Pocket ICU 2013

Pocket
ICU


Pocket
ICU

Edited by
GYORGY FRENDL, MD, PhD
Assistant Professor of Anesthesia
Harvard Medical School
Director of Research, Surgical Critical Care
Brigham and Women’s Hospital
Boston, Massachusetts
RICHARD D. URMAN, MD, MBA
Assistant Professor of Anesthesia
Harvard Medical School
Director, Procedural Sedation Management and Safety
Brigham and Women’s Hospital
Boston, Massachusetts


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Pocket ICU / [edited by] Gyorgy Frendl, Richard D. Urman.
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ISBN 978-1-4511-0984-9 (alk. paper)
I. Frendl, Gyorgy. II. Urman, Richard D. III. Series: Pocket notebook.
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CONTRIBUTORS
Rae Allain
Harvard Medical School
Boston, Massachusetts

Edwin Pascal Alyea, III
Harvard Medical School
Boston, Massachusetts

Karim Awad
Harvard Medical School
Boston, Massachusetts

Lindsey Baden
Harvard Medical School
Boston, Massachusetts

Rebecca M. Baron, MD
Harvard Medical School

Boston, Massachusetts

Sheri Berg
Harvard Medical School
Boston, Massachusetts

Tarun Bhalla, MD, FAAP
The Ohio State University Medical Center
Columbus, Ohio

Wenya Linda Bi, MD, PhD
Harvard Medical School
Boston, Massachusetts

Nathan E. Brummel, MD
Vanderbilt University School of Medicine
Nashville, Tennessee

Phillip Camp
Harvard Medical School
Boston, Massachusetts

Kenneth B. Christopher, MD
Harvard Medical School
Boston, Massachusetts

Marcus D. Darrabie, MD
Duke University Medical
Center Durham, North Carolina

Christian Denecke, MD
Innsbruck Medical University


Innsbruck, Austria

J. Rodrigo Diaz-Siso
Harvard Medical School
Boston, Massachusetts

Karim Djekeidel
Drexel University College of Medicine
Philadelphia, Pennsylvania

Anquenetta L. Douglas
Johns Hopkins School of Medicine
Baltimore, Maryland

Ian F. Dunn
Harvard Medical School
Boston, Massachusetts

Brian Edlow
Harvard Medical School
Boston, Massachusetts

Ali A. El-Solh
University at Buffalo
Buffalo, New York

E. Wesley Ely, MD, MPH
Vanderbilt University Medical Center
Nashville, Tennessee

Peter J. Fagenholz, MD
Harvard Medical School
Boston, Massachusetts

Michael G. Fitzsimons
Harvard Medical School
Boston, Massachusetts

Gyorgy Frendl
Harvard Medical School
Boston, Massachusetts

Dragos M. Galusca, MD
Johns Hopkins Medical Institutions
Baltimore, Maryland

Samuel M. Galvagno, Jr., DO, PhD
University of Maryland School of Medicine
Baltimore, Maryland

