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Evidence Based Critical Care A Case Study Approach - 2nd Edition Reference Book Download

The document is the second edition of 'Evidence-Based Critical Care: A Case Study Approach,' edited by Robert C. Hyzy and Jakob McSparron, focusing on realistic clinical problems in critical care medicine. It features a unique structure with case studies followed by expert insights, emphasizing evidence-based practices and areas of uncertainty in critical care. The book serves as a valuable resource for healthcare providers at all levels and is useful for board examination preparation.
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© © All Rights Reserved
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100% found this document useful (8 votes)
159 views17 pages

Evidence Based Critical Care A Case Study Approach - 2nd Edition Reference Book Download

The document is the second edition of 'Evidence-Based Critical Care: A Case Study Approach,' edited by Robert C. Hyzy and Jakob McSparron, focusing on realistic clinical problems in critical care medicine. It features a unique structure with case studies followed by expert insights, emphasizing evidence-based practices and areas of uncertainty in critical care. The book serves as a valuable resource for healthcare providers at all levels and is useful for board examination preparation.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Evidence Based Critical Care A Case Study Approach - 2nd

Edition

Visit the link below to download the full version of this book:

https://medipdf.com/product/evidence-based-critical-care-a-case-study-approach-2
nd-edition/

Click Download Now


Editors
Robert C. Hyzy Jakob McSparron
Division of Pulmonary and Critical Care Division of Pulmonary and Critical Care
University of Michigan University of Michigan
Ann Arbor, MI Ann Arbor, MI
USA USA

ISBN 978-3-030-26709-4    ISBN 978-3-030-26710-0 (eBook)


https://doi.org/10.1007/978-3-030-26710-0

© Springer Nature Switzerland AG 2017, 2020


All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights
of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other
physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by
similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
For Silka, Katie, and Marnie
Robert C. Hyzy

For Allie, Maia, and Shai


Jakob McSparron
Preface

We are very pleased to present this second edition of Evidence-Based Critical Care: A Case
Study Approach. We believe that effective learning takes place when individuals challenge
themselves and work through realistic clinical problems. This textbook capitalizes on this
active approach by beginning each chapter with a real case from the authors’ clinical practice.
At the conclusion of each case, a question is asked to allow the reader to reflect on clinical
management before reading the answer and consolidating knowledge from experts in the field.
We feel strongly that the current practice of critical care medicine requires a deep knowl-
edge of existing evidence. However, our knowledge of the field is continuously evolving, and
there are many gaps in the existing literature as well as areas of controversy despite existing
research in the area. To highlight this balance, the chapters contain two distinct sections: the
“Principles of Management” section and the “Evidence Contour” section. The “Principles of
Management” section focuses on the standard practice of diagnosis and management within
critical care with an emphasis on evidence-based care when available. The “Evidence Contour”
section highlights areas of uncertainty and active debate in the literature. This strategy allows
the reader to understand the strength of evidence underlying our current approach to diagnosis
and management within critical care medicine.
This unique approach will benefit critical care providers at all stages in their careers, from
junior trainees to seasoned providers. The spectrum of topics covered in this text also makes
this book a useful tool for board examination preparation.
We would like to thank the many providers who purchased the first version of this textbook.
We would also like to thank our many friends and colleagues who contributed to this book. The
section editors and authors have contributed their time and expertise to create a valuable
resource for practicing clinicians who seek to provide the best care possible to critically ill
patients. We would also like to thank the editors and staff at Springer for their guidance and
support in completing this project.

Ann Arbor, MI, USA Robert C. Hyzy


Ann Arbor, MI, USA Jakob McSparron

vii
Contents

Part I ER-ICU Shock and Resuscitation

1 Cardiac Arrest Management�����������������������������������������������������������������������������������   3


Nathan L. Haas and Robert W. Neumar
2 Post-cardiac Arrest Management ���������������������������������������������������������������������������   9
Cindy H. Hsu and Robert W. Neumar
3 Undifferentiated Shock��������������������������������������������������������������������������������������������� 21
Russell G. Day and Sage P. Whitmore
4 Hypovolemic Shock and Massive Transfusion������������������������������������������������������� 33
Nathan L. Haas, Joshua M. Glazer, Kyle J. Gunnerson, and
Benjamin S. Bassin
5 Acute Respiratory Failure: Non-invasive Ventilation and High Flow
Nasal Cannula����������������������������������������������������������������������������������������������������������� 43
Christopher Fung and David Hackenson
6 Diagnosis and Management of Tricyclic Antidepressant Ingestion��������������������� 51
Patrick George Minges and Robert W. Shaffer
7 Management of Beta Blocker and Calcium Channel Blocker Toxicity��������������� 57
Daniel Overbeek and Robert W. Shaffer
8 Management of Sympathomimetic Overdose Including Designer Drugs����������� 63
Vivian Lam and Robert W. Shaffer
9 Diagnosis and Management of Ethylene Glycol Ingestion����������������������������������� 71
Christine Martinek Brent and Robert W. Shaffer
10 Accidental Hypothermia ����������������������������������������������������������������������������������������� 79
Carrie Harvey and Ivan Nathaniel Co

