2014 machetes review of critical care med

THE MASSACHUSETTS
GENERAL HOSPITAL
REVIEW OF CRITICAL
CARE MEDICINE


Section Editors

Peter J. Fagenholz, MD
Instructor in Surgery, Harvard Medical School
Assistant in Surgery, Department of Surgery
Division of Trauma Emergency Surgery, and Critical Care
Massachusetts General Hospital
Boston, Massachusetts
Jarone Lee, MD MPH
Instructor in Surgery, Harvard Medical School
Trauma, Emergency Surgery, Surgical Critical Care
Massachusetts General Hospital
Boston, Massachusetts
Ala Nozari, MD, PhD
Assistant Professor of Anaesthesia, Harvard Medical School
Team Leader, Neurosurgical Anesthesia; Attending
Physician, Neuroscience Intensive Care Unit,
Massachusetts General Hospital
Co-Director, Massachusetts General Hospital and Brigham and Women’s Hospital Training Program in Neurosurgical Anesthesia
Assistant Anaesthetist, Department of Anesthesia, Critical
Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Ulrich Schmidt, MD, PhD, FCCM

Associate Professor
Department of Anesthesia Critical Care, Pain Medicine
Massachusetts General Hospital
Harvard Medical School
Boston, Massachusetts


THE MASSACHUSETTS
GENERAL HOSPITAL
REVIEW OF CRITICAL
CARE MEDICINE
Editors:
Sheri M. Berg, MD
Instructor of Anaesthesia, Harvard Medical School
Massachusetts General Hospital
Boston, Massachusetts

Edward A. Bittner, MD, PhD
Assistant Professor of Anaesthesia, Harvard Medical School
Program Director, Critical Care Medicine Fellowship
Associate Director, Surgical Intensive Care Unit
Massachusetts General Hospital
Boston, Massachusetts


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Library of Congress Cataloging-in-Publication Data
Massachusetts General Hospital critical care board review / Sheri M. Berg, MD, Department of Anesthesia, Critical Care and Pain
Medicine, Massachusetts General Hospital, Boston, Massachusetts, Edward A. Bittner, MD, PhD, associate director for education,
Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, editors;
Massachusetts General Hospital critical care board review, section editors, Jarone Lee, MD, MPH, Instructor in Surgery, Harvard
Medical School, Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts [and
three others].
pages cm
Includes bibliographical references and index.
ISBN 978-1-4511-7368-0
1. Critical care medicine—Handbooks, manuals, etc. 2. Medical emergencies—Handbooks, manuals, etc. I. Berg, Sheri M. II.
Bittner, Edward A., 1967- III. Lee, Jarone. IV. Title: Critical care board review.
RC86.8.M3935 2014
616.02'8—dc23
2013028741

Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However,
the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the
information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the

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practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in
accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in
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To our fellows: past, present, and future


Contributors

Young K. Ahn, MD
Assistant Clinical Professor
Division of Critical Care
Department of Anesthesia
University of California Los Angeles
Los Angeles, California
Hasan B. Alam, MD
Norman Thompson Professor of Surgery
Section Head, General Surgery
University of Michigan Hospital
Ann Arbor, Michigan
Rebecca Aslakson, MD
Assistant Professor
The Johns Hopkins University School of Medicine
Department of Anesthesiology and Critical Care Medicine
The Johns Hopkins University School of Medicine
Baltimore, Maryland
Aranya Bagchi, MBBS
Instructor in Anesthesia,
Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine

Boston, Massachusetts
Lorenzo Berra, MD
Assistant Professor of Anaesthesia,
Harvard Medical School
Assistant Anaesthetist, Department of Anesthesia, Critical
Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Edward A. Bittner, MD, PhD
Associate Director for Education
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Torrey Boland, MD
Fellow, Neurocritical Care
Massachusetts General Hospital and Brigham & Women’s Hospital
Centennial, Colorado
David Boldt, MD
Assistant Professor
Department of Anesthesiology
University of California, Los Angeles
Los Angeles, California
Kathryn L. Butler, MD
Instructor in Surgery
Division of Acute Care Surgery and Critical Care


Beth Israel Deaconess Medical Center
Boston, Massachusetts
Mark Caridi-Scheible, MD

