Introduction Contributors 

The Illustrator

The Consultant for Point of Care Ultrasound (POCUS)

Chapter 1 The Art of the Patient Presentation 

1.1 Welcome to Acute Hospital Medicine

1.2 How to Summarize Your Patient

1.3 Structure Those Random Thoughts

1.4 Think Data—Diagnosis—Direction

1.5 A Sample Presentation

Chapter 2 Acute Care Chest Radiology 

2.1 Basics of Reading Portable Chest Radiographs

 Is the Radiograph Worth Reading?

 Ignore the Most Interesting Findings

 Get to the Heart of the Matter

 The Pleural Space and Costophrenic Angles

 Finally, the Lungs!

2.2 Our Top Ten X-Ray Bad Guys

 #10 Mediastinal and Hilar Masses

 #9 Pericardial Effusion and Tamponade

 #8 Pulmonary Hypertension and Pulmonary Emboli

 #7 Tube Mishaps

 #6 Pneumothorax and Barotrauma

 #5 Effusions, Empyema, and Hemothorax

 #4 Atelectasis and Lobar Collapse

 #3 Congestive Heart Failure

 #2 Pneumonia

 #1 Adult Respiratory Distress Syndrome

Suggested Reading

  Chapter 3 Point of Care Ultrasound (Pocus) 

3.1 The Three Goals of POCUS

 Procedural Guidance

 Diagnosis

 Shock Management

3.2 POCUS Lingo

3.3 Our Top Ten POCUS Findings in the ICU

 Vessel Location for Catheter Placement

 Pneumothorax

 Pleural Fluid

 Lung Patterns

 Left Ventricle and Right Ventricle Dysfunction

 Valvular Vegetation

 Inferior Vena Cava (IVC) Size

 Distended Bladder

 Peritoneal Fluid

 Deep Venous Thrombosis (DVT)

3.4 POCUS Focus

Chapter 4 Sepsis and Resuscitation 

4.1 Sepsis Defined

4.2 Sepsis and Shock

4.3 Initial Sepsis Management

 Reverse Hypoxemia and Limited Ventilation

 Reverse Hypotension and Support Organ Perfusion

4.4 Fluid Administration in Sepsis

 Crystalloids vs. Colloids

4.5 Vasopressors and Inotropes

4.6 Assessment of Tissue Oxygenation

 Mixed Venous Oxygen Saturation

 Blood Lactate

4.7 Hydrocortisone and Septic Shock

4.8 Antibiotics and Source Control

Suggested Reading

  Chapter 5 Management of Tachyarrythmias 

5.1 Do I Have Time to Think?

5.2 What is the Diagnosis?

 Narrow Complex Tachycardia

 Wide Complex Tachycardia

5.3 How Do I Stop the Arrhythmia?

 Sinus Tachycardia

 Atrial Fibrillation and Flutter

 Multi-focal Atrial Tachycardia

 Paroxysmal Supraventricular Tachycardia (PSVT)

 Ventricular Tachycardia

5.4 What is the Rhythm Trying to Tell Me?

5.5 Do I Need to Anticoagulate?

Suggested Reading

  Chapter 6 Running a Code 

6.1 Chest Compressions

6.2 Circulation: Take Charge and Shock

 Defibrillators

 Pulseless and a Shockable Rhythm

 Pulseless Electrical Activity (PEA)

 Pulseless and Asystole (Flat Line)

6.3 Breathing and Airway

6.4 Post-Arrest Care

Suggested Reading

  Chapter 7 Hemodynamic Monitoring 

7.1 Arterial Blood Pressure

 The Arterial Catheter

7.2 Pressure Transducers

7.3 Vascular Pressures and the Pulmonary Artery Catheter

 Atrial Pressures and Waveforms

 Ventricular Pressures and Waveforms

 Pulmonary Artery Pressure and Waveforms

7.4 Cardiac Chamber Pressures and Pericardial Disease

7.5 Cardiac Output

7.6 Vascular Resistance

7.7 Shock and Hemodynamic Assessment

 Hypovolemic Shock

 Cardiogenic Shock

 Distributive Shock

7.8 Limitations of the Pulmonary Artery (PA) Catheter

7.9 Hemodynamic Assessment without the PA Catheter

 Techniques to Change Preload

 Techniques to Assess Stroke Volume

 Inferior Vena Cava Diameter

 Miscellaneous Methods for Preload Assessment

7.10 Hemodynamic Approach to Your ICU Patient

Suggested Reading

  Chapter 8 Acute coronary syndromes 

8.1 Step 1: Cool down the Heart

8.2 Step 2: Classify the ACS Syndrome (STEMI, Unstable Angina, NSTEMI)

 The ECG

 Cardiac Biomarkers

 ST Elevation Myocardial Infarction (STEMI)

