Preface
Contents
Contributors
Part I: ER- ICU Shock and Resuscitation
1: Cardiac Arrest Management
Introduction
Case Presentation
Principles of Management
Standard Approach to Resuscitation
Introduction
Recognition of Sudden Cardiac Arrest
Chest Compressions
Adjuncts to CPR: Oxygen and Ventilation
Defibrillation
Search for Precipitating Cause of Cardiac Arrest
Ventricular Dysrhythmias
Pulseless Electrical Activity (PEA)
Quality Assurance
Evidence Contour
Are Outcomes with Mechanical Compressions Superior to Manual Compressions During Active CPR?
What Physiologic Parameters Can Guide the Administration of Vasoactive Medications and Provide Feedback Regarding Quality of CPR?
Hemodynamic Directed Resuscitation
References
2: Post-cardiac Arrest Management
Introduction
Case Presentation
Principles of Management
Overview of Post-cardiac Arrest Syndrome
Post Cardiac Arrest Brain Injury
Post-cardiac Arrest Myocardial Dysfunction
Systemic Ischemia/Reperfusion Response
Persistent Precipitating Pathology
Hemodynamic Optimization
Ventilation and Oxygenation
Management of STEMI and ACS
Hypothermic Targeted Temperature Management
Glucose Control
Seizure Management
Neuroprognostication
Organ Donation
Evidence Contour
Patient Selection for Emergency Coronary Angiography
Patient Selection for Hypothermic TTM
Optimizing Hypothermic TTM
Mechanical Support for Refractory Post-cardiac Arrest Cardiogenic Shock
References
3: Undifferentiated Shock
Case Presentation
Standard Approach to Undifferentiated Shock
Shock Types
Evidence Contour
Assessment of Volume Responsiveness
Bedside Echocardiography
Summary
References
4: Hypovolemic Shock and Massive Transfusion
Case Presentation
Principles of Management
Hypovolemic Shock
Establish Adequate IV Access
Consider Physiologic Reserve
Monitor Volume Responsiveness
Administer the Appropriate Fluid(s)
Track Endpoints of Resuscitation
Hemorrhagic Shock
Expedite Anatomic Control of Bleeding
Utilize Damage Control Surgery
Allow for Permissive Hypotension
Correct and Reverse Augmenting Factors of Coagulopathy and Shock
Minimize Crystalloid Administration
Preserve Formed Clot with Antifibrinolytics
Replace Losses via Transfusion Therapy
Evidence Contour
Hypovolemic Shock
Normal Saline vs Balanced Solutions
Role of Albumin
Use and Timing of Pressors
Hemorrhagic Shock
Massive Transfusion Protocol
Ionized Calcium Repletion
Point-of-Care Monitoring the Hemostatic System
Invasive Non-surgical Hemorrhage Control
Timing and Role of Vasopressors
Hemostatic Resuscitation with Concurrent Head Injury
References
5: Acute Respiratory Failure: NIV Implementation and Intubation
Case Presentation
Principles of Management
Definition
Indications, Contraindications and Settings
Predictors of Failure of Non-invasive Ventilation
Evidence Contour
Use in Patients with Pneumonia
Use in Patients with Asthma Exacerbation
Use in Patients with ARDS
Use of NIV in Patients with Altered Mental Status
Use of NIV for Preoxygenation Prior to Intubation
Use of NIV to Facilitate Weaning from Invasive Ventilation
Palliative Care Indications
Use of High-Flow Nasal Cannula as an Alternative to NIV
References
6: Diagnosis and Management of Tricyclic Antidepressant Ingestion
Introduction
Case Presentation
Principles of Management
Diagnosis
Gastrointestinal Decontamination
Plasma Alkalinization
Management of Hypotension and Vasopressor Support
Extracorporeal Elimination
Seizure Management
Evidence Contour
Intravenous Lipid Emulsion
Hypertonic Saline
Antiarrhythmic Drugs
References
7: Management of Calcium Channel Blocker Poisoning
Introduction
Case Presentation
Principles of Management
Gastrointestinal Decontamination
Hemodynamic Support
Calcium Salts
Glucagon
Atropine
Vasopressor Support
High-Dose Insulin Therapy
Invasive Circulatory Support
Evidence Contour
Intravenous Lipid Emulsions
Sodium Bicarbonate
Methylene Blue
Extracorporeal Albumin Dialysis
References
8: Diagnosis and Management of Ethylene Glycol Ingestion
Case Presentation
Principles of Management
Diagnosis
Ventilator and Circulatory Support
Gastric Decontamination/Lavage/Charcoal
Aldehyde Dehydrogenase (ADH) Blockade
Hemodialysis
Evidence Contour
Ethylene Glycol Treatment Threshold
Fomepizole vs Ethanol
ADH Inhibition without Hemodialysis
Serum and Urine Alkalization
Cofactor Supplementation
Other Toxic Alcohols
Methanol
Isopropyl Alcohol
References
9: Accidental Hypothermia
Case Presentation
Principles of Management
Diagnosis
Patient Monitoring
Adjunctive Testing
Rewarming
Hypothermia Without a Pulse
Other Supportive Care
Disposition
Pediatric Patients
Evidence Contour
Withholding CPR
Degree of Rewarming in Cardiac Arrest
Timing of Extracorporeal Support
Selection of Extracorporeal Support
Transcutaneous Pacing
Endovascular Rewarming
Core Afterdrop
References
Part II: Cardiac Disease
10: Management of Cardiogenic Shock
Case Presentation
Principles of Management
Diagnosis
Early Revascularization
Vasopressors/Inotropes