Emory University School of Medicine
Department of Emergency Medicine
Atlanta, Georgia
Christopher M. Celano, MD
Attending Psychiatrist
Massachusetts General Hospital
Boston, Massachusetts
Jonathan E. Charnin, MD
Instructor, Harvard Medical School
Anesthetist and Staff Intensivist Department of Anesthesia,
Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
George Z. Cheng, MD, PhD
Department of Medicine
Division of Pulmonary & Critical Care
Massachusetts General Hospital
Boston, Massachusetts
Daniel Chipman
Assistant Director
Massachusetts General Hospital
Respiratory Care Services
Boston, Massachusetts
Jason Chua, MD
Assistant Professor
Department of Anesthesiology
University of California, Los Angeles
Los Angeles, California
Robert S. Crawford, MD
Assistant Professor

Division of Vascular Surgery
University of Maryland Medical Center
Baltimore, Maryland
Marc A. de Moya, MD, FACS
Assistant Professor of Surgery, Harvard Medical School,
Surgical Critical Care Fellowship Director
Medical Director, Blake 12 ICU
Surgical Clerkship Director, Harvard Medical School
Associate Program Director, Surgical Residency
Department of Surgery
Division of Trauma Emergency Surgery, and Critical Care
Massachusetts General Hospital
Boston, Massachusetts
Ranjit Deshpande, MBBS
Assistant Professor
Department of Anesthesiology
Yale University School of Medicine
New Haven, Connecticut
Anahat Dhillon, MD
Assistant Professor
University of California, Los Angeles
Department of Anesthesiology


Los Angeles, California
José L. Díaz-Gómez, MD
Critical Care Anesthesiologist
Mayo Clinic
Anesthesia/Critical Care Services
Jacksonville, Florida

Anne M. Drewry, MD
Assistant Professor of Anesthesiology
Washington University in St. Louis
Department of Anesthesiology
St. Louis, Missouri
Shawn Fagan, MD
Medical Director
Division of Burns Massachusetts General Hospital
Boston, Massachusetts
Peter J. Fagenholz, MD
Instructor in Surgery, Harvard Medical School
Department of Surgery
Division of Trauma Emergency Surgery, and Critical Care
Massachusetts General Hospital
Boston, Massachusetts
Corey R. Fehnel, MD
Fellow, Neurocritical Care
Massachusetts General Hospital and Brigham & Women’s Hospital
Boston, Massachusetts
Karim Fikry, MD
Resident
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Robert A. Finkelstein, MD
Clinical Fellow, Pediatric Emergency Medicine
Boston Medical Center
Division of Pediatric Emergency Medicine
Graduate Assistant in Pediatrics
Massachusetts General Hospital for Children

Clinical Fellow, Pediatric Emergency Medicine
Division of Pediatric Emergency Medicine
Boston Medical Center
Boston, Massachusetts
Jonathan Friedstat, MD
Resident, Plastic and Reconstructive Surgery
University of North Carolina
Chapel Hill, North Carolina
Miguel M. Gaeta, MD
Instructor in Surgery, Harvard Medical School
Trauma Medical Director, Elliot Hospital,
Manchester, New Hampshire
Assistant in Surgery, Massachusetts General Hospital Division of Trauma,
Emergency Surgery, and Critical Care
Massachusetts General Hospital
Boston, Massachusetts
Luis J. Garcia, MD
Assistant of Surgery
The Johns Hopkins Hospital


Baltimore, Maryland
Edward George, MD, PhD
Assistant Professor
Department of Anesthesia,
Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Brandy S. Golenia, PharmD, BCPS
Clinical Pharmacy Specialist-Drug Information

Department of Pharmacy Services
Cedars-Sinai Medical Center
Los Angeles, California
Jeremy W. Goldfarb, MD
Instructor in Anaesthesia,
Harvard Medical School
Director of Post Anesthesia Care Unit (PACU)
Attending Anesthesiologist, Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
Steven Greenberg, MD
Director of Critical Care Services, Evanston Hospital
Co-Director for Resident Education
Department of Anesthesia
NorthShore University HealthSystem
Assistant Clinical Professor, Department of Anesthesiology Critical Care
University of Chicago, Pritzker School of Medicine
Chicago, Illinois
Vadim Gudzenko, MD
Assistant Clinical Professor
Critical Care Division, Department of Anesthesiology
David Geffen School of Medicine at University of California, Los Angeles
Los Angeles, California
Jessica Hines
Administrative Coordinator
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
John O. Hwabejire, MD, MPH
Trauma Research Fellow
Division of Trauma, Emergency Surgery, and Critical Care

