Anonymous #1
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It seems like vague and subjective territory.

85 yer old lady with blood pressure 75/45?
Someone having a seizure?
GCS 7, from 14?
STEMI?
New AF in an inpatient?
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Anonymous #1
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nobody seems to agree or come to any consensus
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Spencer Wells
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There's no strict definition via physiological criteria. It's any deteriorating patient who is on a clinical trajectory that will result in arrest if timely intervention is not undertaken.
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Anonymous #1
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(Original post by Spencer Wells)
There's no strict definition via physiological criteria. It's any deteriorating patient who is on a clinical trajectory that will result in arrest if timely intervention is not undertaken.
Thanks for the reply

is this not subjective?

A 75 year old gentleman coming in with an exacerbation of COPD and sats of 80% and wheezing might need nebs and ipatropium

A 89 year old lady with septic observations might need the sepsis 6

In this definition, any seizure would also be a peri arrest. Any drop in GCS too
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ecolier
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(Original post by Anonymous)
...is this not subjective?..
It is subjective, that's sort of the point.

There's no rhyme or reason to who will collapse or go into arrest at a precise moment. The best we can do is to look at the trends and hopefully prevent it from happening.

@Spencer Wells's definition is right on target.
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Spencer Wells
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(Original post by Anonymous)
is this not subjective?
Absolutely. Better to over-diagnose peri-arrest [and activate the arrest team] than miss a potentially salvageable deterioration.
I've been to many an arrest call for seizures. I've also been to them when the attending doctor or nurse is struggling and just doesn't know what's going on, is worried, and needs extra pairs of hands, and that's completely ok.
Last edited by Spencer Wells; 1 month ago
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Etomidate
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As above, it's pretty subjective but it's not a subtle thing.

In real life, its those patients that you take one look at and think "oh ****". There is no strict criteria, it's usually just a gut reaction.

Seizures can be pretty dramatic and cause a lot of panic, but 9 times out of 10, it's a case of just waiting, simple airway manoeuvre, oxygen and checking a blood glucose. Usually by the time the oxygen is on, you can tell that the patient is starting to settle.
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Anonymous #1
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(Original post by Spencer Wells)
Absolutely. Better to over-diagnose peri-arrest [and activate the arrest team] than miss a potentially salvageable deterioration.
I've been to many an arrest call for seizures. I've also been to them when the attending doctor or nurse is struggling and just doesn't know what's going on, is worried, and needs extra pairs of hands, and that's completely ok.
(Original post by ecolier)
It is subjective, that's sort of the point.

There's no rhyme or reason to who will collapse or go into arrest at a precise moment. The best we can do is to look at the trends and hopefully prevent it from happening.

@Spencer Wells's definition is right on target.
This is so reassuring.

I guess i don't want any team who rushes in to feel i called them needlessly. I have worked in acute jobs, and seen patients coming in with COPD exacerbations, Sepsis, low saturations, but were managed in the ED department without needing any peri arrest calls.

For example,

If i was on call at night and there was a patient with a temperature spike of 38.9 degrees, and 85/55 blood pressure, and normal saturations, under the definition, this patient would deteriorate if timely intervention is not performed. However, i could perform an A-E and start the SEPSIS six, and i am worried calling the peri arrest team or reg will make them angry if i have not done an assessment and started treatment.

For a patient with increased work of breathing and sats of 89% on RA, giving them a few litres might stabilise them, but again, they would deteriorate without timely intervention.

A patient who was GCS 15, but now GCS10 is where i do get confused.A lot of the elderly often fluctuate , especially at night. Assessing voice is often something that varies wildly, compared to motor and eye movement, when they are sleepy.
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Anonymous #1
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I guess a question could be when to call the reg, verses when to call the peri arrest team?

A septic patient may not be in imminent arrest, would performing an A-E then calling the reg be suitable?
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Spencer Wells
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(Original post by Anonymous)
This is so reassuring.

I guess i don't want any team who rushes in to feel i called them needlessly. I have worked in acute jobs, and seen patients coming in with COPD exacerbations, Sepsis, low saturations, but were managed in the ED department without needing any peri arrest calls.
Indeed. ED is a place with a higher level of care (in theory) than most general wards, and therefore is suited to resuscitating patients who are actively deteriorating (indeed it's what ED teams are trained to do). In the same regard, you can make the argument that most ITU patients are in a constant state of peri-arrest, but that's why they're in a critical care unit, and it'd be unusual to call a peri-arrest team to an ITU (it does happen occasionally.)
(Original post by Anonymous)
For example,

If i was on call at night and there was a patient with a temperature spike of 38.9 degrees, and 85/55 blood pressure, and normal saturations, under the definition, this patient would deteriorate if timely intervention is not performed. However, i could perform an A-E and start the SEPSIS six, and i am worried calling the peri arrest team or reg will make them angry if i have not done an assessment and started treatment.
Yes they would deteriorate without intervention, but you've performed an intervention, and therefore don't need to put out a peri-arrest call, unless the patient continues to deteriorate in spite of your intervention. Unless it is something immediately life-threatening (exsanguinating haemorrhage/airway compromise/tension pneumothorax, for example), it's expected that you will start treatment first (and re-evaluate to see whether the treatment is working).

