EM Critical Care

UNDERSTANDING AND CARING FOR

CRITICAL ILLNESS IN EMERGENCY MEDICINE

Ventilator Management And September/October 2014

Volume 4, Number 5
Troubleshooting In The Author

William Owens, MD

Emergency Department Associate Professor of Clinical Medicine, Division of

Pulmonary, Critical Care, and Sleep Medicine, University of
South Carolina, Columbia, SC

Peer Reviewers
Abstract
Roderick W. Fontenette, MD, FAAEM
Assistant Professor of Emergency Medicine/Critical Care
Critically ill patients with acute respiratory failure frequently board Medicine, Wright State University, Boonshoft School of
in the emergency department while awaiting a bed in the intensive Medicine, Dayton, OH
care unit. Emergency physicians are often called upon to provide Francis Guyette, MD, MS, MPH
initial ventilator settings, troubleshoot ventilator alarms, and as- Associate Professor of Emergency Medicine, University of
Pittsburgh School of Medicine, Pittsburgh, PA
sess and treat decompensating patients. This issue reviews the basic
CME Objectives
concepts of respiratory system compliance, airway resistance, and
disorders of gas exchange. Steps for investigating and treating high Upon completion of this article, you should be able to:
1. Troubleshoot high–airway-pressure alarms on the
pressures, worsening gas exchange, and dynamic hyperinflation ventilator.
are outlined. Methods for determining the degree of airway resis- 2. Identify the presence of dynamic hyperinflation.
tance and auto–positive end-expiratory pressure are provided. The 3. Assess potential causes of hypoxemia in a ventilated
evidence base for lung-protective ventilation and rescue therapies patient.

is reviewed. While there are several rescue therapies and modes of 4. Summarize the evidence base for lung-protective
ventilation and rescue therapies for severe respiratory
ventilation, only lung-protective ventilation with low tidal volumes failure.
has been consistently shown to improve survival from acute respi-
ratory failure. Ventilator management techniques, including lung- Prior to beginning this activity, see “Physician CME
Information” on the back page.
protective ventilation for acute respiratory distress syndrome and
treating dynamic hyperinflation in patients with obstructive lung
disease, is discussed.