Massachusetts General Hospital
Boston, Massachusetts
Joseph A. Hyder, MD, PhD
Instructor in Anesthesia
Department of Anesthesiology
Harvard Medical School
Boston, Massachusetts
Daniel W. Johnson, MD
Critical Care Fellow
University of Nebraska Medical Center
Department of Anesthesiology
Omaha, Nebraska
Haytham M.A. Kaafarani, MD, MPH
Fellow in Trauma, Acute Care Surgery, and Critical Care
Division of Trauma, Emergency Surgery, and Critical Care
Massachusetts General Hospital


Boston, Massachusetts
Rebecca Kalman, MD
Clinical Fellow in Anaesthesia, Harvard Medical School
Fellow, Critical Care Medicine
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
George Kasotakis, MD, MPH
Fellow in Trauma, Acute Care Surgery, and Critical Care
Division of Trauma, Emergency Surgery, and Critical Care
Massachusetts General Hospital
Boston, Massachusetts

Tariq A. Kelker, MD, MSc
Assistant Professor—Trauma/Critical Care Surgery Division
Loma Linda University Medical Center
Diamond Bar, California
Emer Kelly, MD
Pulmonary and Critical Care Fellow
Department of Pulmonary and Critical Care Medicine
Brigham and Women’s Hospital
Boston, Massachusetts
Erik B. Kistler, MD, PhD
Assistant Professor
Department of Anesthesiology & Critical Care
VA San Diego Health Care System/University of California, San Diego
San Diego, California
Terrance Kummer, MD, PhD
Fellow, Neurocritical Care
Massachusetts General Hospital and Brigham & Women’s Hospital
Boston, Massachusetts
Jean Kwo, MD
Assistant Medical Director
Massachusetts General Hospital
Department of Anesthesia, Critical Care and Pain Medicine
Boston, Massachusetts
Ruth Lamm, MD
Assistant Professor of Emergency Medicine
Assistant Professor of Surgery
Department of Emergency Medicine
Emory University School of Medicine
Atlanta, Georgia
Jarone Lee, MD MPH

Instructor in Surgery, Harvard Medical School
Trauma, Emergency Surgery, Surgical Critical Care
Massachusetts General Hospital
Boston, Massachusetts
Jeanette J. Lee, MD
Clinical Instructor of Anesthesia and Critical Care Medicine
Boston University Medical Center
Department of Anesthesia
Boston, Massachusetts
Alexander R. Levine, PharmD
Critical Care Pharmacist
Massachusetts General Hospital


Boston, Massachusetts
Steven M. Lindsey, MD
Department of Emergency Medicine
Emory University School of Medicine
Atlanta, Georgia
Jakob I. McSparron, MD
Clinical Research Fellow
Department of Pulmonary and Critical Care Medicine
Massachusetts General Hospital
Boston, Massachusetts
Daniel C. Medina, MD
Fellow, Department of Surgery
University of Maryland Medical Center
Baltimore, Maryland
Kamal Medlej, MD
Assistant Professor of Clinical Emergency Medicine

Department of Emergency Medicine
American University of Beirut Medical Center
Beirut, Lebanon
Angela Meier, MD, PhD
Clinical Critical Care Fellow
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Andrew D. Mihalek, MD
Clinical and Research Fellow
Division of Pulmonary & Critical Care Medicine
Massachusetts General Hospital
Boston, Massachusetts
Ali Mokdad, MD, MSc
UT Southwestern Medical Center
Department of Surgery
Molly E . Moore, MD
Fellow in Critical Care
Division of Burn Surgery
Massachusetts General Hospital
Boston, Massachusetts
Shamim H. Nejad, MD
Assistant Professor of Psychiatry, Harvard Medical School
Burns and Trauma Psychiatry Consultation
Attending Physician, Dept. of Psychiatry
Massachusetts General Hospital
Boston, Massachusetts
Crystal M. North, MD
Clinical Fellow
Division of Pulmonary and Critical Care Medicine

Massachusetts General Hospital,
Harvard Medical School
Boston, Massachusetts
Ala Nozari, MD, PhD
Assistant Professor of Anaesthesia, Harvard Medical School
Team Leader, Neurosurgical Anesthesia; Attending
Physician, Neuroscience Intensive Care Unit, Massachusetts
General Hospital