Part II Cardiac Disease

11 Management of Cardiogenic Shock ����������������������������������������������������������������������� 87


Michael G. Silverman
12 Management of Acute Heart Failure����������������������������������������������������������������������� 95
Gregory T. Means and Jason N. Katz
13 Management of Acute Coronary Syndrome����������������������������������������������������������� 101
Arman Qamar and Benjamin M. Scirica
14 Management of Cardiac Tamponade ��������������������������������������������������������������������� 111
David D. Berg and Erin A. Bohula

ix
x Contents

15 Hypertensive Crises ������������������������������������������������������������������������������������������������� 117


Benjamin B. Kenigsberg and Christopher F. Barnett
16 Atrial Fibrillation and Other Supraventricular Tachycardias����������������������������� 125
Daniel Sedehi
17 Ventricular Arrhythmias ����������������������������������������������������������������������������������������� 131
Sohaib Tariq and Howard A. Cooper
18 Management of Acute Aortic Syndromes��������������������������������������������������������������� 137
Marc P. Bonaca
19 Management of Endocarditis����������������������������������������������������������������������������������� 145
Janek Manoj Senaratne and Sean van Diepen

Part III Respiratory Disease

20 Community Acquired Pneumonia��������������������������������������������������������������������������� 155


Richard G. Wunderink
21 Management of Acute Respiratory Distress Syndrome����������������������������������������� 161
Robert C. Hyzy
22 Acute Exacerbation of COPD ��������������������������������������������������������������������������������� 169
Lindsay Lief and Jakob McSparron
23 Management of Status Asthmaticus ����������������������������������������������������������������������� 175
Ryan Hadley, Ronak Chhaya, and Jacob Scott
24 Immunocompromised Pneumonia�������������������������������������������������������������������������� 183
Rishi Chanderraj and Robert P. Dickson
25 Venous Thromboembolism in the Intensive Care Unit����������������������������������������� 189
Scott J. Denstaedt and Thomas H. Sisson
26 Massive Hemoptysis������������������������������������������������������������������������������������������������� 201
Frank Genese, Norman Adair, David L. Bowton, and Andrew M. Namen
27 Sedation and Delirium��������������������������������������������������������������������������������������������� 209
Timothy D. Girard
28 Prolonged Mechanical Ventilation��������������������������������������������������������������������������� 217
Thomas Bice
29 Ventilator-Associated Pneumonia��������������������������������������������������������������������������� 223
Jason H. Maley and Jennifer P. Stevens
30 Respiratory Failure in a Patient with Idiopathic Pulmonary Fibrosis ��������������� 231
Anupam Kumar and Ryan Hadley
31 Weaning from Mechanical Ventilation������������������������������������������������������������������� 237
Ayodeji Adegunsoye and John P. Kress
32 Management of Decompensated Right Ventricular Failure
in the Intensive Care Unit ��������������������������������������������������������������������������������������� 245
Matthew K. Hensley and Michael P. Mendez
33 Diffuse Alveolar Hemorrhage ��������������������������������������������������������������������������������� 253
Hem Desai, Joshua Smith, and Mark Daren Williams
34 Pleural Disease ��������������������������������������������������������������������������������������������������������� 259
José Cárdenas-García and Fabien Maldonado
Contents xi