Percutaneous Mechanical Circulatory Support
Intra-Aortic Balloon Pump
ImpellaŸ 2.5, CP, and 5.0
TandemHeartÂź
Venoarterial Extracorporeal Membrane Oxygenation (v-a ECMO)
Temporary Surgical Mechanical Circulatory Support
Evidence Contour
Multivessel Revascularization
Mechanical Circulatory Support
References
11: Management of Acute Heart Failure
Case Presentation
Principles of Management
Diagnosis
Diuretic Therapy
Intravenous Vasodilators
Emergent Mechanical Circulatory Support
Evidence Contour
Pulmonary Artery (PA) Catheters
Inotropic Agents
Diuretic Dosing â Intermittent Versus Continuous
Ultrafiltration
Nesiritide
Renal-Dose Dopamine
References
12: Management of Acute Coronary Syndrome
Case Presentation
Principles of Management
Diagnosis
Initial Assessment and Early Risk Stratification
Initial Medical Therapy
Anti-ischemic Therapy
Anti-thrombotic Therapy
Antiplatelet Therapy
Early Reperfusion and Revascularization
STEMI
NSTE-ACS
Evidence Contour
Routine Early PCI After Successful Thrombolysis in STEMI
Culprit Only vs Complete Revascularization in STEMI
Manual Thrombectomy During Primary PCI in STEMI
Ezetimibe in Acute Coronary Syndromes
Optimal Duration of Dual Antiplatelet Therapy (DAPT)
References
13: Complications of Myocardial Infarction
Case Presentation
Standard Approach to Management
Epidemiology
Diagnosis
Management of LV Failure
Management of Mechanical Complications
Evidence Contour
Timing of Surgery in Ventricular Septal Rupture
Percutaneous Closure of VSR
Intra-aortic Balloon Pump
References
14: Management of Cardiac Tamponade
Case Presentation
Principles of Management
Hemodynamic Derangements
Clinical Findings
Non-invasive Diagnostic Testing
Invasive Diagnostic Testing
Closed Pericardiocentesis
Surgical Drainage
Evidence Contour
Effusive-Constrictive Pericarditis
References
15: Hypertensive Crises
Case Presentation
Principles of Management
Diagnosis
Treatment of Hypertensive Crises
Pharmacotherapy (Table 15.1)
Evaluation for Secondary Causes of Hypertension
Evidence Contour
Specific Subsets of Patients with Hypertensive Crisis May Warrant Specific Treatment Approaches
References
16: Atrial Fibrillation and Other Supraventricular Tachycardias
Case Presentation
Principles of Management
Diagnosis
Physiologic Effects
Treatment Strategies
Rate Control
Rhythm Control
Stroke Prevention
Other Supraventricular Tachycardias (SVT)
Evidence Contour
High Bleeding Risk in Post-operative Cardiac Surgery Patients
Concurrent Inotropic Support
Rhythm Control in HFrEF
References
17: Ventricular Arrhythmias
Case Presentation
Principles of Management
Diagnosis
Classification of VT
Monitoring and Testing
General Measures
Beta Blockers
Amiodarone
Lidocaine
Digoxin Immune Fab
Evidence Contour
Anti-arrhythmic Drug Therapy
Mechanical Circulatory Support â IABP
Advanced Mechanical Circulatory Support â ECMO
Radiofrequency Catheter Ablation
Transcoronary Ethanol Ablation
Cardiac Sympathetic Denervation
References
18: Management of Acute Aortic Syndromes
Case Presentation
Principles of Management
Definition
Diagnosis
Medical Management
Surgical Intervention
Complications
Evidence Contour
Diagnosis of Aortic Dissection
Medical Management of Type A Dissection
Surgical Intervention for Aortic Arch Dissections
References
19: Management of Endocarditis
Case Presentation
Principles of Management
Epidemiology
Diagnosis
Antimicrobial Therapy
Indications for Surgery
Follow-Up Evaluation
Evidence Contour
Timing of Non-emergent Surgery in IE
Neuroimaging in IE
Timing of Surgery in IE with Septic Cerebral Embolic Strokes
Valve Repair Versus Valve Replacement
Cardiac Device Related IE
References
Part III: Respiratory Disease
20: Community Acquired Pneumonia
Case Presentation
Principles of Management
Site-of-Care Decisions
Diagnostic Testing
Microbial Culprits
Empirical Versus Pathogen-Directed Therapy
Parapneumonic Effusions
Evidence Contour
Risk of Multidrug Resistant (MDR) Pathogens
Drugs to Suppress Toxin with MRSA
Procalcitonin
Corticosteroids
References
21: Management of Acute Respiratory Distress Syndrome
Case Presentation
Principles of Management
Risk Factors for ARDS and Diagnosis
Berlin Definition of ARDS
Lung Protective Ventilation
Open Lung Ventilation
Prone Ventilation
Fluid Management
Supportive Care
Evidence Contour
Additional Risk Factors
Subgroups and Subphenotypes
Helmet Ventilation
Transpulmonary Pressure
Pressure Limited Mechanical Ventilation
Neuromuscular Blockade
High Frequency Oscillatory Ventilation (HFOV)
Extra Corporeal Membrane Oxygenation (ECMO)
Corticosteroids
Inhaled Vasodilators
References
22: Acute Exacerbation of COPD: Non-Âinvasive Positive Pressure Ventilation
Case Presentation
Principals of Management
Diagnosis
Bronchodilators
Systemic Corticosteroids
Antibiotics
Non-invasive Positive Pressure Ventilation (NIPPV)
Evidence Contour
NIPPV Use in Individuals with Do-Not-Intubate Orders
NIPPV After Extubation
References
23: Management of Status Asthmaticus
Case Presentation
