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Chapter 11 LIFE-THREATENING INFECTIONS: DIAGNOSIS AND ANTIMICROBIAL THERAPY SELECTION Objectives Understand and apply the terminology specific to life-threatening infections List the risk factors for the development of infection Identify systemic and site-specific clinical manifestations of life-threatening infections, and understand the diagnostic use of clinical laboratory testing Describe the different clinical and epidemiologic variables used to guide the selection of antimicrobial therapy Outline antimicrobial treatment for empiric therapy and for specific infections Case Study A 75-year-old man presents to the emergency department with altered mental status His family reports that he has had a productive cough for the last days His vital signs are: blood pressure 110/70 mm Hg, heart rate 110/min, temperature 102.2°F (39°C), respiratory rate 20/min, and pulse oximetry 92% while receiving L/min oxygen by nasal cannula You are the primary physician and are called to admit him to the hospital – Does this patient have sepsis or severe sepsis? – What level of care is needed for this patient? – What initial interventions should be instituted immediately? I INTRODUCTION Life-threatening infections are both a cause and a consequence of critical illness The incidence of life-threatening infections or sepsis is increasing as a reflection of the growing population of patients at risk, for example, the elderly; immunocompromised patients; those with malignancy, chronic illness, or multiple trauma Septic shock, the most severe form of systemic response to infection, is a common cause of death in critically ill adults and children Early recognition and appropriate management of infections and their sequelae can decrease the mortality rate Sepsis is defined as systemic manifestations of infection Severe sepsis is sepsis associated with organ dysfunction, hypoperfusion, or hypotension Abnormalities that suggest hypoperfusion and organ dysfunction may include, but are not limited to, lactic acidosis, oliguria, coagulation disorders, and an acute alteration in mental status These abnormalities are not specific for sepsis and may be present in other conditions Septic shock is sepsis with arterial hypotension, defined as a systolic blood pressure 40 mm Hg from the patient’s baseline systolic blood pressure despite adequate fluid resuscitation, with concomitant organ dysfunction Patients receiving inotropic or vasopressor agents may not be hypotensive when perfusion abnormalities are measured Definitions of sepsis may be difficult to apply to an individual patient Initial considerations in resuscitation and infection management are described in Table 11-1 Additional details are found in this chapter and in Chapter and II DIAGNOSIS OF INFECTION The diagnosis of serious or life-threatening infection is based on a careful and complete assessment of the patient’s history, including risk factors, and the presence of characteristic clinical manifestations Atypical presentations that may occur, particularly in the elderly and in the immunocompromised patient, must also be considered Laboratory, microbiologic, and imaging results also support the diagnosis of documented or suspected infection A Evaluation of New Fever in Critically Ill Adult Patients In some ICUs, the measurement of a newly elevated temperature triggers an automatic order set that includes many tests that are time consuming, costly, and disruptive to the patient and staff Moreover, the patient may experience discomfort, be exposed to unneeded radiation, require transport outside the controlled