Editor-in-Chief
William A. Knight, IV, MD, FACEP
Assistant Professor of
Emergency Medicine and
Neurosurgery, Medical Director,
Emergency Medicine Midlevel
Provider Program, Associate
Medical Director, Neuroscience
ICU, University of Cincinnati,
Cincinnati, OH
Associate Editors-in-
Chief
Robert T. Arntfield, MD, FACEP,
FRCPC, FCCP
Assistant Professor, Division
of Critical Care, Division of
Emergency Medicine, Western
University, London, Ontario,
Canada
Scott D. Weingart, MD, FCCM
Associate Professor, Department
of Emergency Medicine,
Director, Division of Emergency
Department Critical Care, Icahn
School of Medicine at Mount
Sinai, New York, NY
Editorial Board
Benjamin S. Abella, MD, MPhil,
FACEP
Assistant Professor, Department
of Emergency Medicine and
Department of Medicine, Section
of Pulmonary, Allergy, and Critical
Care, University of Pennsylvania
School of Medicine; Clinical
Research Director, Center
for Resuscitation Science,
Philadelphia, PA
Lillian L. Emlet, MD, MS, FACEP
Assistant Professor, Department of
Critical Care Medicine, Department
of Emergency Medicine, University Haney Mallemat, MD
of Pittsburgh Medical Center;
Program Director, EM-CCM
Fellowship of the Multidisciplinary
Critical Care Training Program,
Pittsburgh, PA
Evie Marcolini, MD, FAAEM
Michael A. Gibbs, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Carolinas
Medical Center, University of North
Carolina School of Medicine,
Chapel Hill, NC
Robert Green, MD, DABEM,
FRCPC
Professor, Department of
Anaesthesia, Division of Critical
Care Medicine, Department of
Emergency Medicine, Dalhousie
University, Halifax, Nova Scotia,
Canada
Andy Jagoda, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Icahn
School of Medicine at Mount Sinai;
Medical Director, Mount Sinai
Hospital, New York, NY
Assistant Professor, Department
of Emergency Medicine, University
of Maryland School of Medicine,
Baltimore, MD
Assistant Professor of Emergency
Medicine, Surgical, and Neurocritical
Care, Yale University School of
Medicine, New Haven, CT
Julie Mayglothling, MD
Assistant Professor, Department
of Emergency Medicine,
Department of Surgery, Division
of Trauma/Critical Care, Virginia
Commonwealth University,
Richmond, VA
Christopher P. Nickson, MBChB,
MClinEpid, FACEM
Senior Registrar, Intensive Care
Unit, Royal Darwin Hospital,
Darwin, Australia
Jon Rittenberger, MD, MS, FACEP
Assistant Professor, Department
of Emergency Medicine, University
of Pittsburgh School of Medicine;
Attending Physician, Emergency
Medicine and Post Cardiac Arrest
Services, UPMC Presbyterian
Hospital, Pittsburgh, PA
Emanuel P. Rivers, MD, MPH, IOM
Vice Chairman and Director
of Research, Department of
Emergency Medicine, Senior
Staff Attending, Departments of
Emergency Medicine and Surgery
(Surgical Critical Care), Henry
Ford Hospital; Clinical Professor,
Department of Emergency
Medicine and Surgery, Wayne
State University School of
Medicine, Detroit, MI
Isaac Tawil, MD, FCCM
Assistant Professor, Department
of Anesthesia and Critical Care,
Department of Emergency Medicine,
Director, Neurosciences ICU,
University of New Mexico Health
Science Center, Albuquerque, NM
Research Editor
Bourke Tillman, MD, BHSc
Critical Care Fellow, PGY4 -
FRCP(C) Emergency Medicine,
London Health Sciences Centre,
University of Western Ontario,
London, Ontario, Canada
Case Presentations
You’re in the middle of a busy shift in the ED when a
43-year-old man with a predicted body weight of 165 lbs
(75 kg) is brought in by EMS. He is febrile, hypotensive,
and tachypneic. You intubate him, place central and arte-
rial lines, and begin fluid resuscitation. Blood cultures are
obtained, and antibiotics are administered. Chest x-rays
show diffuse infiltrates in all lung fields. The ventilator is
set to assist-control with a rate of 20 breaths/min, a tidal
volume of 600 mL, a PEEP of 8 cm H2O, and an FiO2 of
100%. The arterial blood gas shows the patient’s PaO2 is
59 mm Hg, PaCO2 is 33 mm Hg, pH is 7.25, and HCO3-
is 14 mmol/L. The ventilator is alarming with a peak
airway pressure of 42 mm Hg. The respiratory therapist
asks you what you want to do…
Later that same shift, a 29-year-old woman with a
history of asthma requires intubation for severe broncho-
spasm and respiratory failure. Fifteen minutes after she
is intubated, the arterial blood gas shows a pH of 7.28
and a PaCO2 of 51 mm Hg. Her predicted body weight is
132 lbs (60 kg), so the tidal volume is set to 480 mL. You
increase the ventilator rate from 14 to 20 breaths/min.
Five minutes later, the ventilator is alarming with a peak
airway pressure of 47 mm Hg. Her blood pressure, which
was initially 145/90 mm Hg, has fallen to 82/55 mm
Hg. A repeat arterial blood gas shows a pH of 7.19 and a
PaCO2 of 63 mm Hg. The respiratory therapist asks what
changes to the ventilator settings are needed...
Introduction
Airway management is often considered to be the
most important skill an emergency physician should
possess. Emergency physicians are often called upon
to intubate the most critically ill patients in the emer-
gency department (ED) and, at times, in the hospital.
Many emergency physicians have pioneered new
tools and techniques for securing the airway in
different clinical situations, but ventilator manage-
ment is often a secondary consideration to airway
management in the ED. The initial ventilator settings
are often deferred to the respiratory therapist, with
subsequent management performed by the inten-
sive care unit (ICU) team. Ideally, the emergency
physician would secure the airway and perform the
initial resuscitation, and then the patient would be
taken without delay to the ICU for further treatment.
However, often, critically ill patients board in the ED
for hours, even days, at a time. While the ICU team
may write the admission orders, the emergency
physician is the go-to physician for respiratory
therapists when a ventilator problem occurs in the
ED. Ventilator troubleshooting can be difficult, so
it is essential to understand the common problems
that intubated patients face and how to adjust the
ventilator accordingly.
The recommendations in this review apply to
Copyright © 2014 EB Medicine. All rights reserved. 2
patients in the ED with acute respiratory failure who
require mechanical ventilation. Common modes of
ventilation will be discussed. These include volume
assist-control ventilation (VCV), where the physician
sets the tidal volume, and pressure assist-control
ventilation (PCV), where the physician selects an
inspiratory pressure. It is important to keep in mind
that VCV and PCV are generic terms, and the manu-
facturers of different ventilators have their own
“brand name” modes. Dräger CMV, Puritan Ben-
nettTM VC+, and Maquet PRVC are all VCV modes
for those brands. In this article, the generic names
will be used. Additionally, while the case presenta-
tions describe adult patients, the concepts are also
relevant to pediatric patients who are being venti-
lated in the ED.
Critical Appraisal Of The Literature
A literature search was performed using PubMed
and Google Scholar. The areas of research and search
terms included acute respiratory failure, emergency
department, acute respiratory distress syndrome, hypox-
emia, dynamic hyperinflation, autoPEEP, compliance,
tidal volume, ventilator-induced lung injury, mechanical
ventilation, airway pressure, high-frequency oscillatory
ventilation, airway pressure release ventilation, inhaled
nitric oxide, prone positioning, and neuromuscular block-
ade. Priority was given to recent (within the last 15
years) prospective randomized controlled trials and
meta-analyses. Retrospective cohort studies, system-
atic reviews, and observational studies were also
used. The field of mechanical ventilation and acute
respiratory failure has been well studied, but much
of the literature focuses on respiratory mechanics
and measurements of biomarkers related to venti-
lator-induced lung injury. While important, these
studies have little direct relevance to the practicing
emergency physician. The references included in this
review were selected based on both the strength of
evidence and the degree to which the findings are
applicable to current clinical practice.
A search of the National Guideline Clearing-
house at www.guideline.gov for the terms mechanical
ventilation, acute respiratory failure, and acute respira-
tory distress syndrome yielded 2 relevant guidelines.
The guideline for “Capnography/Capnometry
During Mechanical Ventilation: 2011” gives a 1A
recommendation for capnography or capnometry to
confirm proper endotracheal tube (ETT) placement,
and a 2B recommendation for the use of waveform
capnometry to guide management of mechani-
cal ventilation.1 The “Surviving Sepsis Campaign:
International Guidelines for Management of Se-
vere Sepsis and Septic Shock: 2012” guideline also
provides several useful recommendations for the
treatment of acute respiratory failure.2 The use of a 6
mL/kg predicted body weight tidal volume receives
www.ebmedicine.net • Volume 4, Number 5
a 1A recommendation when compared with a tidal
volume of 12 mL/kg predicted body weight. Main-
taining a plateau pressure (PPLAT) ≤ 30 cm H2O is
given a 1B recommendation, as is the use of positive
end-expiratory pressure (PEEP) to maintain alveolar
recruitment. The use of higher PEEP instead of lower
PEEP and the practice of maneuvers to improve
alveolar recruitment and oxygenation both have 2C
recommendations based on current evidence.
Etiology And Pathophysiology
Respiratory Compliance
Understanding the compliance of the respiratory
system is essential to troubleshooting mechanical
ventilation. Recall that compliance is the change in
volume (ΔV) divided by the change in pressure (ΔP):
C = ΔV / ΔP
For the respiratory system, the ΔV is the tidal
volume generated using positive-pressure ventilation.
The ΔP is the pressure required to reach that tidal vol-
ume. Normal respiratory compliance is approximate-
ly 100 mL/cm H2O. During mechanical ventilation,
the compliance can be calculated by dividing the tidal
volume by the difference between the peak airway
pressure (PAP) and the PEEP. Therefore, if a patient
is on assist-control ventilation with a tidal volume
of 450 mL, a PAP of 25 cm H2O, and a PEEP of 10 cm
H2O, the compliance is 30 mL/cm H2O.
C = tidal volume / (PAP-PEEP)
C = 450 / (25-10) = 450 / 15 = 30
Diseases of the lungs and of the chest wall can
affect compliance. Factors that reduce compliance of
the lungs include mainstem bronchus intubation, an
obstructed ETT, pneumonia, bronchospasm, pul-
monary edema, acute respiratory distress syndrome
(ARDS), and pulmonary fibrosis. (See Table 1.) Dis-
orders that reduce chest wall compliance and limit
the excursion of the chest during breathing include
morbid obesity, circumferential burns, and abdomi-
nal compartment syndrome. In VCV, where the
physician sets a tidal volume, worsening compliance
will be reflected by higher PAP. In PCV, where the
physician sets an inspiratory pressure, worsening
compliance will lead to reduced tidal volumes and
a reduced minute ventilation. In general, worsening
compliance means a worsening patient condition.
Airway Resistance
The first question the emergency physician should
ask is, “Is the problem in the airways, or in the
lungs?” This can be answered by estimating the
degree of airway resistance that is present. When the
ventilator delivers a breath in VCV, it applies posi-
www.ebmedicine.net • Volume 4, Number 5
tive pressure until the goal tidal volume is reached.
The amount of pressure needed to deliver the breath
through the ETT, trachea, large conducting airways,
bronchioles, and alveoli is recorded as the PAP. If
the physician were to put a hold on the ventilator
circuit at the end of inspiration (akin to holding
your breath) then flow would stop. This causes the
pressures in the system to equilibrate, meaning that
the pressure in the alveoli equals the pressure in the
large airways and in the ETT. This pressure, record-
ed at the end of a 0.5- to 1-second inspiratory hold
maneuver, is known as the PPLAT.
The PPLAT represents the pressure (and therefore
the compliance) of the lungs during inspiration.
As the PPLAT increases, the compliance of the lungs
decreases. A reduction in chest wall compliance will
also raise the PPLAT. Think of it as a binder restrict-
ing the ability of the lungs to inflate. The PAP, on
the other hand, represents both the compliance of
the lungs and the resistance of the airways (includ-
ing the ETT). The difference between the PAP and
the PPLAT is normally < 5 cm H2O. A significant rise
in the PAP without an increase in the PPLAT reflects
an increase in airway resistance and not necessarily
a problem with the lungs or chest wall. This is seen
in asthma, chronic obstructive pulmonary disease
(COPD), mucus plugging, and kinking of the ETT.
Disruptions In Normal Gas Exchange
Mechanical ventilation will often improve gas
exchange, but occasionally problems persist after in-
tubation that require adjustment of the ventilator. The
2 major mechanisms for significant disruptions in gas
exchange (even after initiation of positive-pressure
ventilation) are shunt and dead space ventilation.
Shunt is easy to visualize: blood passing from
the right side of the heart to the left side of the
heart through areas where there is no ventilation
whatsoever. A shunt can be intracardiac: but, most
of the time, it is intrapulmonary. Intrapulmonary
shunts are caused by prevention of inspired gas
Table 1. Common Conditions That Reduce
Respiratory Compliance
Lungs
• Mainstem bronchus intubation
• Pneumonia
• Bronchospasm
• Pulmonary edema
• Acute respiratory distress syndrome
• Pulmonary fibrosis
Chest Wall
• Morbid obesity
• Abdominal compartment syndrome
• Circumferential burns
• Kyphoscoliosis
3 Reprints: www.ebmedicine.net/emccissues
reaching the alveoli. Examples include atelectasis,
ARDS, pulmonary edema, and consolidation from
pneumonia. With a shunt fraction of 50%, even the
administration of 100% oxygen will not increase the
partial pressure of oxygen (PaO2) to > 60 mm Hg.3
Therefore, the treatment of hypoxemic respiratory
failure resulting from shunting requires positive
pressure ventilation to recruit and stabilize collapsed
lung units. This is accomplished by using PEEP. As
a general rule, the more opacification in the patient’s
lungs, the more PEEP is needed.
Methods for determining the optimal amount of
PEEP are widely debated. The studies performed by
the Acute Respiratory Distress Syndrome Network
(ARDSNet) research group based PEEP settings on
the FiO2 requirement (see Table 2), with titration of
the FiO2 and PEEP to maintain an oxygen saturation
(SpO2) of 88% to 95%.4,5 Some investigators have dem-
onstrated that measuring the lower inflection point
(LIP) on an inspiratory pressure-volume curve can be
used to set the initial PEEP.6,7,8 The LIP is the point at
which alveoli are recruited and the compliance of the
lungs improves. (See Figure 1.) Several commercially
available ventilators can measure the pressure-volume
curve during a period of constant flow. Setting the
PEEP at or just above the LIP may prevent atelectasis
and derecruitment.9 A recent systematic review of the
use of the pressure-volume curve to set the PEEP sug-
gested that, while there may be an association between
this method and increased survival in ARDS, only 3
randomized trials have studied this, and more evi-
dence is needed.10 Other studies have proposed using
a decremental PEEP titration curve, where the initial
PEEP is set at 20 cm H2O and then reduced by 2 cm
every 20 minutes. The optimal PEEP is the lowest level
at which oxygenation is maintained.11 A decremental
PEEP study is time- and labor-intensive, however, and
may not be practical in the ED. Use of a PEEP-FiO2
table or a pressure-volume curve may be a more con-
venient method.
Dead space ventilation is the opposite of shunt.
The paradigm of dead space ventilation is best
illustrated during a cardiac arrest (with no chest
compressions)—the alveoli are ventilated, but there
is absolutely no perfusion. Dead space is seen with
massive pulmonary embolism, venous air embolism,
and during periods of extremely low cardiac output.
It can also be seen with significant overdistension
of alveoli during positive-pressure ventilation and
dynamic hyperinflation in patients with COPD. The
Table 2. Higher Fraction Of Inspired Oxygen–Lower Positive End-expiratory Pressure Settings
FiO2 30% 40% 40% 50% 50% 60% 70% 70%
PEEP* 5 5 8 8 10 10 10 12
*In cm H2O.
Abbreviations: FiO2, fraction of inspired oxygen; PEEP, positive end-expiratory pressure.
Adapted with permission from the Acute Respiratory Distress Syndrome Network (ARDSNet).
Copyright © 2014 EB Medicine. All rights reserved. 4
gas exchange abnormality seen with dead space
ventilation is both hypoxemia and hypercapnia.
The carbon dioxide (CO2) is not cleared because the
venous blood never comes in contact with alveoli.
Lung-Protective Ventilation
Historically, the emphasis of mechanical ventilation
has been on the restoration of normal gas exchange.
Over the last 15 to 20 years, however, a growing body
of research has helped shift the focus from correction
of hypoxemia and hypercapnia toward the avoidance
of ventilator-induced lung injury.4,10 Chief among
these was the classic study from the ARDSNet research
group examining the use of low tidal volume ventila-
tion in ARDS.5 In this study, subjects who were venti-
lated using a tidal volume of 6 mL/kg predicted body
weight had a significantly higher rate of survival when
compared with patients receiving 12 mL/kg predicted
body weight. The absolute reduction in mortality was
8.8%, even though the low tidal-volume group also
had statistically significant worse oxygenation. Subse-
quent studies have validated these findings.13,14 Low
tidal-volume ventilation is a bit of a misnomer. The
normal physiologic tidal volume for healthy people
Figure 1. Pressure-Volume Curve
The LIP is the point at which alveoli open up, improving lung compli-
ance. Increasing the pressure beyond the LIP continues to recruit
lung units, up to the point of the UIP. Ventilator pressures beyond the
UIP do little to increase lung volumes and expose the patient to lung
injury. The LIP is analogous to the necessary end-expiratory lung
pressure—if the pressure falls below the LIP, derecruitment and atel-
ectasis occur. The UIP can be understood as the maximal distending
pressure. Determining the actual points for an individual patient can
be done, but it is difficult to do without neuromuscular blockade, and
it requires a slow constant inspiratory flow.
Abbreviations: LIP, lower inflection point; UIP, upper inflection point.
70% 80% 90% 90% 90% 100% 100% 100% 100%
14 14 14 16 18 18 20 22 24
www.ebmedicine.net • Volume 4, Number 5
is 5 to 7 mL/kg predicted body weight. It is only
considered to be low when it is compared with tidal
volumes used in the past, which were in the range
of 10 to 15 mL/kg and were kept higher to prevent
atelectasis and to normalize gas exchange.15 A better
term would be normal tidal-volume ventilation.
Inappropriately high tidal volumes at the initia-
tion of mechanical ventilation have been associated
with the development of acute lung injury, even in
patients who did not have lung injury at the time of
intubation.16,17
PEEP is used to open up collapsed alveoli and to
keep them open during mechanical ventilation. The
benefit is twofold: first, by recruiting collapsed al-
veoli, shunt fraction is reduced and hypoxemia will
improve. Second, prevention of repetitive opening
and closing of alveoli during ventilation minimizes
shear stress on the alveoli.18 Avoidance of atelectrau-
ma is considered to be an important part of reducing
ventilator-induced lung injury.19
Tools And Techniques For
Ventilator Troubleshooting
Deterioration in the ventilated patient’s respiratory
condition will often be brought to your attention by
the alarms on the ventilator. For VCV, a commonly
used mode of ventilation in the United States, the
high-pressure alarm will sound. For PCV, the low–
tidal-volume alarm or the low–minute-ventilation
alarm will sound. Since most EDs and ICUs use
VCV, this review will focus on the high-pressure
alarm (although the steps to troubleshoot are identi-
cal if PCV is being used).
There are 4 bedside skills that emergency physi-
cians should be able to perform on the ventilator.
Each brand of ventilator is slightly different, and it is
important to learn these on the machines in each ED.
Measuring Alveolar (Plateau) Pressure
While the ventilator is delivering the breath, press and
hold the “inspiratory hold” button on the machine for
Figure 2. Inspiratory Hold Maneuver
Peak airway pressure
Plateau pressure
www.ebmedicine.net • Volume 4, Number 5
0.5 to 1.0 second. (See Figure 2.) The pressure wave
will initially drop, and then the waveform will be-
come horizontal. The pressure at this point is known
as the PPLAT, and it reflects the equilibration of airway
pressures during a period of no airflow at the end of
inspiration. Due to this equilibration, the pressure in
the ETT is equal to the pressure in the alveoli. Release
the button. Most modern ventilators will display the
PPLAT on the screen. A PPLAT > 30 cm H2O is thought to
be potentially injurious to the lung, although no safe
threshold for this pressure has been determined.5,12-14
Determining Airway Resistance
Perform an inspiratory hold, as described above.
Look at the pressure waveform on the ventilator,
and record both the PAP and the PPLAT. A large drop
(> 5 cm H2O) between the PAP and the PPLAT indi-
cates increased airway resistance. (See Figure 3.)
This can occur in the bronchioles (as in asthma), the
larger conducting airways (as in mucus plugging),
or in the ETT (with too-narrow a tube, kinking, or
obstruction).
Identifying Dynamic Hyperinflation
Normally, at end-expiration, the flow of gas out of
the lungs reaches baseline, or zero. In diseases such
as COPD and asthma, the patient may not be able to
exhale completely before the ventilator delivers the
next breath. Inadequate emptying of the alveoli leads
to dynamic hyperinflation (also known as autoP-
EEP or breath stacking). Dynamic hyperinflation has
several consequences: (1) triggering the ventilator by
the patient becomes more difficult, which can increase
patient-ventilator dyssynchrony; (2) the amount of
dead space ventilation is increased, which leads to
worsening hypercapnia and hypoxemia; and (3) when
severe, alveolar pressures can rise to the point where
venous return to the heart is compromised. This leads
to hypotension and even circulatory collapse.
On the flow-time waveform, make sure that the
expiratory flow is coming back up to baseline at the
end of each breath. If it is not, there is some degree
Figure 3. High Airway Resistance
Peak airway pressure
High airway resistance
Plateau pressure
5 Reprints: www.ebmedicine.net/emccissues
of expiratory airflow obstruction. (See Figure 4.)
Lowering the respiratory rate, and thereby permit-
ting more time for exhalation, is the easiest way to
fix the problem. Other solutions include shortening
the inspiratory time or increasing the peak inspira-
tory flow. This will also allow for more time in the
expiratory phase.
Measuring The Degree Of Hyperinflation
If dynamic hyperinflation is suspected, the amount
of autoPEEP can be measured using an expiratory
hold maneuver. This is very similar to the inspira-
tory hold used to measure PPLAT. Press and hold the
“expiratory hold” button at the end of expiration.
(See Figure 5.) Flow will stop, allowing alveolar and
airway pressures to equilibrate. Release the button
after 0.5 to 1.0 second. The total PEEP displayed on
the ventilator represents the alveolar pressure at
end-expiration. Subtract the applied PEEP (the PEEP
that the emergency physician set on the ventilator)
to calculate the patient’s autoPEEP.
Clinical Course In The Emergency
Department
Determining Stability
Stabilizing the patient with acute respiratory fail-
ure in the ED should focus on 2 questions: (1) Is gas
exchange sufficient to meet the patient’s metabolic
needs? and (2) Is the ventilator adjusted in a way
to prevent further injury or decompensation? With
regard to gas exchange, emergency physicians should
keep in mind that oxygenation is the first priority.
A normal PaO2 is 90 to 100 mm Hg while breathing
room air, with an SaO2 of 98% to 100%. In critically
ill patients, however, it is acceptable in most cases to
maintain a PaO2 of 55 to 80 mm Hg and an SpO2 of
88% to 95%.5,13 It has been established that breathing
100% oxygen can cause an acute tracheobronchitis.20
It has not been clearly established that higher concen-
trations of inspired oxygen are associated with worse
Figure 4. Dynamic Hyperinflation
Copyright © 2014 EB Medicine. All rights reserved. 6
clinical outcomes, but the potential for adverse effects
still exists.21 A multicenter cohort study of patients
resuscitated from cardiac arrest found that an initial
PaO2 > 300 mm Hg was independently associated
with higher in-hospital mortality.22 It seems prudent
to treat oxygen as any other drug and only use the
amount necessary to meet the patient’s needs.
Ventilation should be focused on maintain-
ing a pH of at least 7.15. Most often, the rate on
the ventilator can be adjusted safely to keep the
PaCO2 in the normal range of 35 to 45 mm Hg and
the pH in the range of 7.35 to 7.45. In certain cases,
however, it may not be possible to have normal
CO2 clearance. For instance, in status asthmaticus, a
higher respiratory rate may lead to more dynamic
hyperinflation, and higher tidal volumes may cause
excessive alveolar stretch and result in lung injury.23
In many cases, it is better to accept some degree of
respiratory acidosis rather than risk further injury
to the patient. Hypercapnia can increase intracranial
pressure, however, and a respiratory acidosis should
be avoided in patients with traumatic brain injury,
intracranial bleeding, or other conditions associated
with intracranial hypertension. Severe alkalemia
(pH > 7.60) can also have adverse effects. Cerebral
and myocardial arteriolar constriction can occur.
Additionally, alkalemia can lead to ionized hypo-
calcemia, seizures, tetany, and stupor.24 Respiratory
alkalosis should also be avoided.
Obtaining an arterial blood gas after the initial
ventilator settings are applied and after any major
changes in the settings is prudent. Continuous cardiac
monitoring and pulse oximetry are also recommended
for all ventilated patients in the ED. Continuous wave-
form capnography, while not universally available,
is very helpful in monitoring proper ETT placement
and in following ventilation. The end-tidal CO2 does
not correlate exactly with the PaCO2, but significant
changes in the end-tidal CO2 level should prompt
the emergency physician to reassess the patient. An
Figure 5. Auto–positive End-expiratory
Pressure
Abbreviation: PEEP, positive end-expiratory pressure.
www.ebmedicine.net • Volume 4, Number 5
in-depth discussion of the use of waveform capnogra-
phy is beyond the scope of this review, but interested
readers are recommended to the excellent review by
Kodali,25 or refer to the Pediatric Emergency Medicine
Practice issue titled “Capnography In The Pediatric
Emergency Department: Clinical Applications,” avail-
able at www.ebmedicine.net/capnography.
Identifying And Managing Deterioration
Whenever a critically ill patient deteriorates in the
ED, the emergency physician must perform a rapid
primary survey. In ventilated patients, this includes
ensuring that the ETT is still in the trachea (con-
firming aeration of both lungs) and assessing the
patient’s perfusion.
Emergency physicians should always go back to
the primary survey when something goes wrong. An
agitated patient on the ventilator should never be se-
dated before the physician checks the tube, sounds,
and SpO2. Following are some specific targets to
consider, based on the alarm or diagnostic testing,
once the primary survey is completed.
Problem: High Airway Pressure
This is the alarm in VCV. If PCV is being used, the
alarm will be for low tidal volume; however, the
approach is the same. This alarm indicates that there
is a reduction in the compliance of the respiratory
system. The first step is to determine whether this is
a lung problem or an airway problem (See Table 3):
• Perform an inspiratory hold maneuver to deter-
mine the PPLAT. If there is high PAP and low PPLAT,
then the problem is high airway resistance. If
there is high PAP and high PPLAT, then the prob-
lem is in the lungs or compression of the lungs,
leading to decreased lung compliance.
• Bedside ultrasound is an effective way to evalu-
ate for pneumothorax, pleural effusion, and
pulmonary edema.
• Chest x-ray can confirm proper position of the
ETT and will show atelectasis, infiltrates, pneu-
mothorax, or pulmonary edema.
Problem: Hypoxemia
New or worsening hypoxemia is always serious.
The first step is to exclude mechanical problems or
tube dislodgement. Disconnect the patient from the
ventilator, and connect a bag-valve mask with 100%
oxygen. Confirm ETT placement with capnography
and auscultation. Consider direct visualization.
Once it is confirmed that the ventilator and the ETT
are functioning properly, consider the following
workup for hypoxemia:
• Bedside lung ultrasound is a rapid way to diag-
nose pneumothorax, pleural effusion, or pulmo-
nary edema.26
• Chest x-ray will also demonstrate worsening
infiltrates, pneumothorax, pulmonary edema,
atelectasis, or new effusions. Increase the PEEP
if the problem is in the lung parenchyma.
• Always consider pulmonary embolism as a
cause for new hypoxemia in a critically ill
patient. Bedside ultrasonography to assess for
right ventricular strain or noncompressible
femoral veins can aid in the diagnosis. Com-
puted tomography pulmonary angiography is