Principles of Management
Inhaled Bronchodilators
Corticosteroids
Monitoring of Arterial Blood Gases
Ventilator Strategies
Permissive Hypercapnia/Hypoventilation
Monitoring for Hyperinflation
Recognizing Barotrauma
Evidence Contour
Adjuvant Pharmacologic Treatments
Magnesium
Intravenous Bronchodilators
Lactic Acidosis from Beta Agonist
Heliox
Noninvasive Positive Pressure Ventilation (NIV)
Anesthetics
Bronchoscopy
Extracorporeal Life Support (ECLS)
References
24: Immunocompromised Pneumonia
Case Presentation
Principles of Management
Presentation
Etiology
Diagnosis
Empiric Treatment
Supportive Care
Evidence Contour
Utility of Invasive Testing
Serum Indices of Infection
Noninvasive Ventilation
References
25: Venous Thromboembolism in the Intensive Care Unit
Case Presentation
Case Scenario
Standard Approach to Diagnosis and Management
Risk Factors
Epidemiology of VTE in the ICU
Clinical Presentation
Pulmonary Embolism Severity
Diagnosis
Treatment
Evidence Contour
Reperfusion Therapy in Patients with Hemodynamically Stable Pulmonary Embolism
IVC Filter Placement
Direct Factor Xa and Thrombin Inhibitors
References
26: Massive Hemoptysis
Case Presentation
Principles of Management
Epidemiology
Sources of Hemorrhage
Diseases Associated with Massive Hemoptysis
Imaging
An Approach to Managing Life Threatening Hemoptysis (Algorithm, Fig. 26.4)
Assessment
Evidence Contour
Rigid Versus Flexible Bronchoscopy
Dual Lumen Versus Unilateral Airway Intubation: Benefits and Limitations
One Transport or Two?
Recurrent Bleeding; Repeat Embolization or Surgery?
References
27: Sedation and Delirium
Case Presentation
Principles of Management
Monitoring Sedation and Delirium
Minimizing Sedation
Risk Factors for Delirium
Evidence Contour
Sedative Choice
Spontaneous Awakening Trials (SATs)
Sedative-Related Delirium
Prevention of Delirium
Antipsychotics
Delirium and Long-Term Outcomes
References
28: Prolonged Mechanical Ventilation
Case Presentation
Principles of Management
Diagnosis
Assess Expected Survival
Place Tracheostomy
Daily Tracheostomy Collar Trials
Early Mobility
Speaking Valve Trials
Tracheostomy Removal
Evidence Contour
Timing of Tracheostomy
Benefit of Transfer to LTAC
Survivorship Clinics and Symptom Burden
References
29: Ventilator-Associated Pneumonia and Other Complications
Case Presentation
Principles of Management
Rapid Identification and Empiric Treatment of VAP Is Essential
Treat Patients with VAP Broadly for Multidrug Resistant Organisms
Duration of Therapy â 8 or 15 Days
Rapidly De-Escalate Antimicrobial Therapy
Clinicians Should Remain Vigilant for Other Causes of Fever in the ICU
Evidence Contour
Invasive Versus Noninvasive Sampling Strategies
Effective Treatment Strategies for MRSA VAP
Utility of ATS/IDSA Recommendations for Dual Gram-Negative Coverage
Evolving Surveillance Definitions
New and Old Strategies to Prevent VAP
References
30: Respiratory Failure in a Patient with Idiopathic Pulmonary Fibrosis
Case Presentation
Principles of Management
Incidence and Prognosis
Corticosteroids
Supportive Care
Palliative Care
Ensure Correct Diagnosis
Exacerbation During Surgical Procedures
Evidence Contour
Noninvasive Ventilation
High Flow Nasal Cannula
Ventilator Settings
Anticoagulation
Cyclophosphamide
Cyclosporin A
Restrictive Operative Fluid Balance
Pulmonary Transplantation
Extracorporeal Life Support
Anti-fibrotic Medications
References
31: Weaning from Mechanical Ventilation
Case Presentation
Principles of Management
Strategies to Minimize the Requirement for Mechanical Ventilation
Strategies to Reduce the Duration of Mechanical Ventilation
Evaluation of Patientâs Readiness for Spontaneous Breathing
Perform a Spontaneous Breathing Trial in Patients Deemed Ready
Assess Patientâs Ability to Protect the Airway
Evidence Contour
Assessing the Need for an Artificial Airway
Weaning Protocols
Sample Ventilator Liberation Pathway
Diaphragmatic Ultrasound as an Index for Discontinuation of Mechanical Ventilation
Pressure Support Versus T-Tube for Weaning from Mechanical Ventilation
Tracheostomy for Prolonged Transition
References
32: The Post-intensive Care Syndrome
Case Presentation
Principles of Management
Diagnosis
Prevention and Rehabilitation
Components of the ABCDEF Bundle
Evidence Contour
ICU Follow Up Clinic
Cognitive Rehabilitation
References
33: Management of Decompensated Right Ventricular Failure in the Intensive Care Unit
Case Presentation
Principles of Management
Diagnosis
Monitoring of End-Organ Perfusion
Optimization of Right-Sided Filling Pressures
Reversal of Conditions that Heighten Pulmonary Vascular Tone
Ventilation Strategy
Supportive Care
Evidence Contour
Pulmonary Artery Catheter Use in Decompensated RV Failure
Choice of Vasopressor
Selective Use of Inotropic Agents
Use of Selective Pulmonary Vasodilators
Ventilatory Considerations in the Face of ARDS
Extra Corporeal Membrane Oxygenation (ECMO)
References
34: Diffuse Alveolar Hemorrhage
Case Presentation
Principles of Management