Brett Glotzbecker
Harvard Medical School
Boston, Massachusetts

William B. Gormley

Harvard Medical School
Boston, Massachusetts

David Greer
Harvard Medical School
Boston, Massachusetts

Michael Gropper
University of California San Francisco
San Francisco, California

Hiroto Hatabu
Harvard Medical School
Boston, Massachusetts

Joaquim M. Havens, MD
Harvard Medical School
Boston, Massachusetts

Galen V. Henderson
Harvard Medical School
Boston, Massachusetts

Kathryn A. Hibbert, MD
Harvard Medical School
Boston, Massachusetts

Jennifer Hofer, MD
The University of Chicago Medical Center

Chicago, Illinois

Peter C. Hou, MD
Harvard Medical School
Boston, Massachusetts

Danny O. Jacobs
Duke University School of Medicine
Durham, North Carolina

George Kasotakis, MD
Harvard Medical School
Boston, Massachusetts

Edward Kelly
Harvard Medical School
Boston, Massachusetts

Emily Z. Keung, MD
Harvard Medical School
Boston, Massachusetts

George Koenig
Jefferson Medical College
Philadelphia, Pennsylvania


Yasser El Kouatli
University of Michigan Health System
Ann Arbor, Michigan

John P. Kress
University of Chicago
Chicago, Illinois

Kelly B. Kromer
Harvard Medical School
Boston, Massachusetts

Peggy S. Lai, MD
Harvard Medical School
Boston, Massachusetts

Col. Geoffrey S.F. Ling
Medical Corps, US Army
Arlington, Virginia

Tensing Maa, MD
Ohio State University Medical Center
Columbus, Ohio

Sayeed K. Malek, MD, FACS
Harvard Medical School
Boston, Massachusetts

Atul Malhotra
Harvard Medical School
Boston, Massachusetts

Ernest I. Mandel, MD

Harvard Medical School
Boston, Massachusetts

Oveys Mansuri
University of Nebraska College of Medicine
Omaha, Nebraska

Shannon S. McKenna, MD
Harvard Medical School
Boston, Massachusetts

Brijesh P. Mehta, MD
Harvard Medical School
Boston, Massachusetts

Alessandro M. Morandi
Vanderbilt University School of Medicine
Nashville, Tennessee

Lena M. Napolitano
University of Michigan Health System
Ann Arbor, Michigan


Emily Nelson
Harvard Medical School Brigham and Women’s Hospital
Boston, Massachusetts

Patrice K. Nicholas
Massachusetts General Hospital

Boston, Massachusetts

Chong Nicholls
Harvard Medical School
Boston, Massachusetts

Heikki Nikkanen
Harvard Medical School
Boston, Massachusetts

John J. O’Connor, Jr., MD
South Shore Hospital
South Weymouth, Massachusetts

Michael F. O’Connor, MD, FCCM
University of Chicago Medical Center
Chicago, Illinois

Yuka Okajima
Harvard Medical School
Boston, Massachusetts

David Oxman
Jefferson Medical College
Philadelphia, Pennsylvania

Bhakti K. Patel
University of Chicago
Chicago, Illinois

Mary Pennington
Brigham and Women’s Hospital
Boston, Massachusetts

Sujatha Pentakota, MD
Harvard Medical School
Boston, Massachusetts

Bohdan Pomahac, MD
Harvard Medical School
Boston, Massachusetts

Pankajavalli Ramakrishnan
Harvard Medical School
Boston, Massachusetts

Mary B. Rice, MD
Harvard Medical School
Boston, Massachusetts


Steven A. Ringer
Harvard Medical School
Boston, Massachusetts

Angela J. Rogers, MD
Harvard Medical School
Boston, Massachusetts

Selwyn O. Rogers, Jr., MD, MPH

Harvard Medical School
Boston, Massachusetts

Allan Ropper
Harvard Medical School
Boston, Massachusetts

Daniel S. Rubin, MD
University of Chicago
Chicago, Illinois

Amod Sawardekar
Northwestern University Feinberg School of Medicine
Chicago, Illinois

