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Dengue Viruses and Severe Dengue: EMT Assessment and Emergency Management

Why dengue requires careful reassessment. Dengue is a mosquito-borne viral infection that may improve after several days of fever or suddenly enter a critical phase with plasma leakage, shock, severe bleeding or organ impairment. The temperature may fall just as the patient deteriorates. Management is therefore guided by warning signs, perfusion, urine output, haematocrit trend, fluid balance and organ function—not by fever alone. Use current Ministry of Health, WHO and facility protocols.

1. Learning objectives

Describe dengue transmission, clinical phases and risk factors for severe disease.
Recognise warning signs, compensated shock, hypotensive shock, severe bleeding and organ impairment.
Perform a focused ABCDE assessment and identify important differentials such as malaria, sepsis, VHF and chikungunya.
Explain oral hydration, cautious IV fluid therapy, monitoring and criteria for referral/admission.
Apply safe analgesic, antipyretic, bleeding and transfusion principles.
Provide nursing care, mosquito-control advice, discharge safety-netting and outbreak prevention.

2. Definition, virus and transmission

Dengue is caused by dengue virus serotypes DENV-1, DENV-2, DENV-3 and DENV-4 and is transmitted mainly by infected Aedes mosquitoes. The mosquito often bites during daylight hours and breeds in small collections of clean standing water around homes, schools, health facilities and workplaces. A person with viraemia can infect mosquitoes that bite them; ordinary direct person-to-person spread is not the usual route, although blood, organ, pregnancy-related and sexual transmission have been described in specific circumstances.

Most infections are asymptomatic or mild. A second infection with a different serotype, infancy with maternal antibodies, pregnancy, very young/older age and major comorbidity can increase the risk of severe disease, but severe dengue can occur in anyone.

3. Clinical phases

Phase	Typical timing and features	What the EMT must do
Febrile phase	Usually 2–7 days of high fever, headache, retro-orbital pain, myalgia/arthralgia, nausea, vomiting, rash and fatigue	Assess hydration, malaria/VHF risk and warning signs; give safe oral fluids and paracetamol if appropriate.
Critical phase	Often around defervescence, approximately illness days 3–7; plasma leakage may cause rising haematocrit, pleural effusion, ascites, tachycardia and shock	Do not be reassured by falling fever. Observe closely, reassess after fluids and transfer warning-sign patients.
Recovery phase	Reabsorption of leaked fluid, improved appetite, stable perfusion, diuresis and sometimes a convalescent rash	Reduce IV fluid as perfusion improves; watch for fluid overload and pulmonary oedema.

Key warning: the 24–48 hours after fever settles can be the most dangerous period. A cooler patient may be entering shock, not recovering.

4. History and risk assessment

4.1 Symptom history

Day of illness and exact time fever began or settled.
Abdominal pain/tenderness, persistent vomiting, diarrhoea and ability to drink.
Nose/gum bleeding, heavy menstruation, haematemesis, melaena, haematuria or unusual bruising.
Breathlessness, chest pain, cough, restlessness, lethargy or reduced urine.
Severe headache, seizures, confusion, weakness or visual symptoms.

4.2 Exposure and host factors

Residence or travel in a dengue-affected area and mosquito exposure.
Previous dengue illness, pregnancy, infancy, older age or chronic liver, renal, cardiac or haematological disease.
Use of aspirin, ibuprofen, diclofenac, anticoagulants, antiplatelets, steroids or traditional remedies.
Potential malaria, VHF, COVID-19, typhoid or other infection exposure.

5. Warning signs and severe dengue

Warning sign	Why it matters	Action
Severe abdominal pain or tenderness	May indicate plasma leakage, organ involvement or an alternative surgical abdomen	Urgent clinician review and close observation/admission.
Persistent vomiting	Prevents oral hydration and accelerates dehydration	Measure losses, check perfusion and consider supervised IV therapy.
Clinical fluid accumulation	Pleural effusion or ascites may signal leakage	Monitor breathing, lung signs, oxygen need and fluid response.
Mucosal bleeding	May precede severe bleeding or reflect thrombocytopenia/coagulopathy	Avoid NSAIDs and trauma; assess haemoglobin/platelets and escalate.
Lethargy or restlessness	Can reflect poor perfusion, hypoxia, encephalopathy or pain	ABCDE, glucose and repeated mental-status assessment.
Liver enlargement or marked tenderness	Suggests significant disease and risk of organ impairment	Admit/observe according to protocol and monitor liver function.
Rising haematocrit with falling platelets	Supports plasma leakage and haemoconcentration	Trend results with clinical status; do not treat the number alone.

Severe dengue: severe plasma leakage causing shock or respiratory distress, severe bleeding, or severe organ impairment such as hepatitis, encephalopathy, myocarditis or acute kidney injury. Any of these requires urgent hospital-level management.

6. Initial contact and ABCDE

Perform hand hygiene, use standard precautions and isolate/triage according to respiratory, bleeding or VHF risk.
Airway: look for haematemesis, reduced consciousness, persistent vomiting and aspiration risk.
Breathing: check respiratory effort, SpO₂ and signs of pleural effusion or pulmonary oedema.
Circulation: assess pulse pressure, pulse quality, capillary refill, extremity temperature, blood pressure, urine output and mental status. Narrow pulse pressure and tachycardia may precede hypotension.
Disability: check AVPU/GCS and glucose; investigate seizures or confusion urgently.
Exposure: inspect for rash, petechiae, bleeding, dehydration, jaundice and fluid accumulation while preserving warmth and dignity.

7. Differential diagnosis

Condition	Overlapping features	Clues/tests that help
Malaria	Fever, headache, vomiting, thrombocytopenia, anaemia, confusion	Malaria RDT/microscopy, travel/residence, hypoglycaemia and severe-malaria signs.
Viral haemorrhagic fever	Fever, GI symptoms, rash, bleeding and shock	Outbreak/contact/travel history; follow high-risk isolation and public-health testing pathway.
Sepsis/meningitis	Fever, hypotension, confusion, vomiting and rash	Focal source, meningism, cultures, lactate and organ dysfunction.
Chikungunya/Zika	Fever, rash, myalgia/arthralgia	Prominent joint pain, conjunctivitis and pregnancy/travel context; local testing.
Leptospirosis or viral hepatitis	Fever, jaundice, renal/liver abnormalities	Animal/water exposure, conjunctival suffusion, renal/liver tests.

8. Investigations

Serial vital signs, capillary glucose, weight and urine output.
Full blood count with platelet count and haematocrit trend; a single platelet number does not define severity.
Electrolytes, urea/creatinine, glucose, AST/ALT, bilirubin, albumin and coagulation tests when severe.
Malaria testing in endemic/travel settings and tests for alternative diagnoses.
Dengue NAAT/RT-PCR or NS1 antigen early in illness, and IgM/IgG according to illness day and laboratory guidance.
Chest ultrasound/X-ray or other imaging when effusion, pulmonary oedema, abdominal pathology or organ impairment is suspected.
Do not delay resuscitation while waiting for dengue confirmation.

9. Management of dengue without warning signs

Confirm that the patient is haemodynamically stable, drinking, passing urine and has no warning sign or high-risk comorbidity.
Encourage frequent oral fluids, oral rehydration solution, soups and other tolerated liquids; monitor urine frequency and colour.
Use paracetamol/acetaminophen for fever or pain within safe age/weight and liver limits.
Avoid aspirin, ibuprofen, diclofenac and other NSAIDs because of bleeding and kidney risks.
Avoid routine corticosteroids and prophylactic platelet transfusion; use only under specialist indications.
Use mosquito nets/repellent during the first week of illness to prevent a mosquito from acquiring virus from the patient.
Arrange daily or protocol-based review during the critical window and give written return precautions.

10. Management of warning signs and shock

10.1 Goals

Restore effective circulation without worsening plasma leakage or causing fluid overload.
Maintain oxygenation, glucose, urine output and mental status.
Detect severe bleeding, organ injury and transition from leakage to reabsorption.

10.2 Compensated shock

Move to a monitored area and obtain IV access with minimal attempts.
Give a carefully calculated isotonic crystalloid bolus according to the local dengue algorithm and patient group.
Reassess pulse pressure, capillary refill, heart rate, blood pressure, breathing, lungs, mental status, urine output and haematocrit.
Repeat, reduce or stop fluids based on response and signs of overload; do not continue a fixed rate without reassessment.

10.3 Hypotensive shock or severe dengue

Activate senior, paediatric/obstetric and critical-care support immediately.
Use oxygen for hypoxaemia or shock; prepare airway support for exhaustion or reduced consciousness.
Administer the minimum IV crystalloid required to restore perfusion, reassessing after each intervention.
Consider colloid or blood products only under specialist/dengue protocol when shock is refractory or bleeding is significant.
Use vasopressors in critical care when shock persists after appropriate volume and the cause is addressed.
Monitor for pulmonary oedema, pleural effusion and rising abdominal pressure during resuscitation.

11. Bleeding, organ impairment and special situations

Apply direct pressure to external bleeding, use gentle handling and avoid IM injections, arterial puncture and unnecessary catheterisation.
Transfuse packed red cells or other components for clinically significant bleeding or haemodynamic compromise, not solely for a low platelet count.
Severe hepatitis: monitor glucose, coagulation and encephalopathy; avoid hepatotoxic medicines and seek specialist help.
Acute kidney injury: measure urine output, adjust medicines and avoid nephrotoxins; seek renal/critical-care advice.
Myocarditis or arrhythmia: ECG, troponin/echo where available and cautious fluid strategy.
Pregnancy: admit or consult obstetrics for warning signs, bleeding, shock or reduced fetal movement.
Infants and older adults may deteriorate quickly and require lower thresholds for admission and observation.

12. Nursing care and monitoring table

Need	Interventions	Escalation triggers
Perfusion	Frequent pulse/BP/pulse pressure, capillary refill, extremities, mental status and urine output	Narrowing pulse pressure, tachycardia, hypotension, cold skin or oliguria
Fluid balance	Measure oral/IV intake, urine, stool/vomit; review haematocrit and lungs	Persistent losses, rising haematocrit with instability or fluid overload
Bleeding	Inspect gums, nose, stool, urine, menses, skin and IV sites; use pressure and gentle care	Haematemesis, melaena, shock, falling haemoglobin or uncontrolled bleeding
Temperature/pain	Paracetamol when indicated, rest, light clothing and hydration	Severe pain, altered mental state or fever with new warning signs
Psychosocial support	Explain the critical phase, encourage safe fluids and involve caregivers in observation	Confusion, anxiety preventing intake or inability of caregiver to monitor

13. Infection prevention and mosquito control

Use standard precautions for blood and body fluids; add respiratory or VHF precautions when the differential requires them.
Keep the patient under a mosquito net or use repellent during the viraemic period.
Eliminate stagnant water in containers, tyres, gutters and flower pots; cover household water storage.
Use screens, long sleeves and approved repellents; support community vector-control campaigns.
Clean equipment and dispose of sharps safely; do not share needles or unsterile injection equipment.

14. Discharge and safety-net advice

Give a written return plan, especially for days 3–7 or whenever the fever is settling:

Return urgently for severe abdominal pain, repeated vomiting, bleeding, black stool, vomiting blood, extreme thirst, pale/cold skin, faintness, restlessness, drowsiness, difficulty breathing or very little urine.
Continue oral fluids and prescribed paracetamol; avoid aspirin, ibuprofen, diclofenac and unregulated herbal mixtures.
Use a mosquito net and return for scheduled platelet/haematocrit or clinical review.
Do not self-start antibiotics; seek review if fever returns, persists or another family member becomes ill.

15. Clinical scenarios

Scenario 1 – Fever settles, patient worsens. On day 5, a 19-year-old says the fever stopped but now has severe abdominal pain, persistent vomiting, tachycardia and cool hands. The EMT recognises the critical phase, checks perfusion and glucose, obtains IV access, avoids NSAIDs, arranges urgent monitored admission and starts protocol-guided fluids with repeated reassessment. Falling temperature is not used as reassurance.

Scenario 2 – Dengue with fluid overload. A patient treated for shock becomes breathless with basal crackles and rising oxygen requirement. The team pauses indiscriminate fluids, reassesses ultrasound/haematocrit and perfusion, gives oxygen, calls critical care and adjusts fluid therapy. More fluid is not automatically the answer.

Scenario 3 – Bleeding and thrombocytopenia. A patient has gum bleeding and a low platelet count but stable perfusion and haemoglobin. The team uses gentle oral care, avoids IM injections and NSAIDs, monitors for progression and does not order prophylactic platelets solely because the number is low; specialist guidance directs transfusion decisions.

16. Common errors

Assuming defervescence means recovery.
Giving large unmonitored IV volumes or stopping all fluid despite shock.
Using aspirin/NSAIDs or routine steroids.
Transfusing platelets prophylactically without a clinical indication.
Failing to test for malaria or other common causes of fever.
Sending a warning-sign patient home without critical-phase follow-up.
Ignoring pregnancy, infancy, older age, renal/liver disease or a second dengue infection.

17. Quick revision questions

Why can dengue become dangerous when the fever decreases?
List the seven major warning signs of severe dengue.
What findings suggest compensated shock?
Why is fluid therapy in dengue different from routine dehydration?
Which analgesics should be avoided and why?
When is blood transfusion considered?
What should be monitored after every IV-fluid change?
How can the patient and household prevent mosquito transmission?
Which dengue patients need admission or close observation?
Write a discharge safety-net message for day 5 of illness.

18. Key takeaways

References and further reading

Dengue Viruses and Severe Dengue: EMT Assessment and Emergency Management Read More »

Fever in Emergency Care: Assessment, Differential Diagnosis and Management

Why fever deserves an emergency approach. Fever is a sign, not a diagnosis. In Uganda and other tropical settings it may reflect malaria, sepsis, pneumonia, meningitis, urinary infection, typhoid, dengue, viral haemorrhagic fever, tuberculosis or a non-infectious inflammatory process. A patient can have a dangerous infection with only a modest temperature, while a high temperature can occur without infection. EMT care therefore combines temperature assessment with perfusion, breathing, mental status, exposure history, age, pregnancy, comorbidities and response to treatment. Apply the current Uganda Clinical Guidelines, facility protocols and senior clinician orders.

1. Learning objectives

Define fever, hyperpyrexia and hyperthermia and explain why they are different.
Take a structured fever history, including travel, malaria, VHF, drug and occupational exposures.
Recognise sepsis, shock, meningitis, severe malaria and other time-critical causes.
Perform a safe ABCDE assessment and select focused tests without delaying resuscitation.
Describe pre-hospital, emergency-department, pharmacological and nursing management.
Adjust assessment for infants, pregnancy, older adults and immunocompromised patients.
Give discharge advice, prevention counselling and a clear safety-net plan.

2. Definitions and physiology

Fever (pyrexia) is a regulated rise in the hypothalamic set-point, usually during infection or inflammation. The patient may feel cold and shiver while the set-point is rising. Hyperthermia is an uncontrolled temperature rise from excess heat production, impaired heat loss or drugs; the set-point is not reset. Heat stroke, serotonin syndrome, neuroleptic malignant syndrome and malignant hyperthermia are hyperthermic emergencies. Hyperpyrexia refers to an exceptionally high fever and requires urgent assessment, but the exact threshold and method depend on the guideline and measurement site.

Fever can improve host immune function, but excessive metabolic demand, dehydration, delirium, seizures or cardiorespiratory stress may make it dangerous. Treat the underlying cause and the patient’s physiological compromise, not the number alone.

Core rule: a normal temperature does not exclude sepsis, especially in neonates, older adults, people with severe malaria, hypothermia, immunosuppression or recent antipyretic use.

3. Causes of fever in emergency practice

Category	Examples	Clues at first assessment
Malaria and other parasitic infections	Uncomplicated or severe falciparum malaria, babesiosis where relevant	Endemic exposure, rigors, headache, anaemia, jaundice, altered consciousness, hypoglycaemia or seizures.
Bacterial infection and sepsis	Pneumonia, meningitis, urinary infection, abdominal infection, skin/soft-tissue infection, typhoid, endocarditis	Tachypnoea, hypotension, confusion, focal pain, purpura, productive cough, dysuria or abdominal tenderness.
Viral infection	Influenza-like illness, COVID-19, dengue, viral hepatitis, Ebola/Marburg/Lassa and other VHFs	Respiratory or gastrointestinal symptoms, rash, thrombocytopenia, travel/outbreak or body-fluid exposure.
Fungal, opportunistic and HIV-related infections	Cryptococcal disease, pneumocystis, disseminated fungal infection and tuberculosis	Immunosuppression, weight loss, chronic symptoms, hypoxia or neurological findings.
Non-infectious inflammation	Autoimmune disease, vasculitis, malignancy, drug fever	Persistent/recurrent fever with negative infection work-up, rash, joint symptoms or medication timing.
Environmental and toxicological hyperthermia	Heat stroke, serotonin syndrome, neuroleptic malignant syndrome, malignant hyperthermia	Hot environment, exertion, rigidity, clonus, altered mental state, sweating pattern or recent anaesthetic/drug exposure.

4. Triage: who needs immediate resuscitation?

At triage, record temperature using a validated device and method, but prioritise airway, breathing, circulation, disability and exposure. Use an early warning score if available and do not allow a waiting-room queue to delay unstable patients.

Red flags in any age: airway compromise, severe respiratory distress, SpO₂ below target, cyanosis, shock, systolic hypotension, weak pulse, capillary refill delay, altered consciousness, seizure, severe dehydration, persistent vomiting, active bleeding, stiff neck, non-blanching purpura, severe headache, jaundice with deterioration, hypoglycaemia, severe pain, pregnancy with instability, immunosuppression or rapid worsening.

4.1 High-risk groups

Neonates and young infants, especially those under 3 months.
Children with malnutrition, sickle-cell disease or incomplete immunisation.
Pregnant or recently postpartum patients.
Older adults who may have delirium, hypothermia or few localising symptoms.
People living with HIV, on chemotherapy, transplant medicines, long-term steroids or other immunosuppression.
Patients with diabetes, renal disease, heart failure, chronic lung disease or severe anaemia.
Recent travellers, healthcare workers, laboratory staff, animal handlers and contacts of outbreak cases.

5. Initial contact and infection prevention

Perform hand hygiene and offer a mask to a coughing patient if tolerated.
Screen for cough, diarrhoea, vomiting, rash, bleeding, travel, outbreak contact and VHF risk before placing the patient in a crowded area.
Separate patients with respiratory symptoms or a credible VHF exposure while maintaining dignity and confidentiality.
Use standard precautions and add droplet, contact, airborne or high-level VHF precautions according to the suspected syndrome and local policy.
Use gloves and eye protection for blood, vomit, diarrhoea, suction or other splash risk; do not use gloves as a substitute for hand hygiene.

6. Fever history: the questions that change management

6.1 Chronology and temperature

When did fever begin? Was onset sudden or gradual?
What was the highest measured temperature, at which site and with which device?
Is the fever continuous, intermittent, periodic or associated with rigors or night sweats?
Has the patient taken paracetamol, NSAIDs, antibiotics, antimalarials, steroids or traditional medicines?