Table 3. Differential Diagnosis Of High Peak Airway Pressure

PAP/ PPLAT Problem Solution
High PAP, Kinked or obstructed See if a suction catheter will pass easily. Check the tube holder and make sure the tube is not kinked
Low PPLAT endotracheal tube by the device. Look for any other areas where the tube may be pinched.
Mucus plugging Pass a suction catheter to remove secretions from the trachea. Chest x-ray may show lobar collapse
or mediastinal shift toward the opacified lung. Bronchoscopy may be required to effectively remove
secretions.
Bronchospasm Administer inhaled bronchodilators.
Too narrow an endotra- Change the tube, or accept higher PAP. Some ventilators have a feature called ATC, which takes the
cheal tube volume of the endotracheal tube into account. Make sure that the ATC is set to the size of the tube.
High PAP, Mainstem bronchus Pull the endotracheal tube back into the trachea.
High PPLAT intubation
Atelectasis of a lobe Chest percussion or bronchoscopy to open up the airway.
or lung
Cardiogenic pulmonary Administer diuretics or inotropes.
edema
Acute respiratory dis- Use a lower tidal volume (4-6 mL/kg predicted body weight)
tress syndrome
Pneumothorax Insert a chest tube.
Pneumonia Administer antibiotics.

Abbreviations: ATC, automatic tube compensation; PAP, peak airway pressure; PPLAT, plateau pressure.

www.ebmedicine.net • Volume 4, Number 5 7 Reprints: www.ebmedicine.net/emccissues