Part IV Neurologic Disease

35 Acute Stroke Emergency Management������������������������������������������������������������������� 273


Scott R. DeBoer, Pravin George, and Lucia Rivera Lara
36 Bacterial Meningitis in the ICU������������������������������������������������������������������������������� 283
Paula M. Gutierrez and Indhu M. Subramanian
37 Approach to Encephalitis in the ICU ��������������������������������������������������������������������� 291
Anne Damian and Arun Venkatesan
38 Management of Intracerebral Hemorrhage����������������������������������������������������������� 301
Shamir Haji and Neeraj Naval
39 Management of Subarachnoid Hemorrhage ��������������������������������������������������������� 307
Avni M. Kapadia and Sarah E. Nelson
40 Status Epilepticus����������������������������������������������������������������������������������������������������� 315
Hannah Breit and Lauren Koffman
41 Neuroleptic Malignant Syndrome��������������������������������������������������������������������������� 323
Kathryn Rosenblatt
42 Traumatic Brain Injury������������������������������������������������������������������������������������������� 331
Krista Lim-Hing and Wan-Tsu W. Chang
43 Management of Anoxic Brain Injury ��������������������������������������������������������������������� 337
Maximilian Mulder and Romergryko G. Geocadin
44 Neuromuscular Disease in the ICU������������������������������������������������������������������������� 347
Christopher L. Kramer and Alejandro A. Rabinstein

Part V Renal Disease

45 Traditional and Novel Tools for Diagnosis of Acute Kidney Injury��������������������� 361
Fadi A. Tohme and John A. Kellum
46 Management of Acute Kidney Injury��������������������������������������������������������������������� 367
Fadi A. Tohme and John A. Kellum
47 Rhabdomyolysis ������������������������������������������������������������������������������������������������������� 375
Saraswathi Gopal, Amir Kazory, and Azra Bihorac
48 Hyponatremia����������������������������������������������������������������������������������������������������������� 381
Lenar Yessayan and Ryan E. Krahn
49 Hypernatremia ��������������������������������������������������������������������������������������������������������� 389
Kenneth B. Christopher
50 Hyperkalemia ����������������������������������������������������������������������������������������������������������� 393
Ryann Sohaney and Michael Heung

Part VI Endocrine Disease

51 Management of Severe Hyponatremia and SIADH����������������������������������������������� 401


Robyn Scatena
52 Diabetic Ketoacidosis����������������������������������������������������������������������������������������������� 405
Hira Bakhtiar and Robyn Scatena
xii Contents

53 Thyroid Storm����������������������������������������������������������������������������������������������������������� 411


Santosh Vaghela and Robyn Scatena
54 Adrenal Insufficiency����������������������������������������������������������������������������������������������� 417
Akhil Khosla and Amy M. Ahasic
55 Critical Illness Related Corticosteroid Insufficiency (CIRCI)����������������������������� 423
Akhil Khosla and Amy M. Ahasic
56 Management of Hyperglycemic Hyperosmolar Syndrome����������������������������������� 429
Elaine C. Fajardo
57 Management of Myxedema Coma��������������������������������������������������������������������������� 435
Aydin Uzun Pinar

Part VII Infectious Disease

58 Zika Virus and Guillain–Barré Syndrome������������������������������������������������������������� 441


Wilma González–Barreto, Gloria M. Rodriguez-Vega, Jorge Hidalgo, and
William Acevedo–Rosario
59 Urosepsis ������������������������������������������������������������������������������������������������������������������� 445
Glenda Euceda, Benjamin Keveson, and Garth W. Garrison
60 Management of Sepsis and Septic Shock ��������������������������������������������������������������� 449
Rommel Sagana and Robert C. Hyzy
61 Invasive Aspergillus�������������������������������������������������������������������������������������������������� 461
Matthew K. Hensley and Michael P. Mendez
62 Management of Strongyloides Hyperinfection Syndrome ����������������������������������� 467
Shijing Jia, Hedwig S. Murphy, and Melissa A. Miller
63 Treatment of Viral Hemorrhagic Fever in a Well-Resourced Environment������� 473
Laura Evans and Amit Uppal
64 Management of Severe Malaria������������������������������������������������������������������������������� 481
Jorge Hidalgo, Pedro Arriaga, and Gloria M. Rodriguez-Vega
65 Dengue����������������������������������������������������������������������������������������������������������������������� 493
Pedro Arriaga, Jorge Hidalgo, and Gloria M. Rodriguez-Vega
66 Leptospirosis������������������������������������������������������������������������������������������������������������� 497
Jorge Hidalgo, Gloria M. Rodriguez-Vega, and Pedro Arriaga

Part VIII Gastrointestinal Disease

67 Management of Acute Upper Gastrointestinal Hemorrhage������������������������������� 505


Navin L. Kumar and Jakob McSparron
68 Variceal Hemorrhage����������������������������������������������������������������������������������������������� 511
Elizabeth A. Belloli and Steven E. Gay
69 Acute Pancreatitis����������������������������������������������������������������������������������������������������� 519
Margaret F. Ragland and Curtis H. Weiss
70 Management of Acute Liver Failure����������������������������������������������������������������������� 523
Jessica L. Mellinger and Robert J. Fontana
71 Acute Lower Gastrointestinal Bleeding ����������������������������������������������������������������� 533
Jose Castaneda-Nerio and Anoop M. Nambiar
Contents xiii

