01Principles and purposeThe professional or clinical skill and the decisions it supports.
Start with scene and system. Check hazards, infection risk, aggressive behaviour, traffic, pets, smoke, electricity and space. State the exact address, access code and landmarks to emergency services and send someone to guide the crew if possible. Ask a colleague to bring the emergency trolley and automated external defibrillator. If alone, call early on speakerphone. Establish whether resuscitation or emergency care plans exist, but do not infer a treatment limitation from age, disability, residence in a care home or an incomplete record.
The ABCDE approach identifies and treats what kills first. At Airway, look for obstruction, swelling, vomit, blood, abnormal sounds and inability to speak. Open the airway with an appropriate manoeuvre, remove visible obstruction only when accessible and use adjuncts within training. At Breathing, assess rate, effort, symmetry, oxygen saturation and air entry; support oxygenation or ventilation according to current emergency guidance and the clinical context. Reassess after intervention rather than assuming improvement.
At Circulation, inspect colour, temperature, capillary refill and bleeding; palpate pulse and measure blood pressure when it does not delay care. Control catastrophic external bleeding with direct pressure and appropriate dressings. Position and support the patient according to physiology and condition. At Disability, assess responsiveness, pupils when relevant, glucose and seizure activity. At Exposure, look for rash, injury, swelling, bleeding, medical-alert information or injection sites while preserving dignity and temperature.
Observations add precision but do not replace judgement. Respiratory rate is often an early marker of deterioration and deserves an actual count. Compare readings with prior values, repeat abnormal measurements and consider device limitations such as poor perfusion, movement, nail products or carbon monoxide exposure. A normal oxygen saturation does not exclude shock or metabolic illness; a normal early blood pressure does not make a deteriorating child safe. Scores support escalation only within the population and setting for which they were designed.
Time-critical patterns include acute coronary syndrome, stroke, sepsis, anaphylaxis, severe asthma, pulmonary embolism, ectopic pregnancy, major haemorrhage, meningitis, status epilepticus, hypoglycaemia and poisoning. Pattern recognition must trigger action while the differential stays open. For suspected stroke, establish last known well time, glucose, anticoagulant use and baseline function without delaying transfer. For chest pain, instability, ongoing pain, arrhythmia or associated breathlessness strengthens urgency; a normal single community ECG cannot safely exclude acute coronary syndrome.
NICE replaced NG51 with population-specific sepsis guidance. For people aged 16 or over who are not and have not recently been pregnant, any high-risk criterion in the community warrants emergency medical referral, usually a 999 ambulance. Moderate-to-high risk requires assessment that reaches a definitive diagnosis and determines whether care outside hospital is safe; if either cannot be achieved, urgent emergency referral follows. Use the correct current pathway for children and for pregnancy or recent pregnancy because thresholds and physiological context differ.
Key points
- Make the scene safe, use personal protective equipment where indicated, confirm exact location and call for help early; a lone clinician should use speakerphone while continuing assessment.
- Use ABCDE, treating a life-threatening problem as it is found before moving on, then repeat the sequence after each intervention or clinical change.
- Do not delay 999 transfer to finish a full history, obtain routine tests or reach a precise diagnosis when physiology or a high-risk pattern already mandates emergency care.
- Record respiratory rate, oxygen saturation, pulse, blood pressure, temperature, consciousness and glucose when feasible, but interpret trends and the whole patient rather than a single score.
- Use only equipment and emergency medicines for which you are trained and authorised, follow current local emergency protocols and check expiry, access and readiness regularly.
- A safe transfer includes identity, working diagnosis, onset and trajectory, ABCDE findings and trends, treatments with times and response, allergies, medicines, relevant history and safeguarding or access concerns.
- If the patient remains in the community, give diagnosis-specific written and verbal safety-netting, a definite reassessment interval and a route that remains available if symptoms worsen.
- After the event, restore equipment, document contemporaneously, notify usual care teams, report safety incidents and support involved patients, relatives and staff.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Stridor, silent chest, exhaustion, central cyanosis, inability to speak, falling consciousness or severe work of breathing needs immediate 999 support and ABCDE treatment.
Cool mottled skin, weak pulse, delayed refill, hypotension, major bleeding or altered mentation signals impaired perfusion even before a cause is established.
New focal deficit, seizure, sudden severe headache, confusion or reduced consciousness requires glucose assessment and emergency disposition matched to the presentation.
Use the current age and pregnancy-specific NICE criteria; high-risk adult findings in the community require emergency medical referral, usually by 999 ambulance.
Frailty, immunosuppression, pregnancy, very young age or communication difficulty can blunt fever, pain or tachycardia and should lower the threshold for reassessment.
Clinical stability is insufficient when the patient cannot understand advice, obtain medicines, summon help, maintain hydration or access timely review.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Immediate ABCDE assessment - Why
- Identify and treat life-threatening physiology in priority order.
- Interpretation and limitations
- Treat each critical finding before moving on and repeat the sequence after interventions, transfer decisions or deterioration.
- 02
Core physiological observations - Why
- Quantify severity and establish a trend for handover.
- Interpretation and limitations
- Record respiratory rate, saturation, pulse, blood pressure, temperature and consciousness when feasible; a single normal value does not overrule concerning presentation.