 considered to be the gold standard for diagnosis
of a pulmonary embolism.
• If there are absent breath sounds on one side, pull
the ETT back a few centimeters if it is entering the
mainstem bronchus on the chest x-ray. Direct vi-
sualization of tube placement with bronchoscopy
is another alternative.
• If there are absent breath sounds on one side,
even with the tube in the correct place, consider
pneumothorax or mucus plugging with com-
plete atelectasis of the lung.
• Tension pneumothorax should be suspected if
breath sounds are absent on one side and if the
patient is hypotensive, tachycardic, and hypoxic.
Unilateral absent breath sounds are not sensi-
tive to diagnose this condition, and a deviated
trachea is a late sign.
Problem: Dynamic Hyperinflation
Dynamic hyperinflation is usually due to inad-
equate time for exhalation. High airway resistance
only makes it worse. On the ventilator, the expi-
ratory flow will not return to baseline before the
next breath begins, and there will be measurable
autoPEEP. On physical examination, the patient
will appear uncomfortable. The patient’s abdominal
muscles will contract during forced exhalation, and
there may be jugular venous distension. Due to the
increasing amount of dead space, the PaCO2 will ac-
tually go up as the ventilator rate is increased. Below
are some steps to correct dynamic hyperinflation:
• If the patient is hemodynamically unstable, dis-
connecting the ventilator is a rapid way to allow
trapped air to escape. Ventilation with a bag-
valve mask can be performed until the patient’s
condition has stabilized, after which the ventila-
tor can be adjusted.
• Lower the ventilator rate, usually between 10
and 14 breaths/min. This is the easiest and
quickest way to improve expiratory flow.
• Shorten the inspiratory time to keep the inspira-
tory time to expiration time (I:E) ratio in the 1:3
to 1:5 range.
• Keep the tidal volume in the 6 to 8 mL/kg
range. A higher tidal volume will often slow the
patient’s spontaneous respirations, but a tidal
volume > 8 mL/kg predicted body weight may
cause lung injury.16,17
• Increase the inspiratory flow to 60 to 80 L/min
to permit more time for exhalation.
• Adequate sedation with opioids will help blunt
tachypnea, but can also lead to CO2 retention
and respiratory acidosis. This may be harmful in
patients with increased intracranial pressure.
• Treat bronchospasm with inhaled bronchodila-
tors and systemic steroids.
Copyright © 2014 EB Medicine. All rights reserved. 8
Special Circumstances
In certain circumstances, the emergency physician may
want to maintain a higher PaO2 and avoid permissive
hypercapnia. In patients with acute injury or illness
of the brain, allowing the PaCO2 to rise and the pH
to fall may increase intracranial pressure via cerebral
vasodilation. It may be necessary to increase the tidal
volume beyond what is considered lung-protective in
order to prevent this complication, although increasing
the respiratory rate is usually sufficient to maintain a
PaCO2 in the normal range. In brain-injured patients,
it is also prudent to maintain a PaO2 closer to what is
considered normal, ie, at least 90 mm Hg.27
Controversies And Cutting Edge
The strongest evidence for lung-protective ventila-
tion comes from the studies performed by the ARD-
SNet group.4,5 Some have offered criticism, claiming
that 6 mL/kg predicted body weight is too low and
that ≥ 8 mL/kg predicted body weight should be
used. A prospective multicenter randomized con-
trolled trial testing other lung-protective strategies
would be necessary to justify this claim, however.
There is also evidence that using tidal volumes in
excess of 8 mL/kg predicted body weight in patients
without primary lung injury may cause alveolar
overstretch and be deleterious.16,28,29 Keeping the
tidal volume at ≤ 8 mL/kg predicted body weight is
likely the best course of action.
PPLAT has been proposed as another way of guid-
ing therapy, with the suggestion that if the PPLAT is
kept < 30 cm H2O, it does not matter what the tidal
volume is. There are 3 problems with this approach.
First, there is no randomized clinical trial compar-
ing this method with the ARDSNet protocol to show
superiority (or even equivalence). Second, in the
ARDSNet study analysis, mortality increased with
each quintile of increasing PPLAT.5 No safe threshold
was identified. Third, animal studies have demon-
strated that overstretch of the alveoli (and not the
distending pressure) is responsible for the majority
of ventilator-induced lung injuries. Dreyfuss et al
used both a mini-iron lung and thoracoabdominal
binding in rats to demonstrate that escalating tidal
volumes caused increasing amounts of lung per-
meability and injury, irrespective of the pressure
required to generate such a volume.30
Rescue Maneuvers
Various alternative modes of ventilation and other
rescue therapies have been proposed for refractory
hypoxemia. These include recruitment maneuvers,
high-frequency oscillatory ventilation, airway pressure
release ventilation, inhaled nitric oxide, therapeutic
neuromuscular blockade, and prone positioning.
www.ebmedicine.net • Volume 4, Number 5
Recruitment Maneuvers
Recruitment maneuvers have been shown to im-
prove oxygenation in ventilated patients31,32 and
they can easily be performed in the ED for refrac-
tory hypoxemia. Placing the patient on continuous
positive airway pressure of 35 to 40 cm H2O for 30 to
40 seconds can help with alveolar recruitment and
improve short-term oxygenation, although the long-
term benefit of these maneuvers is less clear.33 The
Alveolar Recruitment for ARDS Trial is a prospective
randomized controlled trial designed to compare
conventional lung-protective ventilation with a pro-
tocol designed to maximize alveolar recruitment.34
This trial is currently underway.
High-frequency Oscillatory Ventilation
High-frequency oscillatory ventilation (HFOV)
operates on the concept of using a tidal volume
smaller than a patient’s anatomic and physiologic
dead space, with oscillations of a diaphragm in
the ventilator between 3 and 15 Hz (180-900 oscil-
lations/min). This should, theoretically, allow gas
exchange without distension of vulnerable lung
units and without creating high transpulmonary
pressures. During the H1N1 influenza epidemic of
2009, HFOV was reported to have been a successful
ventilation rescue mode in critically ill adults.35,36
HFOV requires a special ventilator that may not be
available in the ED, however, and recent clinical
trials have not shown a benefit with this mode of
ventilation. The multicenter Oscillation for Acute
Respiratory Distress Syndrome Treated Early
(OSCILLATE) and OlmeSartan and Calcium An-
tagonists Randomized (OSCAR) studies, published
in 2013, did not demonstrate a survival benefit in
patients with ARDS, even when used early in the
patient’s illness.37,38 There was no statistical differ-
ence in mortality in OSCAR, and the OSCILLATE
trial was stopped early due to an increased risk of
death in the HFOV group (47% vs 35%).
Airway Pressure Release Ventilation
Airway pressure release ventilation (APRV) uses
prolonged periods of a high inspiratory pressure
with brief (usually < 1 second) drops in the airway
pressure to allow CO2 to escape the lungs. Unlike
HFOV, APRV can be performed with most com-
mercially available ventilators, which makes this
more useful as a rescue mode. Additionally, APRV
does not require heavy sedation or neuromuscular
blockade, both of which are often necessary with
HFOV.39 By maintaining a higher mean airway pres-
sure, oxygenation can improve compared to conven-
tional ventilation.40 While improving oxygenation is
appealing and is likely to be the major reason behind
the popularity of APRV, this, in itself, has not been
demonstrated to improve survival in patients with
acute respiratory failure. A single-center study of 63
www.ebmedicine.net • Volume 4, Number 5
trauma patients comparing APRV with low–tidal-
volume synchronized intermittent mandatory venti-
lation did not find a difference in mortality, days on
ventilator, pneumonia, or pneumothorax.41 To date,
there are no large clinical studies demonstrating a
survival benefit with APRV when compared to lung-
protective ventilation.
Inhaled Nitric Oxide
Inhaled nitric oxide (iNO) is a selective pulmonary
vasodilator that improves ventilation/perfusion
matching by dilating only the pulmonary capil-
laries that are adjacent to ventilated alveoli. This
improves oxygenation in patients with ARDS; how-
ever, iNO has not translated into a survival ben-
efit in adults. A recent meta-analysis showed that
iNO was not associated with improved outcomes,
regardless of the severity of ARDS.42 Use of iNO in
the ED cannot be recommended.
Therapeutic Neuromuscular Blockade
Therapeutic neuromuscular blockade, along with
appropriate sedation, has also been studied in
patients with ARDS. Presumably, relaxation of the
chest wall improves respiratory system compliance
and improves ventilation. There may also be a ben-
efit from a reduction in systemic oxygen consump-
tion. A recent trial comparing the use of cisatra-
curium besylate with placebo did claim to show a
survival benefit.43 The hazard ratio for death at 90
days was better in the cisatracurium besylate arm
(0.68, 95% confidence interval [CI], 0.48-0.98), but the
overall 90-day mortality between the 2 arms did not
reach statistical significance. One way to interpret
this is that the cisatracurium besylate group lived
longer in the ICU and the hospital, but there was no
difference in long-term survival. In addition, 56% of
the patients in the placebo arm received open-label
cisatracurium besylate during their ICU stay as well,
which makes it difficult to ascertain a true benefit to
this therapy.
Prone Positioning
Prone positioning during mechanical ventilation
affects ventilation/perfusion matching by redistrib-
uting pulmonary blood flow to the anterior lung
fields (thus enhancing alveolar recruitment) and by
improving airway secretion clearance. Initial studies
of this maneuver showed an improvement in gas ex-
change, but it did not demonstrate a mortality bene-
fit.44,45 However, a recent multicenter study was able
to show an improvement in survival with prolonged
(16 h/day) prone positioning in patients with severe
ARDS.46 Extended-duration proning was also associ-
ated with a reduction in mortality in a meta-analysis
of 2246 patients in 11 studies.47 Of the 11 studies
included in the analysis, however, 10 had a 95% CI
that crossed 1. Only the Guérin et al study had a 95%
9 Reprints: www.ebmedicine.net/emccissues
CI < 1, and its reported reduction in the risk of death
seems to account for a large part of the treatment ef-
fect seen in this meta-analysis.46 It is difficult recom-
mend prone positioning as an evidence-based rescue
maneuver, given that only 1 clinical trial out of the
11 analyzed showed a survival benefit. Addition-
ally, prone positioning may not be practical in the
ED. Placement of central venous and arterial lines is
much more difficult in the prone patient, and turn-
ing the patient safely requires multiple personnel.
Specialized beds for proning are available, but it is
unlikely that these will be available to the emergen-
cy physician. This may be a rescue maneuver better
suited for the ICU than the ED.
Must-Do Markers Of
Quality ED Critical Care
1. Ensure that gas exchange is adequate to meet
the patient’s needs. This does not necessarily
mean that it has to be normal. A PaO2 of 55 mm
Hg (SpO2 of 88%-95%) is acceptable in most
cases, and so is permissive hypercapnia. Notable
exceptions to this are patients with neurologic
illness or injury.
2. Adopt a lung-protective approach to mechani-
cal ventilation. Open the lungs and keep them
open using PEEP (the more infiltrates, the more
PEEP is needed). Many physicians use a mini-
mum of 5 cm H2O PEEP, which has been shown
to reduce the work of breathing in patients
with normal lung function and in those with
COPD.48 Using a PEEP-FiO2 table (See Table 2,
page 4) is the most convenient method in the
ED, but using the LIP on a pressure-volume
curve is also acceptable. Do not overdistend
the patient with too high a tidal volume (6-8
mL/kg predicted body weight is sufficient in
most patients; patients with ARDS should have
a lower tidal volume of 4-6 mL/kg predicted
body weight).
3. Troubleshoot high PAP with an inspiratory hold
maneuver to measure the PPLAT. If the PAP and
PPLAT are both high, then there is a lung problem.
If the PAP is significantly higher than the PPLAT,
the problem is one of airway resistance. Check
the ETT, and listen for wheezing.
4. Dynamic hyperinflation is common in patients
with COPD and asthma. Fast ventilator rates do
not allow enough time for exhalation and can
worsen the problem. Allow plenty of time for
the patient to exhale.
5. Most importantly, always go back to the primary
survey if something goes wrong. An agitated pa-
tient on the ventilator should never be sedated
before you check the ETT, sounds, and SpO2.
Copyright © 2014 EB Medicine. All rights reserved. 10
Disposition
Patients with acute respiratory failure requiring me-
chanical ventilation should be admitted to the ICU.
Consultation with an intensivist or pulmonologist
for ventilator troubleshooting may be necessary. Re-
ferral and transfer to a tertiary center by a transport
team specially trained in ventilator management
should occur quickly if the emergency physician
feels that the degree of respiratory failure is severe
enough to warrant rescue maneuvers that are not
available in his or her institution.
Summary
Troubleshooting ventilator alarms and making
adjustments to the settings are parts of being an
acute care physician to critically ill patients. Pro-
longed boarding of mechanically ventilated patients
in the ED is a common problem, and emergency
physicians must have an understanding of what the
alarms signify and how to address problems with
high airway pressures, hyperinflation, and worsen-
ing gas exchange. A review of the primary survey,
followed by a stepwise approach to common issues,
will be sufficient in the majority of cases.
Case Conclusions
After confirming proper placement of the ETT in the
43-year-old man, you auscultated his chest. Coarse rhonchi
were present bilaterally. Bedside ultrasound showed adequate
pleural sliding and some B lines in the anterior lung fields.
You measured the PPLAT, which was 39 cm H2O (PAP was 42
cm H2O). Based on the patient’s predicted body weight of 75
kg, the tidal volume was lowered to 450 mL, and the PEEP
was increased to 14 cm H2O. The PAP decreased to 33 cm
H2O, with a PPLAT of 28 cm H2O. The pulse oximeter reading
improved to 97%, so the FiO2 was lowered to 0.8.
Turning to your patient with status asthmaticus,
you confirmed that the ETT was in place by capnogra-
phy. Breath sounds were equal, but diminished, with
forced wheezing. The expiratory flow on the ventilator
waveform was not reaching baseline before the next
breath cycled. PAP was 47 cm H2O. PPLAT was 21 cm
H2O, which indicated a high degree of airway resistance.
Using an expiratory hold maneuver, you measured
the autoPEEP at 11 cm H2O. You lowered the respira-
tory rate to 12 breaths/min and administered nebulized
albuterol. The respiratory therapist adjusted the inspira-
tory time to make the I:E ratio 1:5. Expiratory gas flow
seemed to improve, and a repeat measurement showed
the autoPEEP fell to 3 cm H2O. The patient appeared
more comfortable, and her blood pressure improved to
125/70 mm Hg.
www.ebmedicine.net • Volume 4, Number 5
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43. Papazian L, Forel JM, Gacouin A, et al. Neuromuscular
blockers in early acute respiratory distress syndrome. N Engl
J Med. 2010;363(12):1107-1116. (Multicenter double-blind
trial; 340 subjects)
44. Abroug F, Ouanes-Besbes L, Elatrous S, et al. The effect of
prone positioning in acute respiratory distress syndrome
or acute lung injury: a meta-analysis: areas of uncertainty
and recommendations for research. Intensive Care Med.
2008;34(6):1002-1011. (Meta-analysis)
45. Sud S, Friedrich JO, Taccone P, et al. Prone ventilation
reduces mortality in patients with acute respiratory failure
and severe hypoxemia: systematic review and meta-analysis.
Intensive Care Med. 2010;36(4):585-599. (Systematic review
and meta-analysis)
46. Guérin C, Reignier J, Richard JC, et al. Prone positioning in
severe acute respiratory distress syndrome. N Engl J Med.
2013;368(23):2159-2168. (Multicenter prospective random-
ized controlled trial; 466 subjects)
47. Lee JM, Bae W, Lee YJ, et al. The efficacy and safety of prone
positional ventilation in acute respiratory distress syndrome:
updated study-level meta-analysis of 11 randomized con-
trolled trials. Crit Care Med. 2014;42(5):1252-1262. (Meta-
analysis; 2246 patients)
48. Sydow M, Golish W, Buscher H, et al. Effect of low-level
PEEP on inspiratory work of breathing in intubated patients,
both with healthy lungs and with COPD. Intensive Care Med.
1995;21(11):887-895. (Prospective controlled study; 12 sub-
jects)
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6. Which ventilator parameter measures the
this issue, scan the QR code below with your
smartphone or visit www.ebmedicine.net/C0914.
5. If a patient has significant autoPEEP and hy-
percapnia, which of the following is the best
initial treatment?
a. Increase the tidal volume to 15 mL/kg
predicted body weight
b. Therapeutic neuromuscular blockade
c. Increase the ventilator rate
d. Decrease the ventilator rate
amount of dynamic hyperinflation?
a. Total PEEP following an expiratory hold
maneuver
b. PPLAT following an inspiratory hold
maneuver
c. PAP
d. Peak expiratory flow

