P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Civetta, Taylor, & Kirby’s
MANUAL OF
CRITICAL CARE
Andrea Gabrielli, MD, FCCM
Mihae Yu, MD, FACS
Professor of Anesthesiology and Surgery
Division of Critical Care Medicine
Section Head, NeuroCritical Care
University of Florida College of Medicine
Medical Director, Cardiopulmonary Service
and Hyperbaric Medicine
Shands Hospital at the University of Florida
Gainesville, Florida
Professor of Surgery
University of Hawaii John A. Burns School of Medicine
Vice Chair of Education
University of Hawaii Surgical Residency Program
Program Director of Surgical Critical Care Fellowship
Program
Director of Surgical Intensive Care
The Queen’s Medical Center
Honolulu, Hawaii
A. Joseph Layon, MD, FACP
Director, Critical Care Medicine
Geisinger Health System
Danville, PA
i
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Acquisitions Editor: Brian Brown
Product Manager: Nicole Dernoski
Production Manager: Bridgett Dougherty
Senior Manufacturing Manager: Benjamin Rivera
Marketing Manager: Angela Panetta
Design Coordinator: Teresa Mallon
Production Service: Aptara, Inc.
© 2012 by LIPPINCOTT WILLIAMS & WILKINS, a WOLTERS KLUWER business
Two Commerce Square
2001 Market Street
Philadelphia, PA 19103 USA
LWW.com
All rights reserved. This book is protected by copyright. No part of this book may be reproduced in
any form by any means, including photocopying, or utilized by any information storage and retrieval
system without written permission from the copyright owner, except for brief quotations embodied
in critical articles and reviews. Materials appearing in this book prepared by individuals as part of
their official duties as U.S. government employees are not covered by the above-mentioned copyright.
Printed in China
Library of Congress Cataloging-in-Publication Data
Gabrielli, Andrea.
Civetta, Taylor, and Kirby’s manual of critical care / Andrea Gabrielli, A. Joseph Layon,
Mihae Yu. – 1st ed.
p. ; cm.
Manual of critical care
Includes bibliographical references and index.
ISBN 978-0-7817-6915-0 (alk. paper)
I. Layon, A. Joseph. II. Yu, Mihae. III. Civetta, Joseph M. IV. Title.
V. Title: Manual of critical care.
[DNLM: 1. Critical Care–Handbooks. 2. Intensive Care Units–Handbooks. WX 39]
616.02 8–dc23
2011035304
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
contents of the publication. Application of the information in a particular situation remains the
professional responsibility of the 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 government regulations, and the
constant flow of information relating to drug therapy and drug reactions, the reader is urged to
check the package insert for each drug for any change in indications and dosage and for added
warnings and precautions. This is particularly important when the recommended agent is a new or
infrequently employed drug.
Some drugs and medical devices presented in the publication have Food and Drug
Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility
of the health care provider to ascertain the FDA status of each drug or device planned for use in their
clinical practice.
To purchase additional copies of this book, call our customer service department at (800) 638-3030
or fax orders to (301) 223-2320. International customers should call (301) 223-2300.
Visit Lippincott Williams & Wilkins on the Internet: at LWW.com. Lippincott Williams & Wilkins
customer service representatives are available from 8:30 am to 6 pm, EST.
10 9 8 7 6 5 4 3 2 1
ii
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
D E D I C AT I O N
To the memory of my father and mother, Pietro and Giuliana:
They would have been proud to see the results of my efforts
—Andrea Gabrielli
To my best friend and partner Susana E. Picado—who makes me better.
To those who, in service to our people, struggle for justice and peace;
Giuliana and Pietro were two.
—A. Joseph Layon
To my dad, General Jae Hung Yu, and the Seventh Division for their sacrifices and
changing history for the better.
To my Mom, the late Esang Yoon who was the wind beneath our wings.
To the late Dr. Thomas J. Whelan Jr. who continues to mentor me in the practice of
Surgery and Code of conduct.
To Joe and Judy Civetta who sparked my continuing love for Critical Care and being the
guiding light for all Peepsters.
And to my late daughter Pearl (and CD) who has the Master Key to All. . .
—Mihae Yu
iii
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
iv
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
■ CONTRIBUTING AUTHORS
The authors would like to gratefully acknowledge the efforts of the contributors of the original chapters in Civetta, Taylor, and
Kirby’s Critical Care, Fourth Edition.
Steven G. Achinger, MD
Maher A. Baz, MD
Gareth Adams, MD
Elizabeth Cordes Behringer, MD
Olufemi Akindipe, MD
Giuseppe Bello, MD
Serge Alfandari, MD, MSc
Rinaldo Bellomo, MBBS, MD, FRACP, FJFICM
Adrian Alvarez, MD
Howard Belzberg, MD, FCCM
Marcelo Amato, MD
Ira M. Bernstein, MD
Giuditta Angelini
Rebecca J. Beyth, MD
Djillali Annane, MD, PhD
Indermeet S. Bhullar, MD
Massimo Antonelli, MD
Luca M. Bigatello, MD
Juan Carlos Ayus, MD, FACP, FASN
Thomas P. Bleck, MD, FCCM
Keri A. Baacke, MD
Ernest F.J. Block, MD, MBA
Sean M. Bagshaw, MD, MSc, FRCPC
Eric L. Bloomfield, MD