Raghu Seethala
Harvard Medical School
Boston, Massachusetts

Mouhsin Shafi
Harvard Medical School
Boston, Massachusetts

Sajid Shahul
Harvard Medical School
Boston, Massachusetts

Peter H. Stone
Harvard Medical School
Boston, Massachusetts

Daniel S. Talmor, MD, MPH
Harvard Medical School
Boston, Massachusetts

Candice Tam
University of California San Francisco
San Francisco, California

Stefan G. Tullius, MD, PhD, FACS
Harvard Medical School
Boston, Massachusetts

Avery Tung
University of Chicago School of Medicine
Chicago, Illinois


Dirk J. Varelmann, MD, DESA, EDIC
Harvard Medical School
Boston, Massachusetts

George Velmahos
Harvard Medical School
Boston, Massachusetts

Binbin Wang
University of California San Francisco
San Francisco, California

M. Brandon Westover, MD, PhD
Harvard Medical School
Boston, Massachusetts

Lashonda Williams
East Texas Medical Center
Tyler, Texas

Neil J. Wimmer
Harvard Medical School
Boston, Massachusetts

Traci A. Wolbrink, MD, MPH
Harvard Medical School
Boston, Massachusetts


PREFACE
Critical care has always been a multi-disciplinary specialty. The multidisciplinary nature is
practiced two ways: (a) critical care integrates knowledge and practices from many medical
specialties (trauma, transplant medicine, cardiology, pulmonary medicine, anesthesiology and pain
medicine, and many others); and (b) it requires the close collaboration of medical professionals
from many specialties (nurses, physico-therapists, respiratory therapists, nutritionists, pharmacists,
physicians, etc.). For that, critical care professionals are required to be masters of communication,
team building, and management.
Since its inception in the polio era (1950s), critical care has grown beyond adolescence and
now is considered to be an evidence-based specialty. Dozens of high-quality clinical trials built a
solid scientific foundation for critical care, and allowed us to significantly improve both patient
survival and quality of life following critical illness. Our mission was to highlight these for our
readers.

As we reach for personalized (individualized) medicine to custom tailor our management for
every one of our patients, provide care for the elderly in their 80s and 90s, treat diseases that were
untreatable just years before, the knowledge has to be solid and the commitment firm that critical
care professionals will always put their patients first. The challenges remaining are substantial and
will require a well-trained, collaborative, patient-centered and cost-effective effort from all of us.
This book is intended to provide concise, evidence-based information for all critical care
professionals, as well as for those who are having their first encounter with ICUs and critically ill
patients. To accomplish our goals, we were joined by many leading critical care specialists. We
are grateful for their contribution and for sharing their many years of experience.
The rewards of providing care for the most needy are great. With our book, we invite all of you
for a great and satisfying professional journey.
GYORGY FRENDL, MD, PhD
RICHARD D. URMAN, MD, MBA
Harvard Medical School
Boston, Massachusetts


CONTENTS
Contributors
Preface

COMMON ICU PROBLEMS
Raghu Seethala
MONITORING
Samuel M. Galvagno, Jr. and Anquenetta L. Douglas
MECHANICAL VENTILATION AND PULMONARY ISSUES
Rebecca M. Baron
AIRWAY MANAGEMENT
Tarun Bhalla, Tensing Maa, and Amod Sawardekar
ACUTE LUNG INJURY (ALI) AND ACUTE RESPIRATORY DISTRESS SYNDROME

(ARDS)
John J. O’Connor and Daniel S. Talmor
HEMATOLOGY, FLUID AND ELECTROLYTE MANAGEMENT
Yasser El Kouatli and Lena M. Napolitano
ACID–BASE MANAGEMENT
Mary B. Rice, Kathryn A. Hibbert, and Atul Malhotra
ANALGESIA, SEDATION, AND DELIRIUM
Nathan E. Brummel, Alessandro M. Morandi, and E. Wesley Ely
NUTRITION
Marcus D. Darrabie and Danny O. Jacobs
INFECTIOUS DISEASE, SEPSIS, AND THE SURVIVING SEPSIS GUIDELINES
David Oxman, Karim Djekeidel, Gyorgy Frendl, Lindsey Baden
ENDOCRINE AND RENAL ISSUES
Ernest I. Mandel and Kenneth B. Christopher
SCORING SYSTEMS FOR THE SEVERITY OF ILLNESS
Edward Kelly


