12. Red flags and emergency escalation
Escalation follows the resident’s orders and facility policy; the following are representative. Domain-specific red flags live in each clinical reference.
🚩 Red flags — escalate / transfer |
|---|
Chest pain or suspected ACS (diaphoresis, dyspnea, radiation) — activate EMS/transfer per policy; administer prescribed nitroglycerin per order while awaiting transport. Do not delay transfer to complete repeated doses. Acute respiratory distress, SpO₂ persistently below the ordered threshold unresponsive to intervention, or new stridor — emergency evaluation/transfer; tracheostomy obstruction → emergency airway per protocol + transfer. New focal neuro deficit / positive BE-FAST — activate the stroke/transfer pathway (time-critical, especially on anticoagulation). Post-fall on an anticoagulant with any new headache, vomiting, confusion, drowsiness, unequal pupils, or focal deficit — transfer (delayed intracranial bleed). Sepsis signs — fever/hypothermia, hypotension, new confusion, tachypnea with an infectious source — escalate/transfer per the sepsis pathway. Major bleeding (GI bleed, severe epistaxis, hematuria with clots, head injury) or thromboembolic signs on an anticoagulant — transfer per severity. Suspected fracture after a fall (shortened/externally rotated limb, unable to bear weight) — immobilize and transfer. |