environment of the ICU, or lose considerable blood to this testing, which is often repeated several times within 24 hours and daily thereafter In an era when utilization of hospital and patient resources is under intensive scrutiny, such fevers should be evaluated in a prudent and costeffective manner A new fever in a patient in the ICU should trigger a careful clinical assessment rather than automatic orders for laboratory and radiologic tests The goal of such an approach is to determine, in a directed manner, whether infection is present so that additional testing can be avoided and therapeutic decisions can be made Recommendations for the evaluation of new fever are listed in Table 11-2 Table 11-1: Initial Resuscitation and Infection Issuesa,b Initial Resuscitation (first hours) Begin resuscitation immediately in patients with hypotension or elevated serum lactate >4 mmol/L; not delay pending ICU admission Follow resuscitation goals: CVP 8-12 mm Hg Mean arterial pressure ≥65 mm Hg Urine output ≥0.5 mL/kg-1/h-1 Central venous (superior vena cava) oxygen saturation ≥70% Diagnosis Obtain appropriate cultures before starting antibiotics provided this does not significantly delay antimicrobial administration Obtain two or more blood cultures (Table 11-2) Cultures other sites as clinically indicated Perform imaging studies promptly to confirm and sample any source of infection, if safe to so Antibiotic Therapy Begin intravenous antibiotics as early as possible and always within the first hour of recognizing severe sepsis and septic shock Choose broad-spectrum agent(s): one or more agents active against likely bacterial/fungal pathogens and with good penetration into presumed source Reassess antimicrobial regimen daily to optimize efficacy, prevent resistance, avoid toxicity, and minimize costs Source Identification and Control Establish specific anatomic site of infection as rapidly as possible Implement source control measures as soon as possible Remove intravascular access devices if potentially infected Abbreviation: CVP, central venous pressure aSee Chapter and bAdapted with permission from Lippincott, Williams & Wilkins.4 Dellinger RP, Levy MM, Carlet JM, et al Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 Crit Care Med 36(1):296-327 Table 11-2: Evaluation of Fever in the Critically Ill Adultsa Abbreviations: CT, computerized tomography; EIA, enzyme immunoassay; PCR, polymerase chain reaction; CFU, colonyforming units; CSF, cerebrospinal fluid aAdapted with permission from Lippincott, Williams & Wilkins.9 O’Grady NP, Barie PS, Bartlett JG, et al Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America Crit Care Med 36(4):1330–1349 B Epidemiologic Factors Serious or life-threatening infections may occur in patients from the community, long-term care facilities (ie, nursing homes), or hospital settings Serious or life-threatening community-acquired infections include bacterial pneumonia, central nervous system (CNS) infections or meningitis, urosepsis, intra-abdominal sepsis due to a ruptured or obstructed viscus, or sporadic uncommon infections, such as necrotizing fasciitis Patients from long-term care facilities share this spectrum but often have infections with more resistant pathogens and may develop different device-related infections Finally, hospitalized patients are exposed to antimicrobial-resistant flora and numerous invasive devices, and they have more comorbidities and greater severity of illness than the other populations C Predisposing Conditions The presence of predisposing conditions should alert the care team to patients at higher risk of developing infections (Table 11-3) Permanent prosthetic implants, such as heart valves, intravascular grafts, or orthopedic devices, may become infected in either the early or the late postoperative period Invasive procedures (eg, surgery, vascular catheterization, placement of urinary catheters, and endotracheal intubation) breech the normal mucosal defense barriers and predispose patients to infection The lack of predisposing conditions does not eliminate the possibility that a serious infection is present, particularly in patients admitted directly to the ICU from the community Table 11-3: Conditions Predisposing to Infection D Clinical Manifestations The clinical manifestations of life-threatening infections are diverse, and they may be subtle or overt and localized or systemic An awareness of the signs and symptoms associated with specific infections allows early recognition and prompt institution of appropriate empiric antimicrobial and supportive management However, most of the clinical manifestations are not specific Systemic Signs and Symptoms Fever is the most frequent systemic manifestation of infection, but patients with serious infection may be normothermic or even hypothermic, particularly if they are elderly or if antipyretic medications, alcoholism, or renal or hepatic failure are involved Temperature probes on a urinary catheter, when available, are the most reliable methods to measure the core temperature Temperature measurement is most practically obtained via the oral or rectal routes, although the limitations of each method should be considered Axillary temperatures are unreliable, and tympanic measurements have not been validated in the critically ill Hypothermia is a poor prognostic sign in serious infections Other systemic manifestations include chills, rigors, hypotension, tachypnea, dyspnea, tachycardia, and nausea and vomiting Tachycardia is almost always present but may be absent in the presence of cardiac conduction disturbances, autonomic dysfunction, β-blockers or calcium channel blockers, and drug fever Hypotension may be due to dehydration and hypovolemia but may also indicate septic shock, particularly if the blood pressure does not respond to volume resuscitation Hypoperfusion of the kidneys may result in oliguria or anuria Encephalopathy is a common clinical manifestation and ranges from lethargy/irritability to delirium and coma Petechiae and/or ecchymosis may be present, particularly on distal extremities Site-Specific Signs and Symptoms Some signs and symptoms of infection could be associated with the specific source of infection: Infections of the CNS may be associated with headache, seizures, meningismus, or focal neurologic findings Altered mental status is often present but not specific for CNS infections Diffuse or localized respiratory tract infections may be associated with dyspnea, tachypnea, cough, sputum production, or (rarely) hemoptysis Chest auscultation findings, such as crackles, rhonchi, or tubular breath sounds, indicate whether the process is localized or diffuse Diminished breath sounds and dullness on percussion are suggestive of a pleural effusion Intra-abdominal infections may cause abdominal pain, abdominal distension, nausea and/or vomiting, diarrhea, and anorexia Diaphragmatic irritation can be perceived as pain in the side of the neck and proximal shoulder area or may cause hiccups Findings on examination may include diffuse or local tenderness, rebound tenderness, ileus, or guaiac-positive stool A wound infection with evidence of fascial disruption may signal an intra-abdominal infection below the fascia Urinary tract infections may produce