2011 critical care emergency medicine

Critical Care
Emergency Medicine


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Critical Care
Emergency Medicine
David A. Farcy, MD, FAAEM, FACEP, FCCM
Medical Director of the Surgical Intensivist Program
Director of Emergency Department Critical Care

Mount Sinai Medical Center
Miami Beach, Florida
William C. Chiu, MD, FACS, FCCM
Associate Professor of Surgery
Director, Fellowship Programs in Surgical
Critical Care and Acute Care Surgery
R Adams Cowley Shock Trauma Center
University of Maryland School of Medicine
Baltimore, Maryland
Alex Flaxman, MD, MSE
Director, Emergency Medicine Critical Care
Emergency and Critical Care Attending
St. Joseph’s Regional Medical Center
Paterson, New Jersey
Attending Intensivist
Pittsburgh Critical Care Associates, Inc
Staff Intensivist
Upper Allegheny Health System
Olean, New York
John P. Marshall, MD, FACEP
Chair
Department of Emergency Medicine
Maimonides Medical Center
Brooklyn, New York

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To my father Dr Jean Pierre Farcy for his love and for sharing and
instilling in me the passion for medicine, to Dr Thomas M. Scalea for
teaching me to have compassion and to always put patients first, to
Dr Amy Church and Dr John P. Marshall for believing in me. To my mother,
Poe, Eve, Frederic, and Sarah for always being there for me, and all my
patients and their families, who have helped me become a better doctor
and believed in me during their most difficult moments.
— David A. Farcy —

To all those who have been influential to me:
Terri, Anthony, Katherine, Victoria, and the extended Shock Trauma family.
— William C. Chiu —

To all those who helped, worked, and sacrificed, to get me to where
I am: Mom, Dad, Sally, grandparents, great grandparents, cousins, aunts and
uncles, great aunts and uncles, and great great uncle, this effort is for you.
— Alex Flaxman —

To my wife, Seriti, and my three boys, Sahm, Siahvash,
and Kianoosh. Your love, patience, and support make everything possible.
— John P. Marshall —

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CONTENTS
Contributors .............................................................................................................................................................. xi
Foreword ................................................................................................................................................................ xix
Preface .................................................................................................................................................................... xxi

SECTION I

INTRODUCTION

1 The Emergency Department Intensivist ...................................................................................................................... 3
Scott D. Weingart
SECTION II

AIRWAY AND VENTILATORY SUPPORT

2 Approach to the Difficult Airway ................................................................................................................................ 9
Timothy B. Jang and Jason C. Wagner
3 The Failed Airway ...................................................................................................................................................... 21
David R. Gens, David A. Farcy, and Dale J. Yeatts
4 Mechanical Ventilation ............................................................................................................................................... 31
David A. Farcy, Paul L. Petersen, Dennis Heard, and Peter DeBlieux
5 Weaning and Extubation ............................................................................................................................................ 41
Alex Flaxman
6 Noninvasive Ventilation.............................................................................................................................................. 55
Brian J. Wright and Todd L. Slesinger
7 Extracorporeal Cardiopulmonary Membrane Oxygenation ..................................................................................... 71

David A. Farcy, David Rabinowitz, and Paola G. Pieri
SECTION III

PULMONARY DISORDERS

8 Acute Respiratory Failure ........................................................................................................................................... 81
Imoigele P. Aisiku
9 Acute Respiratory Distress Syndrome (ARDS) .......................................................................................................... 89
Isaac Tawil and Megan L. Garcia


viii

CONTENTS

10 Severe Asthma and COPD ......................................................................................................................................... 99
Michael T. Dalley and Triminh Bui
11 Pulmonary Embolism ............................................................................................................................................... 109
Rayan A. Rouhizad and Beth A. Longenecker
SECTION IV CARDIOVASCULAR DISORDERS
12 Hemodynamic and Perfusion Monitoring ............................................................................................................... 117
Elizabeth Lea Walters and H. Bryant Nguyen
13 Acute Coronary Syndrome ....................................................................................................................................... 127
John P. Marshall and Jonathan Rose
14 Hypertensive Crises .................................................................................................................................................. 139
Christopher M. Perry, Qiuping Zhou, and Todd L. Slesinger
15 Post-Cardiac Arrest Management ............................................................................................................................. 149
Alan C. Heffner
16 Vasopressors and Inotropes ..................................................................................................................................... 159
Amber Rollstin, John P. Marshall, and William C. Chiu