Philip S. Barie, MD, MBS, FCCM, FACS
Karen L. Booth, MD
Claudia L. Barthold, MD
Karen Bordson, DO
Robert H. Bartlett, MD
Adrien Bougle, MD
Miho K. Bautista, MD
Philip Boysen, MD
v
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
vi
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Contributing Authors
James E. Calvin, Jr., MD
Clifford S. Deutschman, MS, MD, FCCM
William G. Cance, MD
Karen E. Doucette, MD, MSc
Lawrence J. Caruso, MD
Quan-Yang Duh, MD
Juan C. Cendan, MD
Stephanie H. Dunlap, DO
Cherylee W.J. Chang, MD, FACP
Herbert L. DuPont, MD
Marianne E. Cinat, MD, FACS
Soumitra R. Eachempati, MD, FACS
Cornelius J. Clancy, MD
Rodney K. Edwards, MD, MS
Michael Coburn, MD
Elamin M. Elamin, MD, MSc, FACP, FCCP
Giorgio Conti, MD
Timothy C. Fabian, MD, FACS
Jamie B. Conti, MD, FACC, FHRS
Samir M. Fakhry, MD, FACS
Timothy J. Coons, RRT, MBA
Kevin J. Farrell, MD
Mark S. Cooper, BM, BCh, PhD
Robert J. Feezor, MD
C. Clay Cothren, MD, FACS
Niall D. Ferguson, MD, FRCPC, MSc
Douglas B. Coursin, MD
Sebastian Fernandez-Bussy, MD
Claudia Crimi, MD
Joseph Ferreira, BS, CPTC, CTOP II
Kristina Crothers, MD
Henry E. Fessler, MD
Gohar H. Dar, MD
Jay A. Fishman, MD
Rabih O. Darouiche, MD
Timothy C. Flynn, MD
Elizabeth Lee Daugherty, MD, MPH
Michael A. Frölich, MD, MS
David A. Decker, MD
Brian Fuehrlein, PhD
Leonardo De Luca, MD
Andrea Gabrielli, MD, FCCM
Demetrias Demetriades, MD, PhD, FACS
Robert Peter Gale, MD
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Contributing Authors
George D. Garcia, MD
Charles W. Hoopes, MD
Achille Gaspardone, MD, Mphil
Ramona O. Hopkins, PhD
Dany E. Ghannum, MD
David B. Hoyt, MD, FACS
Lewis R. Goldfrank, MD
Laurence Huang, MD
Shankar P. Gopinath, MD
Thomas S. Huber, MD, PhD
Dietrich Gravenstein, MD
Ahamed H. Idris, MD
J.S. Gravenstein, MD
Steven R. Insler, DO
David M. Greer, MD, MA
Felicia A. Ivascu, MD
Jeffrey S. Groeger, MD
James C. Jackson, PsyD
Jonathan Haft, MD
Sridivya Jaini, MD, MS
Stephen B. Hanauer, MD
Michael A. Jantz, MD, FCCP
Ikram U. Haque, MD
Edgar Jimenez, MD, FCCM
Cathleen Harris, MD
Aaron Joffe, MD
Kevin W. Hatton, MD
Raja Kandaswamy, MD
George Hatzakis, MSc, PhD
Scott R. Karlan, MD
Steven O. Heard, MD
Paraskevi A. Katsaounou, MD
Alan W. Hemming, MD, MSc
Robin D. Kim, MD
Dean R. Hess, PhD, RRT
Craig S. Kitchens, MD
Zoltan G. Hevesi, MD
Charles T. Klodell, MD
Thomas L. Higgins, MD, MBA
Marin H. Kollef, MD
Brian L. Hoh, MD
Meghavi S. Kosboth, DO
M. Barbara Honnebier, MD, PhD
Andreas H. Kramer, MD, FRCPC
vii
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
viii
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Contributing Authors
Anand Kumar, MD
Jerome H. Modell, MD
Aseem Kumar, PhD
Ernest E. Moore, MD
Franco Laghi, MD
Frederick A. Moore, MD, FACS
A. Joseph Layon, MD, FACP
Sharon E. Moran, MD
Marc Leone, MD, PhD
Jan S. Moreb, MD
Olivier Y. Leroy, MD
Alison Morris, MD, MS
David M. Levi, MD
Thomas C. Mort, MD
Lawrence Lottenberg, MD, FACS
David W. Mozingo, MD, FACS
Harrinarine Madhosingh, MD
Susanne Muehlschlegel, MD
Michael E. Mahla, MD
Deane Murfin, MBBCh, DA(SA), FCA(SA)
Patrick T. Mailoux, DO
Michael J. Murray, MD, PhD
Daniel R. Margulies, MD, FACS
Neil A. Mushlin, DO
Paul E. Marik, MD, FCCm, FCCP
Ece A. Mutlu, MD, MBA
Claude Martin, MD
Gökhan M. Mutlu, MD
Larry C. Martin, MD
Bhiken I. Naik, MBBCh(Wits), DA(SA)
Mali Mathru, MD
Minh-Hong Nguyen, MD
S. Anjani D. Mattai, MD
Minh-Ly Nguyen, MD
Kristin L. Mekeel, MD
Jennifer A. Oakes, MD
Richard J. Melker, MD, PhD
Nimisha K. Parekh, MD, MPH
Scott T. Micek, PharmD
Robert I. Parker, MD
William M. Miles, MD
David A. Paulus, MD
Taro Mizutani, MD, PhD
V. Ram Peddi, MD
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Contributing Authors
Kevin Y. Pei, MD
Sherry J. Saxonhouse, MD
Carl W. Peters, MD
Thomas M. Scalea, MD
Frederic M. Pieracci, MD, MPH
Denise Schain, MD
Michael R. Pinsky, MD, CM, Drhc, FCCP, FCCM
Carten M. Schmalfuss, MD
F. Elizabeth Poalillo, RN, MSN, ARNP, CCRN
Eran Segal, MD
Andrew Pollak, MD
Allen M. Seiden, MD, FACS
David T. Porembka, DO, FCCM
Steven A. Seifert, MD, FACMT, FACEP
Raymond O. Powrie, MD, FRCP, FACP
Hani Seoudi, MD
Issam I. Raad, MD
Christoph N. Seubert, MD, PhD
Amin Rahemtulla, PhD, FRCP
David Shade, BA, JD
S. Sujanthy Rajaram, MD
Stephen D. Shafran, MD, FRCPC
H. David Reines, MD
Jack D. Shannon, MD
Zaccaria Ricci, MD
Marc J. Shapiro, MD, MS, FACS, FCCM
Winston T. Richards, MD
Takeru Shimizu, MD, PhD
Claudia S. Robertson, MD
William C. Shoemaker, MD
Steven A. Robicsek, MD, PhD
Marc A. Simon, MD, MS, FACC
Claudio Ronco, MD
Jennifer A. Sipos, MD
Amy F. Rosenberg, PharmD
Lee P. Skrupky, PharmD, BCPS
Stephen J. Roth, MD, MPH
Robert N. Sladen, MBChB, MRCP(UK),
FRCP(C), FCCM
Daniel T. Ruan, MD
Matthew S. Slater, MD
Steven Sandoval, MD
Danny Sleeman, MD, FACS, FRCS
Stephanie A. Savage, MD
Wendy I. Sligl, MD
ix
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
x
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Contributing Authors
Arthur S. Slutsky, MD
Kimi R. Ueda, PharmD
Eric S. Sobel, MD, PhD
Kürsat Uzun, MD
Howard K. Song, MD, PhD
Johannes H. van Oostrom, PhD
Edward D. Staples, MD
Thomas C. Vary, PhD
John K. Stene, MD, PhD
Theordoros Vassilakopoulos, MD
Deborah Stern, MD, MPH
George C. Velmahos, MD, PhD, MSEd
Andrew Stolbach, MD
J. Matthias Walz, MD