Co-Director
Massachusetts General Hospital and Brigham and Women’s
Hospital Training Program in Neurosurgical Anesthesia
Assistant Anaesthetist
Department of Anesthesia, Critical Care and Pain Medicine
Boston, Massachusetts
Airadion Omoruan, MD
Clinical Fellow in Cardiothoracic Anesthesiology
Department of Anesthesiology, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Britta Panda, MD, PhD
Assistant Professor
Division of Maternal-Fetal Medicine
Tufts Medical Center
Boston, Massachusetts
Donald Park, MD
Department of Anesthesiology and Critical Care Medicine
Cedars-Sinai Hospital
Los Angeles, California

Riccardo Pinciroli, MD
Research Fellow in Anaesthesia
Department of Anesthesia, Critical Care, and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Paritosh Prasad, MD, DTM&H
Clinical Fellow
Infectious Disease/Critical Care
Massachusetts General Hospital/National Institutes of Health
Boston, Massachusetts
Sadeq A. Quraishi, MD, MHA, MMSc
Assistant Professor of Anaesthesia
Harvard Medical School
Anesthetist and Staff Intensivist
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Farbod Nicholas Rahaghi, MD, PhD
Research Fellow
Pulmonary and Critical Care
Brigham and Women’s Hospital
Boston, Massachusetts
Celine Rahman DeMatteo, MD
Fellow, Neurocritical Care
Massachusetts General Hospital and Brigham and Women’s Hospital
Boston, Massachusetts
Pankajavalli Ramakrishnan, MD, PhD
Fellow, Neurocritical Care
Massachusetts General Hospital and Brigham & Women’s Hospital
Boston, Massachusetts

Robert A. Ratzlaff, DO
Assistant Medical Director of the Cardiovascular Intensive
Care Units and Assistant Professor of Anesthesiology
Cleveland Clinic Lerner College of Medicine of Case Western Reserve
Anesthesiology Institute, Cardiothoracic Anesthesiology


Cleveland Clinic
Cleveland, Ohio
Daniel M. Rolston, MD, MS
Chief Resident
Department of Emergency Medicine
St. Luke’s-Roosevelt Hospital Center
New York, New York
James K. Rustad, MD
Core Courtesy Assistant Professor
Department of Psychiatry & Behavioral Medicine
Morsani College of Medicine
University of South Florida
Tampa, Florida
Karim Sadik, MD
Clinical Fellow, Surgical Critical Care
Massachusetts General Hospital
Boston, Massachusetts
Ulrich Schmidt, MD, PhD, FCCM
Associate Professor
Department of Anesthesia Critical Care, Pain Medicine
Massachusetts General Hospital
Harvard Medical school
Boston, Massachusetts

William B. Schoenfeld, MD
Instructor in Anesthesia, Harvard Medical School
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Torin D. Shear, MD
Evanston Hospital, NorthShore University HealthSystem
Assistant Clinical Professor, Department of Anesthesiology
Critical Care
University of Chicago, Pritzker School of Medicine
Evanston, Illinois
Kenneth Shelton, MD
Clinical Fellow
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Antonios C. Sideris, MD
Trauma Research Fellow
Division of Trauma, Emergency Surgery, and Critical Care
Massachusetts General Hospital
Boston, Massachusetts
Sumit Singh, MD
Assistant Professor
Department of Anesthesiology
University of California, Los Angeles
Los Angeles, California
Leigh Ann Slater, MD
Assistant Faculty
Departments of Surgery and Anesthesiology and Critical Care Medicine
Trauma/Acute Care Surgery Division of Surgery

Baltimore, Maryland


David Stahl, MD
Clinical Fellow, Anesthesia Critical Care
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Lauren Steffel, MD
Anesthesia Resident
Department of Anesthesia
Stanford University School of Medicine
Stanford, California
Henrikas Vaitkevicius MD, MS
Clinical Fellow
Department of Neurology
Massachusetts General Hospital
Boston, Massachusetts
George C. Velmahos, MD, PhD
John F. Burke Professor of Surgery
Chief of Division of Trauma Emergency Surgery
& Surgical Critical Care
Massachusetts General Hospital
Boston, Massachusetts
Nicholas C. Watson, MD
Assistant Professor
Anesthesia Practice Consultants, PC
Grand Rapids, Michigan
Anesthesiology and Critical Care
Michigan State University College of Human Medicine