- 03
Capillary blood glucose - Why
- Detect a rapidly reversible contributor to altered behaviour, collapse or seizure.
- Interpretation and limitations
- Treat according to the current emergency protocol and recheck response; normal glucose does not end the neurological assessment.
- 04
Focused point-of-care test within competence - Why
- Answer a disposition-changing question without delaying definitive care.
- Interpretation and limitations
- An ECG, urinalysis or ketone measurement is useful only if technically adequate and interpreted in context; a normal result rarely excludes all serious causes.
- 05
Capacity and environment assessment - Why
- Determine whether refusal or continued home care can be managed safely.
- Interpretation and limitations
- Assess the specific decision, reversible impairments, support, access and follow-up; document why the plan remains feasible.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked case: collapse in the waiting roomStabilise, summon and hand overA 72-year-old becomes pale and unresponsive for about twenty seconds, then wakes confused with a weak rapid pulse and chest discomfort.+
- 1Call 999, bring the defibrillator and emergency equipment, position safely and assess Airway and Breathing while a colleague records times and obtains the patient record.
- 2Continue Circulation, Disability and Exposure: control any bleeding, obtain pulse, pressure, saturation, respiratory rate, glucose and ECG only if it does not delay care; treat life-threatening findings within competence.
- 3The final action is emergency transfer because collapse, ongoing chest discomfort, confusion and abnormal circulation create an unstable time-critical presentation; the patient must not self-transport.
- 4Repeat ABCDE, record trends and treatment response, then verify transfer with an SBAR handover containing onset, loss-of-consciousness duration, observations, ECG if obtained, medicines and allergies, interventions and exact times.
02Suspected adult sepsisApply current community risk criteriaInfection is possible and the adult has physiological or behavioural deterioration.+
- 1Use the current NICE adult sepsis criteria and obtain observations without delaying immediate treatment.
- 2Refer any high-risk presentation for emergency care, usually by 999, and urgently refer when moderate-to-high risk cannot be definitively diagnosed or safely treated outside hospital.
- 3Communicate suspected source, onset, risk factors, observations and deterioration; repeat assessment while awaiting transfer.
03Patient declines transferAddress risk, capacity and barriersEmergency assessment is advised but the patient says they will remain at home.+
- 1Treat immediate reversible problems and assess capacity for this specific decision, including understanding, retention, weighing and communication.
- 2Explain the likely risks, uncertainty, proposed transfer and alternatives; explore fear, cost, caring duties, previous trauma or practical barriers.
- 3Seek senior and emergency-service support, document the decision, and create the safest achievable active follow-up and safety net if a capacitous refusal persists.
04Stable but time-sensitiveBuild an active community safety netNo immediate instability is found, but diagnosis or trajectory could worsen before routine review.+
- 1Define the working diagnosis, unresolved risks and expected clinical course.
- 2Arrange treatment, a definite review time and ownership of investigations rather than leaving an open invitation.
- 3Give specific deterioration thresholds and verify access, understanding and support before the patient remains at home.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Repeat ABCDE and core observations after every intervention, during any wait for transport and whenever symptoms or behaviour change.
- Record exact times for onset, emergency call, deterioration, medicines, defibrillation, clinical response, ambulance arrival and handover where relevant.
- For patients remaining at home, arrange a named clinician or service to reassess at the specified interval and act if contact fails.
- Check that urgent referrals reach the intended destination and that critical results or ambulance non-conveyance decisions return to the practice for review.
- Restore emergency bags, oxygen, medicines and defibrillator consumables immediately after use and log expiry and readiness checks.
- Review emergencies and near misses with the team for address, access, equipment, role clarity, communication and escalation lessons.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Disposition precedes precision
When physiology is unstable, selecting emergency transfer is more urgent than naming the exact pathology.
Reassessment detects trajectory
An intervention can temporarily improve one sign while another system deteriorates, so repeat the whole ABCDE sequence.
Normal tests have boundaries
A single ECG, saturation or blood pressure in the community cannot erase a high-risk history or rapidly changing clinical picture.
Handover has a time axis
Trends and exact intervention times are more useful to the receiving team than an undifferentiated list of observations.
Refusal may reveal a barrier
Fear, caring responsibility, previous discrimination or transport concerns should be addressed before assuming the patient simply rejects care.
Simulation tests the system
Short drills reveal locked cupboards, expired supplies, uncertain roles and poor location information before a real emergency.
07Common pitfallsFrequent interpretation and management errors.
- 01
Do not complete a comprehensive history before calling for help when immediate instability is apparent.
- 02
Do not rely on a scoring system outside its intended population or allow a low score to overrule clinical deterioration.
- 03
Do not send an unstable patient to hospital by private car or without an appropriate escort.
- 04
Do not use a normal single ECG or oxygen saturation to exclude a serious time-critical diagnosis.
- 05
Do not apply adult sepsis thresholds to children or pregnant and recently pregnant people.
- 06
Do not give emergency medicines or use equipment beyond current training, authorisation and protocol.
- 07
Do not interpret a refusal as capacitous until the specific decision and reversible barriers have been assessed.
- 08
Do not leave a vulnerable patient with passive advice when active follow-up is needed.