For a patient with increased work of breathing and sats of 89% on RA, giving them a few litres might stabilise them, but again, they would deteriorate without timely intervention.
See above

A patient who was GCS 15, but now GCS10 is where i do get confused.A lot of the elderly often fluctuate , especially at night. Assessing voice is often something that varies wildly, compared to motor and eye movement, when they are sleepy.
Which is why it's recognised that motor score is the most important thing with GCS assessment. If I woke you up from a deep sleep it would take you a few minutes to fully orientate yourself, and it'll take longer for an 1) unwell patient who is 2) elderly and 3) in an unfamiliar environment. Therefore GCS 14 is completely normal for overnight obs. Absolute values are also less important than changes. If they were GCS 15 at 10pm and GCS 10 at 2am (giving them adequate time and stimulation to wake) then this is more likely to be significant than someone who has a baseline GCS 10.
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Spencer Wells
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(Original post by Anonymous)
I guess a question could be when to call the reg, verses when to call the peri arrest team?

A septic patient may not be in imminent arrest, would performing an A-E then calling the reg be suitable?
Perform A-E and then treat the abnormalities that you find, before you call your senior.
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Anonymous #1
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(Original post by Etomidate)
As above, it's pretty subjective but it's not a subtle thing.

In real life, its those patients that you take one look at and think "oh ****". There is no strict criteria, it's usually just a gut reaction.

Seizures can be pretty dramatic and cause a lot of panic, but 9 times out of 10, it's a case of just waiting, simple airway manoeuvre, oxygen and checking a blood glucose. Usually by the time the oxygen is on, you can tell that the patient is starting to settle.
Would seizures not warrant a peri-arrest call as a lone junior on call?
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Anonymous #1
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(Original post by Spencer Wells)
Indeed. ED is a place with a higher level of care (in theory) than most general wards, and therefore is suited to resuscitating patients who are actively deteriorating (indeed it's what ED teams are trained to do). In the same regard, you can make the argument that most ITU patients are in a constant state of peri-arrest, but that's why they're in a critical care unit, and it'd be unusual to call a peri-arrest team to an ITU (it does happen occasionally.)

Yes they would deteriorate without intervention, but you've performed an intervention, and therefore don't need to put out a peri-arrest call, unless the patient continues to deteriorate in spite of your intervention. Unless it is something immediately life-threatening (exsanguinating haemorrhage/airway compromise/tension pneumothorax, for example), it's expected that you will start treatment first (and re-evaluate to see whether the treatment is working).


See above


Which is why it's recognised that motor score is the most important thing with GCS assessment. If I woke you up from a deep sleep it would take you a few minutes to fully orientate yourself, and it'll take longer for an 1) unwell patient who is 2) elderly and 3) in an unfamiliar environment. Therefore GCS 14 is completely normal for overnight obs. Absolute values are also less important than changes. If they were GCS 15 at 10pm and GCS 10 at 2am (giving them adequate time and stimulation to wake) then this is more likely to be significant than someone who has a baseline GCS 10.
Thank you for the informative reply. The final part made complete sense, in essence i need to look at the context.

In summary, would you agree with the following in very rough terms (i would always escalate to a senior at the bare minimum as expediently as i could after taking basic steps if appropriate):

1. Called to see a patient , 89M,with 39 degrees temperature, 80/45 BP, GCS 11/15 (late, they aren't really making sense verbally). Initial actions A-E swiftly, they will have IV access so if not in HF, 500ml bolus of 0.9% Saline, to stabilise BP. Call the reg to inform them i have done an A-E , initiated some treatment, and will be now doing the SEPSIS six and would like them to come down to assess the patient with me.

2. Patient having a fit, still having one after 4 minutes. Put them in recovery position on their left, put out a peri-arrest call (ask the nurse to do that on the phone)

3. Patient having tachycardia - ask the nurse to do an ECG and say i am on the way. Do an A-E, review ECG, probably look for source of infection if sinus tachy, but make sure they are stable and then call reg.

4. Patient having low sats of 84%, in for Covid, 4L oxygen, go in, get them on rebreathable at 10L, re-assess, do A-E, call reg to let them know because patient may possibly require CPAP - look at notes for ceiling of care while reg on the way.

Now, other than the fit, the only other peri-arrest i can think of is a patient having BP of 75/35, sats of 87% on 15L, for instance, STEMI, GCS down especially motor, extreme chest pain and palpitations.
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Anonymous #1
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(Original post by ecolier)
It is subjective, that's sort of the point.

