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Civetta, Taylor, & Kirby’s MANUAL OF

CRITICAL CARE

Andrea Gabrielli, MD, FCCM

Professor of Anesthesiology and SurgeryDivision of Critical Care MedicineSection Head, NeuroCritical CareUniversity of Florida College of MedicineMedical Director, Cardiopulmonary Serviceand Hyperbaric Medicine

Shands Hospital at the University of FloridaGainesville, Florida

A Joseph Layon, MD, FACP

Director, Critical Care MedicineGeisinger Health SystemDanville, PA

Mihae Yu, MD, FACS

Professor of SurgeryUniversity of Hawaii John A Burns School of MedicineVice Chair of Education

University of Hawaii Surgical Residency ProgramProgram Director of Surgical Critical Care FellowshipProgram

Director of Surgical Intensive CareThe Queen’s Medical CenterHonolulu, Hawaii

i

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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]

616.028–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

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D E D I C A T 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

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■ C O N T R I B U T I N G A U T H O R S

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.

James E Calvin, Jr., MD

William G Cance, MD

Lawrence J Caruso, MD

Juan C Cendan, MD

Cherylee W.J Chang, MD, FACP

Marianne E Cinat, MD, FACS

Cornelius J Clancy, MD

Michael Coburn, MD

Giorgio Conti, MD

Jamie B Conti, MD, FACC, FHRS

Timothy J Coons, RRT, MBA

Elamin M Elamin, MD, MSc, FACP, FCCP

Timothy C Fabian, MD, FACS

Samir M Fakhry, MD, FACS

Contributing Authors vii

David T Porembka, DO, FCCM

Raymond O Powrie, MD, FRCP, FACP

Allen M Seiden, MD, FACS

Steven A Seifert, MD, FACMT, FACEP

Lee P Skrupky, PharmD, BCPS

Robert N Sladen, MBChB, MRCP(UK), FRCP(C), FCCM

Matthew S Slater, MD

Danny Sleeman, MD, FACS, FRCS

Wendy I Sligl, MD

Danny M Takanashi, Jr., MD, FACS

Christopher D Tan, PharmD, BCPS

■ P R E F A 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 otherguidance and moral support, and will share any failures andsuccesses of our travail

A Joseph Layon (ajlayon@geisinger.edu) Danville, Pennsylvania Andrea Gabrielli (agabrielli@anest.ufl.edu) Gainesville, Florida

Mihae Yu (mihaey@hawaii.edu) Honolulu, Hawaii

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xiii

xiv

■ C O N T E N T S

AND NONINVASIVE

xv

SECTION IV ■ ESSENTIAL PHYSIOLOGIC CONCERNS

AND THE ENVIRONMENT

POSTOPERATIVE EVALUATION AND TRAUMA

Contents xvii

CHAPTER 63 Hemorrhagic and Liver Disorders of Pregnancy 400

(OTHER CV DISEASE): ACS IN THE ICU

Contents xix

SECTION XVI ■ RENAL DISEASE AND DYSFUNCTION

AND DYSFUNCTION

SECTION I ■ EMERGENCY SITUATIONS

CARDIOPULMONARY RESUSCITATION

MAJOR PROBLEMS

sCardiopulmonary resuscitation (CPR) is a series of

assess-ments 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.”

cIn the prehospital arena, CA is most commonly due toventricular fibrillation (VF) secondary to ischemic heartdisease

– Asystole and pulseless electrical activity (PEA) are lesscommon initial rhythms with SCA, although theserhythms may represent the initial identified rhythm inadults who actually experienced an acute VF or ven-tricular tachycardia (VT) event

cAlthough VF and VT are considered to be the most mon out-of-hospital (OOH) arrest rhythms, only 20%

com-to 38% of in-hospital arrest patients have VF or VT astheir initial rhythm

cChildren and young adults require CPR most monly for respiratory arrest, airway obstruction, or drugtoxicity

com-– VF/VT is identified as the initial rhythm in 5% to 15%

of OOH arrests in children

cOther conditions such as trauma, external or internalhemorrhage, and drowning may call for resuscitation atany 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

main-tain cellular viability while attempting to restore a perfusing

cardiac rhythm by defibrillation, pharmacologic

sThis is cut in half (3%–4% per minute) when bystander

CPR preceded attempted defibrillation

sDefibrillate immediately if a defibrillator is rapidly

avail-able (less than 3–5 min) in patients with VF

cThis is the primary treatment focus within the first fewminutes of SCA due to VF

– For each minute delay in defibrillation, chances ofeventual hospital discharge decreased by 8% to10%

– 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 rillation is associated with improved outcome

defib-s“Push hard and fast” during chest compressions and mize the duration of interruptions to reassess the patient’srhythm

mini-sInterrupt chest compressions only briefly, about every

2 minutes, to assess the rhythm, and switch rescuer if sible

fea-sWhile CPR is in progress, attempt to identify the cause ofarrest

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

sConsider therapeutic hypothermia to maximize survival

and cerebral recovery

sIf there is no response to effective CPR, appropriate ment is needed in determining when to stop resuscitativeefforts

judg-1

TA B L E 1 1

POTENTIAL CORRECTABLE PROBLEMS DURING

CARDIAC ARREST: “6 H’S AND 5 T’S”

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

cBradycardia 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

loca-tion and monitoring at time of arrest, outcome was prisingly worse when the rhythm was VF/VT in childrencompared with asystole and PEA

sur-cFurther analysis of these data showed that VF/VToccurred during CPR in children more commonly than

it occurred as the initial rhythm

cSurvival to discharge is highest (35%) when VF/VT isthe initial rhythm compared with survival of 11% if thisrhythm 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 managementsuch 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 dayswill fail to survive

sThose who do survive often have poor neurologic recovery.

cNeurocognitive impairment ranges from dependency onothers for care to remaining in a minimally conscious orvegetative state

sAchieving good functional outcome is the ultimate goal forsuccessful CPR

sThe financial implications of caring for patients with

dis-ordered consciousness are substantial

sMost studies reporting outcome data have used crude

methods to describe neurologic outcome, such as the posite scores from the Glasgow Outcome Scale and Cere-bral Performance Category

com-cAn important limitation of these scales is the possibility

of wide variation of neurologic function for the same score

cIn children, the Pediatric Cerebral Performance Categoryand Pediatric Overall Performance Category have beenused

s11% to 48% of CA patients admitted to the hospital will

be discharged with good neurologic outcome

cRecent data from the National Registry for monary Resuscitation (NRCPR) show that neurologicoutcome in discharged adult survivors is generally good,with 73% of patients with Cerebral Performance Cate-gory 1

Cardiopul-INITIAL CONSIDERATIONS

sCPR is primarily based on two principles.

sProviding artificial ventilation and oxygenation through anunobstructed airway

sCardiac output is limited; avoid ventilation in excess of

that required for adequate ventilation/perfusion matching

Chapter 1: Fundamentals of Cardiopulmonary Resuscitation 3

sDelivering chest compressions to maintain threshold blood

flow

sEspecially to the heart and brain, while minimizing

inter-ruption 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

out-put 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 oflife-threatening arrhythmias using electrical therapy includ-ing defibrillation, cardioversion, pacemaker insertion, andpharmacologic therapy

sInclusion of the use of pharmacologic therapy and advancedprocedures extending into the postarrest setting such as theuse of therapeutic hypothermia