7. If a ventilated patient suddenly becomes hy-

poxemic, the first thing the emergency physi-
cian should do is to:
1. What is the respiratory system compliance (in
a. Order a chest x-ray.
mL/cm H2O) in a patient with a tidal volume of
b. Obtain an arterial blood gas.
450 mL, a PAP of 25 cm H2O, and a PEEP of 10
c. Repeat the primary survey to confirm
cm H2O?
endotracheal tube placement.
a. 100 mL/cm H2O
d. Increase the FiO2.
b. 50 mL/cm H2O
c. 30 mL/cm H2O
8. With PCV a reduction in compliance will trig-
d. 15 mL/cm H2O
ger which ventilator alarm?
a. High pressure
2. Which of the following worsens respiratory
b. Low FiO2
system compliance?
c. Low tidal volume
a. Pneumonia
d. Apnea
b. Pulmonary edema
c. ARDS
9. What physical examination findings are associ-
d. All of the above
ated with autoPEEP?
a. Jugular venous distension
3. Areas of lungs that are perfused but not venti-
b. Abdominal wall contraction during
lated have what condition?
expiration
a. Dead space ventilation
c. Wheezing
b. Shunt
d. All of the above
c. Normal lung
10. High PAP and high PPLAT is associated with
4. PPLAT best represents which of the following?
which of the following?
a. AutoPEEP
a. Kinked endotracheal tube
b. Alveolar pressure at the end of inspiration
b. Bronchospasm
c. Airway resistance
c. Mucus plugging of the ETT
d. Oxygenation
d. Pneumothorax

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Diagnosis And Emergency Dep

August 2014 Man June 2014 artment April 2014
8
Urinary Tract Infe agement Of : New tification
Diabetic Emergencies
6 4

Heat Illness In The

Volume 16, Number Volume 16, Number
Management Of Volume 16, Number
Syncope: Risk Stra
July 2014 May 2014
ctions In The Mos
Disease Borne Illness: Mal quito-
Volume 16, Numbe
Making
Authors Author Volume 16, Numbe Authors

nt: Emergency Dep

Emergency Departme Strategies For An Old And Clinical Decision
Authors r7 DO, MPH Authors r5 MD
Jaron Santelli, MD of Texas Gerald Beltran, Medicine, Suzanne Y. G. Peeters, Haga Teaching
Department of Emergency
Medicine, University
artment Department of Emergency Kalamazoo, MI
aria
Residency Director,

And West Nile Viru , Dengue,

Jessica Best, Assistant Professor, of Medicine, Hector Caraball Emergency Medicine
TX MD University School The Netherlands
Southwestern, Austin, Assistant Professor,o, MD Hospital, The Hague,

