Table of Contents

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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
Critical Care and Hospitalist Medicine Made Ridiculously Simple
by Mark T. Gladwin, M.D., Michael Donahoe, M.D.,
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