Advanced Airway Management

sTracheal intubation

sEndotracheal intubation (ETI) is indicated if unable to quately ventilate or oxygenate the arrested or unconsciouspatient with bag-mask ventilation or if prolonged ventila-tion is required and airway protective reflexes are absent inthe patient with a perfusing rhythm

ade-sA properly placed endotracheal tube (ET) is the gold dard method for securing the airway

stan-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

Adult lay rescuer:≥ 8 y

HCPs: Adolescent and older

Child lay rescuers: 1– 8 y HCPs: 1 y to adolescent Infant≤ 1 y of age

Suspected trauma, usejaw thrust)

Breathing: Initial Two breaths at 1 sec/breath Two breaths at 1 sec/breath

HCPs: Rescue breathing without

chest compressions

10–12 breaths/min(approximate)

12–20 breaths/min (approximate)

HCPs: Rescue breaths for CPR

with advanced airway

8–10 breaths/min(approximately)Foreign-body airway obstruction Abdominal thrusts Back slaps and chest thrust

sPush hard and fast

sAllow complete recoil

Heel of one hand, otherhand on top

Heel of one hand or as for adults Two or three fingers

HCPs (two rescuers):

Two thumb–

encircling handsCompression depth 11/2–2 inches Approximately one-third to

one-half the depth of the chestCompression rate Approximately 100/min

Compression:ventilation ratio 30:2 (one or two rescuers) 30:2 (single rescuer)

HCPs: 15:2 (two rescuers)

Do not use child pads

Use AED after five cycles of CPR(out of hospital)

No recommendation forinfants<1 y of age

Use pediatric system for child 1–8

y if availableHCPs: For sudden collapse (out ofhospital) or in-hospital arrestuse AED as soon as availableAED, 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.

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 ETCO2detector

or esophageal detector is indicated to confirm correct tube

placement

sETCO2detector device is a disposable colorimetric device

that detects ETCO2 has been investigated as a guide to

correct ET placement

cThe 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

cThe positive predictive value of this device for correct

tube placement is close to 100%, but the negative dictive value ranges from 20% to 100% depending onwhether the patient has a perfusing rhythm

pre-– False-negative results are seen if there is no or very lowpulmonary blood flow, such as during CA or with alarge pulmonary embolus

– False-positive (i.e., the detector remains yellow) resultsare 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)

cBulb EDD consists of a bulb that is compressed and

attached to the ET When released, if the tube is in theesophagus, the suction collapses the lumen of the esoph-agus or pulls the esophageal tissue against the tip of thetube, and the bulb will not re-expand (positive result foresophageal placement)

cSyringe EDD consists of a syringe attached to the ET; the

rescuer attempts to pull the plunger of the syringe If thetube is in the esophagus, it will not be possible to pullout the plunger (i.e., aspirate air) with the syringe

– This device has high sensitivity for esophageal ment of ETs in both CA and patients with aperfusing rhythm but poor specificity for trachealplacement

place-Electrical Therapy

sOne of the mainstays of ALS, especially in adults

sElectrical energy is used to treat life-threatening cardiac

dys-rhythmias

sConstitute 16% to 85% of OOH and 14% to 56% of

in-hospital CAs

cRecent data suggest that VF and VT are decreasing, with

only 24% of the initial rhythms in more than 36,000adult arrests being VF- or VT-based in a recent analysisfrom the NRCPR

cIn hospitalized children with CA, VF is the initial rhythm

in approximately 10% of cases and subsequently occursduring 15% of the cases

sDefibrillation

sDefined as delivery of electrical energy resulting in

termina-tion 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

ana-lyze the rhythm and then manually set and determine the

electrical energy dose

sAutomatic defibrillator devices analyze the rhythm,

deter-mine whether a shock is required, and deliver the shock ifneeded automatically

cTwo types of automatic defibrillators: internal able cardioverter defibrillator and automated externaldefibrillator (AED)

implant-sDefibrillators are also characterized by the mode and

waveform of electrical current delivered into monophasicand biphasic defibrillators

cAnimal and human data show that biphasic tors have a higher first-shock success in terminating VFcompared with monophasic devices

defibrilla-sDefibrillation dose

sOptimal initial energy dose for the first shock\ required

for effective defibrillation remains unknown despite tiple studies

mul-cReasonable 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 shockcFor second and subsequent biphasic shocks, the same orhigher energy can be given

– Most manual defibrillators are set to an initial default

– Recommended manual defibrillation (monophasic orbiphasic) doses for children are 2 J/kg for the firstattempt 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

cThe right (sternal) chest pad is placed on the victim’sright superior–anterior (infraclavicular) chest, and theapical (left) pad is placed on the victim’s inferior–lateralleft 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 thepads

sPaddles that are too small increase the risk of skin burn

injury

sElectrical cardioversion

sUsed for some life-threatening arrhythmias causing rapidcardiovascular deterioration

sIncluding VT and supraventricular tachycardias (SVTs)

such as paroxysmal atrial tachycardia, atrial flutter, oratrial fibrillation with a rapid ventricular response

sThe technique, unlike defibrillation, must be synchronizedwith 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

car-dioversion varies with the rhythm

Chapter 1: Fundamentals of Cardiopulmonary Resuscitation 5

c100 J is recommended for atrial fibrillation and 50 J foratrial flutter

cMonomorphic VT responds well to cardioversion, and

100 J should be attempted first

cPulseless VT behaves like VF, and 200 J should be usedinitially

cIn conscious patients, sedation with intravenousdiazepam, midazolam, or methohexital is indicated, andthe cardioversion is accomplished with the lowest energypossible (50–200 J)

cIn 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

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

advan-tage of not interrupting CPR

cRapidly follow the medication bolus with a 10- to 20-mLfluid bolus to ensure central delivery

cIntraosseous cannulation is an effective alternate fordrug delivery

cInstillation can be made through an ET, if available

Lipid-soluble medications that can be delivered via ETare lidocaine, epinephrine, atropine, naloxone, and vaso-pressin

cRecommended to administer at least 2 to 21/2times 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

sLittle pharmacologic data supporting the currently

rec-ommended dose of 1 mg of epinephrine in adult CA and0.01 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

epi-nephrine, offers theoretical advantages of cerebral

vasodi-lation, possibly improving cerebral perfusion

sLack ofβ1-adrenergic activity potentially avoids

unneces-sary increases of myocardial oxygen consumption, ing in postresuscitation arrhythmias

result-sHalf-life of 10 to 20 minutes compared to the 3 to 5 minutesobserved with epinephrine

sSodium bicarbonate

sMetabolic and respiratory acidosis develops during CAresulting from anaerobic metabolism, leading to lactic acidgeneration and inadequate ventilation along with reducedblood flow during CPR, which leads to inadequate pul-monary delivery of carbon dioxide for elimination

sUntreated acidosis suppresses spontaneous cardiac ity, decreases the electrical threshold required for theonset of VF, decreases ventricular contractile force, anddecreases cardiac responsiveness to catecholamine such asepinephrine

activ-sElevated PCO2 tension probably is more detrimental to

myocardial function and catecholamine responsivenessthan 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 sion or frequent premature ventricular contractions (PVCs)secondary to unsuppressed ectopic electrical activity arising

hypoten-in the area of hypoten-injured tissue durhypoten-ing the prolonged periodafter repolarization

sSinus bradycardia after myocardial infarction may pose the heart to the onset of VF

predis-sWhen profound bradycardia is present, acceleration of the

heart rate above 60 bpm may improve cardiac output andreduce the incidence of VF

sDosage of atropine for severe symptomatic bradycardia is0.5 to 1.0 mg intravenously repeated every 3 to 5 minutesuntil the desired pulse rate is obtained or a maximum of0.04 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 raisingthe electrical stimulation threshold of the ventricle duringdiastole

sIn ischemic myocardial tissue after infarction, it may press re-entrant arrhythmias such as VT or VF

sup-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 ifventricular function is not decreased

sLoading dose of lidocaine is approximately 1 to 1.5 mg/kggiven 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 becauserenally excreted lidocaine degradation products also havepharmacologic effects and toxic potential

sEarly signs of lidocaine toxicity are due to central

ner-vous system effects and include anxiety, loquacity, tremors,metallic taste, and tinnitus