R. Todd Stravitz, MD, FACP, FACG
Hsiu-Po Wang, MD
Kathirvel Subramaniam, MD
Michael F. Waters, MD, PhD
Murat Sungur, MD
Carl P. Weiner, MD, MBA, FACOG
David E.R. Sutherland, MD, PhD
Eelco F.M. Wijdicks, MD
Maria Suurna, MD
Robert D. Winfield, MD
Sankar Swaminathan, MD
Charles C.J. Wo, BS
Danny M. Takanashi, Jr., MD, FACS
Linda L. Wong, MD
Christopher D. Tan, PharmD, BCPS
Gregory W. Woo, MD
Jamie Taylor, MD
Kenneth E. Wood, DO
Lisa Thannikary, MD
Jean-Pierre Yared, MD
S. Rob Todd, MD, FACS
Mihae Yu, MD, FACS
Krista L. Turner, MD
Arno L. Zaritsky, MD
Andreas G. Tzakis, MD, PhD
Janice L. Zimmerman, MD
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
■ P R E FA C E
In the Preface to the Fourth Edition of the textbook, we quote
Nikos Kazantzakis’ Report to Greco. Did our attempt succeed?
Early reports suggest yes.
However much we have succeeded, the foundation for this
was laid by Doctors Civetta, Taylor and Kirby—our teachers
and mentors. We truly stand on the shoulders of giants.
We hope you—our readers—will provide us feedback on the
quality of this handbook, as you have the textbook. Our desire
with the Manual was to distill the full textbook into a short,
pithy and readable contribution. We are pretty sure the “short”
part did not work too well; let us know if we have, however,
created something useful for you.
As we noted in the Preface to the textbook, the mistakes of
omission or commission found herein are ours and ours alone.
We three editors share a friendship, have given each other
guidance and moral support, and will share any failures and
successes of our travail.
A. Joseph Layon
()
Danville, Pennsylvania
Andrea Gabrielli
()
Gainesville, Florida
Mihae Yu
()
Honolulu, Hawaii
xi
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
xii
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
■ ACKNOWLEDGMENTS
We thank our colleagues at Lippincott—Nicole Dernoski, Tom Gibbons, and Brian Brown–for
their assistance. Indu Jawwad from Aptara did superb work.
Our families are part of this handbook, to them, we bow in thanks and respect.
Andrea Gabrielli
A. Joseph Layon
Mihae Yu
xiii
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
xiv
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
■ CONTENTS
Contributing Authors
Preface
Acknowledgments
v
xi
xiii
SECTION I ■ EMERGENCY SITUATIONS
CHAPTER 1
Fundamentals of Cardiopulmonary Resuscitation
1
CHAPTER 2
Airway Management
9
CHAPTER 3
Temporary Cardiac Pacemakers
21
CHAPTER 4
Altered Consciousness and Coma in the Intensive Care Unit
27
CHAPTER 5
Bioterrorism
33
SECTION II ■ CARDIOVASCULAR MONITORING: INVASIVE
AND NONINVASIVE
CHAPTER 6
Invasive Pressure Monitoring: General Principles
48
CHAPTER 7
Hemodynamic Monitoring: Arterial and Pulmonary Artery
Catheters
50
CHAPTER 8
Noninvasive Cardiovascular Monitoring
60
CHAPTER 9
Pulse Oximetry and Photoplethysmography
61
CHAPTER 10
Capnography
63
CHAPTER 11
Echocardiography in the ICU
64
SECTION III ■ TECHNIQUES, PROCEDURES, AND TREATMENT
CHAPTER 12
Clean and Aseptic Techniques at the Bedside
65
CHAPTER 13
Vascular Cannulation
66
CHAPTER 14
Feeding Tube Placement
74
CHAPTER 15
Flexible Bronchoscopy
76
CHAPTER 16
Other Important Intensive Care Procedures
83
xv
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
xvi
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Contents
SECTION IV ■ ESSENTIAL PHYSIOLOGIC CONCERNS
CHAPTER 17
Fluids and Electrolytes
CHAPTER 18
Blood Gas Analysis and Acid-Base Disorders
93
103
SECTION V ■ MODULATING THE RESPONSE TO INJURY
CHAPTER 19
The Host Response to Injury and Critical Illness
114
CHAPTER 20
Multiple Organ Dysfunction Syndrome
117
SECTION VI ■ SHOCK STATES
CHAPTER 21
Shock: General
124
CHAPTER 22
Cardiogenic Shock
125
CHAPTER 23
Sepsis and Septic Shock
129
CHAPTER 24
Hypovolemic and Hemorrhagic Shock
136
CHAPTER 25
Neurogenic Shock
141
CHAPTER 26
Anaphylactic Shock
143
SECTION VII ■ PHARMACOLOGY, NUTRITION, TOXICOLOGY,
AND THE ENVIRONMENT
CHAPTER 27
Sedation and Neuromuscular Blockade
144
CHAPTER 28
Nutritional Issues
151
CHAPTER 29
Practical Aspects of Nutritional Support
154
CHAPTER 30
Toxicology
162
CHAPTER 31
Substance Abuse and Withdrawal: Alcohol, Cocaine,
Opioids, and Other Drugs
185
Envenomation
196
CHAPTER 32
SECTION VIII ■ THE SURGICAL PATIENT: PREOPERATIVE, IMMEDIATE
POSTOPERATIVE EVALUATION AND TRAUMA
CHAPTER 33
Perioperative Pulmonary Function Testing and
Consultation
211
CHAPTER 34
Preoperative Evaluation of the High-Risk Surgical Patient
215
CHAPTER 35
Anesthesia: Physiology and Postanesthesia Problems
227
CHAPTER 36
Initial Management of the Trauma Patient
236
CHAPTER 37
Secondary and Tertiary Triage of the Trauma Patient
239
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Contents
CHAPTER 38
Surgical and Postsurgical Bleeding
246
CHAPTER 39
Abdominal Trauma: Nonoperative Management and
Postoperative Considerations
251
CHAPTER 40
Neurologic Injury: Prevention and Initial Care
255
CHAPTER 41
Orthopedic Trauma
262
CHAPTER 42
Facial Trauma
264
CHAPTER 43
Burn Injury: Thermal and Electrical
268
CHAPTER 44
Temperature-Related Injuries
272
CHAPTER 45
Evaluating the Acute Abdomen
279
CHAPTER 46
The Difficult Postoperative Abdomen
285
CHAPTER 47
Critical Care of Hepatopancreatobiliary Surgery Patients
292
CHAPTER 48
Critical Care of The Thoracic Surgical Patient