flank pain or abdominal pain, tenderness, dysuria, hematuria, and oliguria Typically, a urinary catheter–associated infection does not produce localized symptoms Cutaneous manifestations may result from a primary infection of the skin or skin structures (eg, pain, erythema, and induration due to cellulitis; wound margin erythema; tenderness or purulent discharge; vesicular lesions due to herpes infection) or be a consequence of disseminated systemic infection (eg, erythematous indurated papules or nodules of ecthyma gangrenosum due to bacteremia, septic emboli due to infective endocarditis, diffuse macular erythema due to toxic shock syndrome, distal symmetric purpura fulminans due to meningococcemia) E Laboratory Manifestations Routine laboratory tests are not specific in the diagnosis of life-threatening infections but may be suggestive and allow assessment of organ function The white blood cell count is usually elevated with a shift to more immature forms (called a left shift) Leukocytosis is commonly observed in noninfectious processes such as the early postoperative period, corticosteroid therapy, massive transfusions, and polytrauma Conversely, a normal leukocyte count may be observed despite active infection in the elderly and in patients with hypersplenism or chronic myelosuppressive disorders Neutropenia may result from overwhelming infection (especially in neonates and AIDS patients), severe viral infection, typhoid fever, brucellosis, and other infections Toxic granulation within neutrophils may also be noted The most common coagulation abnormality in sepsis is isolated thrombocytopenia A decline in platelet count may be a subtle, early clue to the presence of infection Disseminated intravascular coagulation is a less common finding but is a poor prognostic sign It is characterized by elevations in prothrombin time, partial thromboplastin time, fibrin split products, and/or D-dimer, and decreased fibrinogen Sepsis causes relative insulin resistance, usually resulting in hyperglycemia, whereas hypoglycemia is less frequent and often reflects low hepatic glycogen stores Arterial blood gas measurements usually reflect metabolic acidosis, a low PaCO2 due to respiratory compensation and often hypoxemia An elevated serum lactate level is a significant sign of compromised peripheral perfusion and oxygen balance due to severe sepsis or septic shock Hepatic dysfunction is usually not severe but presents as a cholestatic picture with elevated bilirubin and mild elevation of transaminases Renal insufficiency often occurs due to multiple factors such as hypotension and hypovolemia Other possible nonspecific markers of inflammation/infection include procalcitonin and C-reactive protein F Microbiologic Studies Microbiologic studies are divided into those with immediately available results (minutes to a few hours) and those requiring a period for incubation or laboratory determinations Among the studies with quickly available results is Gram stain of body fluids Special stains (such as fungal and acidfast stains), immunoassays (such as urine Legionella antigen and Clostridium difficile toxins), and counterimmunoelectrophoresis panels require time to process Empiric antimicrobial therapy for the patient with a presumptive life-threatening infection should be initiated based on clinical and epidemiologic clues Ideally, all cultures should be obtained before initiation or modification of antimicrobial therapy, but of oxyhemoglobin saturation, 6-8, 6-9t of right ventricular filling pressures, 6-13–6-14, 6-14f of shock patients, 7-7 in trauma, 9-8 Morphine sulfate, 10-8t Mucolytics, 4-14 