There's no rhyme or reason to who will collapse or go into arrest at a precise moment. The best we can do is to look at the trends and hopefully prevent it from happening.

@Spencer Wells's definition is right on target.
I'd be making peri-arrests if:

- bp 75/35
- any patient having a seizure
- any patient who clearly was having significant WOB despite good saturations and oxygenation
-any patient not saturating well on 15L (less than 90%)
- any patient with a GCS drop pending context
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ecolier
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(Original post by Anonymous)
I'd be making peri-arrests if:...
I wouldn't make a set of artibitary figures... otherwise the NHS trusts / resus council would have made a guideline years ago.

As @Etomidate said, this is all very "hunch" and "I think something's wrong here" territory. It's experience - speak to your reg / cons if you think something's wrong. No one will fault you for being over-cautious.

Just because someone's BP is still 90/40 (and above your arbitary "75/35" level) doesn't mean they won't go into an arrest. It's the trend, it's the clinical presentation - it's not just "oh their BP is now X/Y and I am worried".
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nexttime
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(Original post by Anonymous)
I'd be making peri-arrests if:

- bp 75/35
- any patient having a seizure
- any patient who clearly was having significant WOB despite good saturations and oxygenation
-any patient not saturating well on 15L (less than 90%)
- any patient with a GCS drop pending context
- There are plenty of stable heart failure patients, or tiny little old ladies, with blood pressures of 75 as normal.
- People with known epilepsy have self-terminating seizures sometimes, not a cause to panic.
- Basically half of medical admissions have increased WOB
- Ok, THAT is respiratory failure despite maximal oxygen therapy - that is really bad. Depending on speed of deterioration that's a call to a senior or peri-arrest call
- Loads of reasons to drop GCS e.g. being asleep!

A STEMI needs a urgent antiplatelets and a fast bleep of the cardiologist. New AF... I mean, the GP could potentially sort that out, depending on context.

This is why we have highly educated doctors running our hospitals, not just some untrained guideline monkey. These are far too black and white, and not based on experience.

In general your threshold for a peri-arrest call seems far too low. You will be, i assume, a doctor. You can deal with emergencies, with the help of your nursing colleagues. A peri-arrest call is for when you need more hands and you need them within minutes. That is normally a patient with a sudden, severe change who staff have identified as looking really unwell.

Overall I think peri-arrest calls are severely underused in all hospitals I have worked in, but some of your examples are way too far!
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Anonymous #1
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(Original post by nexttime)
- There are plenty of stable heart failure patients, or tiny little old ladies, with blood pressures of 75 as normal.
- People with known epilepsy have self-terminating seizures sometimes, not a cause to panic.
- Basically half of medical admissions have increased WOB
- Ok, THAT is respiratory failure despite maximal oxygen therapy - that is really bad. Depending on speed of deterioration that's a call to a senior or peri-arrest call
- Loads of reasons to drop GCS e.g. being asleep!

A STEMI needs a urgent antiplatelets and a fast bleep of the cardiologist. New AF... I mean, the GP could potentially sort that out, depending on context.

This is why we have highly educated doctors running our hospitals, not just some untrained guideline monkey. These are far too black and white, and not based on experience.

In general your threshold for a peri-arrest call seems far too low. You will be, i assume, a doctor. You can deal with emergencies, with the help of your nursing colleagues. A peri-arrest call is for when you need more hands and you need them within minutes. That is normally a patient with a sudden, severe change who staff have identified as looking really unwell.

Overall I think peri-arrest calls are severely underused in all hospitals I have worked in, but some of your examples are way too far!
Thank you for the reply, this was definitely informative. I agree, i was too black and white in what i wrote. Your experience is obviously on another level here, but i'll try to qualify some of what i have said.

In essence, i have seen a lot of sick patients managed effectively in ED. I've seen a 75/45 patient return to 95/45 with an IV Fluid bolus who had not prior to that been on heart failure. But that was in the context of a well supported department, and not say, a newly qualified looking after 200 patients at night. I guess this is more a change. A patient who has deteriorated over the past few hours, from 110/65, to 75/45 and only being informed at the very last minute.

Most patients with epilepsy will usually have their rescue medication, but every seizure i've personally seen has resulted in the red buzzer, and several consultants and senior doctors at the side of the patient, especially if they are/were sick enough to be in hospital, as opposed to having stable epilepsy with rescue medication at home.

In terms of increased WOB, i've helped look after a lot of covid/COPD exacerbations, but again within the context of a well supported department and seniors. A patient who has been admitted and is stable suddenly dropping sats, and nurses saying is suddenly having worsening of breathing, compared to a prior baseline would be worrying.