17 Management after Cardiac Surgery .......................................................................................................................... 167
Justin T. Sambol and LaMont C. Smith
18 Pericardial Diseases .................................................................................................................................................. 181
Joseph R. Shiber
SECTION V

GASTROINTESTINAL AND RENAL DISORDERS

19 Gastrointestinal Bleeding ......................................................................................................................................... 195
Marie-Carmelle Elie-Turenne, Carrie A. Cregar, and Selwena Brewster
20 Acute Liver Failure: How to Orchestrate Emergency Critical Care Interventions ................................................. 207
Thomas H. Kalb and Jennifer A. Frontera
21 Acid–Base Disorders................................................................................................................................................. 221
Kevin M. Jones and William C. Chiu
22 Electrolyte Disorders ................................................................................................................................................ 231
Kevin M. Jones, Samantha L. Wood, and William C. Chiu
23 Acute Renal Failure and Renal Replacement Therapy ........................................................................................... 247
Alex Flaxman and Deborah M. Stein
SECTION VI

NEUROLOGIC AND NEUROSURGICAL DISORDERS

24 Alterations in Mental Status...................................................................................................................................... 261
Nestor D. Tomycz and David W. Crippen
25 Management of Acute Intracranial Hypertension ................................................................................................... 269
Asma Zakaria and Imoigele P. Aisiku


CONTENTS

ix

26 Stroke ........................................................................................................................................................................ 275
Alex M. Barrocas and Beth A. Longenecker
27 Intracranial Hemorrhage .......................................................................................................................................... 285
Alex M. Barrocas and Beth A. Longenecker
28 Traumatic Brain Injury and Spinal Cord Injury ....................................................................................................... 293
Jason A. Ellis, Kiwon Lee, and Dorothea Altschul
SECTION VII

HEMATOLOGIC AND ENDOCRINE DISORDERS

29 Transfusion in Critical Care ...................................................................................................................................... 307
Julie A. Mayglothling and Therese M. Duane
30 Deep Venous Thrombosis ........................................................................................................................................ 315
Amy Tortorich and David R. Gens
31 Hyperglycemic Emergency ...................................................................................................................................... 327
Grace S. Lee and Shyoko Honiden
32 Glucose Management in Critical Care ..................................................................................................................... 333
Ari J. Ciment and Joseph Romero
33 Adrenal Insufficiency................................................................................................................................................ 343
Evie G. Marcolini and William C. Chiu
SECTION VIII

INFECTIOUS DISORDERS

34 Approach to Fever in Critical Care .......................................................................................................................... 349
Marnie E. Rosenthal
35 Principles of Antimicrobial Use in Critical Care...................................................................................................... 359
Anu Osinusi and Manjari Joshi

36 Sepsis and Septic Shock ........................................................................................................................................... 371
David A. Farcy, John Yashou, and Emanuel Rivers
37 Nosocomial and Health Care-Associated Pneumonia ............................................................................................ 383
Michael T. McCurdy
38 Infectious Endocarditis ............................................................................................................................................. 391
Joseph R. Shiber
39 Clostridium Difficile Infection (CDI) ....................................................................................................................... 401
Claudio D. Tuda
SECTION IX

TOXICOLOGIC CONDITIONS

40 Approach to Poisoning ............................................................................................................................................ 409
Mohan Punja and Robert J. Hoffman
41 The Critically Ill Poisoned Patient ........................................................................................................................... 419
Robert J. Hoffman


x

CONTENTS

42 Acetaminophen Overdose ....................................................................................................................................... 435
Seth R. Podolsky
43 Salicylate Overdose .................................................................................................................................................. 447
(Shawn) Xun Zhong and Andrew Stolbach
SECTION X

ULTRASONOGRAPHY IN CRITICAL CARE

44 Point-of-Care Echocardiography in the Emergency Department ........................................................................... 455
Stephen J. Leech, Falk Eike Flach, and L. Connor Nickels
45 Ultrasound-Guided Critical Care Procedures .......................................................................................................... 477
Ashika Jain, Lawrence E. Haines, and Eitan Dickman
SECTION XI

