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July 2007

Critical Care Monitoring In The Authors

Volume 9, Number 7

Emergency Department Chad M. Meyers, MD

Critical Care Fellow, Department of Anesthesiology,
Brigham and Women's Hospital, Harvard Medical
Another four patients have been triaged and placed on the tracking board as the School, Boston, MA
emergency department census continues to climb well beyond capacity. You’ve
Scott D. Weingart, MD
already notified the administrator on duty that patient transport to the floor will Director, Division of Emergency Critical Care,
need to be expedited, but unfortunately the hospital has no available beds and you’ve Department of Emergency Medicine,
been told that significant delays should be expected. Adding to an already difficult Mount Sinai School of Medicine, New York, NY
situation, you will be short staffed for another 2-3 hours. Unfortunately, this isn’t a
Peer Reviewers
new situation; it’s a typical Monday night. You take a deep breath, another drink of
coffee, and get back to work. Peter M. C. DeBlieux, MD
LSUHSC Clinical Professor of Medicine, Tulane
Before you can see anyone new, you are called to the nursing triage desk to
University Professor of Clinical Surgery, Director of
evaluate a patient. She is an elderly woman brought from home with increasing con- Emergency Medicine Services, LSUHSC Director of
fusion, fever, and cough over the past several days. Lying on the EMS gurney, she is Faculty and Resident Development, New Orleans,
breathing quickly and is only barely responsive to your questions. Suspecting pneu- LA
monia, you place a peripheral IV and obtain basic labs and cultures. Her chest X-
ray confirms your suspicion of pneumonia and she perks up with a little IV fluid Andy Jagoda, MD, FACEP
and antibiotics but remains hypotensive at 90/50 mmHg. You administer an addi- Professor and Vice-Chair of Academic Affairs,
Department of Emergency Medicine; Mount Sinai
tional 500 cc of normal saline and place her on a dopamine drip through a peripheral School of Medicine; Medical Director, Mount Sinai
IV. Hospital, New York, NY
Her blood pressure now looks great, so you admit her to the floor, pat yourself
on the back for a job well done, and continue to see patients. The next morning you CME Objectives
get an email from your medical director asking, “Do you remember the elderly
Upon completion of this article, you should be able to:
patient with pneumonia you admitted yesterday morning . . . “ 1. Review the applications of critical care monitoring
in the ED.
2. Understand the implications for end-tidal CO2.

P roviding optimal care of the critically ill patient can present a

dilemma for the emergency physician. While the importance of
the emergency department’s (ED) role in the early care of critical
3. Recognize the proper application of critical care
4. Understand respiratory monitoring, hemodynamic
monitoring, tissue perfusion monitoring, and neu-
patients continues to be reinforced and redefined, an estimated 15% rologic monitoring.
of a patient’s total hospital critical care is provided in the ED.1 The
Date of original release: July 1, 2007
additional responsibilities of caring for complex patients and pro- Date of most recent review: June 21, 2007
longed “boarding” of admitted patients place an increasing strain Eligible for CME credit through: July 1, 2010
See “Physician CME Information” on back page.
on already overcrowded facilities and often overextended emer-