PREVENTIVE STRATEGIES AND EVIDENCE-BASED PRACTICE
Shannon S. McKenna
ADVANCED CARDIAC LIFE SUPPORT (ACLS)
Dragos M. Galusca
GENERAL TRAUMA I
Joaquim M. Havens, George Koenig, and Samuel M. Galvagno, Jr.
GENERAL TRAUMA II
Peter J. Fagenholz, George Kasotakis, and George Velmahos
BURN MANAGEMENT
Emily Z. Keung and Joaquim M. Havens
HEAD TRAUMA AND SPINAL CORD INJURY
Wenya Linda Bi, William B. Gormley, and Ian F. Dunn

NEUROLOGICAL CRITICAL CARE
Brian Edlow, Brijesh P. Mehta, Pankajavalli Ramakrishnan, and Allan Ropper
NEUROVASCULAR CRITICAL CARE
Karim Awad and David Greer
SEIZURES
M. Brandon Westover and Mouhsin Shafi
WEAKNESS IN THE CRITICAL Care Setting
Galen V. Henderson
ACUTE CORONARY SYNDROMES AND MYOCARDIAL ISCHEMIA
Neil J. Wimmer and Peter H. Stone
CARDIAC SURGICAL CRITICAL CARE
Candice Tam, Binbin Wang, and Michael Gropper
HEART AND LUNG TRANSPLANTATION
Phillip Camp
LIVER, KIDNEY, AND PANCREAS TRANSPLANTATION
Christian Denecke, Stefan G. Tullius, and Sayeed K. Malek
BONE MARROW AND STEM CELL TRANSPLANTATION
Brett Glotzbecker and Edwin Pascal Alyea, III


PLASTIC SURGICAL CRITICAL CARE
J. Rodrigo Diaz-Siso and Bohdan Pomahac
THORACIC SURGICAL CRITICAL CARE
Shannon S. McKenna
VASCULAR SURGICAL CRITICAL CARE
Sheri Berg and Rae Allain
NEONATAL INTENSIVE CARE
Steven A. Ringer
PEDIATRIC INTENSIVE CARE
Kelly B. Kromer and Traci A. Wolbrink

OBSTETRIC CRITICAL CARE
Dirk J. Varelmann
OBESITY: SPECIAL CONSIDERATIONS
Ali A. El-Solh
THE ELDERLY: SPECIAL CONSIDERATIONS
Alessandro M. Morandi, Nathan E. Brummel, and E. Wesley Ely
TOXICOLOGY
Heikki Nikkanen
DISASTER PREPAREDNESS
Geoffrey S.F. Ling
INFORMED CONSENT, PROCEDURAL STANDARDIZATION AND SAFETY
Jennifer Hofer
COMMON PROCEDURES
Jennifer Hofer and Avery Tung
BEDSIDE SURGICAL PROCEDURES
Oveys Mansuri, Lashonda Williams, and Selwyn O. Rogers, Jr.
ULTRASOUND-GUIDED THERAPY AND PROCEDURES
Sajid Shahul and Gyorgy Frendl
RADIOLOGIC IMAGING
Yuka Okajima and Hiroto Hatabu


NURSING STANDARDS IN CRITICAL CARE
Mary Pennington
OCCUPATIONAL AND PHYSICAL THERAPY
Bhakti K. Patel and John P. Kress
TRANSITIONING FROM ACUTE CARE TO REHABILITATION
Shannon S. McKenna
PATIENT- AND FAMILY-CENTERED CARE
Mary Pennington and Patrice K. Nicholas

ETHICS AND PALLIATIVE/END OF LIFE CARE
Michael F. O’Connor and Daniel J. Rubin
INTER AND INTRA-HOSPITAL TRANSPORT OF CRITICALLY ILL PATIENTS
Michael G. Fitzsimons and Chong Nicholls
OPERATING ROOM: CARING FOR THE EXTREMELY CRITICALLY ILL PATIENT
Emily Nelson and Gyorgy Frendl
EMERGENCY DEPARTMENT TO ICU COMMUNICATION STRATEGIES
Peter C. Hou
GENOMICS IN CRITICAL CARE
Peggy S. Lai and Angela J. Rogers
APPENDIX: ICU CALCULATORS, CALCULATIONS, DRUGS
Sujatha Pentakota
APPENDIX: STATISTICS AND EVIDENCE-BASED MEDICINE (EBM)
Sujatha Pentakota
INDEX