6.2 Localising symptoms and exposure

Headache, photophobia, neck stiffness, confusion, seizures or weakness.
Cough, sore throat, pleuritic pain, breathlessness or sputum.
Abdominal pain, diarrhoea, vomiting, jaundice or urinary symptoms.
Rash, wound, skin infection, joint pain, muscle pain or bleeding.
Malaria prevention, recent mosquito bites, travel, sick contacts, sexual history and vaccination status.
Animal, tick, rodent, cave, occupational, healthcare, funeral or body-fluid exposure.
Pregnancy possibility, last menstrual period, breastfeeding and recent delivery.

7. Examination: ABCDE plus a fever-focused survey

A – Airway

Check speech, secretions, vomiting, facial swelling, stridor and ability to protect the airway. Prepare suction and a senior airway plan for reduced consciousness.

B – Breathing

Count rate, effort and pattern; check SpO₂, chest signs, cyanosis and fatigue. Consider pneumonia, pulmonary oedema, metabolic acidosis and severe anaemia.

C – Circulation

Measure pulse, blood pressure, capillary refill, skin temperature and urine output. Look for dehydration, bleeding, mottling, jaundice and signs of septic or hypovolaemic shock.
Use weight or a paediatric length-based method for fluid and drug calculations; never guess a child’s dose.

D – Disability

Assess AVPU/GCS, pupils, seizures and glucose. Delirium may be the first sign of sepsis in an older adult.

E – Exposure

Inspect skin, rash, petechiae, purpura, wounds, joints, meningism, injection sites and hydration while preserving warmth and dignity.

8. Pattern recognition and differential diagnosis

Pattern	Likely considerations	Immediate action
Fever + confusion/seizure/neck stiffness	Meningitis, encephalitis, cerebral malaria, hypoglycaemia, severe sepsis	ABCDE, glucose, oxygen, urgent clinician review, seizure precautions and time-critical antimicrobials/antimalarial pathway.
Fever + cough/hypoxia	Pneumonia, COVID-19/influenza, pulmonary TB, heart failure or PE	Isolation as indicated, oxygen, chest assessment, imaging/testing and sepsis evaluation.
Fever + jaundice/bleeding	Severe malaria, viral hepatitis, dengue, VHF, leptospirosis or liver failure	Bleeding precautions, avoid NSAIDs/IM injections, glucose and urgent laboratory/public-health pathway.
Fever + shock	Sepsis, severe malaria, dehydration, haemorrhage, anaphylaxis or toxic shock	Resuscitate, obtain cultures/tests safely, give indicated antimicrobials promptly and reassess perfusion.
Fever + focal skin/wound pain	Cellulitis, abscess, necrotising infection, infected bite	Mark erythema, assess pain out of proportion, urgent surgical review if rapidly progressive.
Fever after a drug or heat exposure	Drug fever, serotonin syndrome, NMS, malignant hyperthermia or heat stroke	Stop the trigger, cool safely, manage airway and autonomic instability, seek toxicology/critical-care help.

9. Investigations and interpretation

Test	Purpose	EMT/clinical caution
Glucose, full vital-sign trend and urine output	Identify immediately reversible deterioration	Repeat after treatment; a single normal observation does not exclude sepsis.
Malaria RDT or microscopy	WHO recommends prompt diagnostic testing for suspected malaria before treatment when feasible	A negative test does not end evaluation if severe illness persists; follow local repeat-testing guidance.
FBC, platelets, renal/liver tests and electrolytes	Anaemia, thrombocytopenia, organ injury, dehydration and electrolyte disturbance	Interpret with pregnancy, age and baseline disease; protect specimens when VHF is possible.
Blood cultures and urine culture	Identify bacterial infection and guide de-escalation	Collect safely and avoid delaying indicated antibiotics in an unstable patient.
Lactate/ABG or VBG where available	Perfusion, acid–base status and respiratory/metabolic stress	Trend with clinical examination; lactate is not a stand-alone diagnosis.
Chest imaging, ultrasound or other focused imaging	Pneumonia, effusion, abdominal source, pregnancy or cardiac disease	Use only when it changes management and infection-control measures are safe.
VHF, dengue, respiratory-virus, HIV or TB tests	Targeted diagnosis guided by risk, epidemiology and syndrome	Notify laboratory/public health before high-risk specimen collection.

10. Immediate and pre-hospital care

Move the unstable patient to a resuscitation area; do not delay for a complete history.
Position for airway and perfusion; use recovery position if unconscious and breathing with no contraindication.
Give oxygen for hypoxaemia or respiratory distress and monitor response.
Check glucose, treat hypoglycaemia under protocol and reassess consciousness.
For dehydration or shock, use oral rehydration if alert and able to drink; use isotonic IV fluid cautiously with frequent perfusion and lung reassessment.
Use paracetamol/acetaminophen within local dose limits for distressing fever; avoid aspirin/NSAIDs when bleeding, renal injury or dengue/VHF is possible.
Do not give antibiotics or antimalarials blindly when a trained diagnostic pathway is available, but never delay time-critical treatment in a patient meeting severe-malaria or sepsis criteria.
Call the receiving facility, state the suspected syndrome and transmit serial observations, treatments and exposure risks.

11. Hospital management of fever

11.1 Treat the physiology first

Use an early warning score, sepsis screen or paediatric emergency triage tool where available.
Repeat ABCDE after every intervention and document time, dose, route and response.
Provide oxygen, airway support, cautious fluid resuscitation and vasopressors in critical care when indicated.
Measure urine output and consider catheterisation only when essential and safe.
Control seizures, hypoglycaemia, severe pain and agitation while investigating the cause.

11.2 Sepsis pathway

Recognise suspected infection plus organ dysfunction or deterioration; fever is not required.
Obtain cultures and lactate/other tests when this can be done safely without delaying treatment.
Give empiric antimicrobials according to local formulary and likely source, ideally promptly in shock or high-risk sepsis.
Give crystalloid for hypoperfusion with repeated assessment of blood pressure, capillary refill, lung sounds, mental status and urine output.
Escalate to senior/critical-care care for persistent hypotension, rising lactate, increasing oxygen requirement or organ failure.

11.3 Malaria pathway in Uganda

Ask about residence/travel, prophylaxis, prior malaria, pregnancy and antimalarial use.
Use an RDT or microscopy promptly where feasible. WHO recommends testing suspected malaria before treatment.
Severe malaria features include impaired consciousness, repeated seizures, respiratory distress, shock, severe anaemia, hypoglycaemia, acidosis, jaundice with other severe features, haemoglobinuria, acute kidney injury or inability to drink.
Severe malaria is a hospital emergency: activate the local parenteral artesunate and referral protocol, manage glucose and airway, and monitor for post-treatment haemolysis and other complications.
Uncomplicated malaria should receive the nationally recommended oral antimalarial with adherence counselling; do not use leftover or incomplete courses.

12. Fever in children, pregnancy and older adults

Children and infants

Measure temperature accurately and assess feeding, breathing, interaction, capillary refill, urine, rash, seizures and immunisation.
Any young infant with fever, hypothermia, poor feeding, lethargy, fast breathing, apnoea or abnormal colour requires urgent assessment.
Use weight-based or length-based medication and fluid calculations; avoid aspirin in children.
Do not force oral fluids in a drowsy or vomiting child who cannot protect the airway.

Pregnancy and postpartum

Ask about gestation, fetal movement, rupture of membranes, urinary symptoms, malaria risk, breast symptoms and postpartum wounds.
Assess maternal ABCDE first while considering fetal assessment and obstetric referral.
Use pregnancy-safe medicines and antimicrobials according to Uganda guidelines; avoid self-medication and tetracycline/other contraindicated drugs unless specifically directed.

Older or immunocompromised patients

Fever may be absent; look for confusion, falls, weakness, tachypnoea, hypotension, reduced intake or functional decline.
Review corticosteroids, chemotherapy, transplant medicines and recent hospitalisations.
Have a lower threshold for cultures, observation, admission and senior review.

13. Pharmacological principles

Medicine group	When considered	Safety reminders
Paracetamol/acetaminophen	Distress, pain or uncomfortable fever	Use weight/age and liver-safe limits; check combination products and avoid cumulative overdose.
Antimicrobials	Confirmed or strongly suspected bacterial, parasitic or selected viral infection	Choose by source, severity, allergy, pregnancy, renal function and local resistance; obtain cultures when appropriate.
Antimalarials	Test-confirmed malaria or protocol-defined severe malaria	Use the current national regimen; severe malaria needs parenteral treatment and monitoring.
Fluids/electrolytes	Dehydration, shock, significant gastrointestinal loss or maintenance need	Reassess lungs, perfusion, sodium and urine; excess fluid harms heart/renal patients.
Anticonvulsants/antidotes	Seizures, hypoglycaemia or toxicological syndromes	Protect airway and seek senior/critical-care support; doses must be protocol-based.

14. Nursing interventions and monitoring

Record temperature, pulse, respirations, blood pressure, SpO₂, pain, AVPU/GCS and urine output at the required frequency.
Trend rather than merely record: a rising respiratory rate or falling alertness may precede hypotension.
Maintain fluid balance, monitor stool/vomit losses and inspect IV sites.
Provide tepid comfort measures, light clothing, ventilation and hydration; avoid ice baths or aggressive cooling in routine fever.
Administer medicines safely, check allergies, observe response and document adverse effects.
Use infection-control precautions, safe specimen handling and environmental cleaning.
Prevent pressure injury, falls, delirium and aspiration in weak or confused patients.
Explain the diagnosis uncertainty, testing plan, red flags and family communication pathway.

15. Discharge, admission and safety net

Discharge is appropriate only when the patient is clinically stable, can drink or has a reliable plan, serious causes have been considered, follow-up is available and the responsible clinician agrees.

Give written instructions for dose, timing and maximum daily antipyretic amount.
Explain return immediately for confusion, difficulty breathing, persistent vomiting, severe headache/neck stiffness, seizure, bleeding, jaundice, inability to drink, reduced urine, worsening weakness or fever that persists/returns.
Use mosquito prevention, hand hygiene, respiratory etiquette, safe food/water and vaccination advice where appropriate.
Advise against leftover antibiotics, incomplete antimalarial courses, aspirin/NSAIDs when contraindicated and unregulated injections.
Arrange review for malaria, pregnancy, infants, immunocompromise, recurrent fever, abnormal tests or unresolved diagnostic uncertainty.

16. Clinical scenarios

Scenario 1 – Fever with shock. A 42-year-old has fever, diarrhoea, confusion, pulse 132/min, cool skin and delayed capillary refill. The EMT identifies probable sepsis or severe malaria, moves the patient to resuscitation, checks glucose, gives oxygen if hypoxic, obtains safe access, starts cautious isotonic fluid with reassessment, arranges urgent malaria testing and cultures, alerts the senior clinician and gives empiric treatment according to local protocol. The temperature is not the only problem; perfusion and organ dysfunction drive priority.

Scenario 2 – Child with fever and fast breathing. A 2-year-old is hot, lethargic, refusing feeds and breathing rapidly. The team checks glucose and oxygen saturation, assesses for chest indrawing and danger signs, weighs or measures length, provides oxygen for hypoxaemia, avoids forced oral fluids, tests for malaria and treats suspected severe infection under the paediatric pathway. The child is not left in a routine queue.

Scenario 3 – Fever after travel and bleeding. A traveller develops fever, severe headache, vomiting and gum bleeding after visiting an outbreak area. The EMT uses high-risk screening, separates the patient, applies the required PPE, avoids NSAIDs and unnecessary injections, calls the public-health/treatment pathway and transports with a structured handover. VHF and dengue remain possible until evaluated.

17. Common mistakes

Treating the temperature while ignoring shock, hypoxia or altered consciousness.
Assuming every fever is malaria without testing or considering sepsis and VHF.
Using a single normal temperature or blood pressure to declare a patient safe.
Giving incorrect paediatric doses because weight was guessed.
Using antibiotics without a source, review plan or attention to local resistance.
Overcooling, ice bathing or withholding fluids from a stable patient who can drink.
Missing pregnancy, immunosuppression, sickle-cell disease or recent hospital exposure.
Discharging without return precautions, follow-up and documented patient understanding.

18. Quick revision questions

Differentiate fever, hyperthermia and hyperpyrexia.
List eight red flags in a febrile patient.
Why can sepsis exist without a high temperature?
What exposure questions raise concern for VHF?
When should a febrile patient be moved to resuscitation rather than a routine queue?
What does WHO recommend about malaria testing before treatment?
List severe-malaria features that require urgent hospital care.
How do you modify fever assessment for infants, pregnancy and older adults?
What should be documented after antipyretic, fluid or antimicrobial treatment?
Give six discharge safety-net instructions.

19. Key takeaways

References and further reading

Fever in Emergency Care: Assessment, Differential Diagnosis and Management Read More »

Viral Haemorrhagic Fevers: Recognition, Isolation and Emergency Management

Why this topic matters. Viral haemorrhagic fevers (VHFs) can begin like malaria, influenza or gastroenteritis and then deteriorate rapidly with shock, organ failure or bleeding. The emergency medical technician (EMT) must protect the team, identify a possible VHF early, start safe supportive care and activate the public-health pathway without waiting for a laboratory confirmation. This lesson is educational and must be applied with Uganda Ministry of Health, facility and outbreak-specific protocols.

1. Learning objectives

By the end of this lesson, the learner should be able to:

Define VHF and distinguish a suspected VHF from a confirmed infection.
Identify relevant exposure, incubation, prodromal and severe-disease features.
Protect self, the patient, other patients and the community from avoidable transmission.
Perform a structured ABCDE assessment without creating unnecessary exposure.
Give safe pre-hospital and hospital supportive care while arranging testing and referral.
Recognise shock, bleeding, encephalopathy, respiratory failure, renal injury and other complications early.
Document, hand over, report and follow up occupational exposures correctly.

2. Definition and scope

Viral haemorrhagic fevers are severe illnesses caused by several virus families that injure the vascular system, immune system and multiple organs. The name does not mean that every patient bleeds. Many patients initially have fever, weakness, headache, myalgia, vomiting or diarrhoea; haemorrhage may be absent, late or microscopic. Severe disease may result from capillary leak, dehydration, shock, coagulopathy, encephalitis, acute kidney injury or secondary infection.

A suspected case is a person whose acute illness and epidemiological history meet the current national or outbreak case definition. A probable case meets the clinical and epidemiological definition but is awaiting or unable to have definitive testing. A confirmed case has a validated laboratory result or other accepted confirmation. EMTs should not attempt to diagnose or rule out VHF by appearance alone.

Safety rule: treat a patient with compatible illness and a relevant exposure as a potential VHF until the designated clinician/public-health team advises otherwise. Do not wait for bleeding before escalating precautions.

3. Important VHF pathogens and transmission patterns

Group / examples	Typical reservoir or exposure	Human-to-human points for EMTs	Practical distinction
Filoviruses: Ebola and Marburg viruses	Wildlife exposure, caves/mines, infected people or contaminated body fluids	Direct contact with blood, vomit, stool, urine, saliva, breast milk, semen, sweat or other infectious material; risk rises with wet symptoms and unsafe care or burial.	Severe febrile illness with gastrointestinal symptoms, weakness, rash, shock or bleeding; early features are non-specific.
Arenaviruses: Lassa and South American haemorrhagic fevers	Rodent excreta or infected persons, depending on virus	Infection can follow contaminated food, inhalation of rodent excreta or healthcare exposure; Lassa can spread in healthcare settings.	May include fever, weakness, facial oedema, hearing symptoms, bleeding or neurological complications.
Crimean-Congo haemorrhagic fever (CCHF)	Tick bite, crushing an infected tick, infected livestock blood or tissue	Human-to-human transmission occurs through blood and body fluids, particularly during severe illness, procedures and unsafe handling of bodies.	Sudden fever, severe headache, back/joint pain, abdominal symptoms, mood change, jaundice and bleeding may occur.
Rift Valley fever	Mosquitoes and contact with infected animal blood, tissues or aborted material	Protect against mosquitoes and unprotected animal handling; person-to-person spread is not the usual route.	Often a self-limited febrile illness, but ocular disease, encephalitis or haemorrhagic disease can develop.
Yellow fever and other regional viral febrile illnesses	Usually mosquito-borne; pattern depends on virus	Vector control and vaccination where indicated are central; apply precautions until the cause is known.	Jaundice, fever, bleeding or organ failure may overlap with other VHFs and severe malaria.

4. Epidemiology, incubation and risk assessment

Symptoms may appear after an incubation period that varies by virus and exposure. CDC screening guidance commonly uses a 2–21 day window for several high-consequence VHFs, but the exact period depends on the suspected pathogen. Ask about the entire risk window specified by current national guidance.

4.1 Ask about exposure, not just travel

Residence in, travel to or transit through an area with a current or recent VHF outbreak.
Contact with a person who had an unexplained febrile illness, bleeding, vomiting or diarrhoea.
Attendance at a funeral, burial or body-washing ceremony, or handling human remains.
Unprotected healthcare, laboratory, ambulance, mortuary or cleaning work.
Contact with bats, caves, mines, non-human primates, livestock, ticks, mosquitoes or rodents.
Contact with blood, body fluids, needles, linen, clothing, equipment or surfaces contaminated by a patient.
Recent injections, invasive procedures, sexual exposure or breastfeeding considerations where relevant to the suspected virus.

4.2 Questions that improve risk stratification

When did fever or the first symptom begin, and how has it progressed?
Where has the patient been during the possible incubation period?
Who has been ill at home, work, school, a health facility or a funeral?
Which body fluids were encountered, by whom, and was PPE used?
Were there animal, tick, mosquito, rodent, cave or occupational exposures?
Has the patient taken antimalarials, antibiotics, NSAIDs, anticoagulants or traditional medicines?
Is anyone else at home or in the facility ill, and where can contacts be reached?

5. Clinical course and warning features

Phase	Possible findings	EMT interpretation
Early or dry phase	Fever, chills, severe headache, myalgia, arthralgia, fatigue, weakness, sore throat, cough, conjunctival injection or anorexia	Looks like many common infections. Exposure history and infection prevention are decisive.
Gastrointestinal or wet phase	Persistent vomiting, watery diarrhoea, abdominal pain, hiccups, dysphagia, dehydration and reduced urine	Fluid and electrolyte loss can rapidly produce hypovolaemic shock. Vomitus and stool create a high-contact hazard.
Severe systemic phase	Tachypnoea, hypoxia, confusion, agitation, seizures, jaundice, oliguria, hypotension, severe weakness or respiratory distress	Suspect organ dysfunction, sepsis-like physiology or shock; escalate and transfer urgently.
Haemorrhagic/coagulopathic phase	Petechiae, gum or nose bleeding, haematemesis, melaena, haematuria, vaginal bleeding, bleeding from puncture sites or unexplained bruising	Avoid unnecessary invasive procedures. Use gentle pressure, protect staff and alert the treatment team.
Recovery or death	Some patients recover with prolonged weakness; others develop multiorgan failure, shock or encephalitis	Continue monitoring after apparent improvement and follow pathogen-specific public-health guidance.