And i totally am with you on the sleep and GCS. Well and truly, i'll focus on the Motor component - if they aren't rousable, localising pain etc. A lot of elderly patients , especially those at nigh won't talk, or will mumble.

But my take home from this is, guidelines are just frameworks, look at what is in front of you, do what you can within your competency and if you feel out of it, especially early on, escalate.
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Anonymous #1
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(Original post by Anonymous)
Thank you for the reply, this was definitely informative. I agree, i was too black and white in what i wrote. Your experience is obviously on another level here, but i'll try to qualify some of what i have said.

In essence, i have seen a lot of sick patients managed effectively in ED. I've seen a 75/45 patient return to 95/45 with an IV Fluid bolus who had not prior to that been on heart failure. But that was in the context of a well supported department, and not say, a newly qualified looking after 200 patients at night. I guess this is more a change. A patient who has deteriorated over the past few hours, from 110/65, to 75/45 and only being informed at the very last minute.

Most patients with epilepsy will usually have their rescue medication, but every seizure i've personally seen has resulted in the red buzzer, and several consultants and senior doctors at the side of the patient, especially if they are/were sick enough to be in hospital, as opposed to having stable epilepsy with rescue medication at home.

In terms of increased WOB, i've helped look after a lot of covid/COPD exacerbations, but again within the context of a well supported department and seniors. A patient who has been admitted and is stable suddenly dropping sats, and nurses saying is suddenly having worsening of breathing, compared to a prior baseline would be worrying.

And i totally am with you on the sleep and GCS. Well and truly, i'll focus on the Motor component - if they aren't rousable, localising pain etc. A lot of elderly patients , especially those at nigh won't talk, or will mumble.

But my take home from this is, guidelines are just frameworks, look at what is in front of you, do what you can within your competency and if you feel out of it, especially early on, escalate.
Just to qualify the epilepsy part, not every seizure is epilepsy - but even in known epileptics, i've never seen a case just dealt with nurses, or juniors. The consultants often rush like the wind even to patients who have fitted dozens of times in the same day with known self-terminating seizures.

If they are sick enough to be in hospital, i'd be worried about any kind of seizure and want to get help in immediately. That is perhaps because of my experience/low level.
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Lionheartat20
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Your Reg doesn't necessarily want to know about all these patients you have reviewed either. This is at your discretion.

Firstly your SHO is able to offer advice - you don't always need to escalate to the reg. But if you discuss every single patient you end up seeing, you'll drive your seniors mad.

If you are an SHO, I would expect a lot of these to be managed only by yourself:
e.g.
sinus tachycardia
hypotensive 90/50 that is febrile with an already defined ceiling of care --> The FY1 might want support from the SHO with calling a family to break the bad news [as a new FY1, that's a bit scary]. What do you want your Reg to do? If there is no ceiling of care, then it's reasonable to discuss. If the ceiling of care is ITU, then you give initial treatment and repeat obs. If still deteriorating, call the ITU team. If BP staying at 90/50, give some more fluid and repeat the obs. Are they anuric? Are they dry?

The Red buzzer on the wall is to get the HCA/Nurse more help - usually in the form of more nurses and the Doctor i.e. you.
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Anonymous #1
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(Original post by ecolier)
I wouldn't make a set of artibitary figures... otherwise the NHS trusts / resus council would have made a guideline years ago.

As @Etomidate said, this is all very "hunch" and "I think something's wrong here" territory. It's experience - speak to your reg / cons if you think something's wrong. No one will fault you for being over-cautious.

Just because someone's BP is still 90/40 (and above your arbitary "75/35" level) doesn't mean they won't go into an arrest. It's the trend, it's the clinical presentation - it's not just "oh their BP is now X/Y and I am worried".
I've heard of people getting shouted at

Ultimately, patient safety and escalation especially early on in ones career is the most important thing.

I've dealt with very sick patients in RESUS. DKAs, T1/2 respiratory failure, Sepsis, GCS fluctuations, SAH etc.

But doing it on my own and not in the right facility with senior support immediately available would make me want to escalate things much sooner.

If a patient was in DKA in RESUS, the consultant or senior reg would be physically there, it would be a verbal exchange and i'd start treatment. An on-call over night, i'd call my reg immediately after getting the numbers.

You are so right on the BP. I'd look at the baseline first, but i put down 75/35 because i've seen a lot of 90/45s being near the baseline, but 75/35s sending off alarm bells so wanted something a bit dramatic BP wise. I went to an ED consultant and told them a patients BP was 89/65, but that was near their baseline and the patient was relatively 'well'. But even in this patient, if i saw 75/35, i would not want to wait around.

The majority of newly qualified doctors would probably have a very low threshold. Mine has been a little skewed having treated a lot of sick patients in the right environment with constant senior support.

I will take your advice and not fear escalation, or calling. I think being safe is the most important thing.
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