SPECIAL CONSIDERATIONS

46 Classification of Shock ............................................................................................................................................. 493
Tiffany M. Osborn and David A. Farcy
47 Fluid Management .................................................................................................................................................... 507
Alan C. Heffner and Matthew T. Robinson
48 Nutritional Support in Critical Care ......................................................................................................................... 519
Colleen Casey
49 Percutaneous Tracheostomy for the Intensivist ...................................................................................................... 529
Jonathan L. Marinaro, Rajeev P. Misra, and Dan Hale
50 Therapeutic Hypothermia: History, Data, Translation, and Emergency
Department Application ........................................................................................................................................... 541
David F. Gaieski and Munish Goyal
51 Pediatric Considerations ........................................................................................................................................... 549
Fernando L. Soto
52 Transportation of the Critical Care Patient .............................................................................................................. 561
Ira Nemeth and Julio R. Lairet
53 End-of-life Issues in Emergency Critical Care ......................................................................................................... 569
Sangeeta Lamba

Index ...................................................................................................................................................................... 577


CONTRIBUTORS

Imoigele P. Aisiku, MD
Associate Professor
Departments of Neurosurgery and
Emergency Medicine
University of Texas Medical School, Houston
Houston, Texas
Acute Respiratory Failure
Management of Acute Intracranial
Hypertension
Dorothea Altschul, MD
Co-Director Department of Neuroscience
Department of Neuroscience
St. Joseph’s Regional Medical Center
Paterson, New Jersey
Traumatic Brain Injury and Spinal Cord Injury
Alex M. Barrocas, MD
Director of Interventional Neuroradiology/
Endovascular Neurosurgery
Mount Sinai Medical Center
Miami Beach, Florida
Stroke
Intracranial Hemorrhage
Selwena Brewster, MD
Attending
Internal Medicine, Emergency Medicine
St Francis Hospital
Hartford, Connecticut
Gastrointestinal Bleeding
Triminh Bui, DO
Emergency Room Resident

Miami Beach, Florida
Severe Asthma and COPD
Colleen Casey, RD, CNSC, LDN
Senior Nutrition Specialist
Department of Clinical Nutrition
R Adams Cowley Shock Trauma Center
University of Maryland Medical Center
Baltimore, Maryland
Nutritional Support in Critical Care

William C. Chiu, MD, FACS, FCCM
Associate Professor of Surgery
Director, Fellowship Programs in Surgical Critical
Care and Acute Care Surgery
R Adams Cowley Shock Trauma Center
University of Maryland School of Medicine
Baltimore, Maryland
Vasopressors and Inotropes
Acid–Base Disorders
Electrolyte Disorders
Adrenal Insufficiency
Ari J. Ciment, MD, FCCP
Associate Professor
Mount Sinai Medical Center
Pulmonary and Critical Care
Miami Beach, Florida
Glucose Management in Critical Care
Carrie A. Cregar, MD
Clinical Instructor
Department of Emergency Medicine

University Hospitals Case Medical Center
Case Western Reserve University School of Medicine
Cleveland, Ohio
Gastrointestinal Bleeding
David W. Crippen, MD, FCCM
Professor, Department of Critical Care Medicine
University of Pittsburgh Medical Center
Co-Director, Neurovascular ICU
Presbyterian University Hospital
Pittsburgh, Pennsylvania
Alterations in Mental Status
Michael T. Dalley, DO, FAAEM
Associate Residency Director
Department of Emergency Medicine
Mount Sinai Medical Center
Miami Beach, Florida
Severe Asthma and COPD


xii

CONTRIBUTORS

Peter DeBlieux, MD
Professor of Clinical Medicine
Department of Medicine, Sections of Emergency
Medicine and Pulmonary and Critical Care Medicine
LSUHSC
New Orleans, Louisiana
Mechanical Ventilation

Eitan Dickman, MD, RDMS, FACEP
Vice Chair for Academics
Director, Division of Emergency Ultrasonography
Department of Emergency Medicine
Brooklyn, New York
Ultrasound-Guided Critical Care Procedures
Therese M. Duane, MD, FACS, FCCM
Associate Professor
Department of Surgery
Division of Trauma/Critical Care
Virginia Commonwealth University
Richmond, Virginia
Transfusion in Critical Care
Marie-Carmelle Elie-Turenne, MD
Clinical Assistant Professor
Emergency Medicine
Critical Care Medicine
Hospice, Palliative Care
University of Florida
Gainesville, Florida
Gastrointestinal Bleeding
Jason A. Ellis, MD
Resident, Department of Neurological Surgery
Columbia University Medical Center
New York, New York
Traumatic Brain Injury and Spinal Cord Injury
David A. Farcy, MD, FAAEM, FACEP, FCCM
Medical Director of the Surgical Intensivist Program
Director of Emergency Department Critical Care
Mount Sinai Medical Center