Editor-in-Chief Health Science Center, New Orleans, HSC/Jacksonville, FL. Alfred Sacchetti, MD, FACEP, Beth Wicklund, MD, Regions Hospital
LA. Assistant Clinical Professor, Emergency Medicine Residency,
Andy Jagoda, MD, FACEP, Professor Gregory L. Henry, MD, FACEP, CEO,
Wyatt W. Decker, MD, Chair and Department of Emergency Medicine, EMRA Representative.
and Vice-Chair of Academic Affairs, Medical Practice Risk Assessment,
Associate Professor of Emergency Thomas Jefferson University,
Inc; Clinical Professor of Emergency
Department of Emergency Medicine; Medicine, Mayo Clinic College of
Medicine, University of Michigan, Ann
Philadelphia, PA. International Editors
Mount Sinai School of Medicine; Medicine, Rochester, MN.
Medical Director, Mount Sinai Hospital, Arbor. Corey M. Slovis, MD, FACP, FACEP, Valerio Gai, MD, Senior Editor,
New York, NY. Francis M. Fesmire, MD, FACEP, Professor and Chair, Department of Professor and Chair, Dept of EM,
Keith A. Marill, MD, Instructor,
Director, Heart-Stroke Center, Emergency Medicine, Vanderbilt University of Turin, Italy.
Department of Emergency Medicine,
Erlanger Medical Center; Assistant University Medical Center, Nashville,
Associate Editor Massachusetts General Hospital,
Peter Cameron, MD, Chair, Emergency
Professor, UT College of Medicine,
Harvard Medical School, Boston, MA. Medicine, Monash University; Alfred
John M. Howell, MD, FACEP, Clinical Chattanooga, TN.
Jenny Walker, MD, MPH, MSW, Hospital, Melbourne, Australia.
Professor of Emergency Medicine, Charles V. Pollack, Jr, MA, MD, FACEP,
Michael J. Gerardi, MD, FAAP, FACEP, Assistant Professor; Division Chief,
George Washington University, Professor and Chair, Department of Amin Antoine Kazzi, MD, FAAEM,
Director, Pediatric Emergency Family Medicine, Department of
Washington, DC; Director of Academic Emergency Medicine, Pennsylvania Associate Professor and Vice Chair,
Medicine, Children’s Medical Center, Community and Preventive Medicine,
Affairs, Best Practices, Inc, Inova Hospital, University of Pennsylvania Department of Emergency Medicine,
Atlantic Health System; Department of Mount Sinai Medical Center, New
Fairfax Hospital, Falls Church, VA. Health System, Philadelphia, PA. University of California, Irvine;
Emergency Medicine, Morristown York, NY.
American University, Beirut, Lebanon.
Memorial Hospital, NJ. Michael S. Radeos, MD, MPH,
Editorial Board Assistant Professor of Emergency
Ron M. Walls, MD, Professor and
Hugo Peralta, MD, Chair of Emergency
Michael A. Gibbs, MD, FACEP, Chief, Chair, Department of Emergency
William J. Brady, MD, Associate Medicine, Lincoln Health Center, Services, Hospital Italiano, Buenos
Department of Emergency Medicine, Medicine, Brigham & Women’s
Professor and Vice Chair, Department Bronx, NY. Aires, Argentina.
Maine Medical Center, Portland, ME. Hospital, Boston, MA.
of Emergency Medicine, University of Robert L. Rogers, MD, FAAEM, Maarten Simons, MD, PhD,
Steven A. Godwin, MD, FACEP,
Virginia, Charlottesville, VA. Assistant Professor and Residency Research Editors Emergency Medicine Residency
Assistant Professor and Emergency
Peter DeBlieux, MD Director, Combined EM/IM Program, Director, OLVG Hospital, Amsterdam,
Medicine Residency Director, Nicholas Genes, MD, PhD, Mount
Professor of Clinical Medicine, LSU University of Florida University of Maryland, Baltimore, Sinai Emergency Medicine Residency. The Netherlands.