COMMON ICU PROBLEMS
RAGHU SEETHALA, MD

HYPERKALEMIA
Serum K > 5.0 mmol/l, severe hyperkalemia > 6.0 mmol/l (also see Chapter 6)
Causes
• Renal insufficiency
• Adrenal insufficiency
• Insulin deficiency
• Tissue damage from rhabdomyolysis, trauma, or burns
• Medication related
• Acidosis
Clinical Manifestations

• Peaked T waves on ECG; hyperkalemia depolarizes cardiac membrane leading to further EKG
changes, like widening of QRS (sinusoidal wave forms) which can progress to asystole or
ventricular fibrillation
• Muscular effects can include paresthesias, weakness, or flaccid paralysis
Management
• Stabilize cardiac membrane
• Calcium Gluconate (10%) 10 ml IV push over 2–3 min, can repeat q5min
• Shift potassium intracellularly
• Insulin (regular) 10 U IV push with 25 g of Dextrose IV push (if not hyperglycemic)
• Albuterol 15–20 mg (beta-agonist) nebulized over 10 min
• Sodium Bicarbonate 50 mmol IV push or 150 mmol/l IV at a variable rate (only use if patient has
a severe metabolic acidosis)
• Potassium elimination from body
• Furosemide (Lasix) 40–80 mg IV push
• Sodium polystyrene sulfonate (Kayexalate) 15–30 g in 15–30 ml (70% sorbitol PO)
• Do not administer in ileus or bowel obstruction because of risk of colonic necrosis
• Hemodialysis (if hyperkalemia is unresponsive to conservative measures listed above)

SHOCK
Hypoperfusion causing tissue hypoxia resulting in multiorgan dysfunction (also see Chapter 10
for septic and Chapter 27 for cardiogenic shock).


Differential Diagnosis
• Hypovolemic
• Hemorrhage (trauma, GI bleed, retroperitoneal bleed)
• Dehydration (vomiting, diarrhea, GI fistula)
• Third spacing (burns, malnutrition, SIRS)
• Cardiogenic
• Myocardial infarction

• Myocarditis
• End stage cardiomyopathy
• Valvular failure
• Congestive heart failure
• Arrhythmia
• Distributive
• Sepsis
• Anaphylaxis
• Liver failure
• Neurogenic
• Adrenal insufficiency
• Drugs
• Obstructive
• Tension pneumothorax
• Cardiac tamponade
• Constrictive pericarditis
• Pulmonary embolism
• Aortic coarctation
Clinical Manifestations
• Hypotension
• Tachycardia
• Tachypnea
• Mottled skin
• Cool extremities
• Altered mental status
• Decreased urine output
Management
• Establish and maintain ABCs (airway, breathing, circulation)
• Fluid resuscitation
• Blood and blood product transfusion

• Vasopressors
• Inotropes
• Hemodynamic monitoring (CVC, arterial line, PA catheter, echocardiogram)
• Consider the following resuscitation endpoints for septic shock (the most common type of shock)
• CVP 8–12 mm Hg, 12–15 mm Hg if mechanically ventilated
• MAP ≥ 65 mm Hg


• UOP ≥ 0.5 ml/kg/hr
• ScVO2 ≥ 70% or MVO2 ≥ 65%
• Lactate clearance
• Identification and treatment of underlying problem including source control in septic shock