Miami Beach, Florida
The Failed Airway
Mechanical Ventilation
Extracorporeal Cardiopulmonary Membrane
Oxygenation
Sepsis and Septic Shock
Classification of Shock
Falk Eike Flach, MD
Clinical Assistant Professor
Department of Emergency Medicine
University of Florida
Gainesville, Florida
Point-of-Care Echocardiography in the Emergency
Department

Alex Flaxman, MD, MSE
Director, Emergency Medicine Critical Care
Emergency and Critical Care Attending
St. Joseph’s Regional Medical Center
Paterson, New Jersey
Attending Intensivist
Pittsburgh Critical Care Associates, Inc
Staff Intensivist
Upper Allegheny Health System
Olean, New York
Weaning and Extubation
Acute Renal Failure and Renal Replacement Therapy
Jennifer A. Frontera, MD
Assistant Professor
Neurosurgery and Neurology

Mount Sinai School of Medicine
New York, New York
Acute Liver Failure: How to Orchestrate Emergency
Critical Care Interventions
David F. Gaieski, MD
Assistant Professor, University of Pennsylvania
School of Medicine
Department of Emergency Medicine
Clinical Director, Center for Resuscitation Science
Philadelphia, Pennsylvania
Therapeutic Hypothermia: History, Data, Translation,
and Emergency Department Application
Megan L. Garcia, MD
Resident Physician, Department of Surgery
University of New Mexico Health Sciences Center
Albuqueruqe, New Mexico
Acute Respiratory Distress Syndrome (ARDS)
David R. Gens, MD, FACS
Associate Professor
Department of Surgery
University of Maryland School of Medicine
Baltimore, Maryland
The Failed Airway
Deep Venous Thrombosis
Munish Goyal, MD, FACEP
Associate Professor
Department of Emergency Medicine
Georgetown University School of Medicine
Washington, District of Columbia
Therapeutic Hypothermia: History, Data, Translation,

and Emergency Department Application


CONTRIBUTORS

Lawrence E. Haines, MD, MPH, RDMS
Emergency Ultrasound Fellowship Director
Department of Emergency Medicine
Maimonides Medical Center
Brooklyn, New York
Ultrasound-Guided Critical Care Procedures
Dan Hale, RRT, RPFT
Neo Natal Pediatric Specialist
Respiratory Specialist
Department of Pulmonary Diagnostics
University of New Mexico Hospital
Albuquerque, New Mexico
Percutaneous Tracheostomy for the Intensivist
Dennis Heard, DO
Emergency Medicine Resident
Mount Sinai Medical Center
Miami, Florida
Mechanical Ventilation
Alan C. Heffner, MD
Director, Medical ICU
Director of ECMO Services
Pulmonary and Critical Care Consultants
Department of Internal Medicine
Department of Emergency Medicine
Carolinas Medical Center

Charlotte, North Carolina
Postcardiac Arrest Management
Fluid Management
Robert J. Hoffman, MD, MS
Associate Professor of Emergency Medicine
Department of Emergency Medicine
Albert Einstein College of Medicine
Bronx, New York
Approach to Poisoning
The Critically Ill Poisoned Patient
Shyoko Honiden, MD, MSc
Assistant Professor
Department of Medicine
Yale University School of Medicine
New Haven, Connecticut
Hyperglycemic Emergency
Ashika Jain, MD
Critical Care Fellow
R Adams Cowley Shock Trauma Center
University of Maryland Medical Center
Baltimore, Maryland
Ultrasound-Guided Critical Care Procedures

xiii

Timothy B. Jang, MD
Assistant Professor of Clinical Medicine
Emergency Medicine
David Geffen School of Medicine at UCLA
Harbor-UCLA Medical Center