Keeping Your Cool

Department of Western Michigan
FACEP Emergency Medicine, Clinical Departmen
Julie M. Sullivan, MD, University of Texas Abstra ct Southwestern University of the University
of Texas Health t of Emergenc Amber E. Hoek, MD Medical Centre,
and Advocacy Education, at Austin, Austin, Peer Reviewers
s Physician, Erasmus
Texas y Medicine,
Department of Emergency
Abstract
TX Antonio, TX Science Center
Director of Leadership Attending Emergency
Abstract
Derek Ou, MD San Antonio, The
TX; Staff Physician, Medicine, Rotterdam,
the emergen-
San
Southwestern, Austin, Center, Seguin, TX Mark Clark, MD Icahn School of Kevin King, ent, Department of Emergency
presentations to
Department of
Regional Medical Urinary tract Emergency Medicine, of Emergency Medicine, MD emergency departm
occurrence in the
Medicine, Guadalupe Assistant Professor Medicine Residency, Abstract
infections are Brackenridge,
cies are common
University Medical million Assistant Professor, Netherlands
diabetes affects 25.8 presentations. Syn-
Director, Emergency
a heterogeneous Diabetic emergen
Austin, TX
Syncope is a common
t FACEP n, Austin, involving infectio Center Medicine; Program New York, NY Clinical Director, MD
Ann Czarnik, MD,
Abstrac is estimated that ately 1% to 3% of Susan M. Mollink, Resident, Haga Teaching Hospital, The
Mount Sinai Roosevelt, Department of
of Texas Southwester group of disorde Andrew David Emergency Medicine, Medical Student Education
outcomes Director, University
fined by bacteri n of all or part of the urinary Kitlowski, MD
cy department. It cost of over $174 Mount Sinai St. Luke's,
accounting for approxim
postural
consciousness and
Science Center
of disease, with rs, at an annual total Emergency Medicine
Assistant Program Assistant Professor San Antonio, the University
Up to 700 million as a brief loss of
of Texas Health
a broad spectrum a in tract, and are in the United States, cies: Jonathan Yeo, MD
be acute or chronic the urine with clinical
Medicine, Icahn San Antonio,
. The spec-
of Emergenc Hague, The Netherlands
is s of diabetic emergen
TX
stroke. Heat illness people are infected cope is best defined
TX Southwestern
Heat illness spans de- at Austin, Austin, y Medicine, Universitypeople Department of EmergencyNY
complete recovery
Peer Reviewer
rash to fatal heat symptoms that 2 general categorie cemic emergen-
die each year spontaneous and
of Texas Assistant Professor, s MD
John Bedolla, MDResearch Education, University of Texas tions are treated . Approximately 1 million
TX York, and more than and a J. Stephen Huff, University of
ranging from benign types: classic and exertional. Both
types of may John Bedolla,
MD billion. There are emic. The hypergly School of Medicine
at Mount Sinai, New from
ity of cases occur mosquito-borne illness. While a million Saadia Akhtar, tone followed by to life threatening, Medicine and Neurology,
hypergly- s ranges from benign patients is key to provid-
Assistant Director Austin, TX every year in urinary tract hypoglyc Professor of Emergency VA
into 2 inad- Medicine Program, Assistant Director
cemic and olar Assistant Professor,MD
temperature with ments. The female United States infec- in endemic tropica the vast major- trum of etiologie
le,
broadly divided Southwestern Emergency
of Research Education, University hypergly hyperosm
ketoacidosis and
Virginia, Charlottesvil
international to evaluating these
Southwestern
emergency depart CME Objectives
of exposure to elevated illness occurs without -to-male ratio requires a careful l and subtrop Beth Israel, Icahn Department of Emergency
at Austin, Austin,
cies include diabetic should be able to: travel and migrati
tive. This issue reviews
of Texas
occur as a result are categorized is 6:1. Urinar - these conditions ical regions, structured approach
TX of this article, you School of Medicine Medicine, Mount
, classic Peer Reviewers as upper versus y tract infectio Peer Reviewer ent of , Upon completion prevalence in on patterns have Sinai
, yet cost-effec Peer Reviewers
gulation; however
and at Mount Sinai,
cemic state. Managem and improve perfusion
of hypoglycemic North Americ Suzanne Bentley, g
cooling, ing care that is thorough for managing and risk stratifyin
s
equate thermore t consists of rapid as uncomplicate lower tract involve ns Recognize the epidemiology. a. This review increased their Assistant Professor, MD, MPH
New York, NY
to restore volume
MPH and treatment FACEP
Jarone Lee, MD, d versus compli Andy Jagoda, MD,Department of Emergency Medicine,
Icahn
activity. Treatmen te monitoring. Manage-
Trauma, 1.
Care, Division of
cated. The emerge ment and
Lauren Grossma discusses the evidence
preceding physical Other milder forms Quality Director of
Surgical Critical tts must careful Attending Physician, n, MD, SM hydration strategy electroly hyperglycemic emergencies sequelae of the
seen in the United 3 most common mosqui diagno Medical Education Departments of Emergenc
the most relevant focused history,
physical
beginning with a
support. Care, Massachuse ly categorize and ogy and the potential Professor and Chair, Director, Mount
and physiologic therapy, ng to-borne illnesse sis
y Medicine and
and Surgical Critical ncy clinician ,
Mount Sinai/Elmh Sinai Global Health Training at Mount Sinai, Medical
fluid replacement, syncope, heat edema, Emergency Surgery, School, Boston,
MA patient host the infection First Choice ER,
intravenous insulin tion of the underlyi 2. Describe the pathophysiolemergencies. States: Plasmod the syncope patient, rdiogram, and tailored diagnost
ic testing. School of Medicine
and take emia includes identifica ous dextrose, and
Center Faculty,
heat fatigue, heat Harvard Medical factors Nicole Lazarciu Arvada, CO diabetic and West Nile ium falciparum s urst Hospital Center, York, NY
A working knowle to optimally treat and disposiinto account
from the various Mount Sinai, New
Sinai Hospital, New
and General Hospital,
Assistant Clinical c, MD, MPH ment of hypoglyc virus. With no Icahn School
for perfor-
examination, electroca decision rules are compared
examination
of heat illness include drug side effects, intraven historical and physical
pathog malaria , dengue, York, NY of Medicine at
drug combinations, and/or glucose, Identify the important that emergency FACEP
Kamal Medlej, MD Emergency Medicine, Director of Emergency dge of local or tion patients. clinicians in nonend nomonic findings, it is critical d Scott Silvers, MD,Emergency Medicine, Mayo Clinic,
Professor, Icahn
these etiology, oral food s the current 3. emergencies. CME Objective tion
and heat rash. Drugs, te heat illness and ity patterns of Several risk stratifica how age and associate
Sinai, New York,
. This review evaluate
School of Medicine
of
of Emergency Medicine, the most likely at least nationa NY at Mount findings in diabetic index of suspici
s of
cause or complica cooling maneuve
rs Assistant Professor
Care, Department l suscep tibil- ation of glucagon cies and offers t strategies for diabetic
on, emic areas mainta scenarios, including adverse
Chair, Department
infections can also of special popula pathogens is Upon completion
consider ent of diabetic emergen interpret indirec conduct a thorough history mance in various
managemen
Department Critical Center, Beirut, Lebanon Formulate in a high of this article, m and long-term Jacksonville, FL
not respond to standard
4.
of Beirut Medical tions exist that essential. A variety s, selec- you should be
predict short-ter “Physician CME
Information”
therapy strategies for managem g effective diagnostic strategie emergencies. t findings to initiate /travel history, 1.
comorbidities may care of the this activity, see
manifestations may each requires specific additional
American University including pregna require special Differentiate the able to:
d, evidence-based
Prior to beginning Prior to beginning
nt management, this activity, see
the use of ment. This review prompt and approp and uncomplicated
structure on the back page.
ties, and instrum females, patients with ion regardin
on the Information”
hos-
This n of potassium, “Physician CME presentations and complicate
for
and treatments alone; the cycle of heat and organ damage. ex-
Information”
n” informat that patients requiring
“Physician CME
“Physician CME
new this activity, see gathers the best riate treat-
of mosquito-borne d
events. An algorithm
rehydration, correctio cemia, and management
this activity, see anatomic abnorm on the back page. Informatio
public health 2. illnesses.
is included to ensure and those with benign
Prior to beginning ented patient Prior to beginning on the back page. evidence from Choose the diagnostic
s, and treatment
of tion of fluids for resources, surveil
back page.
or antidotes to reverse s. ali- international syncope patient
confirmatory
mild hypergly demic researc lance studies, mosquito-borne testing with the
appropriately
the physiology, diagnosi mia. Field and pre- for illnesses.
subcutaneous insulin lactic acidosis.
major
h to guidelines, and
review examines potentially lethal give emergency clinicians pitalization are managed
3. Order the most
hypother aca- effective treatment
and drug-induced , with recom- of metformin-induc
ed infections. tools to combat illnesses. of mosquito-borne
are discharg ed safely.
ertional, classic, are also reviewed these causes
s and treatment in rhabdomyolysis.
Editor-In-Chief
hospital diagnosi
Editor-In
and monitoring
-Chief Prior to beginning
ion Research Editor Andy Jagoda, Michael A. Gibbs,
Research Editor this activity, see MD
rehydrat
MD, FACEP Andy Jagoda, Michael A. Gibbs,
mendations for
MD, FACEP MD, FACEP FACEP “Physician CME Joseph D. Toscano,
Scott Silvers,
Michael Guthrie,
MD Professor and
Chair, Department
Professor and Charles V. Pollack, Scott Silvers, MD, Emergency Michael Guthrie,
MD MD, FACEP MD, FACEP
on the back page. Information” Family of Emergency
Jr., MA, MD, of Emergency Residency, Emergency of of Emergency
Chair, Department
Jr., MA, MD, Jr., MA, MD, of Residency,
Professor and
Chair,
Professor and
Chair, Department Charles V. Pollack, Center; Senior Faculty, Chairman, Department Regional
Charles V. Pollack, Chair, Department Jacksonville, FL Emergency Medicine Medicine, Medicine, Carolinas FACEP Scott Silvers, Charles V. Pollack, Chair, Department Jacksonville, FL Emergency Medicine Emergency Medicine,Department of of Emergency Jr., MA, MD, MD Health,
Medicine and Community at Mount Medicine, San Ramon
Michael A. Gibbs,
MD, FACEP Medicine, Mayo Clinic, Medicine at Mount of Medicine at Mount Icahn School Medical Center, MD, MD, FACEP Medicine, Mayo Clinic, Medicine at Mount of Medicine, Carolinas FACEP Keith A. Marill,
Depatment of San Ramon, CA
FACEP
Department of Icahn School of Sinai, Medical University of Professor and Chair, Department FACEP Michael A. Gibbs, FACEP
Department of Icahn School of Medicine at Mount Icahn School Medical Center, Scott Silvers,
MD, MD, PhD Research Faculty, Icahn School of
Medicine Medical Center,
Professor and Chair,
Department
Professor and Chair, Pennsylvania
Director, Mount Carolina School North Chair,
Emergency Medicine,Department of Research Editor Professor and Chair,
Department
Professor and Chair, Pennsylvania
Professor and Chair, Department FACEP Nicholas Genes,
Editor-In-Chief Editor-In-Chief
NY NY University of University of
MD, FACP, FACEP Sinai, New York, Sinai Hospital, of Medicine, Medicine, Mayo of Emergency MD, FACP, FACEP Sinai, New York, Director, Mount Sinai, Medical Carolina School North Chair,
Emergency Medicine,Department of Research Editor Department of Sinai, New York,
NY
Carolinas Corey M. Slovis, York, NY New Hill, NC Chapel Carolinas Corey M. Slovis, Sinai Hospital, Medicine, Mayo of Emergency Editor-In-Chief Assistant Professor, Emergency Medicine,
FACEP of Emergency Medicine, of North Emergency Medicine, Department Hospital, Perelman Pennsylvania Clinic, Jacksonville Michael Guthrie, FACEP of Emergency Medicine, of North Emergency Medicine, Department York, NY
of Medicine,
Chapel Icahn School Center, Pittsburgh, Research Editor
Andy Jagoda, MD, Department of School of Professor and Chair, MD , FL Andy Jagoda, MD, Department of School of Professor and Chair, New Hill, NC Pennsylvania Clinic, Jacksonville Emergency Medicine, Pittsburgh Medical
International Editors
Federica Stella, MD Hospital, Perelman Michael Guthrie, FACEP
Medical Center,
University Hospital, Perelman Vanderbilt Steven A. Godwin, Medicine, UniversitySchool of Corey M. Slovis, Emergency Medicine Medical Center,
University Hospital, Perelman Vanderbilt , FL MD Andy Jagoda, MD, Department of Sinai, New MD
Professor and Chair, Icahn School of Medicine, Chapel of Pennsylvania, of Emergency Medicine, Nashville, Emergency Medicine
Residency, Associat
e Editor-In-Chief MD, FACEP of Pennsylvan MD, FACP, FACEP Professor and Chair, Icahn School of Medicine, Chapel of Pennsylvania, of Emergency Medicine, Nashville, Steven A. Godwin, Medicine, UniversitySchool of Corey M. Slovis, Emergency Medicine of Medicine at Mount PA FACEP
Scott Silvers, MD, Emergency Michael Guthrie,
Emergency Medicine, Sinai, Medical
Carolina School Medicine, University Center, Hospital in Venice, Professor and Philadelphia, ia, Professor and Icahn School Residency,
of Medicine atEmergency Medicine, Carolina School Medicine, University Center, MD Associate Editor-In MD, FACEP MD, FACP, FACEP Professor and Chair, Icahn School Residency,
University Medical Giovani e Paolo Kaushal Shah, Chair, Department PA Chair, Department University Medical Peter Cameron, Professor and Philadelphia, of Pennsylvan Professor and Icahn School Residency,
York, NY Jr., MA, MD, of Emergency Medicine
Hill, NC Philadelphia, PA of Emergency of Emergency Sinai, New York, Mount Sinai, Medical Hill, NC Philadelphia, PA The Alfred Kaushal -Chief Chair, Department PA ia, Chair, Department of Medicine at Emergency Medicine, Sinai, Medical Charles V. Pollack, Chair, Department Jacksonville, FL Medicine at Mount
of Medicine at Mount Hospital, New TN University of Padua,
Italy MD,
Associate Professor,FACEP Medicine, Assistant Michael S. Radeos, Medicine, Vanderbilt NY of Medicine at Mount Hospital, New TN Academic Director, Shah, MD, FACEP of Emergency of Emergency Sinai, New York, Mount MD, FACEP Medicine, Mayo Clinic, Icahn School of
Director, Mount Sinai
MD, FACEP MD, MPH Dean, Simulation Assistant Professor MD, MPH
University Medical
Director, Mount Sinai
MD, FACEP MD, MPH
Emergency and
Trauma Centre, Associate Medicine, Assistant Michael S. Radeos, Medicine, Vanderbilt NY of Medicine at Mount Hospital, New Michael A. Gibbs, FACEP
Department of NY
Steven A. Godwin, Department Michael S. Radeos, of Emergency MD, MPH Department of Education, Center, Nashville, Steven A. Godwin, Department Michael S. Radeos, of Emergency MD, MPH Professor, Dean, MD, University Medical Sinai, New York,
H. Thomas, Emergency University of TN Internati H. Thomas, Melbourne, Department Simulation Assistant MPH Director, Mount Sinai Professor and Chair,
Department Professor and Chair, Pennsylvania MD, FACP, FACEP
International Editors onal Editors York, NY
Medicine, Icahn of Emergency Center, Nashville,
York, NY Professor and Chair, Assistant Professor Stephen Foundation of Medicine at School Florida COM- Medicine, Weill Professor and Chair, Assistant Professor Stephen Foundation Monash University, Emergency Medicine, of University of Education, Professor of Emergency TN International Carolinas Corey M. Slovis,
Emergency Medicine,
George Kaiser Family George Kaiser Family International Editors
Assistant College Jacksonville, Medical College Assistant College Icahn School Florida COM- Medicine, Weill Editors York, NY of Emergency Medicine, of North Department
hief of Emergency Medicine, Medicine, Weill Medical York; Department of
Mount Sinai, of Cornell University, Peter Cameron, of Emergency Medicine, Medicine, Weill Medical York; Department of
of Medicine at School of Professor and Chair,
Editor-In-Chief
MD York, NY New Jacksonville, Stephen H. Thomas, Australia Mount Sinai, Jacksonville, Medical College University
MD Peter Cameron, Hospital, Perelman
Associate Editor-In-C Professor & Chair, Professor & Chair,
Education, New Peter Cameron, FL Education, New Jacksonville, of Cornell University, Stephen H. Thomas, hief Medical Center, Vanderbilt
Dean, Simulation of Cornell University, University of Gregory L. Henry, Research Director, New York; MD, MPH Academic Director, Associate Dean, Simulation of Cornell University, University of York, NY New MD of Medicine, Chapel of Pennsylvania, of Emergency Medicine, Medical MD
The Alfred
Associate Editor-In-C
of Medicine, Director, George Kaiser of Medicine, MD FL New York; MD, Academic University Peter Cameron,
COM- Department Department of Family Foundation The COM- Department Carbone, Gregory Research MPH School Medicine,
Clinical Professor,MD, FACEP
FACEP Academic Alfred FACEP Giorgio George Kaiser Center;
Kaushal Shah, MD, Department of University of Florida Research Director, Emergency
of Community Trauma Centre, Editorial Board Emergency Medicine, Professor & Chair, Emergency and Kaushal Shah, MD, Department of University of Florida Research Director, Emergency
of Community of Emergency L. Henry, Director, Department Family Foundation Director, The Carolina University Medical Academic Director,
The Alfred
FL
Emergency Medicine,
New York Oklahoma School Emergency and Department of New York Department of Trauma Centre, FL
Emergency Medicine,
New York Oklahoma School Chief, Department Editorial Board Clinical Professor,MD, FACEP Emergency Medicine, of Professor & Chair, Emergency and Alfred FACEP
Kaushal Shah, MD, Department of Hill, NC Philadelphia, PA
