Red flags and the first five minutes

Ask the worst question first: what here could kill this patient soon — and have I secured airway, breathing, and circulation before anything else?

The idea

Most patients are fine. The skill is spotting the few who are not before they crash. So you reason worst-first: for every presentation, name the can’t-miss diagnoses and hunt for the red-flag features that would raise them. One red flag flips a case from routine to act-now.

Then, for anyone who looks unwell, you run ABCDE — Airway, Breathing, Circulation, Disability, Exposure — in that order, treating as you find and calling for help early. You do not move to B until A is safe.

How it works

Two habits, run together. First, worst-first triage: name what could kill, then look for its red flags.

presentation: headache
  can't-miss                red-flag feature
  ----------------------    -------------------------------
  subarachnoid bleed    <-  sudden "worst headache of life"
  intracranial bleed    <-  head injury + anticoagulant / older age
  meningitis / sepsis   <-  fever + neck stiffness / non-blanching rash
  stroke                <-  new focal deficit (weakness, speech)

any one red flag  =>  routine becomes act-now

Second, the ABCDE primary survey — strictly in order, treating as you find, escalating early:

Airway      open / protect it            (snoring, stridor?)
Breathing   high-flow oxygen; RR, SpO2   (treat hypoxia now)
Circulation IV access, fluids, cultures  (stop bleeding, treat shock)
Disability  GCS / pupils / glucose       (never forget glucose)
Exposure    expose, temperature, skin    (find the rash / the bleed)

You do not advance to the next letter until the current one is managed. A blocked airway kills faster than a low blood pressure, which is why order is not negotiable.

When to use it

Reach for it when…	The limit
Any acutely unwell or deteriorating patient — it is the universal first approach.	It stabilises and buys time; it is not the definitive diagnosis or treatment.
You feel overwhelmed by a sick patient and need a starting point.	Only works if you actually go in order and re-survey after each change.
Handing over — ABCDE gives a shared, ordered language.	Red-flag lists are presentation-specific; know the ones for your common complaints.

Watch out for

• Anchoring on the routine story. “Just a headache” is right until it is a subarachnoid bleed. Always ask the red-flag question, even when the case looks dull.
• Skipping a letter. Jumping to a CT scanner with an unstable airway or circulation. Secure A, B, and C before the patient leaves the resus bay.
• Forgetting glucose at D. Hypoglycaemia mimics stroke and sepsis and is instantly reversible. “Don’t ever forget glucose.”
• Not exposing. The non-blanching rash, the hidden bleed, the fentanyl patch — all found only at E. Expose and examine, while keeping the patient warm and dignified.
• Escalating late. Calling for senior or critical-care help is an early action, not a last resort. Summon help while you start A.

Worked example

An interviewer says: “A 19-year-old is brought in febrile, drowsy, and mottled. Talk me through your first few minutes.” A strong answer starts worst-first — “fever plus altered consciousness makes me think meningococcal sepsis and meningitis, so I’m acting now and calling for help immediately.” Then ABCDE: check and protect the airway; high-flow oxygen for the low saturations; two large cannulae, blood cultures and a fluid bolus for the shock; at D assess GCS, pupils, and glucose; at E fully expose and find the non-blanching purpuric rash that confirms the fear — and treat for meningococcal sepsis without delay. Naming the killer first, then working A to E while help is already on the way, is exactly the reasoning being tested.