Torrance, California
Approach to the Difficult Airway
Kevin M. Jones, MD, MPH
Department of Emergency Medicine
Department of Surgery
Albany Medical College
Albany, New York
Acid–Base Disorders
Electrolyte Disorders
Manjari Joshi, MBBS
Associate Professor of Medicine
Department of Medicine, Division of Infectious
Diseases
University of Maryland Medical Center
R Adams Cowley Shock Trauma Center
Baltimore, Maryland
Principles of Antimicrobial Use in Critical Care
Thomas H. Kalb, MD
Associate Professor
Department of Medicine
Mount Sinai School of Medicine
New York, New York
Acute Liver Failure: How to Orchestrate Emergency
Critical Care Interventions
Julio R. Lairet, DO, FACEP
Assistant Professor of Military and Emergency Medicine
Uniformed Services University of Health Sciences
Air Force Surgeon General Consultant for Critical Care
Air Transport
San Antonio, Texas

Transportation of the Critical Care Patient
Sangeeta Lamba, MD
Assistant Professor
Department of Emergency Medicine and Surgery
UMDNJ-New Jersey Medical School
Newark, New Jersey
End-of-life Issues in Emergency Critical Care
Grace S. Lee, MD
Hospitalist Physician
Yale New Haven Hospital
New Haven, Connecticut
Hyperglycemic Emergency


xiv

CONTRIBUTORS

Kiwon Lee, MD, FACP, FAHA
Assistant Professor of Neurology and Neurosurgery
Columbia University College of Physicians & Surgeons
Department of Neurology
New York-Presbyterian/Columbia University
Medical Center
New York, New York
Traumatic Brain Injury and Spinal Cord Injury
Stephen J. Leech, MD
Ultrasound Director, Graduate Medical Education
Department of Emergency Medicine
Orlando Regional Medical Center

Orlando, Florida
Point-of-Care Echocardiography in the Emergency
Department
Beth A. Longenecker, DO, FACOEP, FACEP
Clinical Associate Professor
Department of Family Medicine
Nova Southeastern University
College of Osteopathic Medicine
Davie, Florida
Program Director Emergency Medicine Residency
Mount Sinai Medical Center
Miami Beach, Florida
Pulmonary Embolism
Stroke
Intracranial Hemorrhage
Evie G. Marcolini, MD
Assistant Professor of Emergency Medicine
and Critical Care
Department of Emergency Medicine
Yale University School of Medicine
New Haven, Connecticut
Adrenal Insufficiency
Jonathan L. Marinaro, MD
Assistant Professor
Department of Surgery
Department of Emergency Medicine
University of New Mexico Health Sciences Center
Albuquerque, New Mexico
Percutaneous Tracheostomy for the Intensivist
John P. Marshall, MD, FACEP

Chair
Department of Emergency Medicine
Maimonides Medical Center
Brooklyn, New York
Acute Coronary Syndrome
Vasopressors and Inotropes

Julie A. Mayglothling, MD, FACEP
Assistant Professor
Department of Emergency Medicine
Department of Surgery, Division of Trauma/Critical Care
Virginia Commonwealth University
Richmond, Virginia
Transfusion in Critical Care
Michael T. McCurdy, MD
Assistant Professor
Department of Internal Medicine, Division of
Pulmonary & Critical Care
Department of Emergency Medicine
University of Maryland School of Medicine
Baltimore, Maryland
Nosocomial and Health Care-Associated Pneumonia
Rajeev P. Misra, DO, MS
General Surgery Resident
Department of Surgery
University of New Mexico Hospital
Albuquerque, New Mexico
Percutaneous Tracheostomy for the Intensivist
Ira Nemeth, MD, FACEP
Assistant Professor

Department of Medicine, Section of Emergency Medicine
Baylor College of Medicine
Houston, Texas
Transportation of the Critical Care Patient
H. Bryant Nguyen, MD, MS
Director, Emergency Critical Care
Associate Professor
Department of Emergency Medicine and Department
of Medicine, Critical Care
Loma Linda University
Loma Linda, California
Hemodynamic and Perfusion Monitoring
L. Connor Nickels, MD, RDMS
Clinical Assistant Professor
Department of Emergency Medicine
University of Florida
Gainesville, Florida
Point-of-Care Echocardiography in the Emergency
Department
Tiffany M. Osborn, MD, MPH, FACEP
Associate Professor
Department of Surgery
Surgical/Trauma Critical Care and Emergency Medicine
University of Washington
Barnes-Jewish Hospital
St. Louis, Mossouri
Classification of Shock