 Non-ST Elevation Myocardial Infarction (NSTEMI) and Unstable Angina (UA)

8.3 Step 3: Crush the Platelets

8.4 Step 4: Bash the Coagulation System for UA and NSTEMI

8.5 Step 5: Blast Open the Obstruction for STEMI and High-Risk NSTEMI

 Treatment at a PCI-Capable Hospital

 Pharmacologic Therapy for Non-PCI-Capable Hospital

 Coronary Artery Bypass Grafting (CABG)

8.6 Wrapping it up

Suggested Reading

  Chapter 9 Acute Decompensated Heart Failure 

9.1 Diagnosis of Decompensated Left Heart Failure

 Imaging

 Brain Natriuretic Peptide

 Echocardiography

9.2 Treatment of Acute Decompensated Left Heart Failure

 Reduce Left Ventricular Filling Pressure (Preload)

 Reduce Systemic Vascular Resistance (Afterload)

 Fix the Broken Heart (Dam)—Increase Cardiac Output

 Find the Cause

 Arrythmia Management

 Hypertension Management

9.3 Diagnosis of Pulmonary Hypertension and Right Heart Failure

 Pulmonary Hypertension Classification

 Pulmonary Hypertension Diagnosis

 Why Pulmonary Hypertension Matters

9.4 Treatment of Pulmonary Hypertension in the Hospital

 Nitric Oxide

 Endothelin A and B Receptor Blockers

 Prostanoids

 Inotropes

 Heroics

9.5 Pulmonary Hypertension with Shock

Suggested Reading

  Chapter 10 High Systemic Arterial Blood Pressure 

10.1 Pathophysiology of Hypertensive Urgency

10.2 Patient Assessment

10.3 Drug Therapy

 Calcium Channel Blockers

 Nitric Oxide Vasodilators

 Beta-Blockers

 Miscellaneous Medications

10.4 Hypertensive Emergency Clinical Syndromes

 Cardiovascular Disease

 Cerebrovascular Disease

 Subarachnoid Hemorrhage (SAH)

 Renovascular Disease

 Excess Catecholamine States

 Miscellaneous Conditions

  Chapter 11 Pulmonary Thromboembolic Disease 

11.1 Pathophysiology

 Right Heart Failure in PE

 Gas Exchange in PE

11.2 Diagnosis and Risk Stratification

 Diagnostic Risk – PE Clinical Decision Rules

 Mortality Risk

11.3 Treatment of Massive PE

 Oxygenate and Ventilate

 Optimize RV Cardiac Output

 Reduce RV Afterload with Anticoagulation

 To Lyse or Not to Lyse

11.4 Treatment of Submassive PE

Suggested Reading

  Chapter 12 Basic Airway Management 

12.1 Establish a Patent Airway with Ventilation

12.2 Clinical Clues for a Difficult Intubation

12.3 Key Steps to a Successful Airway

12.4 Endotracheal Intubation

 The Tools

 Pre-oxygenation

 Intubation Pharmacology

 Post-intubation Hemodynamics

12.5 The Difficult Airway

12.6 Changing the Endotracheal Tube

Suggested Reading

  Chapter 13 Acute Respiratory Failure 

13.1 Assessment of Arterial Blood Oxygenation

 Partial Pressure of Oxygen (PaO2)

 Pathophysiology of Hypoxemia

 Non-invasive Oxygen Saturation (SpO2)

 Assessment of Tissue Oxygen Delivery (DO2)

13.2 Supplemental Oxygen and Hypoxemic Respiratory Failure

 Low-Flow Oxygen Systems

 High-Flow Oxygen Systems

 High-Flow Nasal Cannula

 Fixing Hypoxemia

13.3 Assessment of Ventilation (PaCO2 )

 Non-Invasive Assessment of Carbon Dioxide

13.4 Hypercapnic Respiratory Failure

 Primary and Secondary Compensation

 Etiology of Ventilation Disorders in the ICU

Suggested Reading

  Chapter 14 Mechanics of Respiratory Failure 

14.1 Simple Mechanics of Lung Inflation – the EOM

14.2 Compliance/Elastance and Pleural Pressure

            Measurement of Compliance

14.3 Resistance and Time Constants

 Measurement of Airways Resistance

14.4 Let’s Put it Together

Suggested Reading

  Chapter 15 Mechanical Ventilation 

15.1 Ventilator Components

15.2 Setting the Breath Rate (Triggering)

 Pressure-Based Triggering

 Flow-Based Triggering

15.3 Setting the Breath Type

 Control Breaths

 Support Breaths

15.4 Modes of Mechanical Ventilation—The Full Monty

 Control (Assist Control) Ventilation

 Intermittent Mandatory Ventilation (IMV)