Commercial Support: Emergency Medicine Practice does not accept any commercial support. Dr. Meyers, Dr. Weingart, Dr. DeBlieux, and Dr. Jagoda report
no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
gency staff. 2 Therefore, an understanding of the util- Advanced Life Support.
ity of advanced monitoring devices is of absolute Neither author has any financial ties, sponsor-
importance, not only to provide emergency physi- ships, or competing interests in regards to monitor-
cians with the confidence that the best care possible ing technologies or the manufacturers of specific
is being supplied to their patients but also to opti- monitoring devices described in this review article.
mize the efficiency of such care. While the addition
of advanced monitoring technologies may seem to Prehospital Care
add more complexity and work, the sine qua non of Advanced monitoring of the critically ill in the pre-
good monitoring is the diagnostic simplification; hospital setting is currently limited by logistical diffi-
good monitoring grants control of chaotic situations. culties, cost, and training. Though few well designed
This issue of Emergency Medicine Practice provides an studies have explored the benefit of monitoring dur-
overview of the current evidence regarding the bene- ing Emergency Medical Services transport, a slowly
fit of respiratory, hemodynamic, and neurologic growing body of evidence suggests significant out-
monitoring of the critically ill patient. come benefit when monitoring devices are used.
While using pulse oximetry is considered standard of
Critical Appraisal Of The Literature care by EMS in many locales, the importance of com-
Evidence regarding the clinical application of moni- prehensive prehospital management in maximizing
toring devices was initiated with a PubMed search of good outcomes is becoming increasingly recognized,
literature published between 1950 and 2007 using the and there is a growing need to equip advanced life
keywords: capnometry, capnography, end-tidal CO2, support units with advanced monitoring technolo-
pulse oximetry, reflectance oximetry, arterial pressure gies. In the following section, evidence regarding the
monitoring, cardiac output monitoring, pulmonary utility of continuous assessment of end-tidal carbon
artery catheter, partial carbon dioxide rebreathing dioxide (ETCO2) in the prehospital environment to
technique, venous arterial CO2 gradient, pulse con- ensure proper endotracheal tube placement as well as
tour analysis, PiCCO, LiDCO, pulseco, FlowTrac, the prevention of inadvertent hyperventilation in
transthoracic electrical bioimpedance, esophageal traumatic brain injury will be discussed.
Doppler, central venous pressure, hemodynamic opti-
mization, fluid responsiveness, cardiac filling pres- Respiratory Monitoring
sure, systolic pressure variation, delta pulse pressure, An EMS notification of prehospital cardiac arrest is
stroke volume variation, pre-ejection period varia- received by your community emergency department. Per
tion, central venous oxygenation, early goal directed the paramedic crew, the patient is a 62- year-old man ini-
therapy, surviving sepsis campaign, microcirculatory tially complaining of chest tightness who became unre-
abnormalities in sepsis, sublingual capnometry, per- sponsive and apneic during transport approximately 3
cutaneous carbon dioxide, and bispectral index. The minutes prior to arrival. The rhythm was noted initially
results were reviewed and relevant citations from to be ventricular fibrillation; after a single biphasic coun-
each study were searched manually. The results of tershock his rhythm became organized but he remained
the fluid and catheter treatment trial (FACTT) and the pulseless. He was intubated en route and is now being
PAC-Man trial regarding the utility of pulmonary wheeled into your critical care area receiving active chest
catheterization were also reviewed. compressions.
A search for practice guidelines and clinical poli- You glance at the EMS monitor and note a slow nar-
cies identified the following: The American College row complex rhythm; chest compressions are continued
of Emergency Physicians’ 2001 Clinical Policy, and his prehospital capnography tubing is connected
“Verification of Endotracheal Tube Placement,” the to the ED monitor. The characteristic waveform
American Society of Anesthesiologists’ 2005 reassures you of proper ETT placement, and the ETCO2
“Standards of Basic Anesthetic Monitoring,” the is 14 mmHg. You obtain central access and a round of
American Association for Respiratory Care’s 2003 ACLS drugs is administered. At the following rhythm
Clinical Practice Guidelines, “Capnography/ check you note ventricular fibrillation; he receives another
Capnometry During Mechanical Ventilation,” and the shock and chest compressions continue. You now note an
2005 International Consensus on Cardiopulmonary ETCO2 of 36 mmHg, a central pulse is appreciated, and
Resuscitation and Emergency Cardiovascular Care his plethysmographic waveform becomes clearly defined.
Science with Treatment Recommendations Section on Hypothermia is induced and the patient is admitted to the