Cardiac arrest

VF/VT Asystole/

PEA

cycles

May give vasopressin 40 U to replace first or second dose of epinephrine

Amiodarone 300 mg IV/IO and then additional 150 mg Lidocaine 1–1.5 mg/kg first dose then additional 0.5–1 mg/kg (max 3 mg/kg)

Magnesium 1–2 g for torsades

cular Care Circulation 2010;122:S729–S767).

Chapter 1: Fundamentals of Cardiopulmonary Resuscitation 7

Tachycardia with pulses

Check instability

other signs of shock

(e.g., adenosine, digoxin,

May repeat 12 mg dose once

Atrial fibrillation or possible atrial flutter or MAT(multifocal

atrial tachycardia) Consider expert consultation Ventricular rate control

Diltiazem

β blockers

Conversion to sinus rhythm?

(Consider expert consultation)

Re-entry supraventricular tachycardia

Adenosine

Longer-acting AV nodal blocking agents

Diltiazem

β blockers

Likely atrial flutter, ectopic atrial tachycardia, or junctional tachycardia

Diltiazem

β blockers

NO YES

NO YES

FIGURE 1.2 Suggested treatment algorithm for tachycardia with pulse BLS, basic life support;

ECG, electrocardiogram; VT, ventricular tachycardia; SVT, supraventricular tachycardia; WPW, Parkinson-White syndrome (Adapted and modified from 2005 American Heart Association Guidelines

Wolff-for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Circulation

2005;112[24]SIV-1–IV-211.

sMay be followed by somnolence, respiratory depression,

apnea and, in severe cases, cardiovascular collapse

sProcainamide

sSuppresses both atrial and ventricular arrhythmias with

mechanisms of action similar to those of lidocaine

sIs used in the management of PVCs, VT, and persistent VF,but amiodarone is usually preferred

sIncremental bolus injections are slowly infused at 20 mg/

minute until

sThe arrhythmia is controlled.

sHypotension occurs.

sThe QRS complex is widened 50% from baseline.

sA total dose of 17 mg/kg (1.2 g in a 70-kg adult) is given,

followed by a continuous infusion of 1 to 4 mg/minute to

prevent recurrent arrhythmias

cTherapeutic plasma level of 4 to 8 μg/mL.

sAmiodarone

sA complex drug with effects on sodium, potassium, and

cal-cium channels on myocardial cells andα- and β-adrenergic

blocking properties

sThe 2005 guidelines denote it the preferred agent for both

atrial and ventricular arrhythmias, especially in the presence

of impaired cardiac function

sAmiodarone is recommended for narrow-complex

tachy-cardias that originate from a re-entry mechanism (re-entry

SVT); ectopic atrial focus; control of hemodynamically

stable VT, polymorphic VT with a normal QT interval, or

wide-complex tachycardia of uncertain origin, and control

of rapid ventricular rate due to accessory pathway

con-duction in pre-excited atrial arrhythmias with AV nodal

blockade in patients with preserved or impaired

ventricu-lar function

sIn treatment of arrhythmias with a pulse, 150 mg

amio-darone is given IV over 10 minutes, followed by a 1 mg/

minute infusion for 6 hours and then a 0.5 mg/minute

main-tenance infusion over 18 hours

sSupplementary infusions of 150 mg can be repeated every

10 minutes as necessary for recurrent or resistant

arrhyth-mias to a maximum manufacturer-recommended total

daily IV dose of 2.2 g

sWhen used in the treatment of VF or pulseless VT, a bolus

dose of 300 mg is recommended diluted in 20 to 30 mL of

D5W

sA single second dose may be given (150 mg) in 3 to

5 minutes for shock-refractory VF or VT

sIn children, 5 mg/kg is given as a rapid bolus and may be

repeated up to 15 mg/kg

sMajor adverse effects of amiodarone are hypotension and

bradycardia

sCan be prevented by slowing the rate of drug infusion

sAmiodarone can increase the QT interval; therefore, its

use should be carefully considered when other drugs that

can prolong the QT interval are administered

sCalcium

sPlays a critical role in myocardial contractility and action

potential generation, but studies have shown no benefit of

calcium in CA

sWhen indicated, the recommended dose is 5 to 10 mL of a

10% solution of calcium chloride (8–16 mg/kg)

sCalcium gluconate is given in a dose of 6 to 8 mL if

periph-eral IV access is available Undiluted calcium chloride given

through a peripheral vein may cause sclerosis and tissue

injury; therefore, if a central site is not available and the

patient is not in CA, it either should be diluted or

cal-cium administered in a less irritating form (e.g., calcal-cium

sIn children, a dose of 25 to 50 mg/kg is used.

Algorithms for Advanced Life Support

sThe treatment algorithms of pulseless CA and tachycardiawith pulse are summarized in Figures 1.1 and 1.2, respectively

ETHICAL CONSIDERATIONS Termination of Cardiopulmonary Resuscitation Efforts

sCPR is inappropriate when survival is not expected.

sThere are few criteria that can reliably predict the futility ofCPR

sRecommended that all patients with cardiopulmonary arrestreceive CPR with the following exceptions:

sThere is a valid Do Not Attempt Resuscitation order, whichcan be verified

sSigns of irreversible death are already present (e.g., rigormortis, decapitation, decomposition, dependent lividity)

sNo physiologic benefit can be expected with further CPR.

sIn newborns, gestational age or congenital abnormality isrelated to almost certain early death

sIn the ICU, CPR is started without a physician’s order, which

is based on implied consent for emergency treatment

sThe decision to stop CPR should be made by a physiciantreating the patient, ideally familiar with the patient’s pre-existing conditions

sRarely good outcome with prolonged CPR has been

reported

cAcceptable to prolong resuscitative efforts in childrenwith recurrent VF or VT, drug toxicity, or a primaryhypothermic insult