CONTRIBUTORS

Anu Osinusi, MD, MPH
Fellow, Department of Infectious Diseases
University of Maryland
Baltimore, Maryland
Principles of Antimicrobial Use in Critical Care
Christopher M. Perry, MD
Attending Physician
Department of Emergency Medicine
North Shore University Hospital
Manhasset, New York
Hypertensive Crises
Paul L. Petersen, MD, FAAEM
Attending Physician
Department of Emergency Medicine
Mount Sinai Miami Beach
Miami, Florida
Mechanical Ventilation

Emanuel Rivers, MD, MPH
Vice Chairman and Research Director
Department of Emergency Medicine
Attending Staff, Emergency Medicine and
Surgical Critical Care
Henry Ford Hospital
Clinical Professor, Wayne State University
Detroit, Michigan
Sepsis and Septic Shock
Matthew T. Robinson, MD
Assistant Professor of Clinical Emergency Medicine

Department of Emergency Medicine
University of Missouri Hospitals and Clinics
Columbia, Missouri
Fluid Management

Paola G. Pieri, MD, FACS
Associate Medical Director, Trauma Program
Maricopa Medical Center
Phoenix, Arizona
Extracorporeal Cardiopulmonary Membrane
Oxygenation

Amber Rollstin, MD
Assistant Professor of Surgery and
Emergency Medicine
Health Sciences Center to University of
New Mexico Health Sciences Center
Department of Surgery
University of New Mexico
Albuquerque, New Mexico
Vasopressors and Inotropes

Seth R. Podolsky, MD, MS
Attending Physician
Department of Emergency Medicine
Maimonides Medical Center
Brooklyn, New York
Acetaminophen Overdose

Joseph Romero, DO

Internal Medicine Chief Resident
Osteopathic Internal Medicine
Mount Sinai Medical Center
Miami Beach, Florida
Glucose Management in Critical Care

Mohan Punja, MD
Resident, Department of Emergency Medicine
Beth Israel Medical Center
New York, New York
Approach to Poisoning

Jonathan Rose, MD
Residency Program Director
Department of Emergency Medicine
Maimonides Medical Center
Brooklyn, New York
Acute Coronary Syndrome

David Rabinowitz, MS
Medical Student
Osteopathic Medical Program
Nova Southeastern University
Davie, Florida
Extracorporeal Cardiopulmonary Membrane
Oxygenation

Marnie E. Rosenthal, DO, MPH
Director, Infectious Disease Research
Jersey Shore University Medical Center

Department of Internal Medicine, Section
of Infectious Diseases
Neptune City, New Jersey
Clinical Assistant Professor
University of Medicine and Dentistry New Jersey
Robert Wood Johnson Medical School
New Brunswick, New Jersey
Approach to Fever in Critical Care

xv


xvi

CONTRIBUTORS

Rayan A. Rouhizad, DO
Emergency Medicine Physician
Wellstar Kennestone Hospital
Marietta, Georgia
Pulmonary Embolism
Justin T. Sambol, MD
Assistant Professor of Surgery
Chief, Division of Cardiothoracic Surgery
UMDNJ-New Jersey Medical School
Newark, New Jersey
Management after Cardiac Surgery

Isaac Tawil, MD
Assistant Professor

Departments of Surgery and Emergency Medicine
University of New Mexico Health Sciences Center
Albuquerque, New Mexico
Acute Respiratory Distress Syndrome (ARDS)
Nestor D. Tomycz, MD
Senior Neurosurgery Resident
Department of Neurological Surgery
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Alterations in Mental Status

Joseph R. Shiber, MD
Associate Professor
Departments of Emergency Medicine and Critical Care
University of Florida School of Medicine
Jacksonville, Florida
Pericardial Diseases
Infectious Endocarditis

Amy Tortorich, DO
Physician, Emergency Medicine
Cheyenne Regional Medical Center
Cheyenne, Wyoming
Deep Venous Thrombosis

Todd L. Slesinger, MD, FACEP, FCCM
Assistant Professor of Emergency Medicine
Hofstra North Shore-LIJ School of Medicine
Manhasset, New York
Noninvasive Ventilation