72 Diagnosis and Management of Clostridium difficile Infection (CDI)������������������� 539


Paul C. Johnson, Minh Le, Matthew D. Sims, and Paul D. Bozyk
73 Principles of Nutrition in the Critically Ill Patient ����������������������������������������������� 545
Jill Gualdoni, Shaiva G. Meka, and Paul D. Bozyk
74 Spontaneous Bacterial Peritonitis��������������������������������������������������������������������������� 551
Ajay M. Ohri and Indhu M. Subramanian
75 The ICU Management of Alcoholic Liver Disease������������������������������������������������� 559
Jessica L. Mellinger and Robert J. Fontana

Part IX Hematologic Disease

76 Diagnosis and Management of Thrombotic Thrombocytopenic Purpura����������� 571


Bravein Amalakuhan and Anoop M. Nambiar
77 Acute Leukemia Presentation with DIC����������������������������������������������������������������� 581
Laurie A. Manka and Kenneth Lyn-Kew
78 Disseminated Intravascular Coagulation��������������������������������������������������������������� 585
Mario V. Fusaro and Giora Netzer
79 Hemophagocytic Lymphohistiocytosis and Other Culture
Negative Sepsis-Like Syndromes in the ICU ��������������������������������������������������������� 591
Scott J. Denstaedt and Benjamin H. Singer
80 ICU Complications of Hematopoietic Stem Cell Transplant,
Including Graft vs Host Disease ����������������������������������������������������������������������������� 599
R. Scott Stephens
81 Tumor Lysis Syndrome��������������������������������������������������������������������������������������������� 611
Himaja Koneru, Anil Pattisapu, and Paul D. Bozyk
82 Management of Hyperviscosity Syndromes����������������������������������������������������������� 615
Hesam Tavakoli and Indhu M. Subramanian
83 Thrombocytopenia in the Intensive Care Unit������������������������������������������������������� 621
James M. Walter
84 Coagulopathy in the Intensive Care Unit��������������������������������������������������������������� 631
Kayla J. Kolbe and Ivan N. Co

Part X Surgical

85 Thoracic Trauma������������������������������������������������������������������������������������������������������� 645


Naveen F. Sangji and Krishnan Raghavendran
86 Blunt Abdominal Trauma���������������������������������������������������������������������������������������� 651
Elizabeth C. Gwinn and Pauline K. Park
87 Abdominal Sepsis and Complicated Intraabdominal Infections������������������������� 659
Sara A. Buckman and John E. Mazuski
88 Intestinal Obstruction: Small and Large Bowel���������������������������������������������������� 665
Allison Blake and Joseph A. Posluszny Jr.
89 Management of Acute Compartment Syndrome��������������������������������������������������� 671
Ming-Jim Yang, Frederick A. Moore, and Janeen R. Jordan
xiv Contents

90 Extracorporeal Membrane Oxygenation (ECMO) and Extracorporeal


CO2 Removal (ECCO2R) ����������������������������������������������������������������������������������������� 677
Eric T. Chang and Lena M. Napolitano
91 Management of Acute Thermal Injury������������������������������������������������������������������� 685
Kavitha Ranganathan, Stewart C. Wang, and Benjamin Levi
92 Acute Arterial Ischemia������������������������������������������������������������������������������������������� 691
Danielle Sutzko and Jonathan L. Eliason
93 Management of Necrotizing Soft Tissue Infection������������������������������������������������� 697
Heather Leigh Evans, Lena M. Napolitano, and Eileen M. Bulger
94 Biliary Infections������������������������������������������������������������������������������������������������������� 703
Gregory A. Watson and Andrew B. Peitzman
95 Hemorrhagic Shock ������������������������������������������������������������������������������������������������� 711
Andrew J. Young and Jeremy W. Cannon
96 Management of the Open Abdomen Patient ��������������������������������������������������������� 719
Madhu Subramanian, Cheralyn Hendrix, Niels D. Martin, and Babak Sarani