300
CHAPTER 49
Postoperative Management of the Adult Cardiovascular
Patient
308
CHAPTER 50
Management of the Pediatric Cardiac Surgical Patient
317
CHAPTER 51
Vascular Surgery in the Intensive Care Unit
329
CHAPTER 52
CNS Vascular Disease
334
CHAPTER 53
Urologic Surgery and Trauma
343
SECTION IX ■ ORGAN TRANSPLANTATION
CHAPTER 54
Critical Care and Transplantation: Overview
351
CHAPTER 55
Heart Transplantation
353
CHAPTER 56
Lung Transplantation
358
CHAPTER 57
Liver Transplantation
363
CHAPTER 58
Pancreatic Transplantation
368
CHAPTER 59
Renal Transplantation
371
CHAPTER 60
Critical Care Aspects of Stem Cell Transplantation
377
SECTION X ■ SPECIAL PATIENT POPULATION
CHAPTER 61
The Obstetric Patient: General
383
CHAPTER 62
Cardiac Disease and Hypertensive Disorders in Pregnancy
389
xvii
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
xviii
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Contents
CHAPTER 63
Hemorrhagic and Liver Disorders of Pregnancy
400
CHAPTER 64
Acute Abdomen and Trauma During Pregnancy
404
CHAPTER 65
Fetal Monitoring Concerns
411
CHAPTER 66
The Obese Surgical Patient
416
CHAPTER 67
The Geriatric Patient
426
SECTION XI ■ INFECTIOUS DISEASE
CHAPTER 68
Universal Precautions: Protecting The Practitioner
436
CHAPTER 69
An Approach to the Febrile Intensive Care Unit Patient
444
CHAPTER 70
The Role of Antibiotics in the Management of Serious
Hospital-Acquired Infections
453
CHAPTER 71
Surgical Infections
465
CHAPTER 72
Skin Wounds and Musculoskeletal Infection
482
CHAPTER 73
Neurologic Infections
490
CHAPTER 74
Infections of the Head and Neck
511
CHAPTER 75
Catheter-Related Bloodstream Infections (CRBSI)
520
CHAPTER 76
Respiratory Infections in the ICU
526
CHAPTER 77
Adult Gastrointestinal Infections in the ICU
545
CHAPTER 78
Catheter-Associated Urinary Tract Infections in the ICU:
Implications for Clinical Practice
551
CHAPTER 79
Fungal and Viral Infections
560
CHAPTER 80
Infections in the Immunocompromised Host
582
CHAPTER 81
Human Immunodeficiency Virus in the ICU
592
CHAPTER 82
Unusual Infections
604
SECTION XII ■ CARDIOVASCULAR DISEASE AND DYSFUNCTION
(OTHER CV DISEASE): ACS IN THE ICU
CHAPTER 83
Non-ST Elevation Acute Coronary Syndrome:
Contemporary Management Strategies
615
ST Elevation Myocardial Infarction (STEMI):
Contemporary Management Strategies
624
CHAPTER 85
Evaluation and Management of Heart Failure
638
CHAPTER 86
Cardiac Mechanical Assist Devices
649
CHAPTER 84
13:18
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 29, 2011
Contents
CHAPTER 87
Valvular Heart Disease
656
CHAPTER 88
Cardiac Dysrhythmias
665
CHAPTER 89
Pericardial Disease
679
CHAPTER 90
Acute Hypertension Management in the ICU
689
SECTION XIII ■ RESPIRATORY DISORDERS
CHAPTER 91
Noninvasive Ventilatory Support Modes
698
CHAPTER 92
Invasive Ventilatory Support Modes
703
CHAPTER 93
High-Frequency Ventilation
712
CHAPTER 94
Extracorporeal Circulation for Respiratory or Cardiac
Failure
714
CHAPTER 95
Weaning from Mechanical Ventilation
716
CHAPTER 96
Acute Lung Injury and Acute Respiratory Distress
Syndrome
722
CHAPTER 97
Drowning
729
CHAPTER 98
Severe Asthma Exacerbation
731
CHAPTER 99
Acute Respiratory Failure in Chronic Obstructive
Pulmonary Disease
741
CHAPTER 100
Pulmonary Embolism (PE)
744
CHAPTER 101
Other Embolic Syndromes (Air, Fat, Amniotic Fluid)
753
SECTION XIV ■ NEUROLOGIC DISEASE AND DYSFUNCTION
CHAPTER 102
Elevated Intracranial Pressure
762
CHAPTER 103
Neurologic Monitoring
769
CHAPTER 104
Behavioral Disturbances in the ICU
783
SECTION XV ■ GASTROINTESTINAL (GI) BLEEDING
CHAPTER 105
Upper Gastrointestinal Bleeding
788
CHAPTER 106
Approach to Lower Gastrointestinal Bleeding
794
CHAPTER 107
Liver Failure: Acute and Chronic
801
CHAPTER 108
Pancreatic Disease
813
CHAPTER 109
Inflammatory Bowel Disease and Toxic Megacolon
819
CHAPTER 110
Mesenteric Ischemia
824
xix
19:11
P1:
Trim: 8.375in × 10.875in
LWBK937-FM
xx
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
September 8, 2011
Contents
SECTION XVI ■ RENAL DISEASE AND DYSFUNCTION
CHAPTER 111
Acute Renal Failure (ARF)
831
CHAPTER 112
Renal Replacement Therapies in the Critically Ill Patient
840
SECTION XVII ■ ENDOCRINE DISEASE AND DYSFUNCTION
CHAPTER 113
Endocrinopathy in the Intensive Care Unit
848
CHAPTER 114
Disordered Glucose Metabolism
856
CHAPTER 115
The Adrenal Gland in Critical Illness
863
CHAPTER 116
Pheochromocytoma
867
CHAPTER 117
Thyroid Disease in the Intensive Care Unit
871
SECTION XVIII ■ HEMATOLOGIC AND ONCOLOGIC DISEASE
AND DYSFUNCTION
CHAPTER 118
Coagulation Disorders in the Intensive Care Unit
881
CHAPTER 119
Antithrombotics and Thrombolytic Therapy
895
CHAPTER 120
Transfusion Therapy: When to Use it and How to
Minimize It
909
CHAPTER 121
Hematologic Conditions in the ICU
919
CHAPTER 122
Oncologic Emergencies
933
Appendices: Critical Care Catalog
Index
955
993
19:43
P1:
Trim: 8.375in × 10.875in
LWBK937-01
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
SECTION I
August 27, 2011
■
EMERGENCY SITUATIONS
CHAPTER 1 ■ FUNDAMENTALS OF
CARDIOPULMONARY RESUSCITATION
MAJOR PROBLEMS
sCardiopulmonary resuscitation (CPR) is a series of assessments and interventions performed during a variety of acute
medical and surgical events wherein death is likely without
immediate intervention.