Family Presence during Cardiopulmonary Resuscitation

sHas been a common practice to exclude family of the arrestvictim during CPR efforts

sHelping the family of a dying patient is an important part

of CPR and should be done in a compassionate mannerconsidering the family’s cultural and religious beliefs andpractices

sConcern that allowing family presence may become

dis-ruptive, interfere with resuscitation, cause them to ence syncope, and increase the risk of legal liability werenot substantiated by good evidence

experi-sFamily surveys after CPR suggested that the majority of

family members want to be present during CPR

sIn pediatric arrest, most parents surveyed wanted an

option to be present during CPR

sThe resuscitation team should be sensitive to the family’s

presence, and a team member should be assigned to fort the family, answer questions, and clarify the proce-dures

com-CHAPTER 2 ■ AIRWAY MANAGEMENT

GENERAL PRINCIPLES

sYou may not neglect the “A” of the ABCs and wait for airway

management to turn into an emergency

sBag-valve-mask should be attempted by application of a mask

and initiation of bag ventilation with an increased FiO2while

equipment for intubation is prepared

sAn appropriate mask provides a tight seal around the nose

and mouth, and the colorless plastic with soft and pliable

edges allows visualization of the mouth and secretions

sThe mask is attached to the resuscitation (self-inflating or

collapsible) bag with a high-flow oxygen source

sProper inflation requires two hands

sOne to hold the mask firmly in place against the patient’s

face

sThe other to compress the bag

sThe mandible must be lifted to create a seal without airway

occlusion

sAn oropharyngeal or nasal airway facilitates oxygen

deliv-ery by bypassing or retracting the tongue

sForceful bag compression should be avoided to prevent

gastric distention and possible pulmonary aspiration

sGentle insufflation allows assessment of lung compliance

and minimizes complications

sContraindications to bag-valve-mask ventilation include:

sAirway obstruction

sPooling of blood or secretions in the pharynx

sSevere facial trauma

sCritically ill patients require tracheal intubation for the

rea-sons listed in Table 2.1

sRelative or absolute contraindications to conventional

sExtensive facial injury and basal skull fracture

sBlind nasal intubation may be contraindicated in the

follow-ing situation:

sUpper-airway foreign-body obstruction, because the tube

may push the foreign body distally and exacerbate airway

compromise

ANATOMIC CONSIDERATIONS

Adult

sNeck flexion aligns the pharyngeal and tracheal axes, whereas

head extension on the neck and opening of the mouth align

the oral passage with the pharyngeal and tracheal axes

sThis maneuver places the patient in a “sniffing position”

(Fig 2.1)

sFlexion/extension of the head decreases 20% by 75 years

of age

sDegenerative arthritis limits cervical spine motion, more

with extension than flexion

sSpine movement is contraindicated in the presence of

potential cervical spine injury

cHence, patient is maintained in a neutral position within-line stabilization

cBarring the edentulous patient, the front component ofthe hard cervical collar is commonly removed to allowfull mandibular movement/optimize mouth opening

sKnowledge of anatomic landmarks may help during directlaryngoscopy (Fig 2.2)

sThe cricoid, a circle of cartilage above the first tracheal ring,can be compressed to occlude the esophagus (Sellick maneu-ver) to prevent passive gastric regurgitation into the trachea

sThe epiglottis lies in the anterior pharynx.

sThe vallecula, a furrow between the epiglottis and base ofthe tongue is placement site for the tip of a curved laryngo-scope blade

sThe larynx is located anterior and superior to the tracheaand contains the vocal cords

Pediatric

sDifferences exist between the adult and the pediatric airways.

sPediatric patients have a relatively large head and flexibleneck

TA B L E 2 1

INDICATIONS FOR TRACHEAL INTUBATION Open an obstructed airway

Provide airway pressure support to treat hypoxemia

PaO2<60 mm Hg with an FiO2>0.5

Alveolar-to-arterial oxygen gradient 300 mm HgIntrapulmonary shunt>15%–20%

Provide mechanical ventilation

Respiratory acidosisInadequate respiratory mechanicsRespiratory rate>30 breaths/min

9

FIGURE 2.1 Demonstration of the “sniffing position” for optimal visualization of the glottic opening.

sThe air passages are small.

sThe tongue, adenoids, and tonsils are larger than those in

adults

sThe epiglottis is floppy.

sThe glottis is typically slanted at a 40-degree to 50-degree

angle, making intubation more difficult

sMucous membranes are softer, looser, and more fragile and

readily become edematous when an oversized endotracheal

sIn the adult, the glottic opening is narrowest.

sThe pediatric vocal cords have a shorter distance from thecarina

sThe mainstem bronchus angulates symmetrically at the level

of the carina at about 55 degrees

sIn adults, the right mainstem angulates at about 25 degrees

and the left at about 45 degrees

sThe cupulae of the lungs are higher in the infant’s neck,increasing the risk of lung trauma

air-MEDICATIONS

sLocal anesthetics

sAerosolized or nebulized 1% to 4% lidocaine can readilyachieve nasopharyngeal and oropharyngeal anesthesia if thepatient is cooperative and capable of deep inhalation, thuslimiting its usefulness in the ICU

sTranstracheal (cricothyroid membrane) instillation of 2 to

4 mL of 1% to 4% lidocaine with a 22- to 25-gauge needlecauses sufficient coughing-induced reflex to afford ample

Chapter 2: Airway Management 11

Assortment of laryngoscope blades and endotracheal tubes

Tape, stylet, lubricant, syringes, and tongue depressors

Monitors (ECG, blood pressure monitor, pulse oximeter,

capnography, or similar device) and defibrillatora

Fiberoptic bronchoscope,arigid fiberscope,aand specialty

bladesa

A drug tray or cart with vasoconstrictors, topical anesthetics,

induction agents, muscle relaxants, and emergency

medications

14-Gauge IV, scalpel, assortment of supraglottic airways,a

bougie,aCombitube,aET exchanger,aand Melker-type

cricothyrotomy kit

aImmediately available.

LMA, laryngeal mask airway; ECG, electrocardiograph;

ET, endotracheal tube.

distribution to anesthetize the subglottic and supraglottic

regions plus the posterior pharynx in 90% of patients

sCocaine provides excellent conditions for facilitating

intu-bation through the nasopharynx due to its outstanding

topical anesthetic and mucosal and vascular shrinkage

capabilities In-hospital availability may limit its use in favor

of phenylephrine or oxymetazoline combined with readily

available local anesthetics

sLidocaine ointment applied to the base of the tongue with a

tongue blade or similar device allows performance of direct

laryngoscopy in many patients

sIf time permits, nasal spraying with a vasoconstrictor

fol-lowed by passing a progressively larger nasal airway pet from 24 French to 32 French that is coated/lubricatedwith lidocaine gel/ointment provides exceptional coverage

trum-of the nasocavity in preparing for a nasal intubation

sBarbiturates

sSodium thiopental, an ultra-short-acting barbiturate,

decreases the level of consciousness and provides amnesia

without analgesia

sIntubation dose in the operating room (OR) of 4 to

7 mg/kg ideal body weight (IBW) (1 to 2 mg/kg in theICU) dose over 20 to 50 seconds (more rapidly via centralvenous line (CVL))

cDuration of action 5 to 10 minutescLowers cerebral metabolic rate while maintaining cere-bral blood flow as long as systemic blood pressure ismaintained within an adequate range

cThiopental may lead to hypotension in critically illpatients due to its vasodilatation properties, especiallywith hypovolemia

sNarcotics

sMorphine, hydromorphone, fentanyl, and remifentanil

reduce pain perception and allay anxiety, making

intuba-tion less stressful

sFentanyl and the ultra-short-acting remifentanil have a

more rapid onset (seconds) and shorter duration of action(about 20 minutes and 5 minutes, respectively) than theconventional narcotics used in the ICU

sMorphine may lead to histamine release and its potential

sequelae

sThough all narcotics cause respiratory depression, the

newer synthetic narcotics may lead to glottic spasm thatmay hamper ventilation

as compared to midazolam

cHypotension may occur with hypovolemia

sNeuromuscular blocking agents

sAdministration of a sedative-hypnotic agent with a acting muscle relaxant, typically succinylcholine, is cited asimproving intubation conditions and leading to fewer com-plications