SEPSIS
Infection associated with a systemic inflammatory response (also see Chapter 10).
Causes
• Pneumonia
• Catheter-related blood stream infections
• Sinusitis
• Clostridium difficile
• Intra-abdominal (cholecystitis, abscess, peritonitis)
• UTI, pyelonephritis
• Meningitis, encephalitis
• Cellulitis, necrotizing soft tissue infection, wound infection
• Septic arthritis, osteomyelitis
• Endocarditis
• Fungemia, fungal abscess
Investigations
• CBC, electrolytes, BUN/Cr, PT/INR, LFT
• Blood culture, urine culture, site specific culture

• ABG/lactate
• Procalcitonin
• Imaging studies: chest x-ray, site specific CT scan, US, etc.
Management
• Source identification and control as rapidly as possible
• Broad spectrum IV antibiotic therapy within first hour
• Early goal directed therapy within the first 6 hr
• CVP 8–12 mm Hg, 12–15 mm Hg if mechanically ventilated
• MAP ≥ 65 mm Hg
• UOP ≥ 0.5 ml/kg/hr
• ScVO2 ≥ 70% or MVO2 ≥ 65%
• Fluid therapy to reach above CVP targets
• Administer vasopressors to maintain MAP ≥ 65 mm Hg (norepinephrine with or without
vasopressin as first choice)
• Inotropic therapy with dobutamine for sepsis induced cardiac dysfunction
• May consider corticosteroids when hypotension is not responding to fluid resuscitation and
vasopressors (ACTH stimulation test is no longer recommended).
• Supportive therapy (ARDSnet ventilation strategy, glycemic control to keep blood glucose in the


140–160 mg/dl range, renal replacement, stress ulcer prophylaxis, DVT prophylaxis)

ARRHYTHMIAS
Bradyarrhythmia: HR < 60 bpm
Differential Diagnosis
• SA node dysfunction
• Sinus arrest
• SA conduction block
• Sick sinus syndrome
• AV node dysfunction

• First degree AV block
• Second degree AV block Mobitz type I
• Second degree AV block Mobitz type II
• Third degree AV block
• Junctional escape rhythm
• Ventricular escape rhythm
• Sinus bradycardia
Management
• 12-lead EKG
• Atropine 0.5 mg IV bolus repeat 3–5 min (maximum 3 mg)
• Dopamine IV infusion 2–10 mcg/kg/min
• Epinephrine IV infusion 2–10 mcg/min
• Transcutaneous pacing (consider pacing for symptomatic bradycardias, 3rd degree AV block,
Mobitz type II 2nd degree block)
• Transvenous pacing
• Treat underlying cause
Tachyarrhythmia: HR > 100 bpm
Differential Diagnosis
• Narrow complex tachycardia
• Sinus tachycardia
• Focal atrial tachycardia
• Atrial fibrillation
• Multifocal atrial tachycardia
• Atrial flutter
• Junctional tachycardia
• AV node reentry tachycardia
• AV reentry tachycardia
• Wide complex tachycardia
• Monomorphic VT

• Polymorphic VT
• SVT with aberrancy
• Pre-excitement tachycardia (WPW)
Management
• 12-lead EKG
• If unstable (hypotension, altered mental status, signs of shock) then proceed to synchronized
cardioversion
• Narrow regular 50–100 J biphasic
• Narrow irregular 120–200 J biphasic or 200 J monophasic
• Wide regular: 100 J biphasic; if ineffective, increase J in a stepwise fashion
• Wide irregular: Defibrillation dose (not synchronized)
• Vagal maneuvers for supraventricular tachycardia
• Adenosine 6 mg IV push (if regular) for paroxysmal supraventricular tachycardia
• β-blocker – Metoprolol 2.5–5 mg IV
• Calcium channel blocker – Diltiazem 0.25 mg/kg IV followed by infusion
• Amiodarone 150 mg IV over 10 min (may consider 150 mg iv repeated dose if unresponsive to first
loading dose), followed by maintenance infusion (1 mg/min for 6 hr, reduced to 0.5 mg/min after
that)
• Treat underlying cause
Atrial Fibrillation
Causes
• Alcohol intake
• Autonomic dysfunction
• Cardiac/thoracic surgery
• Cardiomyopathy
• Electrolyte abnormality
• Heart failure
• Hyperthyroidism
• MI