Hypertensive Crises

Claudio D. Tuda, MD, FACP
Assistant Professor
Department of Medicine, Infectious Disease Division
Program Director, Internal Medicine
Mount Sinai Medical Center
University of Miami Miller School of Medicine
Miami Beach, Florida
Clostridium difficile infection (CDI)

LaMont C. Smith, MD
Assistant Professor of Medicine
University of Pittsburgh School of Medicine
Division of Pulmonary, Allergy, and Critical
Care Medicine
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania
Management after Cardiac Surgery
Fernando L. Soto, MD
Associate Professor
Emergency Medicine Program
University of Puerto Rico School of Medicine
San Juan, Puerto Rico
Pediatric Considerations
Deborah M. Stein, MD, MPH, FACS, FCCM
Associate Professor
Department of Surgery
University of Maryland School of Medicine
Baltimore, Maryland

Acute Renal Failure and Renal Replacement Therapy
Andrew Stolbach, MD
Assistant Professor
Department of Emergency Medicine
Baltimore, Maryland
Salicylate Overdose

Jason C. Wagner, MD, FACEP
Assistant Professor of Emergency Medicine
Washington University School of Medicine
St. Louis, Missouri
Approach to the Difficult Airway
Elizabeth Lea Walters, MD
Associate Professor
Department of Emergency Medicine
Loma Linda University Medical Center
Loma Linda, California
Hemodynamic and Perfusion Monitoring
Scott D. Weingart, MD, FACEP
Director, Division of Emergency Critical Care
Mount Sinai School of Medicine
New York, New York
The Emergency Department Intensivist
Samantha L. Wood, MD
Fellow
Departments of Emergency Medicine, Internal
Medicine, and Critical Care
University of Maryland Medical Center
Baltimore, Maryland
Electrolyte Disorders

CONTRIBUTORS

Brian J. Wright, MD, MPH
Assistant Professor
Department of Emergency Medicine
Hofstra North Shore-LIJ School of Medicine
Manhasset, New York
Noninvasive Ventilation
John Yashou, DO
Attending Physician, Emergency Department
Memorial West Hospital
Pembroke Pines, Florida
Sepsis and Septic Shock
Dale J. Yeatts, MD
Assistant Professor
Department of Emergency Medicine
University of Maryland School of Medicine
Attending, Surgical Critical Care
R Adams Cowley Shock Trauma Center
Baltimore, Maryland
The Failed Airway

xvii

Asma Zakaria, MD
Assistant Professor
Division of Neurocritical Care
Departments of Neurology and Neurosurgery

University of Texas, Health Science Center at Houston
Houston, Texas
Management of Acute Intracranial Hypertension
(Shawn) Xun Zhong, MD
Director of ED-Critical Care
Department of Emergency Medicine
Nassau University Medical Center
East Meadow, New York
Salicylate Overdose
Qiuping Zhou, DO
Assistant Professor
Hofstra North Shore-LIJ School of Medicine
Associate Program Director
Fellowship in Critical Care Medicine
Department of Emergency Medicine
North Shore LIJ Health System
Manhasset, New York
Hypertensive Crises


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Foreword
Critical care by its very nature is a multidisciplinary
disease. Virtually every critically ill patient requires
input from a multiplicity of practitioners. Physicians
in the ICU provide direct care, and orchestrate and
coordinate care for all other practitioners who participate. Given this complexity, it is interesting to note
critical care has been a recent development. The first

true multidisciplinary ICU was opened in 1958 at the
Baltimore City Hospital, now named Johns Hopkins
Bayview. It was also the first ICU that had 24-hour
physician coverage.
Critical care was rapidly becoming its own discipline, yet lacked efficient organization. In 1970, 28 physicians met in Los Angeles and formed the Society of
Critical Care Medicine. The society’s leaders and first
three presidents were: Peter Safar, an anesthesiologist;
William Shoemaker, a surgeon; and Max Harry Weil, an
internist. Throughout the 1970s, 1980s, and 1990s, these
three disciplines represented the backbone of critical
care in the United States.
As critical care began to develop, emergency medicine also began to develop as a real discipline. In 1961,
Dr James Mills started a full-time emergency medicine
practice in Alexandria, Virginia. The American College
of Emergency Physicians was founded shortly after that,
in 1968. Residency training began at the University of
Cincinnati, followed by the Medical College of Pennsylvania, and then Los Angeles County Hospital. Finally,
in 1979, the American Board of Emergency Medicine
was approved. Other institutions then developed emergency medicine residencies. Today, there are over 150
accredited programs. Fellowship training followed in
subspecialties such as toxicology, pediatrics, and now
critical care.
The link between emergency medicine and critical care seems natural. Both require understanding of
complex physiology. Practitioners in both specialties
must understand a multitude of diseases, synthesize
solutions for complex problems, and do this quickly.
When I founded the Department of Emergency Medicine at SUNY Downstate and Kings County Hospital in 1991, we created a 4-year residency program
that was heavy in critical care. However, I soon realized that emergency physicians who wanted to practice real critical care would need additional training.

