood pressure, temperature and conscious level, and calculate the local early warning score accurately. Check glucose in altered consciousness. Interpret the score alongside clinical concern; neither a low total nor one plausible explanation for an abnormality removes the need to assess a deteriorating patient.
Worked reasoning
Six hours after abdominal surgery, a previously alert adult becomes confused. Pulse has risen from 84 to 122/min, systolic pressure has fallen from 132 to 100 mmHg and the nurse reports a new oxygen requirement. The wound dressing is dry.
- Call for immediate senior assistance and begin ABCDE assessment. Allocate monitoring and vascular access while personally checking airway, ventilation and perfusion; do not send the patient unaccompanied for a routine chest radiograph.
- Frame the differential around the actual threats: concealed haemorrhage, respiratory failure, infection and cardiopulmonary events. A dry dressing excludes neither intraperitoneal blood loss nor another concealed source. Obtain the operation and anaesthetic records without interrupting treatment.
- Collect targeted blood and blood-bank samples, review drugs and examine the chest, abdomen and drains. Provide oxygen and cause-directed resuscitation, and activate the major haemorrhage pathway if ongoing bleeding is suspected from the clinical assessment.
- The immediate decision is urgent joint surgical and anaesthetic review in a monitored setting, with definitive investigation or intervention determined there. A normal early haemoglobin, if returned, would not be permission to defer that review.
- Verify that the call has been accepted, repeat the physiological assessment after interventions and document which measurements improve or worsen. Hand over the remaining diagnostic uncertainty and the next decision deadline, not merely the list of tests sent.