Red flags: altered mental status, respiratory distress, SpO₂ below the local target, cold clammy skin, weak pulse, delayed capillary refill, systolic hypotension, persistent vomiting/diarrhoea, oliguria, jaundice, active bleeding, severe abdominal pain, seizures, pregnancy, extremes of age or major comorbidity.

6. Initial contact: protect, recognise, separate and notify

6.1 Before touching the patient

Pause at the doorway or scene perimeter. Ask the patient or caller about fever, gastrointestinal symptoms, bleeding and exposure before entering.
Put on the level of PPE required by the facility or outbreak protocol. Do not improvise by wearing only gloves when splash or aerosol-generating procedures are possible.
Limit the number of responders and move non-essential people away.
Prepare a designated isolation or treatment area and dedicated equipment before transfer.
Notify the senior clinician, infection-prevention lead and public-health focal person early.

6.2 First communication with the patient

Use calm, respectful language: explain that temporary separation protects the patient, family and staff.
Give the patient a mask if tolerated and safe, and provide a lined emesis bag or closed container for secretions.
Ask the patient not to touch staff, surfaces or other patients unnecessarily.
Do not shame the patient or disclose suspected VHF publicly; maintain confidentiality while making the required notification.

7. Structured emergency assessment: safe ABCDE

Use the same emergency priorities as for any critically ill patient, but modify the technique to minimise splashes, sharps and repeated contact. Record the time and trend of every observation.

A – Airway and cervical protection when indicated

Assess whether the patient can speak, protect the airway and clear secretions.
Look for blood, vomitus, facial swelling, seizures or reduced consciousness.
Position safely, suction only with appropriate PPE and closed systems where available.
Prepare for advanced airway support only with the most experienced team, a clear indication and a plan to reduce aerosolisation.

B – Breathing

Count respiratory rate, inspect effort and listen for noisy breathing or focal signs.
Measure SpO₂ with a clean or dedicated probe; correct the reading for poor perfusion and nail products.
Give oxygen according to local emergency protocol and monitor response.
Consider pneumonia, aspiration, pulmonary oedema, metabolic acidosis or severe anaemia in a patient with distress.

C – Circulation, perfusion and haemorrhage

Check pulse rate, rhythm, blood pressure, capillary refill, skin temperature and mental status.
Look for dehydration, ongoing diarrhoeal losses, bleeding, jaundice and signs of shock.
Control visible external bleeding with direct pressure and absorbent material; do not explore wounds unnecessarily.
Establish IV or intraosseous access only when essential, using the minimum number of attempts and sharps safety.
Use isotonic crystalloid cautiously for suspected hypovolaemia and reassess after small boluses, especially if pulmonary oedema or cardiac disease is possible.

D – Disability

Assess AVPU or GCS, pupils, seizures, agitation and focal neurological signs.
Check capillary blood glucose promptly; treat hypoglycaemia according to protocol.
Consider hypoxia, shock, fever, electrolyte disturbance, encephalitis, medication effects and hypoglycaemia.

E – Exposure and examination

Expose only the area needed, preserve dignity and prevent chilling.
Inspect skin, mucosa and conjunctiva for rash, petechiae, jaundice, dehydration and bleeding.
Check for tick attachment, injection sites, pregnancy-related bleeding or injuries only when clinically necessary.
Decontaminate equipment and surfaces immediately according to facility IPC policy.

8. Differential diagnosis and essential tests

Do not label every febrile patient as VHF, but never dismiss a credible exposure. Important alternatives include severe malaria, bacterial sepsis, meningitis, typhoid fever, dengue, yellow fever, rickettsial disease, leptospirosis, acute HIV infection, viral hepatitis, poisoning, obstetric haemorrhage and haematological disease.

Investigation	What it helps answer	Safety point
Point-of-care glucose, pulse oximetry and serial vital signs	Immediate reversible threats and trajectory	Use dedicated or disinfectable equipment; minimise staff movement.
Malaria test where indicated, full blood count and blood film	Common treatable causes, anaemia, thrombocytopenia and inflammation	Follow VHF specimen packaging and laboratory notification rules.
Electrolytes, urea/creatinine and acid–base assessment	Dehydration, kidney injury and metabolic deterioration	Do not send an unlabelled or leaking specimen; use trained personnel.
Coagulation profile, fibrinogen and group/crossmatch when clinically indicated	Coagulopathy, bleeding risk and transfusion planning	Coordinate with the designated laboratory before drawing samples.
VHF RT-PCR/antigen or other validated testing	Specific diagnosis and public-health action	Only authorised staff should collect, package and transport high-risk specimens.
Blood cultures and targeted imaging	Alternative or secondary bacterial infection, pneumonia or another source	Take only when the result changes management and PPE/handling are safe.

9. Immediate and pre-hospital management

Scene safety and isolation: identify a clean zone, transition zone and contaminated zone where feasible; keep a written exposure log.
Call ahead: tell the receiving facility the clinical status, exposure concern, PPE requirements, number of staff exposed and equipment needed.
Position: place a shocked patient supine with appropriate leg elevation only if it improves perfusion and does not worsen breathing; use lateral recovery position for an unconscious breathing patient who is vomiting and has no contraindication.
Oxygen and ventilation: provide oxygen for hypoxaemia or respiratory distress; use bag-mask ventilation only when essential and with a high-efficiency filter and trained team.
Fluids: treat clinically significant dehydration or shock with carefully reassessed isotonic crystalloid. Avoid both under-resuscitation and indiscriminate large-volume boluses.
Glucose and temperature: correct hypoglycaemia, prevent hypothermia and use a safe antipyretic plan. Avoid aspirin and NSAIDs when bleeding, thrombocytopenia or renal injury is possible.
Bleeding: apply firm direct pressure, use absorbent dressings and avoid unnecessary intramuscular injections, rectal temperatures and traumatic procedures.
Transport: use the designated vehicle and route; restrict attendants, secure waste and linen, and perform supervised doffing and disinfection after handover.

10. Hospital management: goals and sequence

Management goals: maintain oxygenation and perfusion, replace gastrointestinal losses, prevent hypoglycaemia and electrolyte catastrophe, control pain/fever/nausea, detect bleeding and organ failure early, treat proven or strongly suspected co-infections, and protect staff and the community.

10.1 Resuscitation and monitoring

Place the patient in a designated isolation area and use a trained, minimum-size clinical team.
Record temperature, pulse, respiratory rate, blood pressure, SpO₂, mental status, urine output, stool/vomit volume and fluid balance at a frequency matched to severity.
Use a resuscitation chart with targets and reassessment after every intervention.
Escalate for persistent hypotension, rising lactate, worsening confusion, oliguria, increasing oxygen need, recurrent vomiting or uncontrolled bleeding.

10.2 Fluids, electrolytes and nutrition

Estimate ongoing losses from diarrhoea, vomiting, fever, bleeding and insensible loss.
Use oral rehydration solution when the patient is alert, protecting the airway and able to drink; give small frequent amounts.
Use IV isotonic crystalloid for shock, severe dehydration or inability to drink, with repeated clinical reassessment.
Monitor sodium, potassium, bicarbonate, calcium, glucose, creatinine and acid–base status where available.
Start enteral nutrition when safe; provide culturally acceptable energy and protein while preventing aspiration.

10.3 Medications and procedures

Give paracetamol/acetaminophen for fever or pain within local dosing limits; review liver function and cumulative dose.
Give an antiemetic and other symptom-directed medicines under protocol, using oral or IV routes rather than intramuscular injections where possible.
Do not give antibiotics simply because VHF is suspected; start empiric antibiotics when bacterial sepsis, pneumonia, meningitis or another treatable co-infection is clinically plausible, and obtain cultures safely if this will not delay treatment.
Specific therapeutics depend on the pathogen, country approval and treatment-centre protocol. WHO recommends monoclonal antibody treatment for eligible Ebola virus disease; this does not automatically apply to Sudan virus, Bundibugyo virus, Marburg or other VHFs.
Specialist teams may consider disease-specific antivirals, investigational medicines or plasma protocols. EMTs should never self-prescribe these or delay referral while seeking them.
Use renal-dose adjustments and avoid nephrotoxic or hepatotoxic medicines when organ injury is suspected.

11. Management of bleeding and coagulopathy

Assess airway risk from oral or gastrointestinal bleeding and prepare suction safely.
Apply local pressure to accessible external sites; use a pressure dressing and document saturation.
Minimise venepunctures, arterial punctures, urinary catheterisation and other invasive procedures.
Review antiplatelet, anticoagulant and herbal medicines with the senior clinician.
Check haemoglobin, platelets, PT/INR, aPTT, fibrinogen and renal/liver function where available.
Give blood components only on a documented clinical indication and with the required laboratory and transfusion safeguards.
Do not assume that every visible bleed explains the shock; capillary leak, diarrhoeal losses, sepsis or occult bleeding may coexist.

12. Infection prevention and control

12.1 Standard and transmission-based precautions

Perform hand hygiene before and after every patient contact and after removing gloves.
Use gloves, fluid-resistant gown/coverall, eye protection, mask/respirator and boots or shoe covers as specified by the risk assessment and current protocol.
For vomiting, diarrhoea, bleeding or aerosol-generating procedures, use the higher-level PPE pathway and trained observers where required.
Use dedicated, disposable or easily disinfected equipment; keep a clean inventory outside the isolation area.
Do not touch the face, phone, pens, door handles or clean notes with contaminated gloves.

12.2 Donning and doffing discipline

Remove jewellery and secure hair; cover skin breaks.
Inspect PPE with a trained observer and put it on in the prescribed order.
Work slowly; avoid splashes, sharp edges and leaning over the patient.
Disinfect gloved hands between high-risk tasks when compatible with the product and protocol.
Remove PPE in the designated doffing area, pausing at each step for inspection.
Perform hand hygiene after every removal stage and report any breach immediately.

12.3 Environment, waste, linen and bodies

Clean and disinfect high-touch surfaces using an approved product, correct concentration and contact time.
Place sharps directly into a rigid puncture-resistant container; never recap needles.
Handle linen as infectious material; do not shake it or carry it against clothing.
Contain vomit, stool and other fluids before cleaning; use trained personnel and appropriate PPE.
Use safe, dignified and culturally sensitive burial procedures led by the authorised response team. Family viewing or touching is allowed only when the protocol makes it safe.

13. Nursing and EMT care plan

Problem	Assessment and interventions	Desired outcome
Risk of transmission	Isolation, PPE, hand hygiene audit, dedicated equipment, safe waste and exposure log	No secondary healthcare-associated transmission
Deficient fluid volume	Strict input/output, stool/vomit measurement, oral or IV replacement, daily weight where feasible and reassessment of perfusion	Improved pulse, mentation, blood pressure, urine output and mucosal hydration
Impaired gas exchange	Position, oxygen, respiratory observations, escalation for fatigue or altered consciousness	Target oxygen saturation and reduced work of breathing
Risk of bleeding	Inspect skin, gums, urine, stool and injection sites; pressure for bleeding; avoid trauma and NSAIDs	No uncontrolled haemorrhage; early escalation when bleeding begins
Hyperthermia and pain	Temperature trend, safe antipyretic/analgesic plan, light clothing and hydration	Comfort without masking clinical deterioration
Anxiety, stigma or isolation distress	Explain procedures, provide communication with family through safe channels and protect confidentiality	Patient participates in care and reports concerns early
Reduced consciousness	Frequent AVPU/GCS, glucose, airway positioning, seizure precautions and urgent clinician review	Airway protected and reversible causes treated promptly

14. Exposure management for staff, family and contacts

Stop the task safely and move to the designated doffing area.
Wash or irrigate the exposed skin or mucous membrane immediately according to the exposure protocol; do not use caustic chemicals.
Report at once to the supervisor, infection-prevention lead and occupational-health/public-health team.
Document the patient, date/time, route of exposure, PPE used, breach, body fluid and witnesses.
Receive risk assessment, baseline testing where indicated, counselling and active monitoring for the pathogen-specific period.
Do not work while symptomatic; notify occupational health immediately if fever, fatigue, vomiting, diarrhoea, bleeding or other compatible symptoms develop.
Contacts require confidentiality, risk communication and follow-up by public-health teams—not informal community labelling.

15. Prevention and public-health control

Early detection and immediate notification prevent delayed isolation and unsafe referral.
Train all staff in triage, hand hygiene, PPE, injection safety, specimen transport, waste and doffing.
Use safe water, sanitation, environmental cleaning and vector/rodent control.
Promote early care seeking and discourage unsafe home treatment, injections, unprotected caregiving and body washing.
Use vaccination when an approved vaccine is indicated for the specific disease and response strategy.
Support survivors and families respectfully; apply pathogen-specific advice on sexual transmission, breastfeeding and follow-up.
Maintain stock of PPE, chlorine/disinfectant, oral rehydration salts, IV fluids, sharps boxes, thermometers and communication forms.

16. Transfer and handover framework

Use an ATMIST/SAMPLE-style handover and state the VHF concern in the first sentence:

A – Alert: “Suspected viral haemorrhagic fever; isolation precautions active.”
T – Time: onset, arrival and key deterioration times.
M – Mechanism/medical history: exposure, travel, contact, comorbidities and medicines.
I – Injuries/illness findings: fever, vomiting, diarrhoea, rash, bleeding, jaundice and neurological status.
S – Signs: serial vital signs, glucose, urine output and response to fluids/oxygen.
T – Treatments: PPE, isolation, oxygen, fluids, medicines, bleeding control, specimens and exposure events.

17. Clinical scenarios

Scenario 1 – Febrile patient after a funeral. A 26-year-old presents with fever, severe weakness and diarrhoea three days after attending a burial where the body was washed. The patient is alert but tachycardic. The EMT asks other patients to step away, puts on the facility-defined PPE, provides a mask and dedicated emesis container, calls the receiving isolation team, obtains glucose and vital signs with dedicated equipment, gives cautious oral/IV rehydration according to protocol, and transfers with a structured handover. The EMT does not wait for bleeding or attempt an unprotected examination.

Scenario 2 – Vomiting and shock. A known VHF-contact develops repeated vomiting, cold extremities, delayed capillary refill and confusion. The priorities are PPE and isolation, airway positioning, oxygen if hypoxic, glucose, cautious isotonic crystalloid with frequent reassessment, measurement of losses, urgent senior review and referral to the treatment centre. Large unmonitored fluid volumes can cause harm; the response must be guided by perfusion, respiratory findings and local protocol.

Scenario 3 – Occupational splash. During cleaning, vomitus splashes a worker’s eye. The worker stops, avoids touching the face, irrigates the eye immediately at the designated station, reports the exposure, records the breach and enters occupational-health monitoring. The worker does not continue the shift or conceal the event.

18. Common errors to avoid

Waiting for haemorrhage before considering VHF.
Taking a detailed history in a crowded waiting room.
Using gloves without eye/body protection during splash-risk care.
Repeatedly attempting IV access or performing unnecessary rectal, IM or invasive procedures.
Giving NSAIDs or aspirin when thrombocytopenia, bleeding or renal injury is possible.
Sending specimens without prior laboratory notification and approved packaging.
Transporting the patient without calling the receiving facility.
Removing PPE hurriedly or without a trained observer.
Forgetting the staff exposure log, patient confidentiality or family communication.

19. Quick revision questions

Why can a patient have VHF without visible bleeding?
Name five exposure questions that change the triage pathway.
What are the first four actions before physically examining a suspected case?
How would you recognise shock in a patient with profuse diarrhoea?
Why are unnecessary IM injections, rectal temperatures and repeated venepunctures unsafe?
Which findings require urgent escalation during transport?
What information must be included in the VHF handover?
Describe the immediate response to a mucous-membrane splash.
Why must pathogen-specific treatment be directed by a designated treatment team?
List six community measures that reduce VHF transmission.

20. Key takeaways

SAFE VHF:
Separate and screen early | Assess ABCDE and perfusion safely | Fluids, fever, glucose and bleeding support | Escalate, expose-report and hand over
Vigilant PPE and hand hygiene | High-risk specimens only through authorised pathways | Follow local/national public-health protocols

References and further reading

Viral Haemorrhagic Fevers: Recognition, Isolation and Emergency Management Read More »

Management of the Different Types of Shock: Complete EMT and Hospital Guide

Management principle: Shock is a race between tissue injury and restoration of oxygen delivery. Every patient needs immediate supportive care and rapid treatment of the mechanism: stop bleeding, restore appropriate volume, treat infection, reverse anaphylaxis, support the failing pump or relieve obstruction. Resuscitation is dynamic—give an intervention, reassess perfusion, then continue, change or stop it.

Safety notice: Use current Uganda Clinical Guidelines, local blood/fluids/vasopressor protocols and senior medical direction. The exact fluid volume, medicine concentration, transfusion ratio, airway decision and vasopressor target depend on age, pregnancy, comorbidities, cause and available monitoring. Never allow a protocol number to override clinical deterioration or fluid overload.

Learning outcomes

Describe universal first-contact and resuscitation priorities for every shocked patient.
Manage hypovolaemic, septic/distributive, anaphylactic, neurogenic, cardiogenic and obstructive shock by cause.
Explain medical/pharmacological, nursing, monitoring, referral and prevention actions.
Recognise treatment failure, fluid overload, worsening acidosis and the need for surgery/critical care.
Deliver a structured handover and document every resuscitation decision and response.

1. Universal management: first contact to definitive care

Scene safety/PPE: protect staff from traffic, violence, chemicals, infection, blood and electrical hazards.
Call for the right team: resuscitation/ALS, trauma, blood bank, theatre, obstetrics, paediatrics, cardiology, ICU, toxicology or surgery.
ABCDE: open airway, oxygenate/ventilate, assess circulation/bleeding, check disability/glucose and expose for hidden cause.
Position and warmth: supine if tolerated, recovery position if vomiting/unconscious and breathing, legs raised only when safe; prevent hypothermia.
Monitoring: ECG, pulse oximetry, BP/MAP, RR, temperature, mental state, capillary refill, urine and ETCO2/ABG where available.
Access and samples: two large-bore IVs or IO, glucose, blood gas/lactate, FBC, electrolytes, renal/liver, coagulation, group/crossmatch and cultures where indicated.
Support circulation: control haemorrhage, use cause-appropriate fluids/blood, consider vasopressor/inotrope support and reassess after each intervention.
Source control/transfer: definitive surgery, drainage, reperfusion, antidote, antibiotics or advanced airway/ICU care.

Reassessment loop: Intervention → repeat ABCDE → check perfusion/mental state/urine/lactate → document response → escalate or modify treatment.

2. Goals of shock management

Goal	How to judge it
Patent airway and adequate ventilation	Speech/airway protection, chest rise, improving SpO2/ETCO2/ABG, reduced work of breathing.
Effective perfusion	Improved mental state, pulse, capillary refill, warmth, BP/MAP appropriate to patient and falling lactate.
Renal perfusion	Urine output improving; no obstruction and no fluid overload.
Cause controlled	Bleeding stopped, infection treated/source controlled, allergy reversed, pump/obstruction addressed.
No treatment harm	No pulmonary oedema, worsening acidosis, hypothermia, dilutional coagulopathy or extravasation.