rapid-sIf one does not fully contemplate the patient’s risk for

air-way management difficulties and does not have access or

a good working knowledge of airway rescue devices ifconventional laryngoscopy techniques fail, disaster mayensue Any clinician who administers drugs such as induc-tion agents, including paralytics, must have developed arescue strategy coupled with the equipment to deploy such

a strategy

sIndications: include agitation or lack of cooperation notrelated to inadequate or no sedation

sNeuromuscular blocking agents may cause depolarization

of the motor end-plate (succinylcholine, a depolarizingagent) or prevent depolarization (nondepolarizer: pancuro-nium, vecuronium, rocuronium)

sSuccinylcholine has a rapid onset and short duration of

effectcIt may raise serum potassium levels by 0.5 to 1.0 mEq/L

cIt is contraindicated in bedridden patients and in thosewith pre-existing hyperkalemia, burns, or recent or long-term neurologic deficits

cOther side effects are elevation of intragastric andintraocular pressures, muscle fasciculation, myalgia,malignant hyperthermia, cardiac bradyarrhythmias, andmyoglobinuria

cAt a dose of 0.25 mg/kg IBW - the ED95 - succinylcholinehas a duration of about 3 minutes This is our recommen-dation, despite the commonly-used dose recommended

in the literature of 1.0 to 1.5 mg/kg IBW

sNondepolarizing muscle relaxants have a longer time to

onset and duration of action as compared to choline

succinyl-cRocuronium (typical OR dose, 0.6 mg/kg) can approachsuccinylcholine in rapid time of onset if dosed at1.2 mg/kg)

sHas a rapid onset and relatively short duration of action

sIts myocardial depressant action is often countered by its

sympathomimetic properties, leading to hypertension and

tachycardia

sUse in the critically ill patient with ongoing activation of

his or her sympathetic outflow could lead to profound

hemodynamic instability, as the underlying myocardial

depression may not be successfully countered

sHas significant bronchodilatory properties but promotes

bronchorrhea, salivation, and a high incidence of dreams,

hallucinations, and emergence delirium (at doses well above

those noted)

sDose at 0.5 to 1 mg/kg leads to anesthesia for about

20 minutes and analgesia for about 60 minutes

sPropofol

sIV administration of 1 to 3 mg/kg IBW results in

uncon-sciousness within 30 to 60 seconds

sAwakening is observed in 4 to 6 minutes.

sHypotension, cardiovascular collapse, and, rarely,

bradycar-dia may complicate its use

sEtomidate

sConsidered the preferred induction agent in the critically ill

patient due to its favorable hemodynamic profile

sRole as a single-dose induction agent is in question due

to its transient depression of the adrenal axis, and this

adrenal suppression may be influential in the outcome of

the critically ill

EQUIPMENT FOR ACCESSING

THE AIRWAY

sEsophageal Tracheal Combitube

sThe esophageal tracheal Combitube (ETC) is recommended

by the American Heart Association Advanced

Cardiovascu-lar Life Support course and other national guidelines as an

advanced variant of the older esophageal obturator airway

and the pharyngeal tracheal lumen airway

sThe double lumens with proximal and distal cuffs allow

ventilation and oxygenation in a majority of nonawake

patients whether placed in the esophagus (95% of all

inser-tions) or the trachea

sThe proximal cuff is placed between the base of the tongue

and the hard palate and the distal cuff within the trachea

or upper esophagus

sThe ETC is inserted blindly, assisted by a jaw thrust or

laryn-goscopic assistance

sLaryngoscopes

sFiberoptic versus conventional is used to expose the glottis

to facilitate passage of the tracheal tube

sThe utility of the laryngoscope under elective circumstances,

with otherwise healthy surgical patients, is essentially

lim-ited to individuals with a grade I or II view that can be easily

intubated

sDifficult view (grade III or IV) has been documented in

14% of patients despite optimizing maneuvers such as

the optimal external laryngeal manipulation (OELM) and

the backward upward right pressure (BURP) technique

(Fig 2.3)

cUp to 33% of critically ill patients have a limited view

with laryngoscopy (epiglottis only or no view at all)

T

C

FIGURE 2.3 Diagrammatic representation of the optimal external laryngeal movement (OELM) and backward upward rightward pres- sure (BURP) maneuvers for optimal visualization of the glottis.

cHence, critical care practitioners responsible for airwaymanagement must be prepared to embark on a plan B orplan C immediately if conventional direct laryngoscopyfails

sBlades

sLaryngoscope blades are of two principal kinds, curved andstraight, varying in size for use in infants, children, or adults(Fig 2.4)

FIGURE 2.4 Various types of laryngoscope blades in common use.

Chapter 2: Airway Management 13

TA B L E 2 3

RECOMMENDED SIZES FOR ENDOTRACHEAL TUBES

Patient age Internal diameter of tube (mm)a

aOne size larger and one size smaller should be allowed for individual

intra-age variations and shorter-stature individuals Where possible,

the subglottic suction endotracheal tube should be used.

sThe stylet is a guide, not a “spear,” and its tip should be

safely inside the ET, never distal to the ET tip

sIdeally, the styleted ET tip should be placed at the entrance

of the glottis, and then, with stylet removal, the ET willadvance into the trachea less traumatically

HOW MIGHT THE AIRWAY BE

ACCESSED?

General Indications and Contraindications

sThe oral approach is the standard method for tracheal

intu-bation today unless there is limited access to the oral cavity

due to trauma, edema, or anatomic difficulties

sIf the nasal approach is not feasible, a surgical approach via

the cricothyroid membrane or a formal tracheostomy would

sAssemble the necessary equipment, such as the ET,

syringes, suction equipment, lubricant, CO2detector, and

a stylet, if desired

sObtain a rapid medical–surgical history.

sReview previous intubation procedures sought.

sComplete an airway examination.

sEnsure IV access and develop a primary plan for induction.

sPlace airway rescue devices at the bedside.

sInsist on clear communication among team members.

sAwake intubation

sAwake intubation techniques comprise both nasal and oralroutes and, most often, involve topically applied local anes-thetics or local nerve blocks

sPractitioners may prefer to maintain spontaneous lation during emergency airway management by avoidingexcessive sedative–hypnotic agents and/or muscle relaxants

venti-sLight sedation and analgesics, however, are typically

administered despite the label of being “awake.”

sAfter proper preparation, unless the patient is unconscious

or has markedly depressed mental status, the “awake look”

technique incorporates conventional laryngoscopy to uate the patient’s airway to gauge the feasibility and ease ofintubation

eval-sIf viewing the airway structures during an “awake look”

proves fruitful, intubation should be performed during thesame laryngoscopic attempt either directly—grade I or IIview—or by bougie assistance—grade I, II, or III—or byother means

sRapid sequence intubation (RSI)

sRSI refers to the administration of an induction agent lowed by a neuromuscular blocking agent, with the goal

fol-FIGURE 2.5 Ramping of an obese patient’s torso to improve glottic visualization is noted on the left

panel The right panel shows the patient position without proper ramping.

of hastening the time needed to induce unconsciousness

and muscle paralysis and minimizing the time the airway

is unprotected with less risk of aspiration

sPreoxygenation is paramount via a bag-mask.