Ada, Michigan
Jean McFall Wheeler, MD, MS
Department of Emergency Medicine
Emory University School of Medicine
Atlanta, Georgia
Stephanie Whitener, MD
Department of Anesthesia, Division of Cardiothoracic
Anesthesia
Duke University Medical Center
Durham, North Carolina
Susan R. Wilcox, MD
Staff Physician
Department of Emergency Medicine
Department of Anesthesia, Critical Care and Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
Phoebe H. Yager, MD
Instructor in Pediatrics, Harvard Medical School
Assistant in Pediatrics, Massachusetts General Hospital
Department of Pediatrics
Division of Pediatric Critical Care Medicine
Boston, Massachusetts
Dante D. Yeh, MD
Instructor in Surgery, Harvard Medical School
Department of Surgery
Division of Trauma Emergency Surgery, and Critical Care
Massachusetts General Hospital
Boston, Massachusetts

Brett C. Young, MD
Department OBGYN, Division Maternal Fetal Medicine
Clinical Instructor, Harvard Medical School
Beth Israel Deaconess Medical Center
Boston, Massachusetts
Hady Latif Zgheib, MD
Resident, Department of Emergency Medicine
American University of Beirut Medical Center
Beirut, Lebanon
George Z. Cheng MD, PhD
Department of Medicine
Division of Pulmonary & Critical Care
Massachusetts General Hospital
Boston, Massachusetts


Preface

Premise:

The field of critical care is constantly expanding and changing, and unfortunately there seems to be a
lack of great, comprehensive critical care board review books on market. A true multidisciplinary
book is needed! We have formatted a concise, although comprehensive review of pertinent critical
care topics and questions with explanation of answers and selected references for your review. The
primary objective of this book is to provide a text for board certification/recertification, which also
serves as a refresher/text for rapid reference.
Requirements:

At least one author must be a critical care attending/fellow either trained at MGH or work at MGH (to
ensure consistency in terminology/approach and to provide the “MGH flavor of critical care”). Editors

are drawn from the major specialty areas that encompass adult critical care medicine, anesthesiology,
emergency medicine, surgery and neurology. The topic list for chapters was developed using the
content outlines for the subspecialty critical care boards.


Contents

Dedication
Contributors
Preface
SECTION

1

Shock
1.1
1.2
1.3
1.4

Septic Shock
Hypovolemic Shock
Cardiogenic Shock
Anaphylactic Shock

SECTION

2

Cardiology

2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13

Coronary Artery Disease
Rhythm Disturbances
Valvular Disorders
Pericardial Disorders
Myocardial Disorders
Congenital Heart Disease in Adults
Noncardiogenic Pulmonary Edema versus Cardiogenic Pulmonary Edema
Cardiac Arrest and Resuscitation
Hypertension
Aneurysms and Dissections
Implantable Cardiac Devices
Monitoring
Pharmacologic Therapies for Cardiac Disorders

SECTION

3

Pulmonary
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8

Pulmonary Mechanics
Respiratory Failure, Mechanical Ventilation, and Weaning
Acute Respiratory Distress Syndrome and Acute Lung Injury
Ventilator-Induced Lung Injury and Ventilator-Associated Lung Injury
Pulmonary Embolism
Pulmonary Hypertension
Reactive Airway Disease (Asthma)
Chronic Obstructive Pulmonary Disease (COPD)


3.9
3.10
3.11
3.12
3.13
3.14
3.15
3.16

Restrictive Airway Diseases
Aspiration Syndromes
Pneumonia
Tracheobronchitis
Pulmonary Contusion
Flail Chest
Sleep-Related Breathing Disorders
Pharmacologic Therapies for Pulmonary Disorders

SECTION

4

Gastrointestinal
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12

Abdominal Compartment Syndrome
Acute Pancreatitis

Gastrointestinal Perforation
Acute Mesenteric Ischemia
Gastrointestinal Bleeding
Malabsorption in the Critically Ill Patient
Ileus and Acute Colonic Pseudoobstruction (Ogilvie Syndrome)
Clostridium Difficile and Toxic Megacolon
Inflammatory Bowel Disease
Vascular Diseases of Small Bowel
Obesity
Pharmacologic Therapies for Gastrointestinal Disorders

SECTION

5

Renal
5.1
5.2
5.3
5.4
5.5

Acute Kidney Injury (AKI)
Infections of the Urinary Tract
Acid-Base Physiology and Disorders
Renal Replacement Therapy
Pharmacologic Therapies for Renal Disorders