3. Universal medical and nursing actions

Keep an accurate fluid, blood-product, urine, drain, vomit and medication balance.
Use aseptic technique and label all lines/infusions; double-check high-alert medicines.
Prevent aspiration, pressure injury, hypothermia, infection and unnecessary movement.
Provide analgesia carefully; untreated pain increases sympathetic stress, but opioids can worsen hypotension/respiratory depression.
Explain care, preserve dignity, involve family appropriately and assess consent/capacity.
Escalate any patient who is worsening despite initial treatment or requires increasing oxygen/vasopressor support.

4. Hypovolaemic and haemorrhagic shock

Aim: stop the loss, restore oxygen-carrying volume, prevent hypothermia/coagulopathy and obtain definitive source control. Shock from bleeding may be internal; never wait for visible blood or a low haemoglobin.

Pre-hospital and first aid

Apply direct pressure, wound packing/hemostatic dressing or tourniquet when trained; reassess bleeding after movement.
Stabilise suspected pelvic/long-bone injury, use a spinal/trauma plan and avoid unnecessary log-rolling.
Keep the patient supine/warm, give oxygen for hypoxaemia and assist ventilation if needed.
Do not give oral fluids; obtain rapid transport and pre-alert trauma/surgical/blood team.
Document mechanism, estimated blood loss, tourniquet time, vital trends and response.

Hospital management

Activate major haemorrhage/massive transfusion protocol when indicated; obtain blood group/crossmatch without delaying emergency blood.
Use warmed blood components and appropriate balanced resuscitation under local protocol; monitor temperature, calcium, potassium, pH and coagulation.
Use crystalloid cautiously as a bridge when blood is unavailable; repeated large volumes can dilute clotting factors and worsen hypothermia/acidosis.
Seek definitive control: theatre, endoscopy, interventional radiology, obstetric intervention, chest decompression or pelvic surgery.
Consider tranexamic acid early in appropriate traumatic/obstetric bleeding according to local protocol and contraindications.
Reassess for ongoing internal bleeding even when BP temporarily improves.

Monitor	Why	Danger trend
Pulse/BP/perfusion	Response to haemorrhage control and volume/blood.	Persistent tachycardia, narrowing pulse pressure, hypotension, cold/mottled skin.
Temperature	Hypothermia worsens coagulopathy.	Falling core temperature despite warming.
Calcium/electrolytes	Citrate in transfusion and tissue injury affect calcium/potassium.	Arrhythmia, hypotension, tetany or ECG changes.
Urine/lactate/ABG	Organ perfusion and metabolic response.	Oliguria, rising lactate, worsening acidosis.

5. Non-haemorrhagic volume loss

Vomiting, diarrhoea, fever, burns, poor intake, diuretics and third spacing cause hypovolaemia without obvious blood. Replace measured and ongoing losses using prescribed fluid type/rate, correct electrolytes, treat infection or burns and reassess after small, appropriate challenges. In severe malnutrition, children, heart failure or renal disease, aggressive fluid can be harmful and specialist protocols are essential.

Record oral/IV intake, urine, diarrhoea/vomit, drains, burns and weight.
Check sodium, potassium, chloride, bicarbonate, urea/creatinine, glucose and lactate.
Assess lungs, JVP, oedema and oxygen requirement after each bolus.
Correct the cause: antiemetic/antidiarrhoeal plan, infection treatment, endocrine therapy, burn care or relief of obstruction.

6. Septic shock

Aim: recognise infection with organ dysfunction, obtain cultures where this does not delay treatment, start effective antimicrobials promptly, support perfusion and control the source. WHO emphasises early diagnosis and timely antimicrobial/fluid management; current sepsis guidance supports crystalloid resuscitation followed by vasopressor support when hypotension persists. 

ABCDE, oxygen/ventilation, ECG, glucose, temperature, lactate and repeated perfusion assessment.
Take blood cultures and source samples if this does not create a dangerous delay; do not wait for results before prescribed antibiotics in septic shock.
Give an appropriate crystalloid bolus only when hypoperfusion is present and reassess lungs, BP, capillary refill, urine and lactate.
If hypotension persists or fluid overload develops, start prescribed vasopressor support—norepinephrine is commonly first-line in adult septic shock—and transfer to critical care.
Control the source: drain abscess, remove infected device, debride tissue, operate, treat obstruction or manage pneumonia/meningitis.
Monitor glucose, electrolytes, coagulation, urine, mental state, temperature and antibiotic toxicity.

Fluid caution: A patient with heart/renal failure, pulmonary oedema, severe malnutrition or obvious fluid responsiveness failure needs smaller reassessed boluses and earlier senior/vasopressor review.

7. Anaphylactic shock

Stop exposure/infusion, call for help and lay flat with legs raised if tolerated; allow a breathless patient to sit with legs extended.
Give IM adrenaline/epinephrine immediately into the outer thigh using the local concentration and age/weight protocol; repeat if airway, breathing or circulation problems persist.
Give oxygen, establish IV/IO access and provide rapid crystalloid for persistent hypotension according to protocol.
Treat bronchospasm with prescribed bronchodilator; antihistamines may relieve skin symptoms but do not replace adrenaline.
Prepare suction, BVM and advanced airway support because airway oedema can progress rapidly.
Observe for biphasic reaction, document trigger/response and arrange allergy follow-up/autoinjector education when appropriate.

8. Neurogenic shock

Neurogenic shock follows loss of sympathetic vascular tone, usually high spinal cord injury. It may present with hypotension, relative bradycardia, warm dry skin and impaired temperature control. Distinguish it from haemorrhage, which can coexist in trauma.

Protect the airway and spine according to trauma protocol; maintain oxygenation and avoid hypoxia/hypotension.
Control obvious bleeding and search for occult haemorrhage before attributing shock to spinal injury.
Use cautious fluids to support preload; persistent vasodilation requires prescribed vasopressor support.
Treat symptomatic bradycardia according to ALS protocol; prevent hypothermia and pressure injury.
Urgent spinal imaging, neurosurgical/trauma consultation and ICU monitoring are required.

9. Cardiogenic shock

Aim: improve myocardial oxygen supply and cardiac output without causing pulmonary oedema, while urgently treating MI, arrhythmia, valve failure or myocarditis.

Position for breathing, give oxygen for hypoxaemia and use NIV/ventilation if pulmonary oedema or fatigue develops.
Obtain a 12-lead ECG, continuous rhythm monitoring, troponin pathway, glucose and bedside echo when available.
Give only cautious, reassessed fluid if preload depletion is suspected; large empiric boluses can worsen congestion.
Activate urgent reperfusion/cardiology pathway for ACS; treat life-threatening dysrhythmia with cardioversion/pacing/antiarrhythmic protocol.
Use vasopressor/inotrope support under critical-care direction for persistent hypotension or low output.
Correct hypoxia, acidosis, potassium/magnesium abnormalities and medication causes; arrange ICU/mechanical support if refractory.

Do	Avoid
ECG, reperfusion, oxygenation, analgesia when safe, cautious preload assessment, vasoactive support and ICU.	Routine large fluids, unmonitored sedatives, delayed ECG or assuming all hypotension is dehydration.

10. Obstructive shock

Cause	Immediate management	Definitive hospital treatment
Tension pneumothorax	Oxygen/ventilation, immediate decompression by trained provider when clinically indicated; do not wait for imaging in arrest/rapid collapse.	Chest drain, imaging, trauma/respiratory review.
Cardiac tamponade	ABCDE, cautious support, avoid delays and urgent echo/surgical consultation.	Pericardiocentesis or surgical drainage.
Massive pulmonary embolism	Oxygen/ventilation, cautious fluids, ECG/echo, anticoagulation/thrombolysis pathway by senior team.	Thrombolysis, embolectomy or catheter intervention when indicated.
Dynamic hyperinflation	Disconnect briefly from ventilator if instructed, allow exhalation, treat bronchospasm and call airway/ICU support.	Ventilator adjustment, bronchodilator, drainage if pneumothorax and critical care.

11. Mixed shock and treatment failure

Trauma may combine haemorrhage, tension pneumothorax, spinal injury, pain and hypothermia.
Sepsis can cause vasodilation, capillary leak, myocardial depression, AKI and respiratory failure.
Cardiogenic shock may develop after excessive fluids in a patient initially thought to be hypovolaemic.
Anaphylaxis can cause bronchospasm, vasodilation, capillary leak and cardiac arrest simultaneously.
Failure to improve after a reasonable intervention means reassess the diagnosis, search for obstruction/ongoing bleeding and call senior/ICU/surgical help.

12. Nursing interventions and ongoing monitoring

Area	Interventions	Escalate when
Airway/breathing	Position, suction, oxygen/ventilation, airway checks, SpO2/ETCO2/ABG and lung assessment.	Increasing support, fatigue, rising CO2, hypoxia or aspiration.
Circulation	ECG/BP/MAP, access, fluids/blood/vasopressor checks, bleeding/drain observation.	Persistent hypotension, arrhythmia, cool mottled skin or no response.
Renal/fluid	Hourly urine where indicated, strict intake/output, weight, electrolytes and renal review.	Oliguria/anuria, overload, rising creatinine or severe potassium/pH change.
Neurology	GCS/AVPU, pupils, glucose, pain, delirium and seizure precautions.	Falling consciousness, focal sign, seizure or new agitation.
Temperature/infection	Warm patient, cultures/antibiotics, aseptic lines, wound/source observation.	Persistent fever/hypothermia, worsening lactate or suspected source failure.
Safety/psychosocial	Explain care, protect dignity, pressure care, family communication and documentation.	Capacity/safeguarding concern, distress, refusal or communication barrier.

13. Prevention of shock and recurrent deterioration

Early recognition and treatment of infection, bleeding, dehydration, allergy, chest pain and breathing difficulty.
Safe medication reconciliation, anticoagulant monitoring and education about steroid/adrenal suppression.
Vaccination, infection prevention, food/water safety, malaria/arbovirus prevention and prompt wound care where relevant.
Fall/trauma prevention, occupational PPE, safe transport and early pregnancy/obstetric referral.
Discharge education: hydration, warning signs, medication adherence, allergy plan and follow-up.

14. Clinical scenarios

Scenario 1 — Haemorrhage: A patient with a stab wound is pale, tachycardic and confused. Apply direct pressure/packing, call trauma team, oxygenate, gain access, activate blood pathway, keep warm and transfer for surgery. Do not delay for a “normal” early haemoglobin.

Scenario 2 — Septic shock: A febrile patient is hypotensive with lactate 5 and low urine. Start sepsis bundle, cultures/antibiotics as directed, cautious crystalloid with reassessment, early norepinephrine/ICU if hypotension persists and urgent source control.

Scenario 3 — Cardiogenic shock: A patient with MI has pulmonary oedema, cool skin and hypotension. Oxygen/NIV, ECG/reperfusion, cautious fluids only if indicated, vasoactive support and cardiology/ICU—not a routine large fluid bolus.

Scenario 4 — Anaphylaxis: After an antibiotic, a patient develops wheeze, urticaria and collapse. Give IM adrenaline immediately, position safely, oxygenate, support circulation and monitor for recurrence; antihistamine alone is not adequate.

Scenario 5 — Tension pneumothorax: A ventilated trauma patient suddenly has unilateral absent breath sounds, hypotension and rising airway pressure. Suspect obstruction; call for immediate decompression by a trained provider and continue BVM/critical-care support.

15. Documentation and handover

Suspected shock type, onset/mechanism, comorbidities, allergies, medicines, pregnancy and baseline.
Serial ABCDE, vital signs, ECG, SpO2/oxygen, glucose, lactate/ABG, urine and fluid balance.
Bleeding control, fluid/blood products, antibiotic/antidote, adrenaline, vasopressor/inotrope and exact times.
Response, adverse effects, complications, escalation calls, destination and outstanding source-control plan.

16. Revision questions

What is the first priority in every type of shock?
How does fluid management differ between haemorrhagic and cardiogenic shock?
When should vasopressor support be considered in septic shock?
Why is IM adrenaline first-line in anaphylactic shock?
What definitive treatments relieve the main causes of obstructive shock?
Which findings suggest fluid overload during resuscitation?
What nursing observations should be repeated after every intervention?
How does mixed shock complicate diagnosis and treatment?
What prevention advice reduces recurrent shock?
What must be included in a shock handover?

17. Key take-home points

Support ABCDE while treating the mechanism—volume loss, vasodilation, pump failure or obstruction.
Control bleeding and source infection early; use fluids/blood/vasopressors thoughtfully.
Reassess perfusion, lungs, urine, mental state, lactate and treatment harm after every intervention.
Cardiogenic and obstructive shock require cause-specific therapy; large fluids can worsen both.
Detailed documentation and early specialist communication improve survival.

Selected authoritative resources

For EMT practice: Shock treatment is a sequence of support, source control, targeted resuscitation, reassessment and escalation. Give only what the patient needs—and keep checking whether it is helping.

Management of the Different Types of Shock: Complete EMT and Hospital Guide Read More »

Types of Shock and Assessment/Diagnosis: Comprehensive EMT Guide

Why this matters: Shock is a time-critical failure of circulation in which tissues do not receive or use enough oxygen. It may begin with normal blood pressure and subtle behaviour change, then progress to organ failure and cardiac arrest. EMTs must recognise compensated shock, identify the likely mechanism, start safe supportive care and communicate deterioration before hypotension appears.

Scope and safety: These are educational notes for emergency-medicine students. Use the Uganda Clinical Guidelines, local ambulance protocols and senior medical direction. Shock requires urgent transfer to a facility able to provide IV/IO access, blood, surgery, vasoactive support and critical care. Never delay ABCDE, haemorrhage control, oxygenation or emergency referral while completing a checklist.

Learning outcomes

Define shock and explain how oxygen delivery, perfusion and cellular metabolism fail.
Classify hypovolaemic, distributive, cardiogenic and obstructive shock and recognise mixed forms.
Identify compensated, progressive and irreversible/decompensated stages.
Perform initial contact, primary survey, focused history and repeated perfusion assessment.
Interpret vital signs, urine output, lactate, ECG, ultrasound and other investigations in context.
Describe first aid, pre-hospital, hospital and nursing priorities without treating blood pressure in isolation.

1. Definition and the oxygen-delivery problem

Shock is a life-threatening state of inadequate tissue perfusion and oxygen utilisation. Oxygen delivery (DO2) depends mainly on cardiac output and arterial oxygen content. Cardiac output depends on heart rate and stroke volume; stroke volume is influenced by preload, contractility and afterload. A patient can be in shock with a normal BP when vasoconstriction temporarily maintains pressure, or with a normal SpO2 when circulation cannot deliver oxygen to cells.

“FLOW”: Fill the tank (preload/volume); Let the pump work (heart/contractility); Open the pipes (vascular tone/obstruction); Watch the tissues (mental state, skin, urine, lactate and capillary refill).

2. Classification of shock

Type	Core mechanism	Common causes	Typical bedside pattern
Hypovolaemic	Too little circulating volume → reduced venous return, preload and stroke volume.	External/internal bleeding, vomiting/diarrhoea, dehydration, burns, third spacing.	Cool clammy skin, tachycardia, narrow pulse pressure, low JVP, thirst, oliguria.
Distributive	Vasodilation and maldistribution; relative hypovolaemia, capillary leak or loss of sympathetic tone.	Sepsis, anaphylaxis, neurogenic shock, toxins and adrenal crisis.	Warm flushed skin early in sepsis, bounding pulse or low SVR; later cool mottled shock.
Cardiogenic	Primary pump failure → low cardiac output despite adequate volume.	MI/ACS, severe arrhythmia, myocarditis, cardiomyopathy, valve failure.	Chest pain, pulmonary oedema, raised JVP, cool skin, dysrhythmia, low urine.
Obstructive	Mechanical block to filling, ejection or pulmonary blood flow.	Tension pneumothorax, cardiac tamponade, massive PE, severe dynamic hyperinflation.	Sudden collapse, PEA, distended neck veins, unequal breath sounds or muffled heart sounds.
Mixed	More than one mechanism at once.	Trauma with bleeding and tension pneumothorax; septic cardiomyopathy; burns with infection.	Features overlap; response to one treatment is incomplete.

3. The stages of shock

Stage	Physiology	Signs	EMT implication
Compensated/early	Sympathetic activation maintains BP by tachycardia and vasoconstriction.	Anxiety, thirst, cool skin, delayed capillary refill, tachycardia, rising RR, normal BP.	Do not reassure; find and treat the cause before decompensation.
Progressive/decompensated	Compensation fails; hypotension and cellular anaerobic metabolism develop.	Confusion, weak pulse, hypotension, oliguria, pallor/mottling, rising lactate and acidosis.	Resuscitate, expedite transport, establish access and call critical-care/surgical help.
Irreversible/refractory	Prolonged hypoperfusion causes mitochondrial, renal, hepatic, cardiac and coagulation failure.	Coma, anuria, severe acidosis, refractory hypotension, dysrhythmia and arrest.	Advanced resuscitation, source control and critical care; prognosis is poor if treatment is delayed.

4. Initial contact and scene approach

Scene safety/PPE: identify traffic, violence, fire, chemicals, infection, electrical risk and ongoing bleeding.
Mechanism and first impression: trauma, delivery, infection, bite/sting, chest pain, diarrhoea, poisoning or sudden collapse.
Call for help early: request ALS, blood, surgical/obstetric team, security or evacuation according to the setting.
Do not make the patient walk: keep them warm, flat when tolerated and in a position that supports breathing; avoid sudden standing.
Use a team leader: allocate airway, circulation, monitoring, access, documentation and transport roles.

5. Primary assessment: ABCDE

Step	Assessment	Immediate action in shock
A — Airway	Speech, obstruction, blood/vomit, swelling, facial trauma and airway protection.	Position, suction, airway adjunct, oxygen/ventilation and early advanced-airway help.
B — Breathing	RR, work, chest rise, breath sounds, SpO2, ETCO2, cyanosis and pneumothorax signs.	Oxygenate/ventilate; treat tension pneumothorax, bronchospasm or pulmonary oedema as indicated.
C — Circulation	Pulse rate/rhythm/quality, BP, capillary refill, skin, JVP, bleeding, ECG and temperature.	Control haemorrhage, IV/IO access, cautious fluids/blood, ECG and urgent cause-specific treatment.
D — Disability	AVPU/GCS, pupils, glucose, seizures, pain and mental-state change.	Correct glucose, protect airway, treat seizures and prevent secondary brain injury.
E — Exposure	Full skin/trauma/infection examination, abdomen, back, pregnancy, burns and environment.	Find hidden bleeding/rash/source; prevent hypothermia and preserve dignity.

ABCDE principle: Assess and treat the immediate life threat before moving on, then repeat the assessment after every intervention. This approach is recommended for deteriorating or critically ill patients. 

6. Perfusion assessment beyond blood pressure

Mental state: anxiety, restlessness, confusion, drowsiness or coma may reflect cerebral hypoperfusion.
Skin: colour, temperature, moisture, mottling, cyanosis and peripheral perfusion.
Capillary refill: interpret with temperature, age and vasoconstrictors; trend it rather than using it alone.
Pulse: rate, rhythm, central/peripheral strength and radio-femoral delay.
Urine: oliguria or anuria suggests reduced renal perfusion, but obstruction and renal disease can mimic it.
Respiratory pattern: tachypnoea or deep breathing may signal compensation for lactic/metabolic acidosis.
Blood pressure: hypotension is late in some patients; compare with baseline and pulse pressure.