sSudden cardiac arrest (SCA) is a leading cause of adult death
in the United States and Canada.
sCardiac arrest (CA) is defined as “cessation of cardiac
mechanical activity as confirmed by the absence of signs
of circulation.”
❝ In the prehospital arena, CA is most commonly due to
ventricular fibrillation (VF) secondary to ischemic heart
disease.
– Asystole and pulseless electrical activity (PEA) are less
common initial rhythms with SCA, although these
rhythms may represent the initial identified rhythm in
adults who actually experienced an acute VF or ventricular tachycardia (VT) event.
❝ Although VF and VT are considered to be the most common out-of-hospital (OOH) arrest rhythms, only 20%
to 38% of in-hospital arrest patients have VF or VT as
their initial rhythm.
❝ Children and young adults require CPR most commonly for respiratory arrest, airway obstruction, or drug
toxicity.
– VF/VT is identified as the initial rhythm in 5% to 15%
of OOH arrests in children.
❝ Other conditions such as trauma, external or internal
hemorrhage, and drowning may call for resuscitation at
any age.
sImmediate and effective CPR can save lives.
sWith witnessed VF CA, CPR doubles or triples the rate of
survival.
sOnly about 27% of OOH arrest victims receive bystander
CPR.
sThe primary goal of CPR is to generate sufficient oxygen
delivery to the coronary and cerebral circulations to maintain cellular viability while attempting to restore a perfusing
cardiac rhythm by defibrillation, pharmacologic intervention, or both.
IMMEDIATE CONCERNS
sEffective CPR can be performed by following a few basic
rules.
sImmediately assess the environment for danger and move
the patient if necessary. Never assume that an environment
is safe.
sMinimize the time from CA recognition to starting effective
CPR.
sFor every minute without CPR during witnessed VF CA,
survival decreases by 7% to 10%.
sThis is cut in half (3%–4% per minute) when bystander
CPR preceded attempted defibrillation.
sDefibrillate immediately if a defibrillator is rapidly available (less than 3–5 min) in patients with VF.
❝ This is the primary treatment focus within the first few
minutes of SCA due to VF.
– For each minute delay in defibrillation, chances of
eventual hospital discharge decreased by 8% to
10%.
– If the time from arrest to emergency medical service
(EMS) arrival and initiation of CPR is more than
5 minutes, provision of 2 minutes of CPR before defibrillation is associated with improved outcome.
s“Push hard and fast” during chest compressions and minimize the duration of interruptions to reassess the patient’s
rhythm.
sInterrupt chest compressions only briefly, about every
2 minutes, to assess the rhythm, and switch rescuer if feasible.
sWhile CPR is in progress, attempt to identify the cause of
arrest.
sOther resuscitation interventions may be indicated based
on the cause of CA.
sIf no response to standard CPR interventions, think
about delayed recognition and recall the H’s and T’s
(Table 1.1).
sGood teamwork increases the effectiveness of resuscitation
when more than one rescuer is available.
sAttention to postresuscitation care is an important element
of neurologic outcome.
sRestore and support adequate cardiac output and tissue
perfusion.
sMonitor and maintain normal blood glucose concentrations.
sTreat the underlying cause of the arrest.
sMaintain normothermia.
sConsider therapeutic hypothermia to maximize survival
and cerebral recovery.
sIf there is no response to effective CPR, appropriate judgment is needed in determining when to stop resuscitative
efforts.
1
16:8
P1:
Trim: 8.375in × 10.875in
LWBK937-01
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
2
August 27, 2011
Section I: Emergency Situations
TA B L E 1 . 1
POTENTIAL CORRECTABLE PROBLEMS DURING
CARDIAC ARREST: “6 H’S AND 5 T’S”
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/hyperkalemia
Hypoglycemia
Hypothermia
Toxins
Tamponade, cardiac
Tension pneumothorax
Thrombosis, coronary or pulmonary
Trauma
Adapted from 2005 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation. 2005;112[24]SIV-1–IV-211.