SECTION

6

Hepatic
6.1
6.2
6.3

Hepatic Dysfunction and Hyperbilirubinemia
Hepatic Encephalopathy
Hepatorenal Syndrome

SECTION

7

Hemacology/Oncology
7.1
7.2
7.3
7.4

Anemia
Thrombocytopenia
Thrombocytosis
Neutropenia


7.5
7.6
7.7

7.8
7.9

Hemoglobinopathies
Bone Marrow and Stem Cell Transplants
Tumor Lysis Syndrome
Coagulopathy
Disseminated Intravascular Coagulopathy

SECTION

8

Endocrine
8.1
8.2
8.3
8.4
8.5
8.6

General Neuroendocrine Axis
Diabetes Mellitus
Adrenal Gland
Pituitary Hormone Disorders
Thyroid Disorders
Pharmacologic Therapies for Endocrine Disorders

SECTION

9

Neurology
9.1
9.2
9.3
9.4
9.5
9.6
9.7
9.8
9.9
9.10
9.11
9.12
9.13
9.14
9.15
9.16

Altered Mental Status
Status Epilepticus
Depressive Disorders
Central Nervous System Infections
Traumatic Brain Injury and Intracranial Hypertension
Spinal Cord Injury
Ischemic Stroke
Hemorrhagic Stroke
Subarachnoid Hemorrhage
Vascular Malformations

Cerebral Venous Thrombosis
Demyelinating Syndromes and Prion Disease
Neuromuscular Disorders
Brain Death
Therapeutic Hypothermia
Pharmacologic Therapies for Neurologic Disorders

SECTION

10

Infectious Disease
10.1
10.2
SECTION

Infectious Diseases
Infectious Disease and Antibiotic Therapy

11

Immunology
11.1

The Immune System


SECTION

12

Dermatology
12.1
SECTION

Dermatologic Conditions

13

Thermoregulation
13.1
13.2
13.3
13.4
SECTION

Malignant Hyperthermia
Neuroleptic Malignant Syndrome
Heat Stroke
Hypothermia

14

Obstetrics
14.1
14.2
14.3
14.4
SECTION

Pre-eclampsia/Eclampsia and HELLP Syndrome
Acute Fatty Liver of Pregnancy
Amniotic Fluid Embolism
Postpartum Hemorrhage

15

Fluids and Electrolytes
15.1
15.2
15.3
15.4
SECTION

Fluids and Electrolytes
Sodium Balance
Potassium Balance
Calcium, Magnesium, and Phosphorous Balance

16

Nutrition
16.1
16.2
16.3
16.4
16.5
SECTION

Basal and Stress Energy Requirements

Stress Hormone Response
Nutritional Deficiency States
Nutrition Support
Refeeding Syndrome

17

Pharmacokinetics and Pharmacodynamics of Drugs
17.1
SECTION

Basic Pharmacokinetics and Pharmacodynamics

18

Transfusion Therapy
18.1

Transfusion Therapy


SECTION

19

Transplants
19.1
SECTION

Transplants: Lung, Heart, Liver, and Other Organs

20

Trauma Management
20.1
20.2
20.3
20.4
SECTION

Fluid Resuscitation/Transfusion Guidelines
Basic Management
FAST: Focused Assessment with Sonography
Complications

21

Pediatric Emergencies
21.1
21.2
21.3
SECTION

Airway and Pulmonary Emergencies
Surgical Emergencies
Cardiovascular Emergencies

22

Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support

(ATLS)
22.1
SECTION

ACLS and ATLS Guidelines

23

Point-of-Care Ultrasound in the ICU
23.1
SECTION

Point-of-Care Ultrasound in the ICU

24

Burns
24.1

Burns

SECTION

25

Exposures
25.1
SECTION

Nuclear, Radiologic, Chemical, and Biologic Exposures

26

Drowning
26.1
SECTION

Drowning

27


Procedures
27.1
27.2
27.3
27.4
27.5
27.6
SECTION

Tracheostomy
Cricothyroidotomy
Bronchoscopy
Tube Thoracostomy (Chest Tube)
Thoracentesis, Paracentesis, and Pericardiocentesis
Feeding Tube Placement