• Pericarditis
• Pulmonary disease
• Valvular heart disease
Management
• If unstable then synchronized cardioversion
• 120–200 J biphasic
• If <48 hr consider cardioversion (DC or pharmacologic)
• Pharmacologic cardioversion – Amiodarone, Sotalol, Ibutilide, Flecainide
• If >48 hr rate control and anticoagulate (if no contraindications)
• Rate control
• Metoprolol 5 mg IV q5min total of 15 mg
• Diltiazem 0.25 mg/kg IV followed by infusion


• Digoxin 0.25 mg IV q2h total of 1.5 mg loading dose
• Amiodarone 150 mg IV over 10 min (may consider 150 mg iv repeated dose if unresponsive to
first loading dose), followed by maintenance infusion (1 mg/min for 6 hr, reduced to 0.5 mg/min
after that)
• Treat underlying cause

HYPOTENSION
MAP < 60 mm Hg, SBP < 90 mm Hg, or decrease in SBP by >40 mm Hg from baseline. MAP = CO
× SVR
Differential Diagnosis
• Decrease in CO
• Decreased preload
• Hypovolemia, hemorrhage, third spacing, decreased venous return, excessive PEEP
• Decreased contractility
• Myocardial infarction, myocarditis, cardiomyopathy, valvular failure, arrhythmia, congestive
heart failure, drugs, electrolyte imbalance

• Obstruction (to inflow or outflow of cardiac pump)
• PE, tension pneumothorax, cardiac tamponade
• Decrease in SVR
• Sepsis, SIRS, anaphylaxis, neurogenic shock, vasodilating drugs, adrenal insufficiency, liver
failure due to decreased SVR
Management
• Hemodynamic monitoring (CVC, arterial line, PA catheter, echo)
• 500 ml NS or LR IVF bolus, then reassess hemodynamics (HR, BP, cardiac output [CO], index
[CI], stroke volume, CVP) and repeat IVF bolus as needed
• Review medications, decrease dose of vasodilating drugs and cardiac depressants (sedatives,
opiods, etc.)
• Vasopressors (norepinephrine, dopamine, phenylephrine, epinephrine)
• Inotropes (dobutamine, milrinone, levosimendan)
• Assess for and treat underlying cause

HYPOXEMIA
PaO2 < 60 mm Hg or SpO2 < 90%
Differential Diagnosis
• Hypoventilation
• COPD, asthma, bronchospasm, inappropriate ventilator settings
• CNS depression – drug overdose, CNS lesion
• Obesity hypoventilation syndrome


• Neuromuscular weakness – myasthenia gravis, critical illness polyneuropathy, Guillain–Barre
syndromé, hypophosphatemia
• V/Q mismatch
• Most common cause of hypoxemia in the ICU
• Imbalance between lung perfusion and ventilation
• Pneumonia, ALI/ARDS, pneumonitis, pulmonary edema, pulmonary embolism

• Right to left shunt
• Intracardiac shunt, pulmonary AVM, hepatopulmonary syndrome
• Diffusion impairment (seen rarely in very advanced pulmonary fibrosis, asbestosis)
• Usually occurs along with V/Q mismatch
• Interstitial lung disease
• Reduced inspired FiO2
• High altitude, equipment failure
Investigations
• SpO2
• ABG – PaO2, PaCO2, A-a gradient
• PaO2/FiO2 ratio
• CXR, CT of chest if needed
Management
• Initially administer 100% FiO2, titrate FiO2 to SpO2 > 90%
• Initiate mechanical ventilation if unresponsive to supplemental O2 therapy
• Appropriate ventilator settings (low tidal volume, higher PEEP, adequate RR)
• Ensure proper position of ET tube
• Bronchoscopy as needed (mucous plug, atelectasis, abundant secretions)
• Bag mask ventilation if considering equipment failure
• Treat underlying cause