OUT-OF-HOSPITAL CARDIAC ARREST
sDespite improvement in the scientific basis for resuscitation
practices and extensive efforts at CPR training of lay and
professional rescuers
sOutcome of most adult victims of out-of-hospital cardiac
arrest (OOHCA) remains poor.
sMedian reported survival to hospital discharge is 6.4%.
sAdults who had a witnessed CA were more likely to arrive
to the hospital alive (39% vs. 31%, p = 0.049) and
were more likely to have a good neurologic outcome after
6 months (35% vs. 25%, p = 0.023) as compared with
patients who had a CA in a nonpublic location.
sIn children, epidemiology and physiology of OOHCA are
different.
sRecent systematic review of 41 OOHCA studies, including
trauma, revealed a restoration of spontaneous circulation
(ROSC) of 30%, with survival to admission of 24% but
survival to discharge of 12% and neurologically intact survival of only 4%.
sInitial cardiac rhythms observed in these children were as
follows:
❝ Asystole, 78%
❝ PEA, 12.8%
❝ VF/pulseless VT, 8.1%
❝ Bradycardia with a pulse, 1%
IN-HOSPITAL CARDIAC ARREST
sObjective survival rates over the years have hardly changed.
sCurrent adult in-hospital cardiac arrest (IHCA) has overall
survival of about 18%.
sAnalysis of data from the national CPR registry found
sPrevalence of VF or pulseless VT as the first documented
pulseless rhythm during IHCA was only 23% in adults
and 14% in children.
sPrevalence of asystole as the initial rhythm was 35% in
adults and 40% in children.
sPrevalence of PEA was 32% versus 24% in adults and
children, respectively.
sSurvival rate to hospital discharge after pulseless CA
sHigher in children than adults (27% vs. 18%, respectively)
sOf these survivors, 65% of children and 73% of adults
had good neurologic outcome.
sAfter adjusting for known predictors, such as arrest location and monitoring at time of arrest, outcome was surprisingly worse when the rhythm was VF/VT in children
compared with asystole and PEA.
❝ Further analysis of these data showed that VF/VT
occurred during CPR in children more commonly than
it occurred as the initial rhythm.
❝ Survival to discharge is highest (35%) when VF/VT is
the initial rhythm compared with survival of 11% if this
rhythm develops during resuscitation.
NEUROLOGIC OUTCOME
sDetermined by the following:
sThe cause of arrest (e.g., degree of shock or hypoxemia prior
to arrest)
sThe duration of no flow, adequacy of flow during CPR
sRestoration of adequate flow after ROSC
sSubsequent injury secondary to postarrest management
such as the occurrence of hyperthermia or hypoglycemia
sSurvivors who ultimately have a good outcome
sGenerally awaken within 3 days after CA
sMost patients who remain neurologically unresponsive due
to anoxic–ischemic encephalopathy for more than 7 days
will fail to survive.
sThose who do survive often have poor neurologic recovery.
❝ Neurocognitive impairment ranges from dependency on
others for care to remaining in a minimally conscious or
vegetative state.
sAchieving good functional outcome is the ultimate goal for
successful CPR.
sThe financial implications of caring for patients with disordered consciousness are substantial.
sMost studies reporting outcome data have used crude
methods to describe neurologic outcome, such as the composite scores from the Glasgow Outcome Scale and Cerebral Performance Category.
❝ An important limitation of these scales is the possibility
of wide variation of neurologic function for the same score.
❝ In children, the Pediatric Cerebral Performance Category
and Pediatric Overall Performance Category have been
used.
s11% to 48% of CA patients admitted to the hospital will
be discharged with good neurologic outcome.
❝ Recent data from the National Registry for Cardiopulmonary Resuscitation (NRCPR) show that neurologic
outcome in discharged adult survivors is generally good,
with 73% of patients with Cerebral Performance Category 1.
INITIAL CONSIDERATIONS
sCPR is primarily based on two principles.
sProviding artificial ventilation and oxygenation through an
unobstructed airway
sCardiac output is limited; avoid ventilation in excess of
that required for adequate ventilation/perfusion matching.
16:8
P1:
Trim: 8.375in × 10.875in
LWBK937-01
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Chapter 1: Fundamentals of Cardiopulmonary Resuscitation
sDelivering chest compressions to maintain threshold blood
flow
sEspecially to the heart and brain, while minimizing interruption of compressions
Basic Life Support
sBasic life support (BLS) is the initial “ABCs” phase of CPR.
sA: airway
sB: breathing
sC: circulation
sEffective BLS can provide almost 30% of normal cardiac output with adequate arterial oxygen content.
sSufficient to protect the brain for minutes until effective
defibrillation or other definitive therapeutic maneuvers are
provided Table 1.2.
Advanced Life Support
sAdvanced life support (ALS) entails the following:
sAdvanced airway management including use of ancillary
equipment to support ventilation and oxygenation
sPrompt recognition and, when appropriate, treatment of
life-threatening arrhythmias using electrical therapy including defibrillation, cardioversion, pacemaker insertion, and
pharmacologic therapy
sInclusion of the use of pharmacologic therapy and advanced
procedures extending into the postarrest setting such as the
use of therapeutic hypothermia
Advanced Airway Management
sTracheal intubation
sEndotracheal intubation (ETI) is indicated if unable to adequately ventilate or oxygenate the arrested or unconscious
patient with bag-mask ventilation or if prolonged ventilation is required and airway protective reflexes are absent in
the patient with a perfusing rhythm
sA properly placed endotracheal tube (ET) is the gold standard method for securing the airway.
sAttempted ETI by less skilled rescuers results in a 6% to
14% incidence of misplaced or displaced ETs.