28

ICU Transport
28.1
SECTION

ICU Transport

29

Epidemiology and Biostatistics
29.1
SECTION

Epidemiology and Biostatistics

30

Infection Control
30.1
SECTION

Infection Control

31

ICU Administration
31.1
SECTION

ICU Administration

32

Ethics and Palliative Medicine
32.1
SECTION

Ethics and Palliative Medicine

33

Emergent Airway Management
33.1
SECTION

Emergent Airway Management

34

Preoperative Evaluation for Surgery
34.1

Preoperative Assessment

Questions
Answers
Index


SECTION

1

Shock
1.1
Septic Shock
Jonathan Friedstat
Septic shock and sepsis are significant causes of morbidity and mortality in the intensive care unit
(ICU).
Sepsis is one of the most common reasons for admission into the ICU.
Definitions

Sepsis = known or suspected infection plus some of:
Temperature > 38.3°C or < 36.0°C
Heart rate > 90 or > 2× normal for age
Tachypnea
Inflammatory markers
WBC > 12,000 or < 4,000 or normal with >10% immature forms
C-reactive protein (CRP) > 2 SD normal value, procalcitonin > 2 SD above normal value
Keep in mind other indirect indicators of infection such as altered mental status and
hyperglycemia
Severe sepsis = sepsis-induced hypoperfusion or organ dysfunction indicated by one or more of:
Septic shock: arterial hypotension = acute systolic blood pressure (SBP) < 90, mean arterial
pressure (MAP) < 70, or SBP decrease > 40 from baseline
Arterial hypoxemia (PaO2/FiO2 < 300)
Acute lung injury (ALI) with PaO2/FiO2 < 250 in the absence of pneumonia
ALI with PaO2/FiO2 < 200 in the presence of pneumonia
Elevated lactate (>1.2 mmol/L)
Acute oliguria (UOP < 0.5 mL/kg for 2 hours despite fluid resuscitation)
Creatinine increase (>0.5 mg/dL or 2× baseline)
Hyperbilirubinemia (Tbili > 4 mg/dL acutely)

Thrombocytopenia (platelets < 100,000 acutely)
Acute coagulopathy (INR > 1.5 or aPTT > 60 s)
Mixed venous saturation > 80% (likely sepsis) or < 65% (rule out cardiogenic source)
Severe acute ileus
Decreased capillary refill or mottling
Common Causes to Remember

ANY infection can be complicated by sepsis!


Examples include:
Gram-positive bacteremia (i.e., Staphylococcus, Streptococcus, Clostridium) via exposed
peptidoglycan in their cell walls, exotoxins
Gram-negative bacteremia (Escherichia coli, Pseudomonas, Acinetobacter) via endotoxins
(lipopolysaccharides)
Pneumonia
Pancreatitis
Necrotizing fasciitis
Meningitis
Urinary tract infections, including pyelonephritis
Indwelling catheters
Epidemiology

28-day mortality rate of more than 30%
Associated with an increased risk of death in the ICU
Approximately 100,000 deaths per year in the United States
National incidence ~750,000 cases
Can occur at any age, but there is a correlation with advanced age and not only incidence of septic
shock, but also increased mortality.
Key Pathophysiology

The pathogenesis of sepsis is a complicated process that occurs as a result of the interaction of
several factors including the infectious organism, the patient’s concomitant medical problems, and
his/her immune system.
The type of infectious source, the duration of exposure, and the patient’s underlying medical
comorbidities are factors addressed with early goal-directed therapy and initiation of appropriate
antibiotics.
Immune response
Pro-inflammatory response mediated by cytokines
Interleukin-1 (IL-1) and IL-6; tumor necrosis factor-α (TNF-α)
Activated by antigen–antibody complexes
The complement system is activated by bacterial wall sugars and endotoxin.
Activates neutrophils, lymphocytes, prostaglandins, and acute phase reactant proteins
Pro-inflammatory mediators are counteracted by anti-inflammatory mediators.
IL-4 andIL-10
Anti-inflammatory mediators can limit the effects of pro-inflammatory mediators, leading to
a state of “relative” immunosuppression, which is referred to as immunoparalysis.
Leads to a reduction of HLA proteins on monocytes
Contributes to increased morbidity and mortality
Cellular dysfunction
Disturbance of mitochondrial oxygen utilization
Results in cytopathic hypoxia: low ATP production in the setting of adequate oxygen
delivery
Pathogenic activation of apoptosis
Endothelial dysfunction and loss of hemostatic balance
Endothelial cells assist in regulation of vascular tone and coagulation (via expression of
heparin sulfate)