Part XI Critical Care in Obstetrics

97 Peripartum Cardiomyopathy����������������������������������������������������������������������������������� 729


Lee Anne Stratton, Soidjon Khodjaev, and Srinivas Murali
98 Management of Amniotic Fluid Embolism������������������������������������������������������������� 739
Susan H. Cheng and Marie R. Baldisseri
99 Respiratory Diseases of Pregnancy������������������������������������������������������������������������� 743
Daniel M. Glass, Tara Zehrer, and Ali Al-Khafaji
100 Preeclampsia, Eclampsia, HELLP Syndrome������������������������������������������������������� 749
Lauren A. Plante and Jane Greene Ryan
101 Obstetric Hemorrhage��������������������������������������������������������������������������������������������� 759
Alejandra Garcia Fernandez and Mary Jane Reed
102 Sepsis in Pregnancy��������������������������������������������������������������������������������������������������� 767
Matthew T. Niehaus and Marie R. Baldisseri

Part XII Other Conditions

103 Management of Severe Skin Eruptions������������������������������������������������������������������� 773


Katherine Menson and Garth W. Garrison
104 Management of Alcohol Withdrawal Syndromes ������������������������������������������������� 779
Lucas A. Mikulic and Garth W. Garrison

Part XIII ICU Care Delivery and Medical Ethics

105 Interdisciplinary Care and Communication in the Intensive Care Unit������������� 785
Jonathan Ludmir, Judy Davidson, and Giora Netzer
106 End of Life Care in the ICU������������������������������������������������������������������������������������� 793
Debasree Banerjee, Sameer Shah, and Nicholas S. Ward
Contents xv

107 Palliative Care in the ICU ��������������������������������������������������������������������������������������� 799


Philip Choi and Michael Murn
108 Family Involvement in ICU������������������������������������������������������������������������������������� 805
Sarah J. Beesley and Samuel M. Brown
109 The Post-Intensive Care Syndrome������������������������������������������������������������������������� 813
Jason H. Maley and Mark E. Mikkelsen

Index������������������������������������������������������������������������������������������������������������������������������������� 819
Part I
ER-ICU Shock and Resuscitation
Cardiac Arrest Management
1
Nathan L. Haas and Robert W. Neumar

Case Presentation 12-lead ECG demonstrated ongoing ST segment depres-


sions, and no ST elevations. Aspirin was administered via
A 58-year-old male with a history of hypertension and hyper- NG tube. Targeted temperature management (therapeutic
lipidemia presented to the Emergency Department (ED) with hypothermia) was initiated in the ED with a target tempera-
6 h of chest pain. Initial vital signs were normal, and 12-lead ture of 33 °C, and the patient was taken to the cardiac cath-
ECG demonstrated sinus rhythm with ST segment depres- eterization laboratory where a culprit lesion was identified
sions in the anterior leads. Following portable chest X-ray, and successfully revascularized. The patient was admitted to
he suddenly clutched his chest and became unresponsive the ICU, where he successfully recovered and was dis-
with agonal breathing. The bedside nurse witnessed the charged neurologically intact.
event, found the patient to be pulseless, and noted ventricular
fibrillation (VF) on the monitor. Chest compressions and
bag-valve-mask ventilations were initiated, and defibrillation  rinciples of Management and Standard
P
was attempted with minimal pre- and post-shock interrup- Approach to Resuscitation
tions in CPR. After 2 more minutes of CPR, rhythm check
revealed persistent VF. CPR was continued, and after a sec- Chest Compressions
ond defibrillation attempt IV epinephrine was administered.
Subsequent 2-min rounds of CPR and defibrillation were The goals of CPR are to achieve ROSC and to preserve vital
accompanied by a single dose of IV lidocaine and epineph- organ function until ROSC is achieved. High quality CPR
rine every 4 min. The patient was endotracheally intubated, includes a compression rate of 100–120 compressions per
and endotracheal tube placement was confirmed by wave- minute and a compression depth of 50–60 mm (2–2.4 in.)
form capnography. A femoral arterial line was placed. [1]. Between compressions, one should allow full chest
recoil to allow the heart to refill with blood and maximize
Question coronary perfusion pressure. Additionally, high quality CPR
Which physiologic parameters can be used to assess the effi- includes a chest compression fraction >60%, meaning the
cacy of CPR? proportion of time spent delivering chest compressions dur-
ing CPR should be at least 60% [1]. Maintaining a chest
Answer End-tidal carbon dioxide (PETCO2) and arterial dia- compression rate of 100–120 compressions/min can lead to
stolic blood pressure. rescuer fatigue. Switching compressors every 2 min may
minimize rescuer fatigue but lead to frequent interruptions
End-tidal carbon dioxide remained above 20 mmHg and and may negatively impact the chest compression fraction.
arterial diastolic blood pressure remained above 35 mmHg One suggestion to decrease this “hands-off” time is to have
during subsequent CPR. Return of spontaneous circulation rescuers switch from opposite sides of the victim [2].
(ROSC) was achieved with subsequent defibrillation attempts One strategy to optimize CPR performance metrics is the
while treatment team was preparing for extracorporeal car- use of commercially available feedback devices that are
diopulmonary resuscitation (ECPR). Immediate post-ROSC either stand alone or bundled with portable monitor/defibril-
lators. These devices give providers real-time audio and
visual feedback on compression rate, depth, pauses, leaning
N. L. Haas (*) · R. W. Neumar on the chest, and ventilation rate. Available evidence sug-
Emergency Medicine, Michigan Medicine, Ann Arbor, MI, USA
gests these devices are most effective in reducing excessively
e-mail: [email protected]; [email protected]

