Emergency Department Resuscitation of the Critically Ill

FIGURE 3-1.
The crashing ventilated patient algorithm. The steps are discussed in more detail in the main text. For the differential
diagnosis in difficult-to-ventilate patients, see Table 3-2.

Cardiac arrest/near arrest Stable/near stable

Determine hemodynamic stability

Rush of air,
improvement

Likely auto-PEEPa: check Step 1: Obtain a focused history.

Step 1: Disconnect from ventilator.
settings and ventilator Step 2: Perform physical examination.

No improvement Improvement, unclear if auto-PEEP

Step 2: Hand ventilate Check settings and ventilator. Step 3: Check gas exchange.
with 100% oxygen.
Look for unequal chest rise Improvement
Listen for air leakb and
unequal breath sounds
-LLSMVYKPMJ\S[`[V Step 4: Check respiratory mechanics.
ventilate and crepitus Step 5: Observe waveforms.

No improvement

Step 3: Determine that the ET tube is Step 6: Evaluate chest radiograph

functioning and in proper position. and ultrasound image.
Pass suction catheter
Pass intubating stylet or
direct visualization
Step 7: Evaluate sedation.
ET tube functioning ET tube not functioning
and in proper position or not in proper position

Step 4: Special procedures

Evaluate for ET tube position
ultrasound, chest radiograph,
adjustment, exchange, or re-intubate.
needle decompressionc

a
For auto-PEEP, see Table 3-1.
b
For air leak, see Figure 3-2.
c
For needle decompression, see Key Point, page 20.

16 Copyright 2011, American College of Emergency Physicians