sConfirmation of correct ET placement
sClinical signs used to confirm correct ET placement
sVisualization of bilateral chest rise
TA B L E 1 . 2
SUMMARY OF BASIC LIFE SUPPORT ABCD MANEUVERS FOR INFANTS, CHILDREN, AND ADULTS FOR LAY
RESCUERS AND HEALTH CARE PROVIDERS (NEWBORN INFORMATION NOT INCLUDED)
Maneuver
Airway
Breathing: Initial
HCPs: Rescue breathing without
chest compressions
HCPs: Rescue breaths for CPR
with advanced airway
Foreign-body airway obstruction
Circulation
HCPs: Pulse check (≤10 s)
Compression landmarks
Adult lay rescuer: ≥ 8 y
HCPs: Adolescent and older
Head tilt–chin lift (HCPs:
Suspected trauma, use
jaw thrust)
Two breaths at 1 sec/breath
10–12 breaths/min
(approximate)
8–10 breaths/min
(approximately)
Abdominal thrusts
Carotid
Child lay rescuers: 1– 8 y
HCPs: 1 y to adolescent
Infant ≤ 1 y of age
Two breaths at 1 sec/breath
12–20 breaths/min (approximate)
Back slaps and chest thrust
Brachial or femoral
Lower half of sternum,
between nipples
Heel of one hand, other
hand on top
Just below nipple line (lower half
of sternum)
Heel of one hand or as for adults
Compression depth
11/2 –2 inches
Approximately one-third to
one-half the depth of the chest
Compression rate
Compression:ventilation ratio
Approximately 100/min
30:2 (one or two rescuers)
Defibrillation AED
Use adult pads
Do not use child pads
Compression method
s Push hard and fast
s Allow complete recoil
3
30:2 (single rescuer)
HCPs: 15:2 (two rescuers)
Use AED after five cycles of CPR
(out of hospital)
Use pediatric system for child 1–8
y if available
HCPs: For sudden collapse (out of
hospital) or in-hospital arrest
use AED as soon as available
Two or three fingers
HCPs (two rescuers):
Two thumb–
encircling hands
No recommendation for
infants <1 y of age
AED, automated external defibrillator; CPR, cardiopulmonary resuscitation.
Note: Maneuvers used by only health care providers are indicated by HCPs. AED, automated external defibrillator; CPR, cardiopulmonary resuscitation.
Adapted from 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.
2005;112[24]SIV-1–IV-211.
16:8
P1:
Trim: 8.375in × 10.875in
LWBK937-01
4
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Section I: Emergency Situations
sBilateral breath sounds over the lateral lung fields
sAbsent breath sounds over the epigastrium
sPresence of water vapor/mist in the tube
sNone of these signs is confirmatory, and an ETCO2 detector
or esophageal detector is indicated to confirm correct tube
placement.
sETCO2 detector device is a disposable colorimetric device
that detects ETCO2 has been investigated as a guide to
correct ET placement.
❝ The device fits on the end of the ET and is normally
purple; exhaled CO2 turns the color to bright yellow,
indicating that the ET is in the trachea.
❝ The positive predictive value of this device for correct
tube placement is close to 100%, but the negative predictive value ranges from 20% to 100% depending on
whether the patient has a perfusing rhythm.
– False-negative results are seen if there is no or very low
pulmonary blood flow, such as during CA or with a
large pulmonary embolus.
– False-positive (i.e., the detector remains yellow) results
are seen when it is contaminated with an acidic drug
(e.g., epinephrine) or gastric contents.
sEsophageal detector device comes in two versions: the bulb
and the syringe esophageal detector devices (EDD).
❝ Bulb EDD consists of a bulb that is compressed and
attached to the ET. When released, if the tube is in the
esophagus, the suction collapses the lumen of the esophagus or pulls the esophageal tissue against the tip of the
tube, and the bulb will not re-expand (positive result for
esophageal placement).
❝ Syringe EDD consists of a syringe attached to the ET; the
rescuer attempts to pull the plunger of the syringe. If the
tube is in the esophagus, it will not be possible to pull
out the plunger (i.e., aspirate air) with the syringe.
– This device has high sensitivity for esophageal placement of ETs in both CA and patients with a
perfusing rhythm but poor specificity for tracheal
placement.
Electrical Therapy
sOne of the mainstays of ALS, especially in adults
sElectrical energy is used to treat life-threatening cardiac dysrhythmias.
sConstitute 16% to 85% of OOH and 14% to 56% of
in-hospital CAs
❝ Recent data suggest that VF and VT are decreasing, with
only 24% of the initial rhythms in more than 36,000
adult arrests being VF- or VT-based in a recent analysis
from the NRCPR.
❝ In hospitalized children with CA, VF is the initial rhythm
in approximately 10% of cases and subsequently occurs
during 15% of the cases.
sDefibrillation
sDefined as delivery of electrical energy resulting in termination of VF for at least 5 seconds after the shock
sThe goal is to quickly depolarize the entire myocardium,
terminating the rhythm and hoping that a sinus rhythm will
start.
sDefibrillator device
sManual defibrillator devices require the rescuer to analyze the rhythm and then manually set and determine the
electrical energy dose.
sAutomatic defibrillator devices analyze the rhythm, determine whether a shock is required, and deliver the shock if
needed automatically.
❝ Two types of automatic defibrillators: internal implantable cardioverter defibrillator and automated external
defibrillator (AED)
sDefibrillators are also characterized by the mode and
waveform of electrical current delivered into monophasic
and biphasic defibrillators.
❝ Animal and human data show that biphasic defibrillators have a higher first-shock success in terminating VF
compared with monophasic devices.
sDefibrillation dose
sOptimal initial energy dose for the first shock \ required
for effective defibrillation remains unknown despite multiple studies.
❝ Reasonable to use selected energies of 150 J to 200 J with
a biphasic truncated exponential waveform or 120 J with
a rectilinear biphasic waveform for the initial shock
❝ For second and subsequent biphasic shocks, the same or
higher energy can be given.
– Most manual defibrillators are set to an initial default
of 200 J of energy.
❝ If only a monophasic defibrillator is available, an energy
dose of 360 J is recommended for all shocks.
sThe optimal dose for effective defibrillation in infants and
children
❝ Not known
❝ Upper limit for safe defibrillation also not known
– Doses more than 4 J/kg (as high as 9 J/kg) have effectively defibrillated children.
– Recommended manual defibrillation (monophasic or
biphasic) doses for children are 2 J/kg for the first
attempt and 4 J/kg for subsequent attempts.
sElectrode position
sEither handheld paddles or self-adhesive pads are used for
shocks.
sElectrodes are applied to the bare chest in the conventional
sternal–apical (anterolateral) position.
❝ The right (sternal) chest pad is placed on the victim’s
right superior–anterior (infraclavicular) chest, and the
apical (left) pad is placed on the victim’s inferior–lateral
left chest, lateral to the left breast.
sElectrode size
sThe largest pad or paddle that can be placed on the chest
while avoiding contact between the pads or paddles should
be used. There should be at least 1 inch between the
pads.
sPaddles that are too small increase the risk of skin burn
injury.
sElectrical cardioversion
sUsed for some life-threatening arrhythmias causing rapid
cardiovascular deterioration
sIncluding VT and supraventricular tachycardias (SVTs)
such as paroxysmal atrial tachycardia, atrial flutter, or
atrial fibrillation with a rapid ventricular response
sThe technique, unlike defibrillation, must be synchronized
with the patient’s electrocardiogram.
sDelivery of the energy during the T wave of the QRS may
result in VF.
sEnergy level
sThe amount of energy recommended for emergency cardioversion varies with the rhythm.