Musculoskeletal injury, 9-16–9-17 Myasthenia gravis, 8-13 Mycobacterium tuberculosis, 11-14 Mycoplasma, 11-14 Myocardial infarction as acute coronary syndrome, 10-2 arrhythmias and, 10-22 coexisting diseases and, 10-22–10-23 complications, 10-20–10-22 in mechanical ventilation, 5-27 non-ST-segment elevation as acute coronary syndrome, 10-2 diagnosis of, 10-4–10-6, 10-5f, 10-5t, 10-6t management, 10-6–10-11 risk factors, 10-4t perioperative, 10-22 recurrent, 10-21 risk stratification for, 10-19 ST-segment elevation as acute coronary syndrome, 10-2 diagnosis of, 10-12–10-13, 10-13f early therapy for, 10-15 fibrinolysis for, 10-16–10-17, 10-17t, 10-18t management, 10-13–10-19 percutaneous coronary interventions for, 10-15–10-16 reperfusion therapy for, 10-15–10-17 thrombolysis for, 10-16–10-17, 10-17t, 10-18t treatment algorithm, 10-14f N Naloxone, 13-14t Nasal cannula, 4-10–4-11, 4-10f Nasogastric tube, 9-14 Nasopharyngeal airway, 2-3–2-4 Necrotizing soft tissue infection, 11-19 Neisseria meningitidis, 11-13 Neurogenic shock, 9-11 Neuromuscular blockers for intubation, 2-13–2-14, 2-14t for mechanical ventilation, 5-22 Next of kin, 15-4 Nicardipine, 13-16t Nitroglycerin, 10-8t, 13-16t, 14-16t Nitroprusside, 13-16t, 14-16t Nonhemorrhagic shock, 9-9–9-11 Noninvasive positive pressure ventilation (NPPV) advantages of, 5-3t contraindications, 5-6, 5-6t disadvantages of, 5-3t initiation of, 5-5t interfaces for, 5-3–5-4, 5-4f mechanics of, 5-3 monitoring for, 5-6, 5-7f overview of, 5-2–5-3 patients benefiting from, 5-4, 5-5t Nonmaleficence, 15-3 Non-ST-segment elevation myocardial infarction (NSTEMI) as acute coronary syndrome, 10-2 diagnosis of, 10-4–10-6, 10-5f, 10-5t, 10-6t management, 10-6–10-11 risk factors for, 10-4t Norepinephrine in pregnancy, 14-16t for shock, 7-9, 7-9t NSTEMI See Non-ST-segment elevation myocardial infarction (NSTEMI) O Obidoxime, 13-14t Obstructive shock, 7-4t, 7-5, 7-14, 16-13 Octreotide, for variceal gastrointestinal hemorrhage, 13-10 Oliguria, 7-14–7-15, 7-15t Opioids in acute respiratory failure, 4-4 toxicity, 13-12t, 13-14t Organ donation, 8-14, 15-7 Organophosphate toxicity, 13-12t, 13-14t Oropharyngeal airway, 2-3 Overdose, 13-11–13-14 Oxygen balance assessment, 6-6–6-7, 6-7f monitoring determinants of, 6-8–6-14 Oxygen therapy for acute respiratory failure, 4-9–4-12, 4-10f aerosol face mask for, 4-10f, 4-11 air-entrainment face mask for, 4-10f, 4-11 arterial oxygen content and, 6-2–6-3, 6-3f cardiac output and, 6-4–6-6, 6-4f, 6-5t devices, 4-10f high-flow nasal cannula for, 4-10f, 4-11 low-flow nasal cannula for, 4-10–4-11, 4-10f principles of, 6-2–6-6 reservoir face mask for, 4-10f, 4-11 resuscitation bag-mask unit for, 4-10f, 4-11–4-12 Oxyhemoglobin dissociation curve, 6-3f Oxyhemoglobin saturation monitoring, 6-8, 6-9t P PE See Pulmonary embolism (PE) PEEP See Positive end-expiratory pressure (PEEP) Pelvic hemorrhage, 9-9 Pelvic thrombophlebitis, septic, 14-14 Penicillin, 11-13, 14-16t Percutaneous coronary interventions (PCIs), 10-15–10-16 Pericardial tamponade, 1-7t Pericarditis, constrictive, 1-7 Peripartum cardiomyopathy, 14-11–14-12 Peritonitis, 16-20t Phencyclidine toxicity, 13-12t Phenobarbital, 14-16t Phentolamine, 13-16t Phenylephrine, for shock, 7-9t, 7-10 Phenytoin, 14-16t Phosphorus disturbances, 12-11–12-12, 16-18 Physical examination in children, 16-2, 16-3t in initial assessment, 1-4t, 1-5–1-8, 1-6t, 1-7t in trauma assessment, 9-11–9-12 Piperacillin, 11-15 Pneumocystis carinii, 11-15 Pneumonia in acute respiratory failure, 4-4 antimicrobials for, 11-14–11-15 nosocomial, 11-15 ventilator-associated, 11-15 Pneumothorax in airway obstruction, 1-6t in