sCricoid pressure is applied to reduce the risk of passive

regurgitation of any stomach contents

cCricoid pressure may sometimes worsen the

laryngo-scopic view, plus impede mask ventilation; hence, ment or release of cricoid pressure should be considered

adjust-in these circumstances

sRSI is said to be associated with a lower incidence of

com-plications and higher first-pass intubation success rate as

compared to the “sedation only” method

sA predetermined induction regimen, such as etomidate

and succinylcholine—0.25 mg/kg IBW etomidate and

0.25 mg/kg IBW of succinylcholine—generally works well

for most critically ill patients

Positioning the Patient

sOne of the most important factors in improving the success

rate of orotracheal intubation is positioning the patient

prop-erly (see Fig 2.1)

sClassically, the sniffing position, namely cervical flexion

combined with atlanto-occipital extension, will assist in

improving the “line of sight” of the intubator

sBringing the three axes into alignment (oral, pharyngeal,

and laryngeal) is commonly optimized by placing a firm

towel or pillow beneath the head (providing mild cervical

flexion) combined with physical backward movement of the

head at the atlanto-occipital joint via manual extension

sThis, when combined with oral laryngoscopy, will improve

the “line of sight” for the intubator to better visualize the

laryngeal structures in most patients

sOptimizing the position of the obese patient (see Fig 2.5,

left panel) is an absolute requirement to assist with the

fol-lowing:

sSpontaneous ventilation and mask ventilation

sOpening the mouth

sGaining access to the neck for cricoid application,

manip-ulation of laryngeal structures, or invasive procedures

sImproving the “line of sight” with laryngoscopy

sProlonging oxygen saturation after induction

Blade Use

sCurved blade

sAfter opening of the mouth either by the extraoral technique

(finger pressing downward on chin) or the intraoral method

(the finger scissor technique to spread the dentition), the

laryngoscope blade is introduced at the right side of the

mouth and advanced to the midline, displacing the tongue

to the left

sThe epiglottis is seen at the base of the tongue and the tip

of the blade inserted into the vallecula

sThe laryngoscope blade should be lifted toward an

imagi-nary point in the corner of the wall opposite the patient to

avoid using the upper teeth as a fulcrum for the

laryngo-scope blade

sA forward and upward lift of the laryngoscope and

blade stretches the hyoepiglottic ligament, thus folding the

epiglottis upward and further exposing the glottis

sWith visualization of the glottic structures, the ET is passed

to the right of the laryngoscope through the glottis into the

trachea until the cuff passes 2 to 3 cm beyond the vocalcords

sA blind guide underneath the epiglottis (tracheal tube

introducer, bougie) or a rigid fiberoptic stylet may be porated to improve the insertion success rate

incor-sStraight blade

sIntubation with a straight blade involves the same vers but with one major difference

maneu-sThe blade is slipped beneath the epiglottis, and exposure of

the larynx is accomplished by an upward and forward lift

at a 45-degree angle toward the corner of the wall oppositethe patient

cLeverage must not be applied against the upper teeth

sRepetitive laryngoscopies are not in the best interest ofpatient care and may place the patient at extreme risk forpotentially life-threatening airway-related complications

sConventional laryngoscopy should be abandoned in favor

of incorporating an airway adjunct to assist the clinician

Nasotracheal Intubation

sNasotracheal intubation is still commonly used in oral andmaxillofacial operative interventions but less commonly inemergency situations outside the OR

sThe presence of midfacial or posterior fossa trauma andcoagulopathy are absolute contraindications to this tech-nique It is also contraindicated in the presence of acutesinusitis or mastoiditis and best avoided in patients with abasilar skull fracture, a fractured nose, or nasal obstruction

sAs the nasal portal dictates a smaller-diameter tracheal tube,the length of the tracheal tube will be shortened; hence, thelength must be considered when placing a small-caliber tube(e.g., a 6.0-mm diameter in an individual taller than about

69 inches), as the nasal tracheal tube may end up as anelongated nasal trumpet, without entrance into the trachea

sThe method of intubation via the nasal approach is variable.

sIt may be placed blindly during spontaneous ventilation,combined with oral laryngoscopic assistance to aid with ETadvancement utilizing Magill forceps; utilize indirect visu-alization through the nares via an optical stylet or a flexible

or rigid fiberscope; or incorporate a lighted stylet for sillumination of the laryngeal structures

oxymeta-sThis is followed by progressive dilation, starting with either

a 26 French or 28 French nasal trumpet, and progressing

to a No 30 French to No 32 French trumpet lubricatedwith 2% lidocaine jelly Conversely, placement of cottonpledgets soaked in a mixture of vasoconstrictor agent andlocal anesthetic is equally effective

sSupplemental oxygen may be provided by nasal cannulaeplaced between the lips or via a face mask

sThe patient is best intubated with spontaneous ventilationmaintained

sIncremental sedation/analgesia may be provided Sitting

upright has the advantage of maximizing the geal diameter

oropharyn-Chapter 2: Airway Management 15

sOrientation of the tracheal tube bevel is important for

patient comfort and to reduce the risk of epistaxis andtearing or dislocation of the nasal turbinates On eitherside of the nose, the bevel should face the turbinate (awayfrom the septum)

sTube advancement should be slow and gentle, with

rota-tion

sIf advancement is met with resistance from glottic/anterior

tissues, helpful maneuvers include sitting the patientupright, flexing the head forward on the neck, and manu-ally pulling the larynx anteriorly

sConversely, if advancement is met with posterior

dis-placement into the esophagus, sitting the patient upright,extending the head on the neck, and applying posterior-directed pressure on the thyrocricoid complex may assist

in intubation

cRotation of the tube and manual depression or elevation

of the larynx may be required to succeed

cVoluntary or hypercapnic-induced hyperpnea helps if thepatient is awake because maximal abduction of the cords

is present during inspiration

sEntry into the trachea is signified by consistent breath

sounds transmitted by the tube and inability to speak, if

the patient is breathing, and by lack of resistance, often

accompanied by cough Confirmation with end-tidal CO2

measurement or fiberoptic viewing is imperative

sNasotracheal intubation may also be accomplished with

fiberoptic assistance.

sAdvancement of the ET into the glottis may be impeded

by hang-up on the laryngeal structures: the vocal cord, theposterior glottis or, typically, the right arytenoid

sWhen resistance is met, a helpful tip is as follows:

With-drawing the tube 1 to 2 cm, rotate the tube wise 90 degrees, and then readvance with the bevel facingposteriorly

counterclock-sMatching the tracheal tube to the fiberscope to minimize

the gap between the internal diameter of the tube and thescope may also improve advancement

sTracheal confirmation and tip positioning are added

advantages to fiberoptic-assisted intubation

sThe nasal approach has decreased in popularity due to

sA restriction of tube size

sThe potential to add epistaxis to an already tenuous airway

sConfirmation of ET location after intubation is imperative

and consists of the following:

sObservation of the ET passing through the vocal cords

sAbsence of gurgling over the stomach with bag-valve

venti-lation

sChest rise with bag-valve ventilation

sPresence of condensation upon exhalation

sPresence of breath sounds over the lateral midhemithoraces

sPresence of CO

Capnography

sIdentification of exhaled CO2 measured via disposable orimetric devices or capnography is a standard of practice

col-sCapnography may fail due to

sLow-flow or no-flow cardiac states (no pulmonary blood

flow as a source of exhaled carbon dioxide)

sSoilage from secretions, pulmonary edema fluid, or blood,

temperature alterations (outside helicopter rescue), age,lack of maintenance

Other Devices

sEsophageal detector devices

sSyringe or the self-inflating bulb models (Fig 2.6) assist inthe detection of ET location based on the anatomic dif-ference between the trachea (an air-filled column) and theesophagus (a closed and collapsible column)

sApplying a 60-mL syringe to the ET and withdrawing air

should collapse the esophagus, while the trachea shouldremain patent

cFalse-negative results may still be seen (no reinflationeven though the ET is in the trachea) in less than 4% ofcases

cTechnique failures include ET soilage, carinal orbronchial intubation in the obese, and those with severepulmonary disease (chronic obstructive pulmonary dis-ease, bronchospasm, thick secretions, or aspiration), andgastric insufflation

sTwo infallible or fail-safe techniques when used under mal conditions

opti-sVisualizing the ET within the glottis

sFiberoptic visualization of tracheal/carinal anatomy

FIGURE 2.6 Esophageal detector devices, either the syringe or the self-inflating bulbs, assist in the detection of endotracheal tube location based on the anatomic difference between the trachea (an air-filled column) and the esophagus (a closed and collapsible column) Note that a 15-mm adaptor inserts onto the tip of the bulb syringe so that the connection may be made.