 Spontaneous Mode of Ventilation

 APRV and BiLevel Ventilation

15.5 Mode summary

15.6 Positive End-Expiratory Pressure—PEEP, CPAP, and EPAP

 Adverse Effects of End-Expiratory Pressure

15.7 How to Set Your Best PEEP on the Ventilator

15.8 Extrinsic vs. Intrinsic PEEP

15.9 Mean Airway Pressure and Oxygenation

Suggested Reading

  Chapter 16 Acute Respiratory Distress Syndrome (Ards) 

16.1 ARDS Ridiculously Simple Overview

16.2 Berlin Definition

16.3 Causes of ARDS

16.4 Pathophysiology of ARDS

 ARDS as a Heterogeneous Lung Disease

16.5 Airway Management in ARDS

16.6 ARDS and the Ventilator – First Do No Harm

 Oxygen Toxicity: Hyperoxic Lung Injury

 Barotrauma—No Pressure!

 Volutrauma—Turn Down the Volume!

 Atelectrauma—The Elusive Best Peep!

16.7 Mechanical Ventilation in ARDS

 Control Breaths

 PEEP Management

 Alveolar Recruitment Maneuvers

16.8 Fluid Management in ARDS—Wet or dry?

16.9 Approach to Intractable Hypoxemia in ARDS

Pharmacologic Paralysis

Prone Ventilation

Inhaled Vasodilators

High-frequency Oscillation

APRV and Bilevel Ventilation

Extracorporeal Support

Hypoxemia Overview

16.10 The Little Things

16.11 Prognosis

Suggested Reading

  Chapter 17 Obstructive Lung Disease (Old) and Respiratory Failure 

17.1 Pathophysiology of Airflow Obstruction

17.2 Intrinsic PEEP (PEEPi) in OLD

 Intrinsic PEEP Assessment

Complications of Intrinsic PEEP

 Limiting Intrinsic PEEP in OLD

17.3 Mechanical Ventilation in OLD

 Non-Invasive Mechanical Ventilation in OLD

 Invasive Mechanical Ventilation in OLD

 Ventilator Management in OLD

17.4 Drug Therapy in OLD

 Antibiotics

 Bronchodilators

 Corticosteroids

           Miscellaneous Interventions

17.5 Patient Outcome

Suggested Reading

  Chapter 18 Weaning From Mechanical Ventilation 

18.1 Control That SOB

18.2 Spontaneous Breathing Trial (SBT)

 Spontaneous Breathing Trial Intolerance

 Removing the Tube

18.3 Non-invasive Ventilation (NIV) and Weaning

18.4 Alternatives to the SBT Trial

18.5 Beyond the SBT Trial – Pain, Sedation, and Delirium

 Sedation Management: Less Is More

 Pain Management

 Delirium

 Early Mobility in the ICU

18.6 Coordination of Ventilator Care – Know Your Alphabet?

18.7 When Is a Tracheostomy Indicated?

 Timing and Technique of Tracheostomy

 Type and Size of the Tracheotomy Tube

 Care of the Tracheotomy Tube

 Swallowing

 Decannulation

Suggested Reading

  Chapter 19 Bleeding, Clotting and Hematological Emergencies 

19.1 Clotting Cascade: Help Me Memorize!!!

 Extrinsic or Tissue Factor Pathway

 Intrinsic or Contact (collagen) Activation Pathway

 Anti-Clotting Pathways

19.2 Overview of Bleeding and Clotting disorders

 Things that Elevate the PT-INR

 Things that Elevate the PTT

 Things that Elevate both PT-INR and PTT

19.3 Top four Bad Boys of ICU Hematology

 Public Enemy #1: Heparin-Induced Thrombocytopenia (HIT)

 Public Enemy #2: Disseminated Intravascular Coagulation (DIC)

 Public Enemy #3: Thrombotic Thrombocytopenic Purpura (and HELLP! and HUS!)

 Public Enemy #4: Catastrophic Antiphospholipid Antibody Syndrome (CAPS)

Suggested Reading

  Chapter 20 Transfusion Medicine 

20.1 Quick-Thinking Rapid Transfusion

20.2 Red Blood Cell Transfusions

 When to Transfuse?