7. Focused history: SAMPLE + shock clues

Question	What it reveals
What happened and when?	Bleeding, sepsis, allergy, trauma, toxin, chest pain or sudden obstruction.
Fluid/bleeding loss?	Vomiting, diarrhoea, urine, burns, childbirth, melena, haematemesis, vaginal bleeding or hidden trauma.
Heart/lung history?	MI, heart failure, arrhythmia, COPD/asthma, pulmonary hypertension or previous PE.
Medicines/substances?	Anticoagulants, antihypertensives, diuretics, insulin, steroids, beta-blockers, toxins or recreational drugs.
Allergy/pregnancy?	Anaphylaxis and obstetric causes require different immediate pathways.
Previous baseline?	Normal BP, mental state, renal function, mobility and urine output improve interpretation.

8. Bedside and hospital investigations

Investigation	What it helps answer	Important limitations
Glucose	Hypoglycaemia/hyperglycaemia causing or worsening altered state and shock.	Point-of-care errors occur with poor perfusion; confirm unexpected values.
ECG/monitor	MI, dysrhythmia, hyperkalaemia, right-heart strain or electrical cause.	A normal initial ECG does not exclude evolving MI/PE.
ABG/VBG + lactate	Acidosis, oxygenation, ventilation, lactate and response to resuscitation.	Lactate is a perfusion marker, not a diagnosis; interpret trend and causes.
Full blood count/group-crossmatch	Anaemia, infection, platelets and blood-product preparation.	Early haemorrhage may have a normal haemoglobin.
Electrolytes/renal/liver tests	AKI, potassium/sodium disturbance, toxin/metabolic disease.	Laboratory delay should not postpone life-saving treatment.
Coagulation/fibrinogen	Anticoagulation, DIC, trauma coagulopathy and bleeding planning.	Values can change rapidly during massive haemorrhage.
Bedside ultrasound	Cardiac contractility, pericardial fluid, lung sliding, IVC/volume clues, free fluid.	Operator-dependent; a negative scan does not exclude all pathology.
Imaging	Source of bleeding, PE, pneumothorax, infection or trauma.	Unstable patients need stabilisation and appropriate bedside alternatives.

9. Recognising shock patterns

Feature	Hypovolaemic	Cardiogenic	Distributive	Obstructive
Skin	Cool, pale, clammy	Cool, clammy, cyanotic	Warm/flushed early; cool late	Cool, clammy; cyanosis possible
JVP	Low/flat	Raised	Low/normal early	Raised in tamponade/PE/tension pneumothorax
Lungs	Usually clear unless aspiration	Crackles/pulmonary oedema	Variable; ARDS/sepsis possible	Absent one side or clear with tamponade/PE
Pulse	Fast, weak, narrow pulse pressure	Fast/irregular, weak	Bounding early or weak late	Fast, weak; PEA possible
Fluid response	Often improves if volume replaced and bleeding controlled	May worsen pulmonary oedema	Partial/temporary; vasodilation and leak persist	Minimal until obstruction relieved

10. Shock severity and reassessment

Do not wait for one threshold. Record trends in RR, pulse, BP, mental state, SpO2/oxygen requirement, capillary refill, temperature, urine output, lactate, ECG and treatment response. A patient with persistent tachycardia, worsening confusion, decreasing urine and rising lactate is deteriorating even if systolic BP remains above a textbook cut-off.

Shock index: Heart rate divided by systolic BP can help flag occult shock when interpreted with age, pregnancy, beta-blocker use, fever and baseline physiology. It is a screening aid, not a diagnosis or replacement for clinical judgement.

11. Differential diagnoses that mimic shock

Vasovagal syncope with rapid recovery when supine.
Severe hypoglycaemia, seizure/post-ictal state or stroke.
Sepsis without hypotension, adrenal crisis, thyroid storm or severe hypothermia.
Medication effects: beta-blockers, calcium-channel blockers, opioids, sedatives, antihypertensives.
Massive PE, tension pneumothorax, tamponade and dynamic hyperinflation.
Psychological distress or panic—diagnosed only after medical threats are assessed.

12. Immediate first aid and pre-hospital priorities

Call emergency help and keep the patient supine/positioned safely; prevent standing or walking.
Open and maintain the airway; suction and use basic adjuncts when indicated.
Give oxygen for hypoxaemia/respiratory distress and assist ventilation if breathing is inadequate.
Control external bleeding with direct pressure, wound packing/tourniquet when trained, and pelvic/limb stabilisation where indicated.
Keep the patient warm with blankets, remove wet clothing and avoid overheating during fever/hyperthermia.
Do not give oral food, drink or medicine to a shocked, vomiting, confused or potentially surgical patient.
Perform glucose, vital signs, ECG/monitoring and repeated perfusion checks; record times and trends.
Expedite transport to the right facility and give a structured pre-alert with suspected mechanism and interventions.

13. Nursing priorities during assessment

Apply continuous monitoring appropriate to severity; repeat ABCDE after every intervention.
Establish and secure IV/IO access; collect blood samples without delaying resuscitation.
Maintain accurate fluid balance, urine output and drain/bleeding measurements.
Administer prescribed oxygen, fluids, blood, antibiotics, adrenaline/vasopressors and analgesia safely; check response and adverse effects.
Prevent hypothermia, pressure injuries, aspiration, infection and medication errors.
Provide calm explanations, preserve dignity, involve family appropriately and document consent/capacity.
Escalate worsening vitals, mental state, perfusion, urine or lactate immediately—not at the next routine round.

14. Hospital diagnostic workflow

Resuscitation bay: ABCDE, monitoring, oxygen/ventilation, access, blood sampling and team leader.
Identify mechanism: bleeding/volume loss, pump failure, vasodilation, obstruction or mixed cause.
Bedside tests: glucose, lactate/ABG, ECG, ultrasound and temperature.
Targeted imaging: trauma, chest, abdomen, pelvis, PE, infection or cardiac pathology based on stability.
Source control: surgery, endoscopy, drainage, catheterisation, reperfusion, antibiotics or antidote pathway.
Disposition: theatre, ICU, high-dependency, blood bank, obstetric/paediatric/medical specialist team.

15. Prevention and early recognition

Use early-warning charts and respond to abnormal trends.
Prevent dehydration and recognise high-output vomiting, diarrhoea, burns, drains and poor intake.
Screen for sepsis, anaphylaxis, bleeding risk, medication toxicity and falls/trauma.
Review medicines that increase hypotension, bleeding or renal injury during acute illness.
Educate patients and families to seek help for faintness, confusion, cold/clammy skin, severe breathlessness, low urine or worsening pain.

16. Clinical scenarios

Scenario 1 — Compensated haemorrhage: A road-crash patient is anxious, pale, tachycardic and thirsty but has a normal BP. Search for hidden bleeding, expose fully, control haemorrhage, keep warm, obtain access and pre-alert trauma surgery. Normal BP does not exclude shock.

Scenario 2 — Cardiogenic shock: An older adult with chest pain is clammy, hypotensive, dyspnoeic and has crackles/raised JVP. Treat as pump failure: oxygenation/ventilation, ECG, cautious fluids, urgent reperfusion/cardiology and avoid reflexive large-volume boluses.

Scenario 3 — Obstructive shock: A ventilated trauma patient suddenly becomes hypotensive with unilateral absent breath sounds and high airway pressure. Suspect tension pneumothorax; ventilate, call for immediate decompression by a trained provider and continue reassessment.

Scenario 4 — Distributive shock: A febrile patient is confused, warm, tachypnoeic and hypotensive with rising lactate. Suspect sepsis; obtain cultures where this does not delay treatment, start the sepsis pathway, give appropriate crystalloid with reassessment and escalate to vasoactive support if needed.

Scenario 5 — Anaphylaxis: Minutes after an injection, a patient develops wheeze, urticaria, dizziness and weak pulse. Give IM adrenaline promptly according to protocol, oxygenate, position safely, establish access/fluids and transfer for observation.

17. Shock handover checklist

Time of onset, suspected mechanism, events, comorbidities, medicines and allergies.
ABCDE findings and trends: HR/rhythm, BP/MAP, RR, SpO2/oxygen, GCS/glucose, temperature, capillary refill and urine.
Bleeding/volume losses, examination findings, ECG/ABG/lactate/ultrasound and imaging.
Interventions with exact time: haemorrhage control, oxygen/airway, IV/IO, fluids/blood, medicines and response.
Concern, destination, specialist contacted, outstanding tests and next reassessment.

18. Revision questions

Define shock in terms of tissue perfusion and oxygen delivery.
Compare hypovolaemic, distributive, cardiogenic and obstructive shock.
Why can a patient be in compensated shock with normal BP?
List six signs of poor perfusion beyond hypotension.
What is the purpose of ABCDE in shock?
Which investigations help identify pump failure, bleeding, acidosis and obstruction?
Why may a haemoglobin result be normal early in acute bleeding?
What findings make large-volume fluid risky?
What information belongs in a shock pre-alert?
How can early recognition prevent irreversible shock?

19. Key take-home points

Shock is inadequate tissue perfusion, not simply a low BP reading.
Classify the mechanism while resuscitating: low volume, vasodilation, pump failure, obstruction or mixed.
Use ABCDE, mental state, skin, urine, lactate, ECG and trends to diagnose severity.
Control bleeding, support oxygenation, avoid harmful delays and transfer to definitive care.
Repeated reassessment and a precise handover are essential to prevent progression to organ failure.

Selected authoritative resources

For EMT practice: A patient who looks “almost okay” may be compensating. Trust trends, repeat ABCDE, search for the mechanism and act before blood pressure collapses.

Types of Shock and Assessment/Diagnosis: Comprehensive EMT Guide Read More »

Management of Acutely Ill Patients: Deterioration, Monitoring and Fluid Balance

Why this matters: Acutely ill patients may deteriorate rapidly from infection, trauma, bleeding, respiratory failure, cardiac disease, poisoning, metabolic crisis or postoperative complications. EMTs and emergency nurses save lives by recognising abnormal trends early, repeating ABCDE assessments, starting simple interventions, escalating clearly and recording fluid balance accurately.

Scope and safety: This is a detailed learning guide, not a substitute for local protocols, senior review or a hospital early-warning system. Treat life-threatening abnormalities immediately, call for help early and reassess the response to every intervention.

Learning outcomes

Recognise clinical signs and trends of deterioration in acutely ill adults.
Use ABCDE, SAMPLE history and early warning tools without allowing a score to replace clinical judgement.
Plan continuous or frequent monitoring according to risk and treatment.
Complete an accurate intake/output and fluid-balance chart, including hidden and ongoing losses.
Assess dehydration, overload, shock, renal dysfunction and electrolyte danger.
Escalate, hand over and document deterioration using a structured approach.

1. What is an acutely ill patient?

An acutely ill patient has a new or rapidly worsening condition that threatens airway, breathing, circulation, neurological function, temperature regulation or organ perfusion. The patient may be in the emergency department, ward, ambulance, theatre or community. A “normal” single observation does not exclude deterioration; the direction and speed of change matter.

Pattern	Possible cause	Immediate concern
Increasing respiratory rate/work	Pneumonia, asthma/COPD, PE, pulmonary oedema, sepsis, acidosis.	Impending ventilatory failure or hypoxaemia.
Falling BP/weak pulse	Bleeding, dehydration, sepsis, cardiogenic/obstructive shock, anaphylaxis.	Inadequate organ perfusion and arrest risk.
New confusion/agitation	Hypoxia, glucose/electrolytes, infection, stroke, toxins, pain or retention.	Delirium/neurological emergency; unsafe airway or self-harm.
Fever or hypothermia	Infection, exposure, drug reaction, endocrine crisis.	Sepsis, metabolic failure or impaired coagulation.
Low urine output	Shock, dehydration, obstruction, AKI or nephrotoxin.	Worsening renal perfusion, fluid/electrolyte crisis.

2. Signs of deterioration

Domain	Warning signs	What to do
Airway	Stridor, gurgling, snoring, drooling, swelling, inability to speak or protect airway.	Call for help, position/suction/open airway and prepare advanced airway support.
Breathing	RR rising/falling, severe effort, cyanosis, low SpO2, silent chest, exhaustion, rising ETCO2.	Oxygen/ventilation, ABG/ETCO2, bronchodilator/NIV/airway escalation as indicated.
Circulation	Tachycardia/bradycardia, hypotension, narrow pulse pressure, cold/mottled skin, delayed capillary refill.	Control bleeding, ECG, IV/IO access, fluids/blood/vasopressor pathway and source treatment.
Disability	New confusion, reduced GCS, seizure, unequal pupils, agitation, weakness or severe headache.	Glucose, oxygenation, neurological exam, seizure precautions and urgent review.
Exposure	Rash, fever/hypothermia, bleeding, abdominal distension, wounds, pressure injury.	Expose systematically while preventing heat loss; search for cause and infection source.

Patient concern counts: “I feel worse,” new breathlessness, dizziness, chest pain, severe pain, confusion or reduced urine can precede abnormal numbers. Listen, reassess and escalate even when an early-warning score is low.

3. ABCDE assessment and immediate treatment

Airway: assess speech, obstruction, secretions, swelling and aspiration risk; open, suction, use an adjunct and call airway help.
Breathing: count RR for a full minute when irregular, inspect work of breathing, measure SpO2/ETCO2, listen and give targeted oxygen/ventilation.
Circulation: pulse, BP, perfusion, ECG, bleeding, temperature, IV/IO access, lactate and cautious fluid/vasopressor strategy.
Disability: AVPU/GCS, pupils, glucose, seizures, pain, delirium and medication/toxin history.
Exposure: inspect skin, wounds, abdomen, back, drains, urine, lines and environment; preserve dignity and warmth.

4. Continuous and frequent monitoring

Monitoring intensity is matched to risk, not convenience. A stable patient may need scheduled observations; a patient with shock, respiratory failure, altered consciousness or active treatment needs continuous ECG/SpO2 and frequent clinical review. Document the frequency and reason rather than writing “stable” without values.

Monitor	What it detects	Limitations/clinical tips
Respiratory rate/work	Early respiratory failure, sepsis, pain, acidosis and fatigue.	Count accurately; do not copy a previous value or rely only on monitor alarms.
SpO2/oxygen device	Hypoxaemia and response to oxygen.	Check waveform/perfusion; oxygen can mask worsening hypoventilation.
ECG/heart rate	Arrhythmia, ischaemia, treatment effects and shock.	Confirm pulse and lead quality; interpret rhythm with symptoms/BP.
Blood pressure/MAP	Perfusion and treatment response.	Trend; cuff size/position and arrhythmia affect accuracy.
GCS/AVPU/pupils	Neurological or metabolic deterioration.	Compare with baseline and consider sedation, language, disability and hypoglycaemia.
Temperature	Infection, hypothermia, drug reaction and heat illness.	Use a reliable method; fever may be absent in older/immunocompromised patients.
Urine/fluid balance	Renal perfusion, shock, overload and treatment response.	Measure, not estimate; include drains, vomit, stool and insensible losses where required.

5. Early warning scores (EWS/NEWS2)

Early warning systems combine observations such as RR, SpO2, oxygen requirement, temperature, systolic BP, pulse and consciousness to trigger a response. They standardise communication and help identify deterioration, but they do not replace clinical judgement. Use the facility’s validated chart and escalation thresholds; do not manually invent scores or ignore a patient who “looks ill.”

Score workflow	Good practice
Measure	Obtain a complete set at the same time; record oxygen device/flow and new confusion.
Calculate	Use the approved chart/calculator; check arithmetic and abnormal single parameters.
Interpret	Look at trajectory, baseline, comorbidities, treatment and clinician concern.
Escalate	Follow the response pathway: repeat observations, urgent clinician review, senior/critical-care call or emergency team.
Reassess	Repeat after intervention and document the effect; a rising score is a clinical event.

6. Frequency of observations

Increase frequency when a vital sign is abnormal, the patient is receiving oxygen/fluids/sedatives, or the condition is changing.
Use continuous ECG/SpO2 and frequent BP/mental-state checks for shock, respiratory failure, arrhythmia, severe sepsis, post-sedation or high-risk transfer.
After an intervention, state when the next reassessment will occur; do not wait for routine rounds.
Document refusal, inability to measure, equipment failure and what alternative assessment was used.

7. Structured history: SAMPLE and deterioration timeline

S — Symptoms: onset, progression, pain, breathlessness, fever, vomiting, urine, mental state.
A — Allergies: medicines, food, latex and previous reactions.
M — Medicines: prescriptions, recent changes, adherence, anticoagulants, insulin, steroids, sedatives.
P — Past history: heart/lung/renal/liver disease, diabetes, pregnancy, surgery and baseline function.
L — Last intake/output: food/fluid, vomiting/diarrhoea, urine and last medication.
E — Events: trauma, infection exposure, procedures, new symptoms and treatment response.

8. Fluid balance: the essentials

Fluid balance compares measurable intake with measurable output over a defined period. It is a clinical tool, not merely a charting task. A positive balance may reflect resuscitation, but persistent accumulation can cause pulmonary oedema, impaired wound healing and organ dysfunction. A negative balance may indicate recovery from overload or dangerous dehydration.

Net balance = total intake − total output. Always state the time period (hourly, shift, 24-hour cumulative) and compare with weight, perfusion, lungs, oedema, renal function and treatment goals.

What counts as intake?

Intake source	Examples	Charting point
Oral	Water, tea, porridge, soup, oral rehydration, nutritional feeds.	Measure cups/bottles; do not write “drank well.”
IV fluids	Crystalloid, blood products, maintenance fluids, flushes and drug diluents.	Record product, volume, rate, start/stop and actual infused volume.
Enteral/parenteral nutrition	NG feeds, free water, TPN.	Include feed water and interruptions; check pump totals.
Medication/flushes	IV antibiotics, boluses, line flushes, contrast.	Small volumes accumulate in renal/cardiac failure.
Blood products	Whole blood, packed cells, plasma, platelets.	Record exact unit volume and completion time; monitor reaction.

What counts as output?

Output source	How to measure	Why it matters
Urine	Graduated container or catheter bag at prescribed intervals; document colour and concentration.	Renal perfusion, AKI, obstruction and response to fluids.
Vomitus/NG aspirate	Measure in a calibrated bowl/canister; note blood/bile.	Dehydration, electrolyte loss and aspiration risk.
Stool/diarrhoea	Estimate/measure frequency and volume; document watery/bloody output.	Fluid/electrolyte loss and infection risk.
Drains/chest tubes	Record hourly/shift volume, colour and sudden changes.	Bleeding, leaks, chyle, infection or surgical complication.
Wounds/burns	Use dressing weights/clinical protocol where required.	Large hidden losses may cause shock.
Insensible losses	Consider fever, tachypnoea, burns and open wounds; use local estimation.	Not directly measured, so interpret balance with weight and examination.