Cheney Test

sClinically useful adjunct for assisting in the verification of the

ET location

sHang-up test

sPassing a bougie or similar catheter-like device for the

purpose of detecting tip impingement on the carinal or

bronchial lumen

sGently advancing a bougie to 27 to 35 cm depth may allow

the practitioner to appreciate hang-up on distal structures

cCompared to unrestricted advancement if ET is in

esoph-aguscCare must be taken not to perforate the trachea

DEPTH OF ENDOTRACHEAL

TUBE INSERTION

sClassic depth of insertion is height and gender based.

sAlso affected by the route of ET placement (i.e., oral vs.

nasal)

sFinal tip position is best at about 2 to 4 cm above the carina

to limit irritation with head movement and patient

reposi-tioning

sET depth in the adult patient less than or equal to 62 inches

(157 cm) in height should be approximately 18 to 20 cm

sOtherwise, 22 to 26 cm may be the appropriate depth.

sChest radiography only determines the tip depth at the

time of film exposure

AMERICAN SOCIETY OF ANESTHESIOLOGISTS PRACTICE

GUIDELINES

sAirway management procedures should be accompanied by

capnography or similar technology to reduce the incidence of

unrecognized esophageal intubation

sPreintubation evaluation to recognize the potential difficult

airway is paramount (Table 2.4)

sIs there a reasonable expectation for successful mask

venti-lation?

sIs intubation of the trachea expected to be problematic?

sShould the airway approach be nonsurgical or surgical?

sShould an awake or a sedated/unconsciousness approach be

pursued?

sShould spontaneous ventilation be maintained?

sShould paralysis be pursued?

Awake Pathway

sIf difficulty is recognized, an awake approach may be

appro-priate

sPatient preparation with an antisialagogue, assembling

equipment and personnel, discussion with the patient, and

optimal positioning should be pursued unless emergent

sThe awake choices, following optimal preparation,

sMay allow an “awake look” with conventional

laryn-goscopy

sMay allow bougie-assisted intubation

sMay allow laryngeal mask airway (LMA) insertion

sMay allow indirect fiberoptic techniques (rigid and

flexi-ble) or proceeding with a surgical airway

sAccess to the airway via cricothyroid membrane puncture vialarge-bore catheter insertion with either modified tubing or ajet device to ventilate, or via Melker cricothyrotomy kit, is anoption prior to other awake or asleep methods

Asleep Pathway

sAfter induction in the patient with a known or suspected ficult airway or in the unrecognized difficult airway (Table2.5)

dif-sAbility to adequately mask ventilate will determine direction

of management

sMask ventilation adequate but conventional intubation is

difficultcThe nonemergency pathway is appropriate, utilizing thebougie, specialty blades, supraglottic airway, flexible orrigid fiberoptic technique, or surgical airway

cMask ventilation is suboptimal or impossible, intubation

of the trachea may be attempted, but immediate ment of a supraglottic airway such as the LMA is thetreatment of choice

place-cIf the supraglottic device fails, an extraglottic device such

as the Combitube or similar device can be placed

– Otherwise, transtracheal jet ventilation may be used or

a surgical airway placed

COMPLICATIONS RELATED TO ACCESSING THE AIRWAY

sComplications occur in four time periods (Tables 2.6 – 2.9):

ven-sCuff pressures above 25 to 35 mm Hg further add to risk

by compressing tracheal capillaries

sOther factors include the duration of intubation, tion, and route of intubation More complications occurfrom: nasal intubation versus oral, patient-initiated self-extubation, excessive tracheal tube movement, trauma dur-ing procedures, poor tube care

reintuba-Failed Intubation

sIn the clinical situation of can’t ventilate, can’t intubate, thepractitioner will need to rapidly deploy the rescue plan

sAfter failure of conventional mask ventilation (no

ventila-tion or oxygen delivery) or when mask ventilaventila-tion is failing

(inadequate gas exchange, SpO2less than 90%, or a falling SpO2)

sSupraglottic airway (LMA) should be placed.

sIf unsuccessful, placement of the LMA, the Combitube

may serve as a backup for LMA failure

Chapter 2: Airway Management 17

TA B L E 2 5

STRATEGY FOR EMERGENCY AIRWAY

MANAGEMENT OF THE CRITICALLY ILL PATIENT

1 Conventional intubation—grade I or II view

2 Bougie—grade III view

a May use for grade I and II if needed

3 LMA/supraglottic device—grade III or IV view

a LMA/supraglottic rescue for bougie failure

b Or use the LMA/supraglottic device as a primary device

(i.e., known difficult airway, cervical spine limitations,Halo-vest)

4 Combitube—rescue device for any failure or as a primary

device if clinically appropriate

5 Fiberscope (optical/video-assisted rigid or flexible

models)—primary mode of intubation, an adjunct for

intubation via the LMA

LMA, laryngeal mask airway.

cBoth devices have a high rate of success for ventilation,

are placed rapidly and blindly, and require a relativelysimple skill set

sLimiting intubation attempts is a key to successful

manage-ment

sRepeated attempts are probably futile (e.g., a grade IV view

with conventional methods) and markedly increase the risk

of hypoxemia and other potentially devastating

sKey point: Use them early and use them often.

sMore invasively, transtracheal jet ventilation via a

large-gauge (12- or 14-large-gauge) IV catheter through the

cricothy-roid membrane may be an appropriate alternative

sHowever, advanced planning with ready access to the properequipment and a sound understanding of “jetting” princi-ples (lowest PSI setting to maintain SpO2in the 80%–90%

range, prolonged inspiration-to-expiration ratio [i.e., 1:5],6–12 quick breaths per minute, allowing a path for exha-lation, constant catheter stabilization, and barotrauma vig-

ilance) must be followed; otherwise, the consequences may

s“Difficult extubation” is defined as the clinical situation

when a patient presents with known or presumed risk tors that may contribute to difficulty re-establishing access

fac-to the airway

sReintubation, immediately or within 24 hours, may be

required in up to 25% of intensive care unit patients

cMeasures to avert reintubation such as noninvasive tilation may reduce mortality rate if done so upon extu-bation

ven-PARAMETERS OF AIRWAY EVALUATION FOR EXTUBATION

NPO Status

sAlthough not thoroughly studied, it makes clinical sense toconsider 2 to 4 hours off of distal enteral feeds prior to

TA B L E 2 6

RISKS OF TRACHEAL INTUBATION

Tube placement Corneal abrasion; nasal polyp

dislodgement; bruise/laceration oflips/tongue; tooth extraction;

retropharyngeal perforation; vocalcord tear; cervical spine subluxation

or fracture; hemorrhage; turbinatebone avulsion

Esophageal/endobronchialintubation; delay incardiopulmonaryresuscitation; ET obstruction;

accidental extubation

Dysrhythmia; pulmonaryaspiration; hypertension;

hypotension; cardiac arrest

Tube in place Tear/abrasion of larynx, trachea,

bronchi

Airway obstruction; proximal ordistal migration of ET;

complete or partialextubation; cuff leak

Bacterial infection (secondary);

gastric aspiration; paranasalsinusitis; problems related tomechanical ventilation (e.g.,pulmonary barotrauma)Extubation Tear/abrasion of larynx, trachea,

bronchi

Difficult extubation; airwayobstruction from blood,foreign bodies, dentures, orthroat packs

Pulmonary aspiration; laryngealedema; laryngospasm;

tracheomalacia; intolerance ofextubated state

ET, endotracheal tube.