P ERICARDIAL TAMPONADE
Accumulation of pericardial fluid under pressure compressing all cardiac chambers resulting in
cardiovascular collapse.
Differential Diagnosis
• Massive PE
• Acute MI with RV involvement
• Constrictive pericarditis
• Large pleural effusion
• Tension pneumothorax

Causes
• Inflammatory – RA, SLE


• Malignancy
• Uremia
• Hypothyroidism
• MI with free wall rupture
• Trauma
• Infectious – viral, TB
• Cardiac interventions – pacemaker placement, cardiac catheterization, heart surgery
Clinical Findings
• Tachycardia, pericardial friction rub
• Beck’s triad – Hypotension, JVD, muffled heart sounds
• Pulsus paradoxus
• Low voltage QRS, Electrical alternans
• Equilibration of diastolic pressures in all chambers of the heart CVP = RVEDP = PCWP = LVEDP
Management
• Diagnosis made with echocardiography
• Optimize preload with IVF bolus in hypovolemic patients
• Consider dobutamine, though heart is usually at maximum inotropic state via endogenous
stimulation
• Definitive therapy is drainage via pericardiocentesis
• Cases of intrapericardial bleeding (trauma, post-op, tumor) usually require surgical intervention

TENSION P NEUMOTHORAX
Progressive accumulation of air in the pleural space that compresses the mediastinum kinking off
venous return leading to cardiovascular collapse.
Differential Diagnosis
• Pericardial tamponade

• Hemothorax
Causes
• Thoracic trauma
• Iatrogenic – CVC placement, transthoracic needle biopsies
• Spontaneous pneumothorax
• Secondary pneumothorax
• Barotrauma from mechanical ventilation
Clinical Findings
• Distended neck veins
• Progressive hypotension (often rapidly severe, may lead to cardiovascular collapse)
• Tracheal deviation to contralateral side
• Absent breath sounds


Management
• Immediate needle decompression with 14–16 gauge needle in the midclavicular line of the second
intercostal space of affected side
• Followed by chest tube placement for definitive therapy

ACUTE MENTAL STATUS CHANGE
A spectrum of states including confusion, delirium, obtundation, stupor and coma.
Differential Diagnosis
• Stroke/hemorrhage
• Seizure
• Encephalitis/meningitis
• Delirium
• Post cardiac arrest brain injury/anoxic encephalopathy
• Drugs (illicit or medication overdose)
• Alcohol withdrawal
• Thiamine deficiency

• Hypo/hyperthyroid
• Adrenal insufficiency
• Hepatic encephalopathy
• Hypo/hyperglycemia
• Hypoxia/hypercarbia
• Electrolyte abnormality (hypo/hypernatremia, hypercalcemia, hypophosphatemia)
• Septic encephalopathy
Investigations
• Vitals signs
• CT head
• Labs – electrolytes, BUN, Cr, CBC, LFTs, ammonia, UA, ABG
• Lumbar puncture to evaluate for meningitis/encephalitis
• EEG to evaluate for nonconvulsive status epilepticus
Management
• Establish and maintain ABCs (airway, breathing, circulation)
• Thiamine 100 mg IV (prior to dextrose to prevent precipitating acute Wernicke’s encephalopathy)
• Dextrose 50 ml of D50W (25 g IV push)
• Naloxone 0.2–0.4 mg by slow (fractioned) IV push if comatose and suspect opiod intoxication
• Search for and treat underlying cause
• Flumazenil 0.2 mg iv maybe repeated 3 more times with a few minute intervals (to reverse the
effects of benzodiazepines; beware of the potential seizures after reversal of benzodiazepine
effect). Do not use in patients that chronically use benzodiazepines: the potential for intractable
seizures is much higher in this group.