 Complications of Red Blood Cell Transfusion

20.3 Platelets

20.4 Fresh Frozen Plasma (FFP)

20.5 Cryoprecipitate

20.6 Recombinant Factor VIIa (Novo-Seven)

20.7 Four-Factor Prothrombin Complex Concentrate

Suggested Reading

  Chapter 21 Acute Kidney Injury 

21.1 Classification of Acute Kidney Injury

21.2 Drug-induced Acute Kidney Injury

21.3 Prevention of Acute Kidney Injury

 Hypoperfusion

 Contrast-Induced AKI

 Aminoglycoside Nephropathy

21.4 Management of Acute Kidney Injury

 Diuretic Use in AKI

 Dialysis Therapy

 Dialysis Methods

 Dialysis Dose

Suggested Reading

  Chapter 22 Gastrointestinal Bleeding 

22.1 ABC’s (and D) of GI Bleeding

 Access

 Blood and Blood Products

 Call for Help

 Diagnose the Bleeding Source

Suggested Reading

  Chapter 23 Acid-Base Disorders 

23.1 Simple Acid-Base

23.2 Primary Disturbance and Secondary Compensation

23.3 The Four Steps of Acid-Base Analysis

 STEP 1: Define the Primary Disorder

 STEP 2: Assess the Compensation

 STEP 3: Calculate the Anion Gap

 STEP 4: Calculate the Delta Gap

23.4 Respiratory Acid-Base Disorders

 Respiratory Acidosis

 Respiratory Alkalosis

23.5 Metabolic Acid-Base Disorders

 Metabolic Acidosis and the Anion Gap

 Metabolic Acidosis and the Osmolar Gap

 Anion Gap Metabolic Acidosis and Management

 Non-Anion Gap Acidosis

23.6 Metabolic Alkalosis

 Contraction Alkalosis

 Post-Hypercapnic Metabolic Alkalosis

 Mineralocorticoid Excess

Suggested Reading

  Chapter 24 Drug Overdose 

24.1 The Basics

 Resuscitate and Stabilize

 Confirm Diagnosis and Toxin

 Antidotes and Toxin Elimination

 The Overdose Booby Traps

24.2 Specific Overdoses

 Acetaminophen

 Alcohols

 Benzodiazepines

 Slow it Down: Beta Blockers and Calcium Channel Blockers

 Speed it Up: Cocaine and Cathinones

 Hypoglycemia Secondary to Insulin and Oral Hypoglycemic Agents

 Antidepressants and the Abnormal ECG

 Salicylates and the Pseudosepsis Syndrome

 Serotonin Syndrome

 Opioids

Suggested Reading

Chapter 25 Neurologic Emergencies 

25.1 Acute Ischemic Stroke

25.2 Acute Intracerebral Hemorrhage

 Blood Pressure Control

 Reversal of Coagulopathy

 Elevated Intracranial Pressure

25.3 Status Epilepticus

25.4 Acute Myasthenic Crisis

Chapter 26 SARS-CoV-2 Infection and COVID-19 Disease 

       26.1 Epidemiology of the Pandemic 

       26.2 SARS-CoV-2 Virus 

                  SARS-CoV-2 Infectivity 

       26.3 COVID-19: Clinical Features 

                 COVID-19 Clinical Phenotypes

                 COVID-19 Timeline 

                 COVID-19 Risk factors 

       26.4 The Diagnosis of COVID-19 

                 Laboratory Testing in COVID-19 

                 Radiology Findings in COVID-19 

                 PCR and Antibody Testing 

                 Pre-Test Probability and PCR Testing 

       26.5 Personal Protective Equipment (PPE) 

       26.6 The Clinical Management of COVID-19 

                Hypoxemic Respiratory Failure in the Non-Intubated Patient 

                Airway Management 

                Hypoxemic Respiratory Failure in the Intubated Patient 

                Cardiovascular Management of the Patient with COVID-19 

                Cytokine Release Syndrome (CRS) 

                Coagulation Disorders 

                Gastrointestinal Manifestations of COVID-19 

                Renal Manifestations of COVID-19 

       26.7 Treatment of COVID-19 

                Empiric Antibiotics for Secondary Infection 

                Antiviral therapy 

                Corticosteroid Therapy 

                Convalescent plasma (CP) 

                Monoclonal Antibody Therapy 

                Anticoagulant and antiplatelet therapy 

                Anti-inflammatory therapy 

                Treatment for Hospitalized Patients with COVID-19 

       26.8 Vaccine for COVID-19 

       26.9 Goals of Care and Resource Limitations 

Suggested Reading

References Index