Associate Professor, Icahn School Jacksonville, Jacksonville, Melbourne, Emergency Medicine, Hospital Queens, Emergency Medicine, Monash University, Professor, Jacksonville, Jacksonville, Gradenigo, Trauma Centre, Fire Department and Emergency and
Trauma Centre,
Flushing, NY Medicine, Tulsa, OK Monash University, William J. Brady, Flushing, NY Melbourne,Associate Medicine, Icahn School Flushing, NY Medicine, Tulsa, OK Medicine Ospedale Emergency Medicine, Department of Hospital Queens, New York Emergency Medicine,Department of Monash University, Associate Professor, Icahn School MD, FACEP MD, MPH Director, Nashville
Emergency Medicine, Sinai, New MD, FACEP Hospital Queens, MD of Michigan Medical University Oklahoma School University of Australia Emergency MD, FACEP Hospital Queens, William J. Brady, Flushing, NY Melbourne, Steven A. Godwin, Department Michael S. Radeos, of Emergency Nashville, TN University, Melbourne,
Gregory L. Henry, Australia Professor of Emergency Ali S. Raja, MD, Sinai, New Gregory L. Henry, Torino, Italy MD of Michigan Medical University Oklahoma School University of Australia Medicine, Airport, Monash
of Medicine at Mount Department of Ali S. Raja, MD,
MBA, MPH Ron M. Walls, MD Medicine Medical Practice School; CEO, MBA,
Director of Network MPH Medicine, Tulsa, of Community of Medicine at Mount Department of Ali S. Raja, MD,
MBA, MPH Ron M. Walls, MD Professor of Emergency Ali S. Raja, MD, Emergency Sinai, New Professor and Chair, Assistant Professor International
Clinical Professor, Operations and Department of and Medicine, Giorgio Carbone, Clinical Professor, Operations and Department of MD, FAAEM Medical Practice School; CEO, MBA, Medicine, Tulsa, of Community of Medicine at Mount Assistant College Australia
York, NY University Professor and Chair, Brigham and Giorgio Carbone, MD Chair, Inc., Ann Arbor, Risk Assessment, Business DevelopmeOperations and
OK
York, NY University Professor and Chair, Brigham and Amin Antoine Kazzi, and Vice Chair, and Medicine, Medicine Director of Network MPH Giorgio Carbone, of Emergency Medicine, Medicine, Weill Medical York; MD, MPH
Emergency Medicine, Director of Network Emergency ResponseMedical MI Ron M. Walls, Chief, DepartmentMD Emergency Medicine, Director of Network Chair, Inc., Ann Arbor, Risk Assessment, OK New Stephen H. Thomas, Foundation MD
School; CEO, Department Emergency Medicine, Department of Emergency Committee, nt, Department MD of Emergency School; CEO, Development, Department Emergency Medicine, Associate Professor Emergency ResponseMedical MI Business DevelopmeOperations and Ron M. Walls, Chief, DepartmentMD York, NY Dean, Simulation
Education, of Cornell University, George Kaiser Family Giorgio Carbone,
of Michigan Medical Business Development, Brigham Medical Chief, Medical John of Emergency Professor Medicine of Michigan Medical Business Medical Medicine, MD Department of of Emergency
Editorial Board Risk Assessment, Women’s Hospital,
Harvard
Medicine Ospedale
Gradenigo, Director, Emergency M. Howell, MD, Medicine, Brigham and Chair, Ospedale Gradenigo,Editorial Board Risk Assessment, Brigham Women’s Hospital,
Harvard
Department of Emergency Medical Director, Committee, John M. Howell, of Emergency nt, Department
Medicine Ospedaleof Emergency University of Florida
COM- Research Director, Department of Chief, Department
Medical Practice of Emergency Medicine,Assistant MA Management, Clinical Professor FACEP and Women’s Emergency Medicine,Department of Torino, Italy Medical Practice of Emergency Medicine,Assistant MA Irvine; Emergency MD, FACEP Medicine, Brigham Professor and
Chair, Editorial Board FL New York Professor & Chair,
University of Gradenigo,
William J. Brady,
MD
and Women’s Hospital; School, Boston, Torino, Italy
University of
Medicine, George of Emergency
Hospital; Assistant
William J. Brady,
MD
and Women’s Hospital; School, Boston, University of California, Management, Clinical Professor and Women’s Emergency Medicine,Department of Torino, Italy Gradenigo,
Jacksonville, Jacksonville, Emergency Medicine, Emergency Medicine, Medicine Ospedale
Inc., Ann Arbor, MI Medical Center, Virginia Professor, Harvard Women’s Hospital, Brigham and Inc., Ann Arbor, MI Beirut, Lebanon University of Hospital; Assistant MD Flushing, NY
Professor of Emergency
Medicine
Professor, Harvard
Medical School, MD, FCCM MD, FAAEM Charlottesville, Washington Boston, MA Medical School, Harvard Medical Amin Antoine Kazzi, MD, Professor of Emergency
Medicine
Professor, Harvard
Medical School, MD, FCCM American University, Medical Center, Virginia Medicine, George of Emergency Professor, Harvard Women’s Hospital, Brigham and William J. Brady, Medicine MD, FACEP Hospital Queens, Oklahoma School
of Community Torino, Italy
Medical John M. Howell,
MD, FACEP Scott D. Weingart, of Emergency Amin Antoine Kazzi, and Vice VA University, Washington School, Boston, FAAEM Medical John M. Howell,
MD, FACEP Scott D. Weingart, of Emergency Charlottesville, Washington Medical School, Harvard Medical Amin Antoine Kazzi, MD, Professor of Emergency Gregory L. Henry, MD, FAAEM
and Medicine, Chair, Committee, Boston, MA
MarkChair,
Clark, MD , DC; Director MA Associate Professor and Medicine, Chair, Committee, Boston, MA VA University, Washington Boston, MA School, Boston, Department of Ali S. Raja, MD,
MBA, MPH Medicine, Tulsa, OK Amin Antoine Kazzi, and Vice Chair,
Clinical Professor
of Emergency Associate Professor Associate Professor of Academic Robert L. Rogers, and Vice Chair, Clinical Professor
of Emergency Associate Professor Hugo Peralta, MD Services, Mark Clark, , DC; Director MA Associate Professor FAAEM Medical
and Medicine, Chair, Committee, Clinical Professor, Operations and
Emergency Response FACEP, Division of Assistant Professor
Medicine, Affairs, Best Practices, Scott D. Weingart, Department of Emergency Response FACEP, Division of MD of Academic Robert L. Rogers, and Vice Chair, University Director of Network Associate Professor
Medicine, George
Washington L. Rogers, MD, Medicine, Director, Department of Emergency Medicine, Program of Emergency
Inc, Inova Fairfax MD, FACEP,
Associate ProfessorMD, FCCM
Emergency Medicine,
Medicine, George
Washington L. Rogers, MD, Medicine, Director, Chair of Emergency Assistant Professor Affairs, Best Practices, Scott D. Weingart, Department of Emergency Response Emergency Medicine, Department Ron M. Walls, MD
Medical Director,
Emergency
DC; Director Robert Icahn School of Irvine; Hospital, Falls FAAEM, FACP University of Medical Director,
Emergency
DC; Director Robert Icahn School of Buenos Aires, Inc, Inova Fairfax MD, FACEP,
Associate ProfessorMD, FCCM
Emergency Medicine, School; CEO, Business Development, Brigham Department of Department of Emergency
Medicine,
of Virginia University, Washington, Practices, FAAEM, FACP ED Critical Care, University of California, Director, Church, VA Assistant Professor Medicine, Director, of Emergency
California, Irvine; of Virginia University, Washington, Practices, FAAEM, FACP ED Critical Care, Hospital Italiano, Medicine, Program of Emergency Hospital, Falls FAAEM, FACP University of Medical Director,
Emergency of Michigan Medical Assessment, Professor and Chair, Brigham and Irvine;
Management, University Sinai, New Lebanon Medicine
Beirut,Emergency American University, Management, University Sinai, New Director, Church, VA California, Irvine; of Virginia Risk of Emergency Medicine,Assistant University of California,
Charlottesville, VA of Academic Affairs,
Best
Assistant Professor
of Emergency Medicine at Mount American University, Residency, Shkelzen Hoxhaj, Medicine, The of Emergency
ED Critical Care, Division of Beirut, Lebanon Charlottesville, VA of Academic Affairs,
Best
Assistant Professor
of Emergency Medicine at Mount Argentina Emergency Medicine Assistant Professor Medicine, Director, of Emergency American University, Management, University Medical Practice Emergency Medicine, Beirut, Lebanon
Mount Sinai Saint Harvard Medical
Medical Center, Hospital, Falls Medicine, The University
of York, NY MD, MPH, MBA University of Icahn School Hugo Peralta, Medical Center, Hospital, Falls Medicine, The University
of York, NY MD
ul,Mount Residency, Shkelzen Hoxhaj, Medicine, The of Emergency
ED Critical Care, Division of Beirut, Lebanon Charlottesville, VA Inc., Ann Arbor, MI and Women’s Hospital; Women’s Hospital, American University,
Inc, Inova Fairfax Hugo Peralta, MD Services, Sinai Roosevelt, Luke's, Mount Chief of Emergency Maryland School Medicine at Mount of MD Inc, Inova Fairfax Dhanadol Rojanasarntik Sinai Saint MD, MPH, MBA University of Icahn School Hugo Peralta, Medical Center, Harvard Medical
School,
Maryland School
of Medicine, New York, NY College of Medicine,Medicine, Baylor
of Medicine, Sinai, New Chair of Emergency
Maryland School
of Medicine, Sinai Roosevelt, Luke's, Mount
Emergency Chief of Emergency Maryland School Medicine at Mount of MD MD, FACEP Professor, Boston, MA MD
Mark Clark, MD Church, VA Editors Chair of Emergency Baltimore, MD York, NY Mark Clark, MD Church, VA Editors Attending Physician, of Medicine, Chair of Emergency John M. Howell, School, Hugo Peralta,
Assistant Professor
of Emergency
MD, MPH, MBA Baltimore, MD Senior Research Hospital Italiano,
Buenos Aires,
Peter DeBlieux, Houston, TX Hospital Italiano, Services,
Buenos Aires, Assistant Professor
of Emergency
MD, MPH, MBA Baltimore, MD Senior Research Medicine, King Chulalongkorn
New York, NY College of Medicine,Medicine, Baylor Baltimore, MD York, NY Sinai, New
Hospital Italiano, Services, Mark Clark, MD of Emergency Clinical Professor
of Emergency Boston, MA MD, FCCM Chair of Emergency
Services,
Shkelzen Hoxhaj, Eric Legome, Alfred Sacchetti, Argentina Shkelzen Hoxhaj, Red Cross, Houston, TX Assistant Professor FACEP, Scott D. Weingart, of Emergency Buenos Aires,
Director,
Medicine, Program Residency, Medicine, Baylor MD, FACEP PharmD, BCPS MD MD MD, FACEP Senior Researc Director,
Medicine, Program Residency, Baylor FACEP PharmD, BCPS Memorial Hospital,
ThaiPeter DeBlieux, MD Eric Legome, Alfred Sacchetti, Buenos Aires,
Medicine, George
Washington L. Rogers, MD, Hospital Italiano,
Chief of Emergency Alfred Sacchetti, James Damilini, Argentina Professor of Clinical Chief Assistant h of Emergency Medicine, TX Alfred Sacchetti, MD, James Damilini, MD MD, Senior Argentina Director,
Medicine, Program Residency, Director Robert Associate Professor
Medicine Houston, TX Professor, Emergency MD Public Medicine, of Emergency Clinical Professor, Editors Dhanadol Rojanasarn Medicine Chief
Houston, Professor, Emergency Thailand; Faculty
of Medicine,
Professor Chief of Emergency Assistant Clinical FACEP Research Editors DC;
University, Washington, Practices, FAAEM, FACP Division of
Emergency
Luke's, Mount College of Medicine, Assistant Clinical Clinical Pharmacist,
Hospital and Dhanadol Rojanasarntik
ul,
Interim King’s County Medicine, Department of Emergency
Luke's, Mount College of Medicine, Assistant Clinical Clinical Pharmacist,
Hospital and Thailandof Clinical Medicine, Dhanadol Rojanasarn Emergency Medicine of Emergency Medicine, Director, Argentina
Mount Sinai Saint Medicine,
Room, St. Joseph’s
Hospital Director Hospital; Professor Emergency Medicine, James Damilini, PharmD, Attending Physician, tikul, MD Mount Sinai Saint Medicine,
Room, St. Joseph’s Chulalongkorn University, Interim Public Hospital King’s County Medicine, Department of Professor,
Luke's, Mount of Academic Affairs,
Best Assistant Professor Icahn School of ul, MD
New York, NY Department of Emergency of Emergency
Emergency
Attending Physician, Louisiana Clinical Emergency of Thomas Jefferson BCPS New York, NY Department of Emergency Director Hospital; Professor Emergency Medicine, James Damilini, PharmD, Attending Physician, tikul, MD Mount Sinai Saint Hospital, Falls of ED Critical Care, Dhanadol Rojanasarntik
Sinai Roosevelt, Eric Legome, MD Medicine, Phoenix, AZ Medicine Services, Clinical Pharmacist, Medicine, King Emergency
Sinai Roosevelt, Eric Legome, MD Medicine, Phoenix, AZ of Emergency
New York, NY; Inc, Inova Fairfax Medicine, The University Sinai, New Emergency
Emergency Thomas Jefferson University, Medical Center,
Medicine, King Chulalongkorn State University Downstate Medicine, SUNY Philadelphia, University,
Room, Emergency Chulalongko Emergency Thomas Jefferson University, Medical Center, Suzanne Y.G. Peeters, MD Louisiana
Medicine Services, Clinical Emergency
Medicine,
of Thomas Jefferson
University, Clinical Pharmacist, BCPS
Medicine, Emergency
Sinai Roosevelt, School of Medicine, Medicine at Mount Attending Physician,
Chief of Red Cross, Health College of Medicine, PA St. Joseph’s Memorial Hospital, rn Chief of Residency State University Downstate College SUNY Philadelphia, Room, St. Joseph’s Emergency King Chulalongko of Emergency Church, VA Maryland
MD Professor of Philadelphia, PA Joseph D. Toscano,
MD
Memorial Hospital,
ThaiScience Center, New Brooklyn, NY Hospital and Professor of Philadelphia, PA Joseph D. Toscano,
MD Emergency Medicine Science PA Memorial Hospital, rn Assistant Professor York, NY Medicine, King Chulalongkorn
Peter DeBlieux, King’s County Hospital; of Emergency Orleans, LA Robert Schiller, Medical Center, Thailand; Faculty Thai Red Cross, Peter DeBlieux, MD King’s County Hospital; of Emergency Hospital,Center, New Health
Brooklyn, NY of Medicine, Hospital and School of Medicine MD, MPH, MBA Baltimore, MD Thai Red Cross,
Professor of Clinical
Medicine, Medicine, SUNY MD Chairman, Department Regional Thailand; Faculty
of Medicine, MD Phoenix, AZ
Chulalongkorn of Medicine, Medicine, Medicine, SUNY MD Chairman, Department Regional Director, Haga Teaching Orleans, LA Robert Schiller, Medical Center, Thailand; Faculty Thai Red Cross, Medicine, Icahn Shkelzen Hoxhaj, Editors Memorial Hospital,
Clinical Emergency Medicine, Robert Schiller, Nicholas Chair, Departmen Professor of Clinical Clinical Emergency Medicine, Robert Schiller, Phoenix, AZ
Director
Interim Public Hospital Services, of of Family Medicine, San Ramon Chulalongkorn University,
Thailand
Genes, MD,
Assistant Professor, PhD
Keith A. Marill,
MD Medicine, Beth t of Family
Joseph D. Toscano, University, Thailand Director of of Family Medicine, San Ramon The Hague, The
Netherlands
Nicholas Genes, Keith A. Marill, Chair, Departmen
MD
Joseph D. Toscano, Chulalongkorn of Medicine, at Mount Sinai, New
York, NY
Chief of Emergency
Medicine, Baylor Alfred Sacchetti, MD, FACEP Senior Research Thailand; Faculty
of Medicine,
Downstate College Chair, Department San Ramon, CA Research Faculty, MD Interim Public Hospital Services, Downstate College Chair, Department San Ramon, CA MD,
Assistant Professor, PhD MD Medicine, Beth t of Family University, Thailand Houston, TX Professor, Thailand
of Emergency Medicine Health
Medical
Medicine, Beth Israel Family Medical Center, MD Department of Depatment of Israel Medical Chairman, Department Suzanne Y.G. Medical
Medicine, Beth Israel Family Medical Center, Research Faculty, Chairman, Department MD MD College of Medicine, Assistant Clinical Medicine, James Damilini, PharmD,
BCPS Chulalongkorn University,
Brooklyn, NY Suzanne Y.G. Peeters,Emergency Emergency Medicine, Center; Senior Medicine, San of Emergency Peeters, of Emergency Medicine Health Brooklyn, NY Depatment of Israel Medical Suzanne Y.G. Peter DeBlieux,
Louisiana State University Residency Medicine, Icahn School Faculty, Family Emergency Medicine MD Emergency Medicine,Department of Emergency Medicine, Center; Senior of Emergency Peeters, Department of Emergency Emergency MD
Center; Senior Faculty, Emergency Medicine of Medicine Pittsburgh Medical University of Medicine and Ramon Regional
Louisiana State University Center; Senior Faculty, Faculty, Family Medicine, San Emergency Medicine MD Professor of Clinical
Medicine,
Eric Legome, MD Medicine, Clinical Pharmacist, Suzanne Y.G. Peeters,Residency
New Orleans, LA Keith A. Marill,
MD Health, Hospital,at Mount Sinai, New Community Health, Medical Center, Director, Haga Residency
New Orleans, LA Keith A. Marill,
MD Health, of Medicine at Icahn School Pittsburgh Medical University of Medicine and Ramon Regional Director Thomas Jefferson
University, Hospital and
Science Center, Depatment of Medicine and Community at Mount Director, Haga TeachingYork, NY PA Center, Pittsburgh, Icahn School San Ramon,
CA Teaching Hospital, Science Center, Depatment of Medicine and Community at Mount Mount Sinai, Center, Pittsburgh, Community Health, Medical Center, Director, Haga Residency
Interim Public Hospital Services, Chief of Emergency Room, St. Joseph’s Emergency Medicine
Research Faculty,
Icahn School of
Medicine of Medicine at The Hague, The Research Faculty,
Icahn School of
Medicine York, NY New PA Icahn School San Ramon, Teaching Hospital, Professor of Philadelphia, PA Phoenix, AZ Hospital,
MD, PhD University of The Hague, The
Netherlands Sinai, New York, Mount Netherlands University of of Medicine at CA The Hague, The of Emergency Medicine Health King’s County Hospital; Medical Center, Director, Haga Teaching
Nicholas Genes, Emergency Medicine, NY NY
Nicholas Genes,
MD, PhD Emergency Medicine, NY Sinai, New York, Mount Netherlands Medicine, SUNY MD Netherlands
Department of Center, Pittsburgh, Sinai, New York, Department of Center, Pittsburgh, Sinai, New York, NY Louisiana State University Clinical Emergency Medicine, Robert Schiller, The Hague, The
Assistant Professor, Pittsburgh Medical Assistant Professor, Pittsburgh Medical New Orleans, LA of of Family
Icahn School Icahn School Science Center, Downstate College Chair, Department
Emergency Medicine, PA Emergency Medicine, PA
Medicine, Beth Israel
Medical
Sinai, New Brooklyn, NY
of Medicine at Mount of Medicine at Mount
Sinai, New
York, NY York, NY