Thus, when I became the Physician-in-Chief at the R

Adams Cowley Shock Trauma Center, I established a
critical care fellowship designed for emergency physicians. The University of Pittsburgh had been training
emergency physicians for some time in its multidisciplinary critical care fellowship. There are now over
100 fellowship-trained emergency physician intensivists. Over two thirds of them are trained at either
Shock Trauma or the University of Pittsburgh. Many
graduates practice in major academic centers and now
provide leadership roles in these institutions.
Emergency physician intensivists have become
commonplace in ICUs. This will continue. Emergency
physicians who wish to be leaders will need to be
clinically excellent, academically productive, and superior educators. The current textbook goes a long way
toward establishing emergency physicians as credible
intensivists. While not every chapter is written by an
emergency physician, many are. The authors are emergency physicians who most of us expect to become the
leaders in critical care. The book is unique as it blends
the perspective of a true intensivist with that of emergency medicine. The book is the first of its kind, and I
predict it will become known as the standard reference
for those emergency physicians, as well as others, who
wish to understand the overlap between emergency
medicine and critical care.
Despite the lack of board certification and many
other local political impediments, some emergency physicians have embraced critical care clinically, academically, and now in this textbook. The role of emergency
physicians in critical care remains controversial but the
controversy is not as sharp as it was at the beginning.
Those of us who have been there from the beginning
look forward to the day that there will be no controversy left at all.

Thomas M. Scalea, MD, FACS, FCCM
Physician-in-Chief, R Adams Cowley
Shock Trauma Center

Francis X. Kelly Professor of
Trauma Surgery and Director, Program in Trauma
University of Maryland School of Medicine
Baltimore, Maryland


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preface
It is with great pleasure that we present the first textbook that focuses on the intersection of critical care and
emergency medicine.
For the sickest patients the quality of the interface
between the emergency department and the intensive
care unit can literally mean the difference between life
and death. As we have seen with early goal-directed
therapy and postarrest hypothermia treatment, aggressive care delivered appropriately in the emergency
department has been shown to decrease mortality and
morbidity for critically ill patients.
Additionally, hospital overcrowding, coupled with
hospital closings and an aging patient population, has
resulted in a nearly 60% increase in the number of critical care patients treated in the emergency department.
Increasingly, these patients are boarded for longer
periods in the emergency department presenting the
emergency physician with continuing care challenges
that have been traditionally managed in an intensive
care unit.
This book hopes to address the challenges faced
by emergency medicine physicians practicing critical
care on the front lines of health care on a daily basis.

It is written for emergency physicians who wish to
improve their knowledge base and the quality of
the care they deliver. This text provides a primer on

acute resuscitative care as well as continued critical
care monitoring and management. Most of chapters
are written by an emergency physician with critical
care training or with an abiding interest in critical
care. The majority of chapters are also coauthored
by a fellowship-trained intensivist with a background
in surgery, internal medicine, or emergency medicine. We are very thankful for the time, patience, and
thoughtful work contributed generously by each of
the authors.
Lastly, the editors would like to express their deep
gratitude to the entire staff at McGraw-Hill and in particular to our Executive Medical Editor, Anne M. Sydor,
PhD. Anne’s vision, persistence, patience, and guiding
hand were essential in bringing this book to reality.
It literally would not have been possible without the
editorial resuscitation and critical care she provided so
generously. Thank you.
David A. Farcy, MD, FAAEM, FACEP, FCCM
William C. Chiu, MD, FACS, FCCM
Alex Flaxman, MD, MSE
John P. Marshall, MD, FACEP


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SECTION I

Introduction


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