9. Fluid-balance chart example

Time	Oral (mL)	IV/feeds/meds (mL)	Total intake	Urine	Other output	Total output	Net
06:00–08:00	150	250	400	120	0	120	+280
08:00–10:00	100	300	400	40	100 vomit	140	+260
10:00–12:00	0	250	250	20	150 drain	170	+80
Running total	250	800	1,050	180	250	430	+620

Charting discipline: Every entry needs a time, source, measured volume and initials/signature. At the end of the shift, add totals, calculate net balance, compare with target and report unexpected changes immediately.

10. Assessing hydration and fluid overload

Dehydration/low volume	Overload/high volume
Thirst, dry mucosa, tachycardia, orthostatic symptoms, poor skin turgor, low urine, cool extremities.	Breathlessness, crackles, raised JVP, peripheral/sacral oedema, rapid weight gain, hypertension or worsening oxygen requirement.
Causes: bleeding, vomiting/diarrhoea, fever, burns, poor intake, diuretics, sepsis.	Causes: excessive IV fluid, renal/heart failure, liver disease, capillary leak, missed diuresis.
Interpret with BP, lactate, electrolytes, creatinine, urine and response to cautious fluid challenge.	Escalate before more fluid; evaluate lungs, renal function, ECG/ultrasound and prescribed diuretic/ventilatory plan.

11. When to escalate urgently

Airway obstruction, severe breathing difficulty, persistent hypoxaemia, exhaustion or rising CO2.
Shock signs: hypotension, weak pulse, altered consciousness, cold/mottled skin, rising lactate or very low urine.
New seizure, falling GCS, unequal pupils, sudden focal deficit or severe hypoglycaemia.
Rapidly rising early-warning score, new oxygen requirement, repeated abnormal observations or staff/patient concern.
Major bleeding, suspected sepsis, anaphylaxis, poisoning, severe electrolyte disturbance or fluid overload.
Failure to respond to initial treatment or inability to monitor safely in the current location.

12. Fluid treatment principles

Identify the goal: restore perfusion, replace a measured loss, maintain hydration, deliver medicine or remove excess fluid.
Choose the correct fluid and route according to diagnosis, age, weight, comorbidities and local protocol.
Give boluses cautiously when appropriate and reassess pulse, BP, perfusion, lungs, urine, mental state and lactate.
Stop or escalate if pulmonary oedema, worsening oxygen need, new crackles, raised JVP or no perfusion response develops.
Adjust maintenance and replacement for renal/heart/liver failure, burns, fever, diarrhoea, drains and ongoing losses.
Record prescription, actual volume, rate, response and adverse effects; never assume pump volume equals delivered volume.

13. Clinical scenarios

Scenario 1 — Sepsis deterioration: A patient’s RR rises from 22 to 34, BP falls, urine output drops and confusion develops. Repeat ABCDE, check glucose/lactate, give oxygen/ventilation support, obtain access, follow sepsis protocol and call the senior/critical-care team.

Scenario 2 — Fluid overload: A heart-failure patient receives IV fluids and develops crackles, orthopnoea and rising oxygen need. Stop/review the fluid, sit upright, oxygenate/consider NIV, assess perfusion and call the clinician; do not continue the chart mechanically.

Scenario 3 — Hidden losses: A patient with vomiting and a high-output drain has “normal” charted urine but becomes tachycardic and dizzy. Add all outputs, recalculate net balance, assess shock/electrolytes and report the ongoing loss.

Scenario 4 — False reassurance: A patient with COPD has SpO2 96% on high oxygen but becomes drowsy with slow breathing. Assess ventilation/ETCO2/ABG, titrate oxygen appropriately and prepare ventilatory support.

Scenario 5 — Early warning trigger: The calculated score is modest, but the nurse says “this patient looks different.” Repeat observations, examine the patient, check the trend and escalate; clinical concern should never be ignored.

14. Documentation and handover

Baseline and repeat ABCDE findings, vital signs, oxygen/device, EWS value and escalation response.
All treatment: oxygen, airway support, fluids/blood, medicines, procedures and response.
Fluid chart totals: oral, IV, feeds, medication/flushes, urine, vomit, stool, drains and cumulative balance.
Prescribed target balance, weight, renal/electrolyte results, lactate, glucose and relevant comorbidities.
Time of senior review, advice received, receiving team, family communication and next reassessment time.

15. Revision questions

Why is a trend more useful than one normal observation?
List six signs of deterioration in breathing or circulation.
What does ABCDE require before moving to the next step?
What parameters commonly contribute to an early warning score?
Why must oxygen flow/device be documented with SpO2?
What sources of intake are often missed on a fluid chart?
What outputs must be measured besides urine?
How can positive fluid balance harm a patient?
What signs suggest fluid overload rather than dehydration?
When should a fluid bolus be stopped and senior help called?

16. Key take-home points

Recognise deterioration early, treat life threats immediately and reassess after every intervention.
Use early-warning tools to standardise escalation, never to replace clinical judgement.
Continuous monitoring means watching trends, treatment response and the patient—not just a screen.
Accurate fluid balance requires measured intake/output, running totals and clinical interpretation.
Escalate promptly for respiratory failure, shock, neurological change, sepsis, poisoning or fluid overload.

Selected authoritative resources

For EMT practice: A complete set of observations, a truthful fluid chart and a timely escalation can reveal deterioration before the patient arrests. Measure carefully, think clinically and communicate early.

Management of Acutely Ill Patients: Deterioration, Monitoring and Fluid Balance Read More »

Management of Agitated and Aggressive Patients: EMT Assessment, Sedation and Safety

Why this matters: Agitation is a clinical emergency when it threatens the patient, family or healthcare team, or when intense activity causes hyperthermia, acidosis, rhabdomyolysis, exhaustion and sudden cardiac arrest. The emergency team must protect everyone while looking for hypoxia, hypoglycaemia, head injury, sepsis, intoxication, withdrawal, psychosis, mania, pain or medication toxicity.

Scope and safety: This guide is educational. Sedation, restraint and involuntary treatment must follow Uganda law, facility policy, trained-team scope and senior medical direction. Use the least restrictive safe option, document the reason, monitor continuously and never use sedation to punish, silence or replace a medical assessment.

Learning outcomes

Define agitation, aggression and acute behavioural disturbance (ABD) and recognise immediate danger signs.
Use scene safety, verbal de-escalation and a medical differential before medication.
Plan safe sedation: indication, drug choice, route, monitoring, airway readiness and reassessment.
Recognise excited delirium-like physiology, hyperthermia, acidosis, rhabdomyolysis and sudden collapse.
Apply ethical, legal, safeguarding and documentation principles to restraint and emergency treatment.

1. Definitions and severity

Presentation	Typical behaviour	Clinical priority
Mild agitation	Restlessness, irritability, pacing, raised voice or anxiety.	Identify triggers, offer choices and prevent escalation.
Moderate agitation	Threats, shouting, invading space, refusing assessment or pushing equipment away.	Team de-escalation, safe environment, medical screen and early senior help.
Severe aggression	Striking, kicking, biting, throwing objects, weapon access or attempts to abscond into danger.	Protect people, call trained security/clinical team, use least-restrictive emergency plan.
Acute behavioural disturbance	Extreme agitation with abnormal strength, pain insensitivity, hyperthermia, sweating, incoherence, intoxication or prolonged struggle.	Time-critical medical emergency: rapid control, sedation by trained team, cooling, glucose/oxygen/ECG and critical-care transfer.

2. Causes: “medical until proven otherwise”

Cause group	Examples	Clues to ask/check
Hypoxia/metabolic	Hypoxia, hypoglycaemia, hyperglycaemia, electrolyte disturbance, renal/liver failure.	SpO2, glucose, temperature, hydration, urine, diabetes/renal history.
Neurological	Head injury, stroke, seizure/post-ictal state, meningitis, raised intracranial pressure.	Trauma, headache, focal signs, unequal pupils, fever, seizure history.
Substances	Stimulants, cannabis, hallucinogens, alcohol, opioids, sedatives and withdrawal.	Last use, amount, co-ingestions, pupils, sweating, tremor, respiratory rate.
Psychiatric	Psychosis, mania, severe depression, personality crisis or trauma reaction.	Baseline function, hallucinations/delusions, mood, sleep, self-harm/violence risk.
Physical distress	Pain, urinary retention, constipation, hunger, sleep deprivation, hypothermia/hyperthermia.	Injury, abdomen/bladder, environment, recent procedures or medication change.
Medication effects	Akathisia, anticholinergic delirium, serotonin syndrome, NMS, steroid psychosis.	New/increased medicine, missed doses, fever/rigidity/clonus, dry skin/pupils.

3. Scene safety and team preparation

Identify weapons, exits, hazards, bystanders, security and available escape routes before approaching.
Use a calm, visible team; nominate one lead communicator and one team leader.
Remove unnecessary equipment and spectators; keep the patient away from corners or dangerous heights.
Maintain personal space, do not block the exit, avoid sudden touch and keep hands visible.
Request trained help early if threats, weapons, intoxication, ABD or repeated escalation are present.
Agree the escalation plan before contact: de-escalation, oral medication, parenteral sedation, restraint, transport and airway rescue.

4. Verbal de-escalation

Introduce yourself and role: use the patient’s preferred name, a respectful tone and simple language.
Listen first: ask what is upsetting them, reflect the emotion and acknowledge fear without agreeing with unsafe beliefs.
Offer choices: quiet room or open area, male/female staff where possible, oral medicine or assessment, family/support person if safe.
Set one clear boundary: “I want to help; I cannot allow hitting. If you keep moving toward staff, we will need to use the safety plan.”
Reduce stimulation: dim noise, remove unnecessary staff, give time to answer and avoid arguing, mocking or rapid questioning.
Plan an exit: do not promise secrecy, discharge or a specific outcome you cannot deliver.

“CALM”: Connect respectfully; Acknowledge distress; Limit stimulation and set boundaries; Make a safe plan and monitor.

5. Immediate risk assessment

Risk	Questions/observations	Response
Violence	Threats, weapon access, target, past violence, escalating posture, clenched fists.	Increase distance, call trained help/security, remove means and agree a team plan.
Self-harm	Suicidal thoughts, plan, access to means, recent attempt, command hallucinations.	Constant observation, remove means, urgent mental-health/medical assessment.
Medical collapse	Fever, sweating, abnormal breathing, collapse, rigidity, seizure, severe pain or confusion.	ABCDE, glucose, oxygen/ventilation, temperature, ECG, cooling and urgent transfer.
Vulnerability	Child, pregnancy, older adult, disability, communication barrier, trauma history.	Adapt approach, safeguard, use interpreter/support and avoid unnecessary force.

6. Rapid medical assessment during agitation

Airway: Can the patient speak? Is there vomiting, trauma, swelling or reduced consciousness?
Breathing: Count RR, check SpO2, work of breathing and ETCO2 when available. Severe agitation can mask hypoxia.
Circulation: Pulse, BP, temperature, ECG, perfusion, bleeding and IV access.
Disability: AVPU/GCS, glucose, pupils, seizure/post-ictal state, focal neurological deficit.
Exposure: trauma, hyperthermia, rash, needle marks, medications, pregnancy and environmental causes.

Red flags for a medical emergency: new onset in an older adult, fluctuating attention, abnormal vital signs, fever/hypothermia, hypoxia, severe headache, head injury, seizure, rigid muscles, clonus, chest pain, extreme exertion, collapse or a sudden change after a medicine/substance.

7. Escalation and consent

Seek consent whenever possible. If the patient lacks capacity and immediate treatment is needed to prevent serious harm, act within emergency law and policy, use the minimum force/time required and involve a senior clinician. Explain what is happening even if the patient cannot respond. Document capacity, risk, alternatives offered, staff involved, proportionality and review.

8. When medication is needed

Use medication when immediate danger persists despite de-escalation, when severe agitation prevents life-saving assessment/treatment, or when ABD physiology is causing exhaustion and collapse. Choose the least restrictive effective medicine and route, give only by trained staff under protocol, and reassess rather than stacking unrecorded doses.

Option	When it may help	Important cautions
Oral medication	Cooperative patient who can swallow and has time for effect.	Slower onset; confirm ingestion, avoid hidden medication and keep observing.
Benzodiazepine (e.g., midazolam/lorazepam/diazepam)	Severe anxiety/agitation, stimulant intoxication, alcohol withdrawal, seizures.	Respiratory depression, hypotension, paradoxical agitation; danger increases with opioids/alcohol and respiratory disease.
Antipsychotic (e.g., haloperidol/olanzapine)	Psychosis or mania when clinically appropriate.	QT prolongation, dystonia, akathisia, NMS, hypotension and sedation; check medical causes and interactions.
Ketamine	Extreme violence/ABD requiring rapid control when other measures are unsafe or ineffective.	Hypersalivation, vomiting, laryngospasm, emergence reaction and hypertension; requires advanced airway readiness.
Combination therapy	Selected severe cases under a senior protocol.	Additive respiratory/cardiovascular depression and medication error; use only with continuous monitoring.

Medication safety: Do not provide a generic dose schedule in place of local protocol. Verify age/weight, indication, allergies, pregnancy, intoxication, cardiac disease, recent sedatives and available rescue equipment.

9. Sedation administration and monitoring

Record baseline RR, SpO2, pulse, BP, temperature, glucose, mental state and airway risk.
Prepare oxygen, suction, BVM, airway adjuncts, capnography, ECG, BP cuff, IV/IO access and reversal/resuscitation support.
Assign one clinician to monitor the patient continuously; the proceduralist should not be the sole observer.
Administer the selected medicine by the authorised route, note exact time/dose/concentration and avoid rapid unplanned repetition.
Reassess every few minutes: response, agitation score, airway tone, RR, SpO2, ETCO2, pulse, BP, temperature and adverse effects.
After control, continue observation because delayed respiratory depression, recurrent agitation or aspiration can occur.

Monitor	What deterioration looks like	Immediate response
Airway	Snoring, gurgling, drooling, swelling, loss of tone.	Reposition, suction, adjunct, BVM/advanced airway help.
Breathing	Slow/shallow breaths, rising ETCO2, falling SpO2, cyanosis.	Oxygen/ventilate, stop sedatives, call resuscitation team.
Circulation	Hypotension, bradycardia, dysrhythmia, poor perfusion.	Monitor ECG/BP, IV/IO access, fluids/advanced support and cause review.
Temperature/metabolic	Hyperthermia, acidosis, severe sweating, rigidity, rhabdomyolysis.	Cooling, glucose/ECG/ABG/CK/renal assessment and critical-care transfer.

10. Physical restraint: last resort

Use only when necessary to prevent immediate harm and after de-escalation/less restrictive measures fail or cannot be attempted.
Use trained staff, a team leader and coordinated commands; never improvise a prone restraint or compress the neck/chest.
Keep the airway accessible; avoid pressure on the chest/abdomen and release restraints as soon as safe.
Continuously observe breathing, circulation, consciousness, skin colour, limb perfusion and distress; restraints do not replace sedation or medical assessment.
Search for injury, document the reason, duration, staff, technique, monitoring, review and debrief the patient/team.

11. Common emergency syndromes to recognise

Syndrome	Clues	Priority
Stimulant toxicity/ABD	Extreme activity, sweating, dilated pupils, tachycardia, hypertension, hyperthermia.	Rapid control, cooling, glucose/ECG, benzodiazepine-led protocol and critical-care review.
Alcohol withdrawal	Tremor, sweating, anxiety, hallucinations, seizures, autonomic instability.	Seizure precautions, thiamine/glucose considerations and supervised withdrawal treatment.
Serotonin syndrome	Agitation, diarrhoea, sweating, tremor, clonus/hyperreflexia, fever.	Stop serotonergic exposure, cooling, seizure/airway support and toxicology review.
NMS	Recent dopamine blocker, rigidity, hyperthermia, altered consciousness, unstable BP/pulse.	Emergency transfer, cooling, fluids and critical-care treatment.
Delirium	Fluctuating attention, disorientation, visual hallucinations, acute medical illness.	Search for hypoxia, infection, glucose, toxins, retention and pain; do not assume primary psychosis.

12. Special populations

Children: involve safeguarding, use age-appropriate communication and weight-based protocol; look for pain, injury, hypoxia or abuse.
Older adults: new agitation is delirium until proven otherwise; reduce noise, check infection/medicines and use lower doses if sedation is authorised.
Pregnancy: protect patient and fetus, use left lateral displacement where appropriate and involve obstetric/senior teams.
Autism/intellectual disability: ask carers about baseline communication, sensory triggers, calming strategies and pain expression.
Trauma/head injury: agitation may reflect hypoxia, intracranial injury or shock; protect the airway and avoid masking neurological change.
Substance dependence: avoid stigma, anticipate withdrawal and respiratory depression, and provide naloxone/withdrawal care according to protocol.

13. Clinical scenarios

Scenario 1 — Hypoglycaemia: A shouting patient threatens staff. Glucose is 2.1 mmol/L. Treat the hypoglycaemia and reassess before sedation; the behaviour was a medical symptom.

Scenario 2 — Stimulant-related ABD: A patient is sweating, hyperthermic and fighting after suspected cocaine use. Protect the team, reduce stimulation, call senior help, give protocol-led rapid sedation with airway readiness, cool and monitor ECG/temperature/renal risk.

Scenario 3 — Akathisia: A patient on a new antipsychotic paces, says they feel unbearable inner restlessness and has suicidal thoughts. Consider akathisia, do not simply increase the antipsychotic, maintain safety and arrange urgent review.

Scenario 4 — Delirium: An older patient becomes suddenly agitated overnight with fever and fluctuating attention. Check oxygenation, glucose, infection, urine retention, medicines and pain; involve family and avoid unnecessary restraint.

Scenario 5 — Sedation complication: After parenteral sedation, the patient becomes snoring and bradypnoeic. Stop further doses, jaw thrust, suction, oxygen/BVM, capnography and resuscitation-team escalation.

14. Documentation and handover

Baseline behaviour, mental state, capacity, triggers, threats, weapons and risk to self/others.
Medical assessment: airway, breathing, circulation, glucose, temperature, trauma, substances and medicines.
De-escalation offered, choices, consent/refusal and why escalation was necessary.
Medication name/concentration/route/dose/time, monitoring, response and adverse effects.
Restraint type, reason, staff, start/stop time, body position, circulation/airway observations and review.
Safeguarding, family/support, police/security involvement, receiving clinician and follow-up plan.

15. Revision questions

Why is acute agitation a medical emergency rather than simply a behavioural problem?
List six reversible medical causes of aggression.
What are the first steps in verbal de-escalation?
When is emergency sedation justified?
What equipment must be ready before parenteral sedation?
Why is physical restraint a last resort?
What signs suggest ABD physiology and rhabdomyolysis risk?
How can akathisia be mistaken for worsening psychosis?
What observations are required after sedation?
What must be documented after restraint?

16. Key take-home points

Protect people while searching for hypoxia, hypoglycaemia, trauma, toxicity, withdrawal, delirium and psychiatric illness.
De-escalation, clear boundaries and a calm team prevent many confrontations.
If sedation is needed, prepare airway rescue, monitor continuously and reassess after every dose.
Extreme agitation with hyperthermia, sweating, acidosis or collapse is time-critical ABD.
Use restraint only when necessary, proportionately and with continuous observation.

Selected authoritative resources

For EMT practice: The goal is safe control and treatment, not domination. Respectful communication, rapid medical assessment, proportionate intervention and continuous monitoring protect both patient and team.