Differential Diagnosis
Classification
Diagnosis
Treatment
Evidence Contour
Rituximab
Recombinant Factor VII
References
Part IV: Neurologic Disease
35: Acute Stroke Emergency Management
Case Presentation
Principles of Management
Diagnosis
Acute Stroke Management, tPA Administration
Acute Stroke Management, Endovascular Thrombectomy
Supportive Care
Atrial Fibrillation, Heart Failure and Anticoagulation
Secondary Stroke Prevention in the Acute Stroke Setting
Evidence Contour
âWake-Upâ Strokes
Acute Cerebral Artery Dissection, Antiplatelets Versus Anticoagulation
Blood Pressure Management in Acute Stroke Patients
Hemicraniectomy in Patients Older than 60 Years Old with Large Hemispheric Stroke
Early Rehabilitation in Stroke Patients
Basilar Artery Thrombosis, Therapy After 4.5 Hours
Endovascular Therapy Without IV tPA, After 4.5 Hours
Stenting in Acute Stroke Therapy
Dual Anti-platelet Therapy, Aspirin plus Clopidogrel for Secondary Stroke Prevention
References
36: Bacterial Meningitis in the ICU
Case Presentation
Principles of Management
Epidemiology
Diagnosis
Antibiotics
Steroids
Long Term Neurologic Complications
Meningococcemia
Evidence Contour
ICP Management
Hypothermia
Gram-Negative Bacilli Meningitis
Shunts and Other Intracranial Devices
Post Exposure Prophylaxis
References
37: Management of Intracerebral Hemorrhage
Case Presentation
Principles of Management
Clinical Presentation
Diagnosis
Acute Management
Natural History
Complications
Evidence Contour
Hyperosmolar Therapy
Seizure Prophylaxis
Hypothermia
Hypertension Management
References
38: Status Epilepticus
Case Presentation
Principles of Management
Diagnosis of SE and Underlying Etiology
Pharmacologic Therapy of SE
Refractory SE (RSE)
Medical Management of SE
Multidisciplinary Care
Evidence Contour
Goals of Treatment
Non-convulsive Status Epilepticus (NCSE)
Other Treatment Options in SE
References
39: Neuroleptic Malignant Syndrome
Introduction
Case Presentation
Principles of Management
Diagnosis
Medication History and Temporal Clues
The Clinical Tetrad of NMS: Clues to Diagnosis and Management Concerns
Hyperthermia
Altered Mental Status
Muscular Rigidity
Autonomic Dysfunction
Evidence Contour
Benzodiazepines
Dantrolene
Bromocriptine
Amantadine
Electroconvulsive Therapy
References
40: Traumatic Brain Injury
Case Presentation
Principles of Management
Primary and Secondary Brain Injury
Severity of Traumatic Brain Injury
Prehospital and Emergency Department
Mechanical Ventilation
Analgesia, Sedation and Neuromuscular Paralysis
Surgical Treatment
Epidural Hematoma
Subdural Hematoma
Intraparenchymal Hematoma/Traumatic Cerebral Contusion
Evidence Contour
Indication of Intracranial Pressure Monitoring and Pressure Threshold
Post-traumatic Seizures
Therapeutic Hypothermia
Advanced Neuromonitoring
Brain Tissue Oxygen (PbtO2)
Cerebral Microdialysis
Jugular Bulb Oximetry
Prophylactic Antibiotics
Steroids and Neuroprotective Agents
References
41: Management of Anoxic Brain Injury
Case Presentation
Principles of Management
Diagnosis
Therapeutic Hypothermia
Maintenance of Normothermia
Supportive Care
Evidence Contour
Therapeutic Hypothermia
Rewarming and Maintenance of Normothermia
Neurologic Prognostication
References
Part V: Renal Disease
42: Traditional and Novel Tools for Diagnosis of Acute Kidney Injury
Case Presentation
Principles of Management
Serum Creatinine and Urine Output
Relationship Between Serum Creatinine and Urine Output
Differentiating Between AKI and CKD
Clinical Use of Novel Biomarkers
Evidence Contour
Determining Baseline Serum Creatinine
Imaging Techniques for Diagnosis of AKI
Emerging Role for Novel Biomarkers
References
43: Management of Acute Kidney Injury
Case Presentation
Principles of Management
Intravenous Fluids and Vasopressors
Consider Alternative Etiologies and Specific Treatments for AKI
Prevention of Further Injury
Diuretics
Medical Management of Complications of AKI
Renal Replacement Therapy
Evidence Contour
Choice of Intravenous Fluid Solution
Nutrition in AKI
Tight Glycemic Control
Vasodilators and Growth Factor Interventions
Early Initiation of Dialysis
References
44: Rhabdomyolysis
Case Presentation
Principles of Management
Diagnosis
Fluid Therapy
Treating Reversible Causes of Muscle Damage
Management of Complications
Evidence Contour
Bicarbonate Therapy
Diuretics and Mannitol
Antioxidants and Free Radical Scavengers
RRT for Prevention of Acute Kidney Injury
References
45: Hyponatremia
Case Presentation
Principles of Management
ABCD Followed by Diagnosis
Bolus Therapy
Avoidance of Overcorrection
Mechanisms Behind the Hyponatremia/Lasting Correction
Hyponatremia with Reduced ECV/Sodium
Hyponatremia with Increased Extracellular Volume/Sodium
Hyponatremia Despite Suppressed ADH
Syndrome of Inappropriate Antidiuretic Hormone
Adrenal Deficiency
Evidence Contour
Rate of Correction/Risk of Osmotic Demyelination
Acute Versus Chronic Hyponatremia
Hyponatremia and Association with Mortality?