mechanical ventilation, 5-26 tension, 3-11, 5-26, 9-10 in trauma, 9-4, 9-10 Poisoning, 13-11–13-14 Positive end-expiratory pressure (PEEP), 5-21–5-22, 5-21t, 5-27 Postpartum hemorrhage, 14-10 Potassium disturbances, 12-2–12-5, 16-17 Power of attorney, 15-4 Pralidoxime, 13-14t Prasugrel, 10-10t, 10-18 Prednisolone, 14-16t Preeclampsia, 14-5, 14-7, 14-9t Pregnancy advanced life support in, 14-15 amniotic fluid embolism in, 14-12–14-13 cardiovascular alterations in, 14-2–14-3 eclampsia in, 14-6, 14-9t fatty liver of, 14-9, 14-9t gastrointestinal alterations in, 14-4 heart enlargement in, 14-3 HELLP syndrome in, 14-8–14-9, 14-9t hematologic alterations in, 14-4 hypertensive disorders in, 14-4–14-8 mechanical ventilation during, 14-14 metabolic alterations in, 14-4 peripartum cardiomyopathy in, 14-11–14-12 pharmacotherapy and, 14-15, 14-15t–14-16t physiologic alterations in, 14-2–14-3 postpartum hemorrhage in, 14-10 preeclampsia in, 14-5, 14-7, 14-9t pulmonary alterations in, 14-3 pulmonary embolism in, 14-10–14-11 septic pelvic thrombophlebitis in, 14-14 severe asthma in, 14-12 thromboembolic disease in, 14-10–14-11 trauma and, 9-14, 14-13–14-14 Preload, 6-5–6-6, 6-6f Procainamide, 14-16t Propofol for intubation, 2-14t in pregnancy, 14-16t toxicity, 13-12t Propranolol, 10-8t Protamine sulfate, 13-14t Pseudomonas, 11-15 Pulmonary edema, in airway obstruction, 1-6t Pulmonary embolism (PE) in airway obstruction, 1-6t clinical manifestations of, 13-3t diagnosis of, 13-2–13-5, 13-4f heparin for, 13-5 in pregnancy, 14-10–14-11 probability assessment for, 13-5t risk factors for, 13-2t therapy for, 13-5–13-6 thrombolysis for, 13-6 warfarin for, 13-6 Pulmonary infections, 11-4t, 11-14–11-15 Pulse, 1-7, 1-7t Pulse oximetry, 6-8, 6-9t Pulsus paradoxus, 1-7 Pyridoxine, 13-14t Q Quinolones, 14-16t R Racemic epinephrine, for acute respiratory failure, 4-12, 4-13t Radiologic evaluation, for trauma, 9-12–9-14 Recognition, of patient at risk, 1-2–1-3 Renal insufficiency, acute, 7-16–7-17 Reperfusion therapy, 10-15–10-17 Respiration See also Airway; Breathing; Intubation; Ventilation Cheyne-Stokes, 1-6 depth, 1-6 normal vs abnormal, 4-9f paradoxical, 4-9f in pregnancy, 14-3 Respiratory acidosis, 6-17, 6-18t Respiratory alkalosis, 6-17, 6-18t Respiratory arrest, 3-10–3-11 Respiratory failure See Acute respiratory failure (ARF) Resuscitation airway management in, 3-4 bag-mask unit, 4-10f, 4-11–4-12 burn injuries and, 9-21 chest compressions in, 3-5 continuing, 3-6 defibrillation in, 3-4 delegation in, 3-4–3-5 documentation and, 3-3 end-tidal carbon dioxide in, 3-7 ethical issues in, 3-2–3-3 in gastrointestinal hemorrhage, 13-9t immediate assessment for, 3-3 implied consent, 3-2 infection and, 11-3t investigations in, 3-6 leader’s role in, 3-3–3-4 level of therapeutic support and, 3-2 primary response in, 3-3–3-5 in shock, end points in, 7-11 targeted temperature management and, 3-7–3-9, 3-8f, 3-8t transport to ICU after, 3-6 treatment vs., 3-2 venous access in, 3-5 warming in, 3-7 Reteplase, 10-18t Retropharyngeal abscess, 16-20t Rib fracture in airway obstruction, 1-6t in trauma, 9-4–9-5 Right ventricular filling pressure monitoring, 6-13–6-14, 6-14f Right ventricular infarction, 10-21 Rocuronium for intubation, 2-14 in pregnancy, 14-16t Rule of nines, 9-20, 9-20f S Salicylate toxicity, 13-12t, 13-14t Sedation for intubation, 2-13 for mechanical ventilation, 5-22 Seizures, 8-12, 14-6–14-7, 16-3t, 16-21–16-22 Sellick maneuver, 2-8 Sepsis, 11-2 See also Infections Septic pelvic thrombophlebitis, 14-14 Septic shock, 11-2 Severity, assessment of, 1-3 Shock cardiogenic, 7-4t, 7-5, 7-13–7-14, 10-20–10-21, 16-13 in