Emergency Medicine Practice© 2 July 2007 •

cardiac critical care unit. tion of the anatomic (functional) dead space of
Monitoring a patient’s respiratory status is cru- the conducting airways.
cial in all but the most benign of emergency depart- • As tidal volume decreases, the fraction of the
ment presentations. If the patient is critically ill, real- lung ventilated but not perfused increases,
time monitoring is obligatory. Respiratory status can widening the PaCO2-ETCO2 gradient.
be divided into monitoring of the airway, ventilation, Likewise, obstructive pulmonary disease
and oxygenation. While monitoring of the airway is increases the gradient secondary to inadequate
often a clinical evaluation, technology can aid our ventilation due to delayed emptying of alve-
assessment of the patient’s ventilatory and oxygena- oli. This proportion of wasted ventilation is
tion status. represented by the dead space/tidal volume
ratio (VD/VT).7
End-Tidal Carbon Dioxide (ETCO2) The determinants of the PaCO2-ETCO2 gradient
Ventilation (the pulmonary exchange of carbon diox- are multi-factorial and the magnitude of their effect
ide [CO2] and its subsequent expiration) is typically is often unpredictable. Therefore, while the correla-
monitored in the ED by two modalities: colorimetric tion between PaCO2 and ETCO2 may be somewhat
capnometry or continuous infrared spectroscopy. reliable in stable unintubated ED patients,8 it is typi-
Colorimetric capnometers display a threshold con- cally considered unreliable in critically ill patients
centration of carbon dioxide qualitatively or semi- and may be assumed only with caution.9,10,11,12,13
quantitatively by color change, providing the clini- It would be reasonable to hypothesize that
cian with confirmation of endotracheal tube place- ETCO2 levels would be useful if the gradient were
ment, see Table 1 on page 6. Capnometry by calculated by an initial PaCO2 determination by
infrared absorbance spectroscopy, on the other hand, blood draw. However, the stability of the PaCO2-
allows continuous quantitative assessment of carbon ETCO2 gradient was found to occur in only 60-80%
dioxide concentrations displayed by numerical of patients, with changes in the opposite direction
value. Many capnometers also graphically depict occurring unpredictably.6 These results were sup-
the CO2 waveform as a function over time; this capa- ported in a study of multi-trauma patients which
bility (known as capnography) provides the clinician found a 27% erroneous prediction of PaCO2 change
with additional information regarding the patient’s by ETCO2.14 However, the PaCO2-ETCO2 gradient is
ventilatory status, see Figure 1. Additionally, volu- almost entirely in the positive direction, and when a
metric capnography plots expired CO2 concentration negative gradient exists it is typically very small.
along with exhaled volume during the respiratory Therefore, while a low ETCO2 value may provide lit-
cycle, providing information regarding alveolar and tle information regarding a patient’s ventilatory sta-
anatomic dead space. This may allow for additional tus, a high ETCO2 value almost always correlates
applications, including the bedside diagnosis or
Figure 1. Capnography Interpretation
exclusion of pulmonary embolism.3,4

Correlation Of End-Tidal CO2 To Arterial PaCO2

End-tidal CO2 concentration (the concentration of
CO2 at the end of exhalation) typically underesti-
mates arterial CO2 concentration (PaCO2) in healthy
individuals by 4-5 mmHg.5 The fact that ETCO2 does
not equate to PaCO2 is a critical point; the discrepan-
cy can primarily be explained by three factors:6
• The PaCO2-ETCO2 gradient is determined at
the level of the alveoli by both venous admix- The capnogram is typically divided into 3 or 4 phases. Phase I represents the empty-
ing of CO2 free anatomic dead space. Phase II represents a mixture of gas from the
ture/shunt (increased by atelectasis, pul- anatomic dead space and CO2 containing alveoli. Phase III represents the emptying
of CO2 from the alveoli. The slope of Phase III is positive in patients with normal
monary edema, or pneumonia) and the alveo- pulmonary function and is a reflection of the continuous elimination of CO2 from the
blood into the alveoli, heterogeneous ventilation-perfusion ratios, and asynchronous
lar dead space of the lungs (increased by pul- emptying of alveoli. However, the slope of Phase III is increased by certain patho-
logic states such as chronic obstructive pulmonary disease and asthma; it can be a
monary emboli, reduced cardiac output, car- valuable tool in assessing the pulmonary status of the critically ill. Occasionally a
terminal upswing (Phase IV) will be present in the pregnant or obese patient. Finally,
diac arrest, or hypovolemia.) Phase 0 represents inspiration.15 (Used with permission of Chad Meyers, MD)