Management of Agitated and Aggressive Patients: EMT Assessment, Sedation and Safety Read More »

Oxygen Therapy Assessment: Hypoxaemia, Devices, Targets and Safety

Why this matters: Oxygen is an essential medicine for hypoxaemia, respiratory distress, shock, trauma, cardiac arrest and many acute illnesses. Too little oxygen injures organs; too much oxygen can also harm selected patients. EMTs must assess the patient, select a delivery device, titrate to a target, monitor response and keep oxygen available during every transfer.

Safety notice: Follow local protocols and patient-specific targets. Oxygen does not replace airway opening, ventilation, circulation support or treatment of the cause. In an emergency with severe hypoxaemia or arrest, give high-concentration oxygen while preparing definitive care, then titrate when reliable monitoring is available.

Learning outcomes

Recognise clinical and oximetry signs of hypoxaemia and respiratory failure.
Use pulse oximetry correctly, understand limitations and confirm with ABG when needed.
Select nasal cannula, masks, BVM, HFNC, CPAP or NIV appropriately.
Set and reassess target saturation for general patients, hypercapnic-risk patients and children/neonates under local guidance.
Handle oxygen cylinders, concentrators, tubing, humidification and fire risks safely.
Document oxygen device, flow/FiO2, saturation, response and escalation.

1. Oxygen physiology in simple terms

Oxygen enters the lungs, crosses the alveoli, binds haemoglobin and is delivered by the circulation to tissues. A normal SpO2 does not guarantee adequate oxygen delivery if haemoglobin is low, circulation is poor or carbon monoxide occupies haemoglobin. Conversely, a patient may have severe respiratory distress before SpO2 falls. Assess the whole patient: work of breathing, mental state, skin, pulse, BP, lactate and urine output.

Term	Meaning	EMT relevance
Hypoxaemia	Low oxygen in arterial blood.	Detected by SpO2/PaO2 and clinical signs; treat promptly.
Hypoxia	Inadequate oxygen at tissue level.	May occur with anaemia, shock or CO poisoning even when SpO2 looks normal.
FiO2	Fraction of inspired oxygen delivered.	Room air is about 0.21; masks/devices deliver variable FiO2 depending on flow and seal.
SpO2	Pulse-oximeter estimate of haemoglobin saturation.	Trend with waveform/perfusion; confirm unexpected values.
PaO2	Dissolved oxygen measured on ABG.	Interpreted with FiO2, altitude, age, haemoglobin and clinical condition.

2. Assessing the patient before oxygen

Ensure scene safety and use PPE; identify smoke/chemical exposure and fire risk.
Check airway patency, breathing rate/effort, chest rise, lung sounds, colour, mental state and ability to speak.
Measure SpO2 with a reliable probe and waveform; check pulse, BP, temperature, glucose and ECG when indicated.
Ask about COPD/hypercapnic respiratory failure, home oxygen, asthma, heart/lung disease, anaemia, pregnancy and recent sedation/opioids.
Identify the cause: pneumonia, asthma/COPD, pulmonary oedema, PE, shock, sepsis, trauma, drowning, poisoning or cardiac arrest.
Choose device and target, start oxygen, reassess within minutes and escalate if work of breathing or mental state worsens.

3. Recognising hypoxaemia and respiratory failure

Finding	Possible meaning	Action
Low SpO2 with distress	Hypoxaemic respiratory failure.	Oxygen/ventilation, ABCDE, treat cause and seek advanced help.
Normal SpO2 but exhaustion	Impending ventilatory failure or severe work of breathing.	Check ETCO2/ABG, prepare BVM/NIV/advanced airway.
Cyanosis	Severe desaturation or dyshemoglobinaemia; can be absent in anaemia.	High-concentration oxygen, verify probe/ABG and urgent review.
Confusion/agitation	Hypoxia, hypercapnia, shock, glucose/toxin or sepsis.	ABCDE and glucose; do not label psychiatric without medical screen.
Silent chest/poor air entry	Critical asthma, obstruction, pneumothorax or fatigue.	Emergency escalation; ventilation may be needed.

4. Oxygen delivery devices

Device	Use	Practical checks
Nasal cannula	Low-flow support for a spontaneously breathing patient with mild hypoxaemia.	Correct prongs, comfort, humidification if prolonged, flow and response.
Simple face mask	Moderate oxygen requirement when a tight seal is possible.	Use sufficient flow to prevent rebreathing; remove for eating/communication with monitoring.
Venturi mask	Controlled FiO2, useful when a precise target is required.	Use the correct colour/flow combination; do not obstruct entrainment ports.
Non-rebreather mask	High-concentration oxygen for severe hypoxaemia, shock or pre-oxygenation.	Inflate reservoir before application; check valves, seal and cylinder supply.
Bag-valve-mask	Apnoea, agonal breathing or inadequate ventilation.	Requires airway opening, mask seal, oxygen/reservoir and controlled breaths.
High-flow nasal oxygen	Heated humidified high flow for selected hypoxaemic patients.	Needs reliable oxygen source and monitoring; does not replace a failing airway.
CPAP/NIV	Selected conscious patients with pulmonary oedema, COPD or respiratory failure.	Contraindicated with vomiting, severe agitation, shock or inability to protect airway.
Tracheostomy/ventilator circuit	Patients with established airway and ventilatory support.	Check tube patency, humidification, cuff, suction, spare tube and backup BVM.

5. Target saturation and titration

Patient context	Typical target approach	Why individualise?
Most acutely ill adults	Often 94–98% once reliable readings are available.	Avoid persistent hypoxaemia and unnecessary hyperoxia; follow local protocol.
Risk of hypercapnic respiratory failure	Often 88–92% pending ABG/clinician direction.	Excess oxygen can worsen CO2 retention in susceptible COPD/neuromuscular patients; never withhold emergency oxygen from a critically hypoxic patient.
Cardiac arrest/peri-arrest	Use high-concentration oxygen during resuscitation; titrate after ROSC and reliable measurement.	Oxygenation and ventilation must be continuously monitored.
Children/neonates	Age-, condition- and gestation-specific targets; use paediatric/neonatal protocol.	Both hypoxia and unregulated hyperoxia can cause harm.
Carbon monoxide suspicion	Give high-concentration oxygen and urgent specialist assessment.	SpO2 can be falsely reassuring; co-oximetry/ABG may be needed.

6. Pulse oximetry technique

Choose the correct probe and site; warm cold extremities and remove nail products where possible.
Check the plethysmography waveform and compare displayed pulse with palpated pulse.
Keep the hand still, shield from strong light and recheck after oxygen/device changes.
Look for poor perfusion, motion, dysrhythmia, skin pigmentation/probe issues and venous pulsation.
Do not rely on SpO2 alone in carbon monoxide exposure, shock, severe anaemia or an unexpected clinical picture.

Oxygen is titrated to the patient, not the monitor. A rising SpO2 with worsening fatigue, confusion or CO2 retention is not a successful outcome—reassess ventilation and the underlying cause.

7. Oxygen in common emergencies

Emergency	Oxygen/ventilation priorities
Asthma/COPD	Titrate to target, bronchodilator protocol, assess fatigue/CO2 and escalate NIV/intubation if failing.
Pulmonary oedema	Upright position, oxygen if hypoxaemic, CPAP/NIV when indicated and treat cardiac cause.
Sepsis/shock	Oxygen for hypoxaemia, support perfusion, lactate/ABG and rapid infection management.
Trauma/haemorrhage	Airway/oxygenation, bleeding control, ventilation and blood/fluid pathway; prevent hypothermia.
Drowning	Ventilation is crucial; oxygen, BVM, airway protection, hypothermia management and observation.
Carbon monoxide	High-concentration oxygen, remove from source, monitor ECG/neurology and arrange co-oximetry/specialist care.
Cardiac arrest	100%/maximum available oxygen during CPR, effective BVM/advanced airway and capnography, then titrate after ROSC.

8. Cylinder, concentrator and fire safety

Oxygen supports combustion: no smoking, flames, sparks, petroleum products or oil/grease near cylinders, regulators or masks.
Secure cylinders upright with three points of contact; separate full and empty cylinders and check pressure before leaving.
Open valves slowly, use the correct regulator and never force a connection. Listen for leaks.
Keep cylinders away from heat, sunlight, impact and vehicle movement; use approved holders.
Check concentrator power, oxygen concentration/flow, filters, alarms and backup cylinder before relying on it.
Do not store oxygen in an unventilated ambulance compartment; follow facility fire and transport policy.

9. Humidification and airway care

Dry high-flow oxygen can irritate mucosa, thicken secretions and worsen discomfort. Use humidification when indicated by flow, duration, tracheostomy or local policy. Keep water traps below the patient, prevent condensate entering the airway, use sterile/clean water as required and change circuits only according to protocol.

10. Monitoring after oxygen starts

Time point	What to record
Before	RR/effort, SpO2 waveform, pulse/BP, mental state, oxygen device/flow, lung signs, glucose and cause.
After initiation	SpO2 response, work of breathing, ability to speak, colour, comfort, pulse/BP and device function.
After change	New device/flow/FiO2, time, target, response and escalation decision.
During transfer	Cylinder reserve, battery, tubing, mask seal, continuous SpO2/ECG and backup BVM/oxygen.
If deterioration	ABCDE, ABG/ETCO2 when available, suction, BVM, chest assessment and urgent senior review.

11. Clinical scenarios

Scenario 1 — COPD exacerbation: A patient is drowsy with RR 30 and SpO2 82% on room air. Give emergency oxygen, titrate toward the locally specified target, obtain ABG/ETCO2 and prepare NIV/airway support; do not withhold oxygen out of fear of CO2 retention.

Scenario 2 — Pulmonary oedema: A breathless patient is sitting upright, coughing pink froth and has low SpO2. Apply appropriate oxygen, consider CPAP/NIV if conscious and haemodynamically suitable, monitor BP/ECG and escalate.

Scenario 3 — Normal SpO2 in CO exposure: Several family members have headache and confusion after a charcoal stove was used indoors. Give high-concentration oxygen, move to fresh air, check for fire/scene safety and arrange urgent specialist assessment; pulse oximetry may be misleading.

Scenario 4 — Cylinder failure: During transfer the reservoir bag collapses and SpO2 falls. Check cylinder/regulator/tubing, switch to backup source, use BVM if ventilation is inadequate and report equipment failure.

Scenario 5 — Hypoxic child: A child with pneumonia has increased work of breathing and low SpO2. Use the correct paediatric probe/device, target the age/condition-specific range, reassess frequently and escalate for CPAP/ventilation if tiring.

12. Oxygen prescription and handover

Indication and suspected cause of hypoxaemia.
Target saturation/range and whether hypercapnic-risk guidance applies.
Device, flow or FiO2, humidification and time started/changed.
Pre/post SpO2, waveform quality, RR/work of breathing, mental state, BP/ECG and ABG/ETCO2 if available.
Response, complications, cylinder/concentrator reserve and escalation plan.

13. Revision questions

Why can oxygen be both lifesaving and harmful?
What are the limitations of pulse oximetry?
Which patients may need a lower target range while awaiting ABG?
Why must a non-rebreather reservoir be inflated before application?
When is NIV unsafe?
What fire-safety rules apply to oxygen cylinders?
Why is high-flow oxygen appropriate immediately after cardiac arrest but titrated after ROSC?
What signs show that a patient needs ventilation rather than oxygen alone?
What details should appear in an oxygen handover?
How can a normal SpO2 be misleading in carbon monoxide exposure?

14. Key take-home points

Assess airway, breathing, circulation and cause before choosing an oxygen device.
Use reliable pulse oximetry and titrate oxygen to an appropriate target; reassess work of breathing and mental state.
Oxygen does not correct hypoventilation—use BVM/NIV/ventilation when CO2 clearance or airway protection fails.
Protect cylinders and concentrators from fire, impact, leaks and empty reserves.
Document device, flow/FiO2, target and response during every handover and transfer.

Selected authoritative resources

For EMT practice: Give oxygen early when the patient needs it, measure its effect, titrate safely and always keep a ventilation rescue plan ready.

Oxygen Therapy Assessment: Hypoxaemia, Devices, Targets and Safety Read More »

Critical and Intensive Care Principles: Monitoring, Organ Support and Safety

Why this matters: Critical care is the organised support of patients with actual or threatened failure of one or more organs. EMTs and emergency nurses do not need to wait for an ICU bed to think critically: early recognition, ABCDE, trend monitoring, infection prevention, communication and timely escalation improve survival in every setting.

Scope: This guide supports learning and does not replace local critical-care protocols, senior review or specialist decisions. Use the WHO/ICRC Basic Emergency Care approach and facility escalation pathways, and adapt interventions to available equipment and staffing.

Learning outcomes

Explain how critical illness causes organ dysfunction and why trends matter.
Use ABCDE, SAMPLE and early warning scores to identify deterioration.
Monitor respiratory, cardiovascular, neurological, renal, metabolic and temperature status.
Describe common organ-support principles: oxygen/ventilation, fluids/vasopressors, renal support and nutrition.
Apply infection prevention, medication safety, pressure injury prevention and human-factors principles.
Communicate escalation, referrals, family updates and end-of-life concerns professionally.

1. What makes a patient critically ill?

Critical illness is a rapidly changing state in which the body cannot maintain oxygen delivery, perfusion, ventilation, neurological function or metabolic balance without support. Causes include sepsis, trauma, burns, respiratory failure, poisoning, cardiac arrest, severe obstetric emergencies and postoperative complications. A patient may compensate for a time and then deteriorate rapidly; repeated observation is therefore essential.

Organ system	Failure clues	Immediate questions
Airway/lungs	Stridor, exhaustion, cyanosis, rising CO2, low SpO2, silent chest.	Is the airway open? Is oxygen reaching the blood? Is ventilation adequate?
Circulation	Hypotension, weak pulse, cold skin, delayed capillary refill, oliguria, rising lactate.	Is there bleeding, sepsis, pump failure, obstruction or dehydration?
Brain	New confusion, agitation, reduced GCS, seizures, unequal pupils.	Glucose? Oxygen/CO2? Stroke, trauma, infection, toxins or hypoperfusion?
Kidneys/metabolism	Low urine, rising creatinine, potassium/pH abnormalities, acidosis.	Perfusion, nephrotoxins, obstruction, fluid balance and dialysis needs?
Skin/temperature	Mottling, fever/hypothermia, rash, burns, pressure injury.	Infection, exposure, shock, drug reaction or heat/cold injury?

2. ABCDE and the first hour

A — Airway: assess voice, obstruction, secretions and protection; suction, position and call airway help.
B — Breathing: rate, effort, chest movement, SpO2, ETCO2/ABG, oxygen/ventilation support and treat reversible causes.
C — Circulation: pulse/BP/perfusion, ECG, bleeding control, IV/IO access, fluids/blood/vasopressor pathway and lactate.
D — Disability: GCS/AVPU, pupils, glucose, seizures, temperature and neurological trend.
E — Exposure: inspect skin, wounds, abdomen, back, lines, urine, pressure areas and environmental hazards while preventing heat loss.

Resuscitation and diagnosis run together. Treat a life threat immediately, but keep asking why the patient is deteriorating: sepsis, bleeding, obstruction, toxicity, endocrine crisis, cardiac disease or trauma may coexist.

3. Monitoring in critical care

Domain	Core observations	Trend that demands escalation
Respiratory	RR, work of breathing, SpO2, oxygen device, ETCO2, ABG, breath sounds.	Increasing oxygen/ventilatory support, fatigue, rising CO2, silent chest or falling SpO2.
Cardiovascular	HR/rhythm, BP/MAP, capillary refill, skin, lactate, urine output.	Persistent hypotension, new arrhythmia, cold/mottled skin, rising lactate or escalating vasopressor.
Neurological	GCS/AVPU, pupils, pain/sedation score, seizures, delirium.	Falling consciousness, new focal deficit, unequal pupils, refractory agitation or seizures.
Renal/fluid	Hourly urine where indicated, fluid input/output, weight, creatinine/electrolytes.	Oliguria/anuria, pulmonary oedema, severe electrolyte/pH change.
Infection	Temperature, cultures, source, WBC/markers, lines/wounds.	New fever/hypothermia, shock, worsening organ function or line infection.

4. Respiratory and cardiovascular support

Support	Principles	Safety checks
Oxygen	Treat hypoxaemia and titrate to a target; reassess work of breathing and cause.	Correct device/flow, cylinder supply, humidification and SpO2 limitations.
NIV	Selected cooperative patients with respiratory failure; allows spontaneous breathing.	Airway protection, mask fit, aspiration risk, CO2/ABG, haemodynamics and escalation plan.
Invasive ventilation	Airway protection or failure of oxygenation/ventilation; use lung-protective strategy.	Tube/capnography, pressures, alarms, sedation/analgesia, infection prevention and backup BVM.
Fluids	Restore perfusion when hypovolaemia is likely; reassess after each bolus.	Overload harms lungs/heart/kidneys; consider bleeding, sepsis, cardiogenic and obstructive shock.
Vasopressors/inotropes	Support vascular tone or cardiac output when fluids alone are inadequate.	Infusion pump, dedicated line, extravasation precautions, ECG/BP and perfusion trend.

5. Shock and perfusion

Shock type	Typical clues	First priorities
Hypovolaemic	Bleeding/dehydration, tachycardia, cool skin, narrow pulse pressure.	Control source, access, blood/fluids, keep warm and reassess response.
Distributive/septic	Infection, fever/hypothermia, warm or mottled skin, vasodilation, lactate.	Early recognition, cultures/antibiotics pathway, fluids/vasopressor support and source control.
Cardiogenic	Chest pain, pulmonary oedema, raised JVP, cool skin, arrhythmia.	ECG/reperfusion pathway, cautious fluids, inotrope/vasopressor and critical-care review.
Obstructive	Tension pneumothorax, tamponade, massive PE; sudden collapse/PEA.	Relieve the obstruction by trained clinicians; avoid delaying for routine tests.
Anaphylactic	Airway/breathing/circulation compromise with possible hives/angioedema.	IM adrenaline first-line, oxygen/airway, fluids and observation for recurrence.

6. Renal, metabolic and nutritional support

Measure urine output, fluid balance, electrolytes, glucose, lactate and acid–base status; trends often reveal deterioration before creatinine changes.
Review nephrotoxic medicines and contrast exposure; adjust doses with pharmacy/renal advice.
Recognise hyperkalaemia, severe acidosis, hypoglycaemia, DKA, hyperthermia, hypothermia and refeeding risk.
Start appropriate nutrition when stable; enteral feeding is often preferred when the gut works, with aspiration and glucose monitoring.
Dialysis/renal replacement decisions require critical-care/nephrology teams; prepare access, haemodynamic support and infection precautions.

7. Delirium, pain and sedation

Intervention	Good practice
Pain	Ask/observe, treat underlying cause, use multimodal analgesia and reassess respiratory/hemodynamic effects.
Sedation	Set a target, use the lightest effective level, review daily and avoid masking neurological deterioration.
Delirium	Look for hypoxia, infection, pain, retention, constipation, withdrawal, drugs, sleep deprivation and metabolic disease.
Communication	Reorientate, explain procedures, involve family/support, use glasses/hearing aids and preserve day/night cues.