© Springer Nature Switzerland AG 2020 3


R. C. Hyzy, J. McSparron (eds.), Evidence-Based Critical Care, https://doi.org/10.1007/978-3-030-26710-0_1
4 N. L. Haas and R. W. Neumar

high compression rates and leaning on the chest during the Vasopressors During CPR
relaxation phase of CPR [1]. However, data is mixed on
whether these devices improve the rate of ROSC, and no Vasopressor therapy during CPR optimizes the ability to
studies have demonstrated improved survival or neurologic achieve ROSC by improving myocardial perfusion through
outcome [1]. increased coronary perfusion pressure. Epinephrine 1.0 mg
Physiologic parameters can also be used to monitor the every 3–5 min is currently recommended during CPR based
efficacy of CPR in real time. The most commonly used on randomized clinical trials demonstrating improved ROSC
parameter is end-tidal CO2 (PETCO2) using continuous wave- and survival [11, 12]. In randomized clinical trials, epineph-
form capnography. In the low flow state of CPR, when venti- rine at higher doses did not improve outcomes [4]. Similarly,
lation is held constant, changes in PETCO2 correlate with vasopressin alone or in combination with epinephrine did not
changes in cardiac output. Technology and portability have improve outcomes compared to epinephrine alone in ran-
improved, allowing capnography to be measured by side-­ domized clinical trials [4]. However, all of these studies were
stream in non-intubated patients and mainstream in intubated performed without physiologic monitoring. The benefit of
patients. The goal of maintaining PETCO2 of at least 20 mmHg titrating vasopressor therapy during CPR based on intra-­
has been proposed based on the association with achieving arterial blood pressure has not been studied (see evidence
ROSC [3]. Conversely, an PETCO2 less than 10 mmHg for contour).
20 min has been proposed as a criteria to consider termina-
tion of resuscitation efforts, although it should not be used in
isolation [4]. A rapid rise in PETCO2 with chest compressions  anagement of Ventricular Fibrillation/
M
(for example, from 10 to 35 mmHg) may signal return of Pulseless Ventricular Tachycardia
spontaneous circulation (ROSC) [4].
Myocardial blood flow during CPR is directly propor- Defibrillation
tional to coronary perfusion pressure (CPP). CPP during Defibrillation is indicated for ventricular fibrillation (VF)
CPR is calculated as aortic diastolic (relaxation) pressure or pulseless ventricular tachycardia (VT). Although tradi-
minus right atrial diastolic (relaxation) pressure [5]. In the tionally monophasic defibrillators have been used to admin-
only human study that has correlated CPP with ROSC, a ister a counter shock, biphasic defibrillators are preferred
CPP of 15 mmHg or greater was required to achieve ROSC due to the greater first shock success. Newer waveforms
[6]. Since CPP monitoring during CPR is technically chal- have been studied which provide patient-specific imped-
lenging, monitoring arterial diastolic pressure has been pro- ance current delivery using biphasic truncated exponential,
posed as an alternative [3]. In a pediatric ICU population, an rectilinear biphasic or pulsed biphasic wave. At this time
arterial diastolic blood pressure >30 mmHg during CPR was there is no specific recommendation regarding which wave-
associated with survival and favorable neurologic outcome form is superior. Current recommendations are to adminis-
[7]. Using arterial diastolic pressure to guide the frequency ter a single counter shock at an optimal energy level
and dosing of vasopressor therapy during CPR may be a rea- (between 120 and 360 J for biphasic defibrillators) with
sonable strategy to optimize therapy (see evidence contour). minimal interruptions in CPR before and after the shock
[4]. In situations requiring repeated defibrillations, manu-
facturers’ guidelines should be followed, and escalating
Ventilation and Oxygenation energy may be considered.