References
Part VI: Endocrine Disease
46: Management of Severe Hyponatremia and SIADH
Case Presentation
Principles of Management
Risk Stratification
Evaluation
Correcting Serum Sodium
Monitoring Correction Rate
Osmotic Demyelination Syndrome (ODS)
Evidence Contour
Diagnostics
Novel Treatments
Osmotic Demyelination Syndrome
Outcomes
Prevention
References
47: Diabetic Ketoacidosis
Case Presentation
Principles of Management
Diagnosis
Fluid Replacement
Insulin
Electrolyte Repletion
Treatment of Precipitating Condition
Complications
Evidence Contour
Bicarbonate Infusion
Site of Care
Form of Insulin Administered
Euglycemic DKA
References
48: Thyroid Storm
Case Presentation
Principles of Management
Incidence
Etiology
Presentation
Diagnosis
Treatment
Beta-Blockers
Thionamides
Iodine Containing Solutions
Glucocorticoids
Patients Unable to Take a Thionamide
Evidence Contour
Diagnostic Clinical Tools
Iodinated Radiocontrast Agents
Extracorporeal Plasmapheresis
L-Carnitine
References
49: Adrenal Insufficiency
Case Presentation
Principles of Management
Presentation of Adrenal Insufficiency
Absolute Versus Relative Adrenal Insufficiency and Critical-Illness Related Corticosteroid Insufficiency (CIRCI)
Interpretation of Test Results in Critically Ill Patients
Measurement of Serum Cortisol
ACTH Stimulation Test
Interpretation of Random Cortisol and ACTH Stimulation Testing
Steroid Replacement Strategies
Choice of Steroid
Dose and Duration
Concurrent Fluid Management
Additional Testing
Evidence Contour
Steroid Replacement in Septic Shock
ACTH Stimulation Test: Low Dose Versus High Dose
Role of Salivary Cortisol Testing
Role of Etomidate and Opiates in Development of Adrenal Insufficiency
References
50: Management of Hyperglycemic Hyperosmolar Syndrome
Case Presentation
Principles of Management
Diagnosis of HHS
Fluid Therapy
Insulin Therapy
Correcting Electrolytes
Sodium
Potassium
Magnesium
Phosphate
Evidence Contour
Type of IV Fluid
Anticoagulation
References
51: Management of Myxedema Coma
Case Presentation
Principles of Management
Diagnosis
Thyroxine Replacement
Corticosteroid Replacement
Supportive Care
Evidence Contour
References
Part VII: Infectious Disease
52: Urosepsis
Case Presentation
Principles of Management
Diagnosis
Empiric Antimicrobial Administration
Procedures/Surgery
Evidence Contour
Empiric Anitbiotic Choice
Indications for Imaging
Intervention Method
References
53: Management of Sepsis and Septic Shock
Case Presentation
Principles of Management
Definition and Recognition
Surviving Sepsis Campaign Sepsis Bundle
Fluid Management
Hemodynamic Response
Tissue Perfusion
Vasopressors
Treatment of Infection and Antimicrobial Stewardship
Ventilator Management
Glycemic Control and Nutrition
Evidence Contour
Early Goal Directed Therapy (EGDT)
Corticosteroids
SIRS Criteria in Sepsis
Blood Pressure Target in Septic Shock
Fluid Resuscitation in Septic Shock
Bicarbonate Infusion in Lactic Acidosis
Heart Rate Control in Septic Shock
Sequella After Surviving Severe Sepsis/Septic Shock
References
54: Invasive Aspergillus
Case Presentation
Principles of Management
Diagnostic Approach
Risk Factors for Invasive Aspergillosis
Classic Risk Factors
Newer Risk Factors
Therapy
Antifungal Therapy
Monotherapy
Combination Therapy
Antifungal Resistance
Evidence Contour
References
55: Management of Strongyloides Hyperinfection Syndrome
Case Presentation
Principles of Management
Epidemiology
Life Cycle
Disseminated Infection and Hyperinfection
Diagnosis
Anti-parasitics
Supportive Care and Follow Up
Evidence Contour
Severe Infections
Hyperinfection Associated with Paralytic Ileus
References
56: Treatment of Viral Hemorrhagic Fever in a Well-Resourced Environment
Case Presentation
Principles of Management
Isolation and Infection Control
Active Screening
Isolation Unit
Protective Equipment
Protocols and Policies
Specimen Collection and Handling
Decontamination
Waste Management
Provisions of Clinical Care
Team Structure
Monitoring
Bedside Assessments
Diagnostic Testing
Blood Analysis
Imaging
Invasive Procedures
Central Venous Catheter(CVC) Placement
Threshold for Placement
Location of Placement
Sterile Precautions
Endotracheal Intubation
Threshold for Intubation
Modality
Emergency Response Teams
Diagnostic Evaluation
Establishing the Likelihood of EVD
Identifying Alternative or Concomitant Diagnoses
Specific Testing for EVD
Supportive Therapy
Fluid and Electrolytes
Mechanical Ventilation
Renal Replacement Therapy
Nutrition
Evidence Contour
Targeted Therapy
Ethical Considerations
Staffing Model
Provisions of Care
References