children, 16-10–16-13 classification of, 7-3–7-5, 7-3t clinical alterations in, 7-2–7-3 defined, 7-2 distributive, 7-4, 7-4t, 7-12–7-13, 7-12f, 16-12 dobutamine for, 7-9t, 7-10 dopamine for, 7-9–7-10, 7-9t end points of resuscitation in, 7-11 epinephrine for, 7-9t, 7-10 fluid therapy in, 7-7–7-8 hemodynamic profiles of, 7-4t hypovolemic, 7-4, 7-4t, 7-11–7-12, 7-12f, 16-3t, 16-11–16-12 management, 7-5–7-14 milrinone for, 7-9t, 7-10 monitoring in, 7-7 neurogenic, 9-11 nonhemorrhagic, 9-9–9-11 norepinephrine for, 7-9, 7-9t obstructive, 7-4t, 7-5, 7-14, 16-13 phenylephrine for, 7-9t, 7-10 renal insufficiency in, 7-16–7-17 septic, 11-2 vasoactive agents for, 7-8–7-10, 7-9t vasoconstriction in, 7-2–7-3 vasopressin for, 7-10 Sinus infections, 11-5t Skin infections, 11-8, 11-18 Skin perfusion, in children, 16-3t Smoke inhalation, 9-18 Social history, 1-5 Sodium disturbances, 12-5–12-9, 16-16–16-17 Somatostatin, for variceal gastrointestinal hemorrhage, 13-10 Spinal cord injury, 8-13 Spironolactone, 14-16t Staphylococcus aureus, 11-16 Staphylococcus pneumoniae, 11-13 STEMI See ST-segment elevation myocardial infarction (STEMI) Steroid therapy, for adrenal insufficiency, 12-15, 12-16t Streptokinase, 10-18t Stress-related gastritis, 13-11 Stroke, 8-10–8-11, 8-11t ST-segment elevation myocardial infarction (STEMI) as acute coronary syndrome, 10-2 diagnosis, 10-12–10-13, 10-13f early therapy for, 10-15 fibrinolysis for, 10-16–10-17, 10-17t, 10-18t management, 10-13–10-19 percutaneous coronary interventions for, 10-15–10-16 reperfusion therapy for, 10-15–10-17 thrombolysis for, 10-16–10-17, 10-17t, 10-18t treatment algorithm for, 10-14f Subarachnoid hemorrhage, 8-9, 8-10t Succinylcholine for intubation, 2-13 in pregnancy, 14-16t Sulbactam, 11-14 Sulfonamides, 14-16t Surgical site infections, 11-5t Suspicion, index of, 1-3 Symptoms, in assessment of severity, 1-3 T Tachypnea, 1-6, 16-3t Targeted temperature management (TTM), 3-7–3-9, 3-8f, 3-8t Tazobactam, 11-15 TBI See Traumatic brain injury (TBI) Temperature measurement, 11-4t Tenecteplase, 10-18t Tension pneumothorax, 3-11 in mechanical ventilation, 5-26 in trauma, 9-10 Terlipressin, for variceal gastrointestinal hemorrhage, 13-10 Theophylline toxicity, 13-12t, 13-14t Thiamine, 13-14t Thrombolysis for myocardial infarction, 10-16–10-17, 10-17t, 10-18t for pulmonary embolism, 13-6 Ticagrelor, 10-10t, 10-18 Tirofiban, 10-10t Tissue plasminogen activator, 8-10–8-11, 8-11t Tobramycin, 14-16t Toxicity, drug, 13-11–13-14 Toxoplasma gondii, 11-14 Tracheitis, 16-20t Transfusions, 9-6–9-7 Trauma abdominal imaging in, 9-13 abdominal injury in, 9-15–9-16 airway assessment in, 9-3–9-5 blunt cardiac injury in, 9-10–9-11 breathing assessment in, 9-3–9-5 cardiac injury in, 9-15 cardiac tamponade in, 9-10 chest imaging in, 9-13 crush syndrome in, 9-16–9-17 death due to, 9-2 disability assessment in, 9-7 exposure in, 9-7 genitourinary tract imaging in, 9-13–9-14 “golden hour” after, 9-2 head imaging in, 9-12 head injury in, 9-15 hemorrhage in, 9-6–9-7 hemorrhagic shock in, 9-8–9-9 history in assessment of, 9-11 hypothermia and, 9-7 initial assessment of, 9-3–9-11 intra-abdominal hemorrhage in, 9-8–9-9 laboratory studies in, 9-12 long-bone fractures in, 9-9 management, 9-2–9-17 monitoring in, 9-8 musculoskeletal injury in, 9-16–9-17 nasogastric tube in, 9-14 neurogenic shock in, 9-11 pelvic hemorrhage in, 9-9 physical examination in, 9-11–9-12 pneumothorax in, 9-4 pregnancy and, 9-14, 14-13–14-14 pulmonary injury in, 9-15 radiologic evaluation for, 9-12–9-14 rib fracture in, 9-4–9-5 secondary assessment in, 9-11–9-14 shock in, 9-8–9-11 spine imaging in, 9-12–9-13 