Although chest compression only CPR (Hands-only-CPR) is Antiarrhythmic Therapy


currently recommended for lay-providers, chest compres- Amiodarone or lidocaine are currently recommended as
sions with ventilation continues to be recommended for first line agents in treating VF or pulseless VT that is
health care providers [1]. Ventilations are delivered in a 30:2 refractory to defibrillation [13]. In a recent prospective
compression-to-ventilation ratio until an advanced airway randomized clinical trial comparing both therapies to pla-
has been established [8]. With an advanced airway in place, cebo, only lidocaine resulted in a statistically significant
rescuers may provide a breath every 6 s (10 breaths/min) increase in the rate of ROSC [14]. However, improvements
while chest compressions are performed continuously, and in survival were not statistically significant for either ther-
100% oxygen should be delivered when ventilating patients apy. The routine use of magnesium is not recommended in
during CPR. Hyperventilation should be avoided as this has adult cardiac arrest, though use may be considered for tor-
been tied to reducing cardiac output during CPR [9, 10]. sades de pointes [13].
1 Cardiac Arrest Management 5

Management of Pulseless Electrical Activity occurs, initial BVM ventilation is appropriate. Attempts to
establish an advanced airway may be postponed to maximize
Pulseless electrical activity (PEA) is defined as the absence other resuscitation efforts, unless BVM ventilation is inef-
of a pulse when electrical cardiac activity is present. This can fective or airway protection is obviously needed. The absence
further be classified as electromechanical dissociation of a capnography waveform during BVM ventilation should
(EMD; no pulse, presence of an electrical signal, no evidence trigger a transition to an advanced airway. Supraglottic air-
of cardiac activity detected by echocardiography) versus way devices are a reasonable advanced airway strategy dur-
pseudo-EMD (no pulse, presence of an electrical signal, car- ing CPR, and may be superior to endotracheal intubation in
diac activity observed by echocardiography). EMD repre- settings where initial intubation success rates are low [21]. If
sents an electromechanical uncoupling of cardiac cells, with endotracheal intubation is performed during CPR, it should
propagation of an electrical signal but no coordinated ven- be initially attempted without interrupting chest compres-
tricular contraction. This situation is usually seen in severe sions when feasible.
hypoxia, acidosis or necrosis. In pseudo-EMD, there is an
electrical signal and weak cardiac contractions (with no pal-
pable pulse) due to conditions such as hypovolemia, massive Hemodynamic-Directed Resuscitation
pulmonary embolism or other mechanical impediments to
flow. In these situations, the predominant rhythm is a tachy- Hemodynamic directed resuscitation (or patient-centric car-
dysrhythmia. A mnemonic to remind clinicians of the com- diopulmonary resuscitation) is a concept whereby chest
mon precipitants of PEA is “4Hs-4Ts:” hypoxia, compressions and vasopressor therapy are guided by con-
hypovolemia, hypo/hyperkalemia, hypothermia, thrombosis tinuously monitored hemodynamic variables rather than a
(pulmonary embolism), tamponade (cardiac), toxins, and one-size-fits-all approach. Animal studies have demonstrated
tension pneumothorax [15]. Distinguishing EMD from improved outcomes when chest compressions and vasopres-
pseudo-EMD can help guide therapy aimed at treating sor therapy are titrated to achieve a systolic blood pressure of
reversible causes during CPR [16]. Bedside echocardiogra- 90 mmHg and a coronary perfusion pressure of 20 mmHg
phy and intra-arterial blood pressure monitoring are the most during CPR [22]. As noted above, real time monitoring of
reliable strategies to distinguish EMD from pseudo-EMD CPP is challenging in the clinical setting. Therefore, using an
(see evidence contour). arterial diastolic blood pressure target of 30–35 mmHg may
be reasonable. This approach is most feasible when intra-­
arterial pressure monitoring is in place prior to cardiac arrest
Quality Assurance onset, but placing a femoral arterial line during CPR is fea-
sible when adequate personnel are available. Whether hemo-
The quality of care should be assessed and debriefed after dynamic directed resuscitation leads to improved outcomes
every cardiac arrest resuscitation [17]. Short debriefing ses- in humans remains to be determined.
sions after a resuscitation have been shown to improve team
performance and outcomes [18]. The ability of rescuers to
retain critical resuscitation skills wanes as early as 6 months Bedside Ultrasound During CPR
after training, and health care providers often perform sub-
optimal chest compression rates [19]. Implementing simu- Bedside ultrasound may be used to investigate the underly-
lated resuscitations has been demonstrated to be useful in ing etiology of cardiac arrest. For instance, a subcostal view
retaining skills [20]. may reveal a large pericardial effusion with diastolic col-
lapse of the right ventricle representing cardiac tamponade.
Alternatively, a parasternal short axis view may demonstrate
Evidence Contour bowing of the intra-ventricular septum, the so called “D-sign”
appearance of the left ventricle being compressed by a
Airway Management During Cardiac Arrest volume-­overloaded right ventricle contracting against a mas-
sive pulmonary embolism. It is essential to minimize inter-
The optimal airway strategy during CPR remains uncertain. ruptions in chest compressions, and every effort should be
Reasonable options include bag-valve-mask (BVM) ventila- made to assure that the compression fraction is not compro-
tion, supraglottic airways, and endotracheal intubation. In mised by performing ultrasound. Transesophageal echocar-
patients without an airway in place when cardiac arrest diography (TEE) is also under investigation as an alternative
6 N. L. Haas and R. W. Neumar