57: Management of Severe Malaria
Case Presentation
Principles of Management in Severe Falciparum Malaria
Definition of Severe Malaria
Diagnosis
Clinical Management
General Principles
Antimalarial Therapy (See Treatment Table 57.4)
Monitoring Parasite Density
Respiratory System
Neurologic Involvement
Seizure Management
Anemia and Coagulopathy
Blood Products
Hypoglycemia
Volume Management
Nutrition
Fever
Bacterial Infection
Evidence Contour
Other Diagnostic Modalities
Quantitative Buffy Coat
Antigen Rapid Detection Test (RDT)
Serology
Molecular Methods
Exchange Transfusion
References
58: Dengue
Case Presentation
Principles of Management
Phases of Illness and Diagnosis
Supportive Treatment
Evidence Contour
Volume Replacement
Other Aspects of Care
References
59: Chikungunya
Case Presentation
Principles of Management
Diagnosis
Volume Management
Evidence Contour
Epidemiology
Treatment
References
60: Leptospirosis
Case Presentation
Principles of Management
Epidemiology
Microbiology
Clinical Presentation
Laboratory Presentation
Differential Diagnosis
Antibiotic Administration
Evidence Contour
Diagnostic Tools
Reference Standard
Serology
Molecular Tests
Culture
Drug Resistance
Role of Corticosteroids
Prevention
References
Part VIII: Gastrointestinal Disease
61: Management of Acute Upper Gastrointestinal Hemorrhage
Case Presentation
Principles of Management
Diagnosis
Risk Stratification
Blood Transfusion
Post-endoscopic Intensive Proton Pump Inhibitor Therapy
Evidence Contour
Nasogastric Lavage
Optimal Dosing of Post-endoscopic Proton Pump Inhibitor Therapy
Pre-endoscopic Proton Pump Inhibitor Therapy
Salvage Therapy
Reversal of Coagulopathy and Thrombocytopenia
Reversal of Warfarin
Reversal of Newer Oral Anticoagulants
References
62: Variceal Hemorrhage
Case Presentation
Principles of Management
Initial Resuscitation
Vasoactive Medications
Hemostasis Interventions
Transjugular Intrahepatic Portosystemic Shunt
Antibiotic Prophylaxis
Evidence Contour
Red Blood Cell Transfusion
Correction of Coagulopathy
Endotracheal Intubation
Acid Suppression
Balloon Tamponade
Transjugular Intrahepatic Portosystemic Shunt
Balloon-Occluded Retrograde Transvenous Obliteration
Surgery
References
63: Acute Pancreatitis
Case Presentation
Principles of Management
Disease Burden, Diagnosis, and Assessment of Severity
Intravenous Fluids
Antibiotics
Pain Control
Etiology
Evidence Contour
Early Nutritional Support
References
64: Management of Acute Liver Failure
Case Presentation
Principles of Management
Etiology of ALF
Correction of Coagulopathy
Hemodynamic Support
Renal Insufficiency
Infection
Neurologic Complications
Evidence Contour
Recombinant Factor VIIa to Correct Coagulopathy
Serial NH3 Levels in ALF Patients
Targeted Temperature Management
Bioartificial Hepatic Support Systems
Criteria for Liver Transplantation
References
65: Acute Lower Gastrointestinal Bleeding
Case Presentation
Principles of Management
Definitions
Initial Evaluation
Initial Resuscitation and Management
Appropriate Patient Disposition
Nasogastric Tube Lavage
Urgent Colonoscopy
Mesenteric Angiography
Surgery
Evidence Contour
Predicting Severity and Outcomes of LGIB
Blood Transfusion Goals
Massive Transfusions
Diagnostic Imaging Modalities
Provocation Testing
References
66: Diagnosis and Management of Clostridium Difficile Infection (CDI)
Case Presentation
Principles of Management
Symptoms of C. Difficile Infection
Diagnosis
Risk Factors
Severity of Disease
Medical Therapies
Surgical Intervention
Epidemiology and Infection Control
Evidence Contour
Fecal Microbiota Transplant
Capsulized Frozen Fecal Microbiota
Probiotics
Monoclonal Antibodies and Vaccines
Nontoxogenic C. Difficile Spores
Investigational Antibiotics
References
67: Principles of Nutrition in the Critically Ill Patient
Case Presentation
Principles of Nutrition
If the Gut Works, Use It
Full Feedings are Preferred; Trophic Feedings May Be Acceptable
Immunologic Benefits of Enteric Feedings
Do Not Use Increased Gastric Residuals or Decreased Bowel Sounds as Markers upon Which to Hold Feedings
Evidence Contour
The CALORIES Trial Did Not Reliably Support PN due to Study Design
Actual Caloric Goals Remain an Area of Ongoing Research
Actual Micronutrient Goals Are Not Clear
No Recommendations Can Be Made for or Against Specific Lipid Choices in Tube Feeds
Obese Patients Should Be Treated Like Normal or Underweight Patients
References
68: Spontaneous Bacterial Peritonitis
Case Presentation
Principles of Management
Diagnosis
Microbiologic Etiology
Treatment
Antibiotics
Albumin