I
n this MEDLINE®-indexed publication, 12 monthly evidence-based issues address current practical
and applicable aspects of common and not-so-common conditions seen in the emergency
department. Focus is placed on patient management from the time of presentation to the point
of disposition, and a critical care section is included, when applicable. Risk management pitfalls to
help you avoid costly errors are addressed, and management algorithms that help you practice more
efficiently are included in each issue.

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Category 2A or 2B CME credits per year are included free with your subscription.

You will also receive full online access to searchable archives, CME testing, and an additional 144
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looking for authors to write review articles on topics that are pertinent to and trending in emergency
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Copyright © 2014 EB Medicine. All rights reserved. 14 www.ebmedicine.net • Volume 4, Number 5

 Additional Resources On Ventilator
And Airway Management
*Ventilator Management: Maximizing Outcomes In Caring For Asthma, COPD, And Pulmonary Edema
Emergency Medicine Practice, August 2008
ABCs, or Airway, Breathing, and Circulation, is a mantra of emergency medicine. There are numerous courses on airway manage-
ment, most of which focus on assessment and intubation. However, postintubation care (ie, ventilator management) is often
overlooked despite the critical importance of this component to patient outcome. Understanding ventilators and their use is an
essential competency in emergency medicine. First, appropriate ventilator management improves patient care while a mishan-
dled ventilator is a dangerous tool. Indeed, misguided ventilator management can be a patient’s worst enemy and significantly
worsen their prognosis. Second, emergency physicians are responsible for both the immediate and short-term care of intubated
patients. In the current age of hospital overcrowding, intubated patients are spending an increasingly longer period of time in
the ED; at times, they are even weaned and extubated in the ED before a bed becomes available upstairs.
*This article is FREE.

Available at: www.ebmedicine.net/ventilator2008

Capnography In The Pediatric Emergency Department: Clinical Applications

Pediatric Emergency Medicine Practice, June 2013
Capnography, often referred to by emergency clinicians as end-tidal carbon dioxide monitoring, is a noninvasive method of
measuring cardiopulmonary and metabolic parameters that can be utilized in many clinical applications. Growing evidence in
the literature in support of the use of capnography has led to increased clinical use of this modality in many pediatric subspe-
cialties. Understanding capnography and the literature supporting its practice will advance its use by emergency clinicians in
the pediatric emergency department, promoting improved patient care and safety. This issue reviews the technology and physi-
ology involved in measuring exhaled carbon dioxide and the interpretation of waveforms, and it highlights uses for capnogra-
phy in pediatric patients in the emergency department. Uses include confirmation of intubation, maintenance of ventilation
in intubated and nonintubated children, monitoring of effectiveness of cardiopulmonary resuscitation, and as an adjunct for
monitoring of sedated children and children with lower respiratory disease and metabolic derangements.

Available at: www.ebmedicine.net/capnography

Evidence-Based Emergency Management Of The Pediatric Airway

Pediatric Emergency Medicine Practice, January 2013
Pediatric airway emergencies are rare, yet they are anxiety-provoking events that can occur in both pediatric and general
emergency departments. Several novel concepts regarding preoxygenation during rapid sequence intubation, anticipation and
prevention of intubation-related complications, the utility of premedication agents, and the selection of induction and paralytic
agents have been highlighted in recent clinical trials and review articles. In this review, we analyze the data behind these con-
cepts, highlight current pediatric literature related to these issues, and present reasonable conclusions based on the best avail-
able evidence. We begin with an analysis of the anatomic and physiologic differences commonly encountered in the pediatric
patient during rapid sequence intubation, and we then review a systematic approach to the assessment of the pediatric patient
in respiratory distress (ie, the pediatric assessment triangle) and conclude with a simple approach to pediatric rapid sequence
intubation, starting with the preparatory phase and ending with postintubation management. We additionally highlight sev-
eral alternative airway devices and discuss special situations, including rapid sequence intubation in the obese pediatric patient
and in the difficult airway patient.

Available at: www.ebmedicine.net/pediatricairway

Ventilator Management In The Intubated Emergency Department Patient

EM Critical Care, August 2013
Emergent airway management is one of the defining skills of the practice of emergency medicine. The emergency physician
must be comfortable with the initial intubation and stabilization of critically ill patients and the ongoing management of me-
chanically ventilated patients in the emergency department. Data show that prolonged emergency department boarding times
while waiting for an intensive care unit bed are common and are correlated with worse patient outcomes. Understanding the
evidence behind, and the application of, basic ventilator strategies, including low-tidalvolume ventilation, will help the emer-
gency physician ensure the best possible care for the mechanically ventilated patient in the emergency department. This review
presents general ventilation approaches as well as strategies for special patient populations, such as those with traumatic brain
injuries and acute respiratory distress syndrome, and it offers troubleshooting approaches to consider if a patient’s condition
deteriorates while he is on the ventilator. Situations in which extubation in the emergency department should be considered
are also discussed.

Available at: www.ebmedicine.net/intubatedpatient

www.ebmedicine.net • Volume 4, Number 5 15 Reprints: www.ebmedicine.net/emccissues

 CME Information
Date of Original Release: September 1, 2014. Date of most recent
review: August 15, 2014. Termination date: September 1, 2017.
Accreditation: EB Medicine is accredited by the Accreditation Council
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Copyright © 2014 EB Medicine. All rights reserved. 16 www.ebmedicine.net • Volume 4, Number 5