tension pneumothorax in, 9-10 tertiary assessment of, 9-14–9-17 transfusions in, 9-6–9-7 Traumatic brain injury (TBI) acute respiratory failure and, 4-4 treatment of, 8-8t Treatment in initial assessment, 1-4t resuscitation vs., 3-2 Triage, ethics of, 15-6, 15-9–15-10 Trimethoprim, 14-16t Triple airway maneuver, 2-3, 2-3f Tropheryma whipplii, 11-16 TTM See Targeted temperature management (TTM) U Unstable angina, 10-2 Upper gastrointestinal hemorrhage, 13-10 Urinary tract infections, 11-5t, 11-8, 11-17–11-18 Urine cultures, 11-9–11-10 V Vancomycin, 11-15, 14-16t Variceal upper gastrointestinal hemorrhage (VUGIH), 13-10 Vasoactive agents, for shock, 7-8–7-10, 7-9t Vasopressin in pregnancy, 14-16t for shock, 7-10 for variceal gastrointestinal hemorrhage, 13-10 Vecuronium, for intubation, 2-14 Venous access, in resuscitation, 3-5 Venous thromboembolism, 13-7 Ventilation See also Airway; Breathing; Intubation; Respiration bag compression, 2-6–2-7 cricoid pressure in, 2-8 manual assisted, 2-4–2-8 mechanical in acute respiratory distress syndrome, 5-22– 5-24, 5-23t alveolar minute, 5-20–5-21 analgesia for, 5-22 assist-control, 5-10, 5-10f, 5-13–5-14, 5-13t assisted breath in, 5-8 for asymmetric lung disease, 5-24–5-25 cardiac arrest with, 3-11 in children, 16-8–16-9, 16-8t, 16-9t choice of, 5-15–5-16 in chronic obstructive pulmonary disease, 5-24 continuing care during, 5-16–5-22 controlled, 5-13t, 5-15 conversion from negative to positive intrathoracic pressure, 5-27 expiration in, 5-7 flow-cycled breath in, 5-9 for heart disease, 5-25 humidification in, 5-21 hypotension associated with, 5-26–5-27 indications for, 5-2t initiation of, 5-16 inspiration in, 5-7 inspiratory pressures in, 5-17, 5-18f inspiratory time and expiratory time in, relation of, 5-19–5-20, 5-19f invasive, 5-7–5-9 in lung injury, 5-22–5-24, 5-23t mandatory breath in, 5-8 minute, 5-20–5-21 modes of, 5-9–5-15 monitoring, 5-25–5-26, 5-25t myocardial infarction in, 5-27 neuromuscular blockade for, 5-22 for neuromuscular disease, 5-25 noninvasive, 5-2–5-6 positive end-expiratory pressure in, 5-21–5-22, 5-21t, 5-27 in pregnancy, 14-14 pressure control inverse ratio, 5-12f pressure support, 5-3, 5-10, 5-11f, 5-13t, 5-14 prophylactic therapies in, 5-22 sedation for, 5-22 settings, 5-15–5-16 synchronized intermittent mandatory, 5-8, 5-10, 5-11f, 5-13t, 5-14–5-15 time-cycled breath in, 5-9 volume-cycled breath in, 5-8–5-9 with no cervical spine injury, 2-5 noninvasive positive pressure advantages of, 5-3t contraindications, 5-6, 5-6t disadvantages of, 5-3t initiation of, 5-5t interfaces for, 5-3–5-4, 5-4f mechanics of, 5-3 monitoring for, 5-6, 5-7f overview of, 5-2–5-3 patients benefiting from, 5-4, 5-5t spontaneous, 2-12 with suspected cervical spine injury, 2-5 two-handed manual, 2-6 Verapamil, 10-9, 14-16t Virchow triad, 13-2 Vital signs in children, 16-4t index of suspicion with, 1-3 Vitamin K1, 13-14t W Warfarin in pregnancy, 14-16t for pulmonary embolism, 13-6 toxicity, 13-14t Warming, in resuscitation, 3-7 ... adults Clin Infect Dis 20 07;44:S27-S 72 Mermel LA, Farr BM, Sherertz RJ, et al Guidelines for management of intravascular catheterrelated infections Clin Infect Dis 20 01; 32: 124 9-1 27 2 O’Grady NP, Barie... shock: 20 08 Crit Care Med 20 08;36 :29 6-3 27 Guerrant RL, Van Gilder T, Steiner TS, et al Practice guidelines for the management of infectious diarrhea Clin Infect Dis 20 01; 32: 33 1-3 51 Leone M, Bourgoin... guidelines for management of severe sepsis and septic shock: 20 08 Crit Care Med 36(1) :29 6-3 27 Table 1 1 -2 : Evaluation of Fever in the Critically Ill Adultsa Abbreviations: CT, computerized tomography;