Discontinue Nonselective Beta Blockers (NSBB)
Prophylaxis
Antibiotic Prophylaxis
Evidence Contour
Duration of Therapy
Choice of Antibiotics
Patient with Non-neutrocytic Bacterascites
References
69: ICU Management of the Patient with Alcoholic Liver Disease
Case Presentation
Principles of Management
Classification of Alcoholic Liver Disease
Prognosis in Alcoholic Hepatitis
ICU Management of Alcohol Use Disorders, Including Alcohol Withdrawal Syndrome (AWS) and Delirium Tremens (DTs)
Nutritional and Micronutrient Supplementation
Upper GI Bleeding in Patients with Alcoholic Liver Disease
Medical Management of Acute Alcoholic Hepatitis
Management of Hepatorenal Syndrome
Evidence Contour
Optimal Medications for Alcohol Withdrawal Syndrome
Intubation for EGD
References
Part IX: Hematologic Disease
70: Diagnosis and Management of Thrombotic Thrombocytopenic Purpura
Case Presentation
Principles of Management
Diagnosis of Thrombotic Thrombocytopenic Purpura
ADAMTS13 Activity Level and Autoantibody Testing
Therapeutic Plasma Exchange
Fresh Frozen Plasma (FFP)
Immunosuppressive Agents
Drug-Induced Thrombotic Microangiopathy
Venous Thromboembolism Prophylaxis
Evidence Contour
Prevention of Relapses with Other Immunosuppressive Agents
Anti-platelet Agents
Duration and Intensity of TPE
Amount of FFP
References
71: Acute Leukemia Presentation with DIC
Case Presentation
Principles of Management
Confirm the Diagnosis of AML
Make the Correct Diagnosis of DIC
Differential Diagnosis of DIC
Laboratory Profile of DIC
Treat the Underlying Disease
Supportive Care/Blood Product Transfusion for DIC
Evidence Contour
Heparin
Anti-thrombin III
Recombinant Factor VIIa
References
72: Disseminated Intravascular Coagulation
Case Presentation
Principles of Management
Diagnosis
Treatment of the Underlying Disorder
Management of Acute Coagulopathy in Hemorrhaging Patients
Thrombotic Predominant DIC and Purpura Fulminans
Evidence Contour
Heparin Therapy
Thrombomodulin-α
Antithrombin III (ATIII)
References
73: Hemophagocytic Lymphohistiocytosis
Case Presentation
Presentation
Diagnosis
Treatment
Evidence Contour
Prognosis
Biomarker Testing
References
74: ICU Complications of Hematopoietic Stem Cell Transplantation Including Graft Versus Host Disease
Case Presentation
Principles of Management
Impact of Graft-Versus-Host Disease on the Critically Ill HCT Patient
Pulmonary Complications in the GVHD Patient
Recovery âPhasesâ Post-HCT
Common Infectious Complications of Phase 1
Common Non-Infectious Phase 1 Pulmonary Complications of HCT
Common Infectious and Non-Infectious Pulmonary Complications in Phase 2
Phase 3 Pulmonary Complications Post HCT
Evaluation of Respiratory Failure
Evidence Contour
When to Withhold or Withdraw Life Support
References
75: Tumor Lysis Syndrome
Case Presentation
Principles of Management
There Are Laboratory and Clinical Classifications of Tumor Lysis Syndrome (TLS)
Risk Stratification for Development of Clinical TLS Is Complex, but Useful
Treatment Prephase with Low Intensity Chemotherapy May Prevent TLS in High-Risk Patients
Hydration Is Essential to Prevention and Treatment of TLS
Hypouricemic Agents Are Essential to the Prevention and Treatment of TLS
Close Monitoring Is Essential in TLS
Prevention of Cardiac Arrhythmias
Acute Renal Failure Requiring Renal Replacement Therapy May Develop Despite Best Practice
Evidence Contour
Use of IV Diuretics in Addition to IV Hydration Has Conflicting Clinical Outcomes
There Is Unclear Utility of Phosphate Binders in TLS with AKI
Choice of Renal Replacement Therapy Has Variable Outcomes
References
76: Management of Hyperviscosity Syndromes
Case Presentation
Principles of Management
Pathophysiology
Diagnosis
Management
Evidence Contour
How to Measure Viscosity
Lack of Procedural Standardization
Efficacy of Leukapheresis in AML
References
Part X: Surgical
77: Thoracic Trauma
Case Presentation
Principles of Management
Pneumothorax
Hemothorax
Rib Fractures
Lung Contusion
Evidence Contour
Pneumothorax
Hemothorax
Rib Fractures
Lung Contusion
References
78: Blunt Abdominal Trauma
Case Presentation
Principles of Management
Unstable Versus Stable Blunt Abdominal Trauma
Balanced Resuscitation
Imaging and Diagnosis
Nonoperative Management (NOM) of Blunt Solid Organ Injury
Angioembolization for Blunt Solid Organ Injury
Post-splenectomy Vaccinations
Evidence Contour
Who Should Be Managed Nonoperatively?
How Should Nonoperative Management Be Accomplished?
Is Follow-Up Imaging Necessary?
When Should We Initiate Venous Thromboembolism (VTE) Prophylaxis in Solid Organ Injury Patients?