method to obtain diagnostic information, and has been asso-


ciated with shorter chest compression pauses [23]. TEE may
also provide a method to visually monitor effectiveness of
chest compressions in real time, by visualizing changes in
the left ventricle with changing hand position, depth, or
technique.
Littman et al. proposed a diagnostic guide to evaluate
causes of PEA which includes evaluating the width of the
QRS complexes and sonographic findings to suggest whether
a mechanical, ischemic or metabolic cause is to blame [24].
There is no randomized study to support ultrasound-guided
resuscitations over resuscitations without ultrasound, but one
study suggested that modifications in traditional approaches
employing ultrasound may be associated with a higher rate
of survival to hospital admission [25].

Mechanical CPR

Based upon currently available data, mechanical chest com-


pressions do not appear associated with improved outcomes
as compared to manual chest compressions. Manual com-
pressions are the most readily available and commonly
taught method of chest compressions. Despite this, many
pre-hospital and hospital systems have chosen to use Fig. 1.1 LUCAS™ chest compression device (Used with permission
mechanical compression devices to administer chest com- of Physio-Control, Inc.)
pressions for various logistical reasons. Mechanical com-
pression devices became available for research and clinical Extracorporeal Cardiopulmonary Resuscitation
applications during the 1970s with the Thumper® (created by
Michigan Instrument) which utilized a hydraulically pow- Extracorporeal cardiopulmonary resuscitation (ECPR)
ered piston to provide chest compressions similar to the “car- involves the addition of veno-arterial extracorporeal mem-
diac pump theory”. Newer devices emerged including the brane oxygenation (VA-ECMO) to standard resuscitation
Lund University Cardiac Arrest System (aka. LUCAS 1 and efforts during cardiac arrest. This allows for temporary
2®) by Physio Control and the Auto Pulse® by Zoll. These perfusion of vital organs and circulatory support while the
employ different mechanisms to enhance chest compres- underlying etiology of cardiac arrest is diagnosed and
sions, namely through an active compression and decom- reversed. Adult ECPR is typically initiated at the bedside
pression mode. The LUCAS® device is predominantly a or in the cardiac catheterization laboratory using percuta-
piston-driven device with a suction area which makes con- neous femoral artery and vein access. ECPR has emerged
tact with the chest (Fig. 1.1). The Auto Pulse® utilizes a load-­ as a feasible and effective strategy for patients failing other
distributing band which wraps around the torso and squeezes resuscitative efforts when the appropriate expertise and
to increase intra-thoracic pressure. infrastructure is in place to both perform timely cannula-
Advocates of mechanical compressions support the con- tion and optimize post-cardiac arrest care while patients
sistency of depth and compression rate. Mechanical CPR can are on VA-ECMO [30]. Based on international registry
minimize interruptions in chest compressions and there is no data, the survival rate when ECPR is used for refractory
need to switch rescuers or halt compressions when perform- adult out-of-hospital cardiac arrest is 27.6% (95% CI
ing defibrillation. Despite these theoretical advantages, clini- 22.1–34.0%) [31]. However, data from randomized clini-
cal trials to date have failed to demonstrate improved cal trials is lacking. The 2015 AHA guidelines indicate
outcomes with the use of mechanical CPR [26–28]. The there is insufficient evidence to recommend routine use of
added cost and upkeep of these devices may prohibit wide- ECPR in the treatment of cardiac arrest, though it may be
spread use. However, providers point to the advantages of considered for select patients with a potential reversible
reducing rescuer fatigue and diminishing risk to rescuers etiology of cardiac arrest in settings where it can be rap-
during transport while CPR is in progress [29]. idly implemented [4].
1 Cardiac Arrest Management 7

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