Chapter 2: Airway Management 19

TA B L E 2 7

AIRWAY COMPLICATIONS CONTRIBUTING TO HYPOXEMIA

Esophageal intubation Regurgitation/aspiration

Mainstem bronchial intubation Multiple attempts

Inadequate or no preoxygenation Duration of laryngoscopy attempt

Failure to “reoxygenate” between attempts Airway obstruction, unable to ventilate

Tracheal tube occlusion: Biting, angulation Accidental extubation after intubation

Tracheal tube obstruction after intubation Bronchospasm, coughing, bucking

Due to:

Particulate matterBlood clotsThick, tenacious secretions

extubation and maintaining the NPO status after extubation

until the patient appears at low risk for failing the extubation

“trial.”

Cuff Leak

sHypopharyngeal narrowing from edema or redundant

tis-sues, supraglottic edema, vocal cord swelling, and narrowing

in the subglottic region of any etiology may contribute to the

lack of a cuff leak

sToo large a tracheal tube in a small airway should be

con-sidered

sIf airway edema is the culprit

sSteps to decrease airway edema include elevation of the

head, diuresis, steroid administration, minimizing furtherairway manipulation, and “time.”

sThe performance of a cuff leak test varies by institution and

protocol

sA relatively crude yet effective method of cuff leak test

involves auscultation for cuff leak with or without a

Sympathetic surge, vasovagal response

Excessive parasympathetic tone

Loss of spontaneous respirations

Positive pressure ventilation

Positive end-expiratory pressure (PEEP)

Auto- or intrinsic PEEP

Hyperventilation with pre-existing hypercarbia

Decrease in patient work

Underlying disease process (i.e., myocardial insufficiency)

Volume imbalances (sepsis, diuretics, hypovolemia,

hemorrhage)

Preload dependent physiology

Valvular heart disease, congestive heart failure, pulmonary

embolus, right ventricular failure, restrictive pericarditis,cardiac tamponade

Hypoxia-related hemodynamic deterioration

Hyperkalemia-induced deterioration (succinylcholine)

sCuff leak volume (CLV) may be measured as the difference

of tidal volume delivered with and without cuff deflationand stated as a percentage of leak or as an absolute vol-ume An absolute CLV less than 110 to 130 mL or 10%

to 24% of delivered tidal volume is helpful in predictingpostextubation stridor

cSingle- or multiple-dose steroids may reduce bation airway obstruction in pediatric patients

postextu-cSteroid use in adults (1–4 mg dexamethasone IV) istered 6 hours prior to extubation—rather than 1 hourprior—may reduce postextubation stridor

admin-Risk Assessment: Direct Inspection

sConventional laryngoscopy is a standard choice for

eval-uation but often fails due to a poor “line of sight.”

sFlexible fiberoptic evaluation is useful but may be limited

by secretions and edema

sVideo-laryngoscopy and other indirect visualization

tech-niques that allow one to see “around the corner” are cially helpful

espe-TA B L E 2 9

TRACHEAL INTUBATION COMPLICATIONS SEEN AFTER EXTUBATION

Time of occurrence Complications

Early (0–72 h) Numbness of tongue

Sore throatLaryngitisGlottic edemaVocal cord paralysisLate (>72 h) Nostril stricture

Laryngeal ulcer, granuloma, or polypLaryngotracheal webs

Laryngeal or tracheal stenosisVocal cord synechiae

TA B L E 2 1 0

RISK FACTORS FOR DIFFICULT EXTUBATION

Known difficult airway

Suspected difficult airway based on the following factors:

Restricted access to airway

Cervical collar, Halo-vest

Head and neck trauma, procedures, or surgery

ET size, duration of intubation

Head and neck positioning (i.e., prone vs supine)

Traumatic intubation, self-extubation

Patient bucking or coughing

Drug or systemic reactions

Angioedema

Anaphylaxis

Sepsis-related syndromes

Excessive volume resuscitation

ET, endotracheal tube.

AMERICAN SOCIETY OF ANESTHESIOLOGISTS PRACTICE

GUIDELINES STATEMENT REGARDING EXTUBATION OF THE

DIFFICULT AIRWAY

sThe American Society of Anesthesiologists guidelines have

suggested that a preformulated extubation strategy should

include:

sConsideration of relative merits of awake extubation versus

extubation before the return of consciousness (clearly more

applicable to the OR setting than to the ICU)

sConsideration of the short-term use of a device that can

serve as a guide to facilitate intubation and/or provide a

conduit for ventilation/oxygenation

Clinical Decision Plan for the Difficult Extubation

sA variety of methods are available to assist the practitioner’s

ability to maintain continuous access to the airway after

extu-bation, each with limitations and restrictions

TA B L E 2 1 1

THE DIFFICULT EXTUBATION: TWO CATEGORIES

FOR EVALUATION

1 Evaluate the patient’s inability to tolerate extubation

a Airway obstruction (partial or complete)

b Hypoventilation syndromes

c Hypoxemic respiratory failure

d Failure of pulmonary toilet

e Inability to protect airway

2 Evaluate for potential difficulty re-establishing the airway

a Difficult airway

b Limited access to the airway

c Inexperienced personnel pertaining to airway skills

d Airway injury, edema formation

b Individual competent with surgical airway?

3 Prepare circumferential tape to secure the airway catheterafter extubation

4 Sit patient upright; discuss with patient

5 Suction ET, nasopharynx, and oropharynx

6 Pass lubricated AEC to 23–26 cm depth

7 Remove the ET while maintaining the AEC in its originalposition

8 Secure the AEC with the tape (circumferential); markAEC “airway only”

11 Aggressive pulmonary toilet

ET, endotracheal tube.

sThe LMA offers the ability for fiberoptic-assisted tion of the supraglottic structures while serving as a venti-lating and reintubating conduit

visualiza-sThe bronchoscope is useful for periglottic assessment afterextubation but requires advanced skills and minimal secre-tions

sThe airway exchange catheter (AEC) allows continuouscontrol of the airway after extubation, is well tolerated inmost patients, and serves as an adjunct for reintubation andoxygen administration Dislodgment may occur, resultantfrom an uncooperative patient or a poorly secured catheter

Observation in a monitored environment with experiencedpersonnel is top priority (Table 2.12)

sClinical judgment and the patient’s cardiopulmonary and

other systemic conditions, combined with the airway tus, will guide in establishing a reasonable time period formaintaining a state of “reversible extubation” with theindwelling AEC (Table 2.13)

Difficult airway, respiratory issues, multipleextubation failures >4 h