References
79: Abdominal Sepsis and Complicated Intraabdominal Infections
Case Presentation
Principles of Management
Diagnosis
Resuscitation
Source Control
Anti-Infective Therapy
Evidence Contour
Laparoscopic Peritoneal Lavage
Minimally Invasive Approaches to Infected Pancreatic Necrosis
Procalcitonin
References
80: Intestinal Obstruction: Small and Large Bowel
Case Presentation
Standard Approach to Management
Evidence Contour
Timing of Operating for SBO
Management Differences Between Small and Large Bowel Obstruction
Management of Acute Small Bowel Obstruction in a Patient with No Prior Abdominal Surgery or Pathology
CT Imaging Findings Indicative of a Need for Exploration
References
81: Management of Acute Compartment Syndrome
Case Presentation
Principles of Management
Diagnosis
Abdomen
Extremity
Decompression
Abdomen
Extremity
Wound Management
Abdomen
Extremity
Evidence Contour
Abdomen
Abdominal Perfusion Pressure
Fluid Management
Percutaneous Drainage
Extremity
Infared Spectroscopy
Dermotraction
References
82: Extracorporeal Membrane Oxygenation (ECMO) and Extracorporeal CO2 Removal (ECCO2R)
Case Presentation
Principles of Management
ECMO Indications
ECMO Contraindications
Initial ECMO Management
Weaning Off of ECMO
Post-ECMO Considerations
Extracorporeal CO2 Removal (ECCO2R)
Evidence Contour
ECMO
Prolonged ECMO
ECMO Trial Data
ECMO Outcome Prediction
References
83: Management of Acute Thermal Injury
Case Presentation
Principles of Management
Diagnosis
Wound Care
Surgical Intervention
Fluid Management
Parkland Formula
Supportive Care
Evidence Contour
Fluid Resuscitation Monitoring
Scar Management
References
84: Acute Arterial Ischemia
Case Presentation
Principles of Management
Initial Evaluation
Diagnostic Imaging
Intervention and Post-operative Management
Evidence Contour
Controversial Aspects of Management/Imaging
Endovascular Treatment Approach to Lower Extremity Vascular Trauma
References
85: Management of Necrotizing Soft Tissue Infection
Case Presentation
Principles of Management
Rapid Diagnosis
Empiric Broad Spectrum Antibiotic Therapy and Resuscitation
Surgical Source Control
Evidence Contour
Predicting NSTI Diagnosis and Outcome
Early Amputation
Adjunctive Therapies
Immunomodulatory Therapy
Hyperbaric Oxygen
References
86: Biliary Infections
Case Presentation
Principles of Management
Diagnosis
Severity Assessment
Medical Management
Surgical and/or Interventional Management
Evidence Contour
Diagnostic Studies
Duration of Antibiotics
Type and Timing of Intervention
References
Part XI: Critical Care in Obstetrics
87: Peripartum Cardiomyopathy
Case Presentation
Principles of Management
Diagnosis
Standard Medical Therapy for Heart Failure
Chronic Medical Therapy
Anticoagulation
Implantable Cardioverter Defibrillator
Mechanical Support
Delivery
Postpartum Supportive Care
Evidence Contour
Immunotherapy and Anti-Âinflammatory Mediators
References
88: Management of Amniotic Fluid Embolism
Case Presentation
Pathophysiology
Principles of Management
Diagnosis
Management
Initial Assessment
Oxygenation
Hemodynamic Support
Delivery of Fetus
Evidence Contour
Diagnosis
Adjunctive Therapies
References
89: Respiratory Diseases of Pregnancy
Case Presentation
Principles of Management
Physiologic Respiratory Changes Seen in Pregnancy
Pulmonary Edema
Airway Disease
Obstructive Sleep Apnea in Pregnancy
Pulmonary Infections in Pregnancy
Viral Pneumonia
Bacterial Pneumonia
Neuromuscular Diseases and Central Causes
Pneumothorax in Pregnancy
Pulmonary Embolism in Pregnancy
Cystic Fibrosis
Evidence Contour
Ventilation Strategies in the Pregnant Patient
Challenges
Goals of Ventilation
Non-invasive Ventilation
Mechanical Ventilation
Extra Corporeal Membrane Oxygenation (ECMO)
Prone Ventilation
Delivery
References
90: Preeclampsia, Eclampsia and HELLP Syndrome
Case Presentation
Principles of Management
Diagnosis
Seizure Prophylaxis
Treatment of Eclamptic Seizure
Antenatal Steroids and Delivery
Anti-hypertensive Therapy
Treatment of DIC
Evidence Contour
Magnesium Sulfate Therapy
Invasive Monitoring
Dexamethasone Therapy in HELLP Syndrome
Differentiation from Acute Fatty Liver of Pregnancy (AFLP)
References
Part XII: Other Conditions
91: Management of Severe Skin Eruptions
Case Presentation
Pathogenesis
Principles of Management
Supportive Care
Evidence Contour
Systemic Corticosteroids
Intravenous Immunoglobulins (IVIG)
Cyclosporine
TNF Alpha Inhibitors
Thalidomide
Summary
References
92: Management of Alcohol Withdrawal Syndromes
Case Presentation
Principles of Management
Diagnosis
Initial Phase of Care
Evidence Contour
Patient Disposition
Propofol
Phenobarbital
Central Alpha 2 Agonists
Antipsychotics
Anticonvulsants
Other Agents
References
Part XIII: Medical Ethics
93: End of Life Care in the ICU
Case Presentation
Principles of Management
Making Decisions in the ICU
Prognostication
What Constitutes Good End of Life Care?
Evidence Contour
Code Status and the ICU Patient
Background
Problems with DNR
Who Should Make Decisions About Life Support?
Going Forward with Life-Sustaining Treatment Decisions
Futility and Requests for Inappropriate Treatments
Defining Futility
References
Index