16:8
P1:
Trim: 8.375in × 10.875in
LWBK937-01
Top: 0.375 in
Gutter: 0.75 in
LWBK937-Gabrielli-v1
August 27, 2011
Chapter 1: Fundamentals of Cardiopulmonary Resuscitation
5
❝ 100 J is recommended for atrial fibrillation and 50 J for
sHalf-life of 10 to 20 minutes compared to the 3 to 5 minutes
atrial flutter.
❝ Monomorphic VT responds well to cardioversion, and
100 J should be attempted first.
❝ Pulseless VT behaves like VF, and 200 J should be used
initially.
❝ In conscious patients, sedation with intravenous
diazepam, midazolam, or methohexital is indicated, and
the cardioversion is accomplished with the lowest energy
possible (50–200 J).
❝ In children, the recommended initial cardioversion dose
is 0.5 to 1 J/kg.
sExternal cardiac pacing
sExternal (transcutaneous) pacing is not recommended for
patients in asystolic CA, but it should be always considered
in the ICU or other critical care areas of the hospital where
the device and adequate skill are promptly available.
sPacing can be considered in patients with symptomatic
bradycardia when a pulse is present.
observed with epinephrine
sSodium bicarbonate
sMetabolic and respiratory acidosis develops during CA
resulting from anaerobic metabolism, leading to lactic acid
generation and inadequate ventilation along with reduced
blood flow during CPR, which leads to inadequate pulmonary delivery of carbon dioxide for elimination.
sUntreated acidosis suppresses spontaneous cardiac activity, decreases the electrical threshold required for the
onset of VF, decreases ventricular contractile force, and
decreases cardiac responsiveness to catecholamine such as
epinephrine.
sElevated PCO2 tension probably is more detrimental to
myocardial function and catecholamine responsiveness
than metabolic acidosis.
sIf arterial blood gas and pH measurements not available:
sRecommended initial dose of sodium bicarbonate is
1 mEq/kg intravenously.
sHalf of this dose may be repeated at 10-minute intervals.
sIn pediatric patients, the 1 mEq/kg dose should be diluted
1:1 with sterile water to reduce the osmolality.
sAtropine
sUsed in sinus bradycardia when accompanied by hypotension or frequent premature ventricular contractions (PVCs)
secondary to unsuppressed ectopic electrical activity arising
in the area of injured tissue during the prolonged period
after repolarization
sSinus bradycardia after myocardial infarction may predispose the heart to the onset of VF.
sWhen profound bradycardia is present, acceleration of the
heart rate above 60 bpm may improve cardiac output and
reduce the incidence of VF.
sDosage of atropine for severe symptomatic bradycardia is
0.5 to 1.0 mg intravenously repeated every 3 to 5 minutes
until the desired pulse rate is obtained or a maximum of
0.04 mg/kg has been given.
sA larger dose has little therapeutic value, and a smaller
dose may actually slow the heart rate.
sEndotracheal dose is 2 to 2.5 mg.
sLidocaine
sDecreases ectopic electrical myocardial activity by raising
the electrical stimulation threshold of the ventricle during
diastole
sIn ischemic myocardial tissue after infarction, it may suppress re-entrant arrhythmias such as VT or VF.
sThe 2005 guidelines recommend lidocaine only when
amiodarone is not available.
sLidocaine may be used in stable monomorphic VT and
polymorphic VT with normal or prolonged QT interval if
ventricular function is not decreased.
sLoading dose of lidocaine is approximately 1 to 1.5 mg/kg
given as an IV bolus.
sIf needed, repeat 0.5 to 0.75 mg/kg every 5 to 10 minutes,
up to a total of 3 mg/kg.
sFollowed by a continuous infusion of 30 to 50 μg/kg/
minute (1–4 mg/min in a 70-kg patient)
sToxicity may occur in oliguric or anuric patients because
renally excreted lidocaine degradation products also have
pharmacologic effects and toxic potential.
sEarly signs of lidocaine toxicity are due to central nervous system effects and include anxiety, loquacity, tremors,
metallic taste, and tinnitus.
Pharmacologic Therapy
sUsed in CA to increase the rate of ROSC and terminate or
limit the risk of recurrent arrhythmias
sRoute of administration for resuscitation medications
sA central venous line may not be available at the time of the
arrest and immediate placement is not necessary to ensure
survival.
sPeripheral IV access can be used effectively with the advantage of not interrupting CPR.
❝ Rapidly follow the medication bolus with a 10- to 20-mL
fluid bolus to ensure central delivery.
❝ Intraosseous cannulation is an effective alternate for
drug delivery.
❝ Instillation can be made through an ET, if available.
Lipid-soluble medications that can be delivered via ET
are lidocaine, epinephrine, atropine, naloxone, and vasopressin.
❝ Recommended to administer at least 2 to 21/2 times the
IV recommended doses.
sEpinephrine
sThe most commonly used medication during CPR
sPrimary action in CA is to increase the coronary perfusion
pressure through systemic vasoconstriction mediated by its
α-adrenergic effects. The β-adrenergic effects are relatively
unimportant.
sEpinephrine is used primarily during CA due to asystole
and PEA.
sA second-line agent used for shock-refractory VF or pulseless VT
sLittle pharmacologic data supporting the currently recommended dose of 1 mg of epinephrine in adult CA and
0.01 mg/kg in children
sVasopressin
sAn endogenous antidiuretic hormone that, when given at
high doses, causes vasoconstriction by directly stimulating
vascular smooth-muscle V1 receptors.
sImproves coronary perfusion pressure but, unlike epinephrine, offers theoretical advantages of cerebral vasodilation, possibly improving cerebral perfusion.
sLack of β 1 -adrenergic activity potentially avoids unnecessary increases of myocardial oxygen consumption, resulting in postresuscitation arrhythmias.
16:8