8. Infection prevention and device safety

Perform hand hygiene before and after every patient/device contact; gloves never replace hand hygiene.
Use aseptic technique for IV/IO, urinary, airway and central-line care; review daily whether each device remains necessary.
Maintain ventilator bundles: head elevation where appropriate, oral care, suction, circuit hygiene and early weaning assessment.
Inspect lines, drains, wounds and pressure points every shift; label infusions and trace every tube from patient to source.
Isolate suspected communicable infection, use PPE, dispose of sharps safely and communicate exposure risks during transfer.

9. Medication and infusion safety

Risk	Prevention
High-alert infusions	Standard concentrations, smart pumps where available, independent double-check and dedicated lines.
Look-alike/sound-alike drugs	Read labels three times, separate storage and verbal read-back.
Line confusion	Trace from pump to patient, label every lumen/tubing and never assume colour means drug.
Transitions of care	Reconcile medicines, last dose, infusion rate, allergies, renal/hepatic function and monitoring plan.
Extravasation	Inspect site, stop infusion without flushing, follow drug-specific protocol and notify senior staff.

10. Pressure injury, mobility and thrombosis prevention

Assess risk, reposition according to condition, protect heels/sacrum/occiput and keep skin clean/dry.
Provide passive/active range-of-motion and early mobilisation with lines/airway secured.
Use venous-thromboembolism prophylaxis when prescribed; balance bleeding/trauma risk.
Maintain nutrition, hydration, temperature and continence care; treat pain before movement.
Use safe manual handling and adequate staff—never pull a ventilated patient by tubes or lines.

11. Human factors and escalation

Use structured handover (SBAR/ATMIST) and state the urgent concern at the beginning.
Escalate based on trend, not a single “normal” value; a rising RR or oxygen requirement may precede hypotension.
Use checklists for airway, transfer, line insertion, medication and resuscitation.
Invite the team to speak up about a safety concern; confirm orders with closed-loop communication.
After a critical event, debrief, document, report near misses and support staff wellbeing.

12. Communication, consent and family-centred care

Explain what is known, what is uncertain and what is being done next using plain language.
Check decision-making capacity; involve a surrogate only when appropriate and document who was consulted.
Respect culture, language, privacy, spiritual needs and the patient’s advance wishes.
Protect confidentiality while sharing information needed for safe care.
When prognosis is poor, senior clinicians should lead honest goals-of-care discussions and symptom-focused care; EMTs provide compassionate support and accurate observations.

13. Transfer to ICU or higher-level care

Before leaving	During transfer	On arrival
Stabilise ABCDE as far as possible, secure airway/lines, prepare oxygen/medicines, verify destination and document.	Continuous monitor, trained escort, backup BVM/oxygen/suction, battery and communication.	Structured handover, repeat vitals/ABG, reconcile infusions and confirm responsibility.
Bring imaging, labs, medication chart, allergies, consent and contact details.	Anticipate deterioration from movement, disconnection, pain or temperature loss.	Trace every device, confirm ventilator/infusion settings and document time of transfer.

14. Critical-care scenarios

Scenario 1 — Sepsis trend: A patient’s RR rises from 24 to 34, SpO2 needs increase, urine falls and lactate rises while BP remains “normal.” Escalate now; trend deterioration can precede shock.

Scenario 2 — Ventilated hypotension: A patient becomes hypotensive after PEEP is increased. Assess preload, right-heart function, pneumothorax, bleeding, sedation and sepsis; involve critical care rather than changing settings alone.

Scenario 3 — Delirium: An ICU patient pulls at lines and becomes confused at night. Check oxygenation, glucose, pain, infection, retention, withdrawal and medicines; use reorientation and the least restrictive safety plan.

Scenario 4 — Transfer risk: During movement to CT, the oxygen cylinder empties and the ventilator alarms. Stop, manually ventilate, call for help and use the backup plan. A transport checklist should have prevented this.

Scenario 5 — AKI: Urine output falls, potassium rises and the patient develops weakness/ECG changes. Escalate urgently, stop nephrotoxins, obtain access and follow hyperkalaemia/renal-replacement protocols.

15. Daily critical-care checklist

Airway/device position, oxygen/ventilation settings, ABG/ETCO2 and weaning readiness.
Circulation: rhythm, BP/perfusion, lactate, access, fluids, vasopressors and bleeding.
Neurology: GCS/pupils, pain, sedation target, delirium, seizures and communication.
Renal/metabolic: urine, fluid balance, electrolytes, glucose, nutrition and medication doses.
Infection: cultures/antibiotics, temperature, lines, wounds and device necessity.
Mobility/skin: pressure areas, turning, physiotherapy, VTE prophylaxis and safe handling.
Family/goals: updates, consent, escalation ceiling, resuscitation status and discharge/transfer plan.

16. Revision questions

Why does a rising respiratory rate matter even when BP is normal?
How can positive-pressure ventilation cause hypotension?
List five causes of new ICU delirium.
What steps reduce ventilator-associated infection?
What should be checked before transporting a ventilated patient to CT?
How do trend monitoring and early warning scores support escalation?
What details belong in a critical-care handover?
Why is a medication/infusion double-check essential for high-alert drugs?
How can EMTs support family-centred care and confidentiality?
What features suggest the need for renal/critical-care review?

17. Key take-home points

Critical care is a system of early recognition, organ support, monitoring, infection prevention and teamwork.
ABCDE is repeated after every intervention and whenever the patient or trend changes.
Trend respiratory effort, perfusion, urine, mental state and oxygen requirement—not isolated “normal” values.
Prevent harm from lines, ventilators, medicines, pressure, immobility and communication failures.
Safe transfers require preparation, backup equipment, trained escort and structured handover.

Selected authoritative resources

For EMT practice: A critically ill patient needs a reliable team, not just a high-technology bed. Recognise early, support the failing organ, prevent avoidable harm and communicate every change.

Critical and Intensive Care Principles: Monitoring, Organ Support and Safety Read More »

Safe Sedation in Emergency Care: Assessment, Monitoring and Rescue

Why this matters: Sedation may allow a painful procedure, imaging, cardioversion or safe management of severe agitation. It can also cause apnoea, airway obstruction, aspiration, hypotension, dysrhythmia, emergence reactions and delayed loss of consciousness. Safety comes from preparation, monitoring, skilled rescue and a plan for complications—not from a particular drug alone.

Scope: These are educational notes. Sedation must be prescribed and delivered by trained clinicians within local policy, with immediate airway and resuscitation capability. Do not give sedatives to “calm” a patient without assessing medical causes, consent/capacity, monitoring and rescue equipment.

Learning outcomes

Distinguish minimal, moderate, deep sedation and general anaesthesia.
Assess patient, procedure, airway and aspiration risk before sedation.
Prepare equipment, team roles, drugs, monitoring and recovery criteria.
Recognise and rescue hypoventilation, apnoea, airway obstruction, hypotension and dysrhythmia.
Compare commonly used sedative/analgesic agents and their complications.
Document consent, pre-sedation assessment, monitoring, adverse events and discharge instructions.

1. Levels of sedation

Level	Response	Airway/ventilation	Emergency implication
Minimal	Normal response to voice; cognition/coordination may be mildly impaired.	Unaffected.	Still monitor and be prepared for deeper-than-intended effect.
Moderate (“conscious”)	Purposeful response to verbal command or light touch.	Usually maintained; spontaneous ventilation adequate.	Can drift into deep sedation; rescue skills required.
Deep	Not easily roused; responds purposefully to repeated/painful stimulation.	Airway intervention may be needed; ventilation may be inadequate.	Continuous capnography and advanced rescue capability required.
General anaesthesia	Unarousable even with painful stimulus.	Airway intervention and positive-pressure ventilation often required.	Managed by an anaesthesia/critical-care team with full resuscitation capability.

Rescue principle: The provider must be able to rescue a patient who becomes one level deeper than intended. Moderate sedation provider must be able to manage deep sedation; deep sedation provider must be able to manage general anaesthesia-level complications.

2. Indications and alternatives

Painful procedures: fracture reduction, abscess drainage, wound care, burns or foreign-body removal.
Short interventions: cardioversion, pacing, imaging or invasive line placement.
Severe agitation after reversible medical causes have been addressed and de-escalation is insufficient.
Facilitating airway management when the patient cannot tolerate necessary treatment.

Ask whether analgesia, local/regional anaesthesia, reassurance, a support person, distraction, positioning or non-pharmacological measures could achieve the goal with less risk. Sedation is not a substitute for treating hypoxia, hypoglycaemia, sepsis, head injury, intoxication or withdrawal.

3. Pre-sedation assessment

Assessment	Questions and findings
Airway	Mouth opening, teeth/dentures, neck mobility, obesity, snoring/OSA, facial trauma, swelling, secretions and previous difficult airway.
Breathing	Baseline RR/SpO2/ETCO2, respiratory disease, oxygen requirement, sleep apnoea, chest infection and current fatigue.
Circulation	BP, pulse, ECG, shock, dehydration, cardiac disease, anticoagulation and access.
Neurology	GCS/AVPU, baseline cognition, seizures, intoxication, head injury and focal deficit.
History	Allergies, medicines, last meal, pregnancy, previous sedation/anaesthesia, alcohol/recreational drugs, kidney/liver disease.
Procedure	Urgency, duration, positioning, painful stimulus, blood loss, need for immobility and who will perform it.

4. Preparation and team roles

Explain the plan, risks, alternatives and expected recovery; confirm consent or emergency necessity and document capacity.
Assign a sedation clinician whose only job is patient monitoring and rescue; the proceduralist must not be the sole observer.
Prepare oxygen, suction, BVM/masks, airway adjuncts, SGA/intubation equipment, defibrillator, IV/IO access, reversal agents where appropriate and emergency drugs.
Check drug name, concentration, expiry, route, dose calculation, allergies and independent double-check.
Record baseline vitals, pain, sedation score, glucose when relevant and pregnancy possibility.
Use a time-out: patient, procedure/site, allergies, airway risk, fasting status, monitoring, rescue plan and recovery destination.

5. Monitoring standards

Monitor	Purpose	When it can mislead
Pulse oximetry	Oxygenation trend.	May remain normal during hypoventilation if supplemental oxygen is given; motion/poor perfusion distort readings.
Continuous capnography	Early detection of apnoea/hypoventilation and airway obstruction; confirms ventilation.	Sampling line obstruction, mouth breathing or low flow can produce a false/absent waveform.
Respiratory observation	Rate, effort, chest movement, colour, airway sounds and speech.	Visual observation alone misses early hypoventilation.
ECG	Detects bradycardia, tachyarrhythmia and QT changes.	Electrode artefact or poor contact.
Non-invasive BP	Hypotension and perfusion trend.	Too frequent cycling can interrupt procedure; a cuff on an active limb may be unreliable.
Level of consciousness	Tracks intended depth and recovery.	Response can fluctuate rapidly after a bolus.

“Monitor before, during and after.” Record baseline, every drug/time, vital-sign trends, procedure milestones, adverse events and recovery—not only the final SpO2.

6. Common sedative and analgesic agents

Agent/group	Useful effects	Important risks
Ketamine	Dissociative sedation, analgesia, bronchodilation; often preserves airway reflexes better than many sedatives.	Hypersalivation, vomiting, emergence reaction, hypertension/tachycardia, laryngospasm; airway protection is not guaranteed.
Midazolam/diazepam	Anxiolysis, amnesia, anticonvulsant effect.	Apnoea, airway obstruction, hypotension, paradoxical agitation, dependence; synergistic respiratory depression with opioids/alcohol.
Propofol	Rapid, titratable sedation and hypnosis.	Apnoea, profound hypotension, loss of airway reflexes and injection pain; no analgesia.
Opioids	Analgesia and cough suppression.	Respiratory depression, chest-wall rigidity with rapid/high dosing, nausea, hypotension and delayed renarcotisation.
Nitrous oxide/oxygen	Short analgesia/anxiolysis where equipment and scavenging are available.	Diffusion into closed spaces, nausea, hypoxia if delivery fails; avoid in selected chest/ear/eye conditions.
Anticholinergic adjuncts	Reduce secretions in selected ketamine or airway situations.	Tachycardia, dry mouth, urinary retention, blurred vision and delirium.

7. Sedation rescue sequence

Recognise early: falling ETCO2, slow breathing, snoring, loss of response, falling BP, cyanosis or abnormal rhythm.
Stop the procedure and stimulate: call the patient’s name, apply a jaw thrust, reposition and remove painful stimulus.
Open and clear the airway: suction, OPA/NPA when appropriate and two-person mask seal.
Oxygenate and ventilate: high-concentration oxygen, BVM if inadequate breathing, SGA/intubation by trained provider.
Support circulation: stop offending drugs, IV/IO access, fluids/vasopressors/antidotes per protocol and ECG monitoring.
Escalate: call anaesthesia/critical care/resuscitation team early; prepare for cardiac arrest.
Document and review: drug/time, event, interventions, response, suspected cause and follow-up plan.

8. Common sedation complications

Complication	Clues	First actions
Airway obstruction	Snoring, paradoxical movement, absent airflow, falling SpO2.	Stop procedure, head positioning/jaw thrust, suction, adjunct, BVM.
Apnoea/hypoventilation	Slow/absent breaths, rising ETCO2, reduced chest rise.	Stimulate, airway opening, BVM oxygenation, reverse selected agents and escalate.
Aspiration/vomiting	Regurgitation, cough, wheeze, hypoxia, coarse breath sounds.	Turn/suction, protect airway, oxygen/BVM and urgent assessment.
Hypotension	Low BP, poor perfusion, dizziness or altered consciousness.	Stop sedative, oxygenate, fluids/vasopressor protocol and search bleeding/anaphylaxis.
Laryngospasm	Stridor or silent obstruction, paradoxical movement, high effort.	Remove stimulus, jaw thrust, positive pressure and advanced airway support.
Paradoxical agitation	Disinhibition, aggression or worsening restlessness after benzodiazepine.	Protect staff/patient, search medical cause, avoid escalating blindly and seek senior help.
Emergence reaction	Confusion, hallucination, distress during recovery, especially after ketamine.	Calm environment, reassurance, reduce stimulation and clinician-led treatment if severe.
Delayed recovery	Persistent drowsiness, hypoventilation or inability to protect airway.	Continue monitoring, glucose/temperature check, consider mixed drugs/organ failure and escalate.

9. Reversal agents: use selectively

Naloxone: titrate for adequate breathing in opioid respiratory depression; recurrence is possible and withdrawal/pain may be severe.
Flumazenil: not routine for benzodiazepine sedation or mixed overdose; seizures and withdrawal can be precipitated.
Reversal is not a substitute for ventilation: open the airway and support breathing while calling for help.
Reassess after reversal: the original sedative may last longer than the antidote, and re-sedation can occur.

10. Special populations

Group	Extra precautions
Children	Weight-based dosing, age-specific airway equipment, fasting/aspiration risk, rapid desaturation and safeguarding.
Older adults	Reduced clearance, delirium, falls, hypotension and increased sensitivity; use the lowest effective dose.
Pregnancy	Airway oedema, aspiration and altered oxygen reserve; involve obstetric/anaesthetic teams.
Obesity/OSA	Difficult mask ventilation, rapid desaturation and opioid sensitivity; ramp position and capnography.
Renal/hepatic failure	Delayed clearance and prolonged sedation; adjust plan with specialist guidance.
Intoxication/withdrawal	Mixed respiratory depression or agitation; identify substances, glucose and trauma before sedating.

11. Recovery and discharge criteria

Monitoring continues until the patient returns to baseline consciousness, airway reflexes, breathing, circulation and mobility appropriate for the procedure. A patient who received deep sedation, opioids, benzodiazepines or ketamine needs a longer observation plan and responsible supervision. Do not discharge solely because the patient opens their eyes once.

Awake or at pre-sedation baseline, with purposeful response and safe airway.
Stable respiratory rate, SpO2/ETCO2 and haemodynamics without escalating oxygen or stimulation.
Pain and nausea controlled; no active bleeding, aspiration concern or uncontrolled agitation.
Ability to sit/stand or use baseline mobility safely when appropriate.
Written instructions: no driving, alcohol, important decisions or unsupervised childcare for the recommended period; return urgently for breathing difficulty, repeated vomiting, confusion or worsening pain.

12. Clinical scenarios

Scenario 1 — Opioid plus benzodiazepine: After analgesia and sedation, a patient becomes snoring and hypoventilates. Stop drugs, jaw thrust, suction, BVM oxygenation, capnography and titrated naloxone when indicated; prepare for re-sedation and airway escalation.

Scenario 2 — Ketamine laryngospasm: A child develops stridor and no effective air movement during dissociative sedation. Call for help, remove stimulus, jaw thrust, positive-pressure oxygen and follow paediatric airway rescue protocol.

Scenario 3 — Hypotension after propofol: BP falls sharply and the patient becomes pale. Stop the infusion, oxygenate, assess bleeding/anaphylaxis/volume status, support circulation and call the anaesthetic/critical-care team.

Scenario 4 — “Agitation” before sedation: A confused patient is found to have glucose 2.2 mmol/L and fever. Correct the medical threats and investigate infection before using a sedative; behaviour was a symptom, not the diagnosis.

Scenario 5 — Delayed recovery: Two hours after a procedure, a patient remains drowsy with a rising ETCO2. Continue airway/ventilation support, check drug doses and co-ingestants, glucose and temperature, and arrange medical review.

13. Documentation checklist

Indication, alternatives, consent/capacity and pre-sedation risk assessment.
Baseline vitals, airway exam, ASA/comorbidity concerns, last meal and medicines/allergies.
Team roles, equipment check, drug name/concentration/route/dose/time and cumulative totals.
Continuous monitoring: ECG, BP, SpO2, respiratory rate, capnography, sedation score and event times.
Procedure success, adverse events, rescue interventions, reversal medicine and response.
Recovery assessment, supervision, discharge instructions and receiving clinician/family handover.

14. Revision questions

What is the difference between moderate and deep sedation?
Why must the provider be able to rescue one level deeper than intended?
Which monitors are required during deep sedation, and why is capnography valuable?
List five airway rescue actions for sedation-related apnoea.
Why is flumazenil not routine in mixed benzodiazepine overdose?
How do obesity and OSA change the sedation plan?
What features show readiness for recovery/discharge?
Why should analgesia be assessed before simply increasing sedation?
What information belongs in a sedation record?
When should a sedation attempt be stopped and senior help called?

15. Key take-home points

Safe sedation is a process: assess, prepare, monitor, rescue and recover.
Continuous capnography detects ventilation failure earlier than pulse oximetry when oxygen is being given.
Airway equipment, suction, BVM, oxygen, ECG/BP monitoring and trained rescue staff must be immediately available.
Use the least risky effective drug and dose; reassess after every increment.
Recovery and documentation are part of the procedure, not optional extras.

Selected authoritative resources

For EMT practice: The safest sedative is never a substitute for a prepared airway team. Monitor ventilation continuously, intervene early and keep observing until the patient truly returns to baseline.

Safe Sedation in Emergency Care: Assessment, Monitoring and Rescue Read More »