• The gradient is further widened by the addi- • July 2007 3 Emergency Medicine Practice©

with an equal or higher PaCO2 value. This concept pared to the 23% incidence of misplaced ETT place-
may prove beneficial in the continuous monitoring ment in those units where continuous ETCO2 moni-
of ventilatory status in patients in respiratory toring was not available.22 Likewise, Grmec et al
extremis secondary to status asthmaticus or conges- studied 81 patients (58 with severe traumatic brain
tive heart failure decompensation. Likewise, in situ- injury) who underwent prehospital intubation (by
ations in which targeted PaCO2 values may be of emergency physicians in Slovenia) and compared
value, such as in patients with evidence of increased auscultation to capnometry with capnography for
intracranial pressure and acute brain herniation, a confirmation of proper endotracheal tube placement.
high ETCO2 value may signal the necessity for Successful intubation was observed in 73 patients;
adjustments in the patient’s mechanical ventilatory however, 8 patients were intubated into the esopha-
parameters or the need for arterial blood gas sam- gus as shown by capnometry. Of those, 4 were
pling. incorrectly thought to be in the trachea based upon
auscultation.23 Confirmation of correct ETT place-
ETCO2 Monitoring Applications ment is critical. Silvestri et al reported a 69% mortal-
Verification Of Endotracheal Tube Placement: ity associated with unrecognized misplaced endotra-
Arguably, the most useful application of continuous cheal intubation and 100% mortality if the patient
ETCO2 monitoring is to allow real-time confirmation was apneic upon arrival to the emergency depart-
of adequate ventilation through capnographic wave- ment.22
form analysis. Continuous ETCO2 monitoring is a Additionally, the use of continuous ETCO2 in
valuable tool for preventing misplacement of the confirming prehospital intubation during cardiac
endotracheal tube (ETT), either through continuous arrest has also been shown to be more effective than
verification of placement following intubation or for colorimetric capnometry and auscultation. The pres-
airway management during CPR or transport. ence of ETCO2 greater than 5 mmHg at breath seven
Stewart et al reported a 90% intubation success rate was found to be 100% sensitive and 100% specific for
in 779 adult patients who were either in a coma or in correct placement of the ETT, while qualitative cap-
cardiopulmonary arrest.16 They reported a 2% nometry was 100% specific but only 80% sensitive in
missed tracheal intubation rate with 14 esophageal cardiac arrest. Both methods were 100% sensitive
intubations. In another study of adults, Pelucio et al and 100% specific in non-arrest intubations.24
reported a 6% esophageal intubation rate before their Continuous ETCO2 monitoring beginning with
system implemented a protocol for detecting laryngoscopy/intubation and continuing throughout
esophageal intubations.17 In a series of studies from surgery is considered standard of care by the
San Diego, paramedics intubated successfully 84% of American Society of Anesthesiologists as a protective
the time; 16% of these patients required a rescue measure to avoid unrecognized misplaced intuba-
device to secure the airway.18,19 These representative tion.25 However, the American College of Emergency
studies stress both the critical importance of CO2 Physicians currently does not differentiate between
detection protocols in any pre-hospital system using the utility of qualitative, quantitative, or continuous
endotracheal intubation and the imperative for these ETCO2 detectors for the verification or reconfirma-
systems to have airway rescue devices available in tion of endotracheal tube placement.26
case of a failed intubation. Auscultation over the
chest does not detect up to 15% of esophageal intu- Monitoring During Procedural Sedation: When per-
bations, while fogging in the ETT is reported in up to forming procedural sedation, reliable monitoring of
85% of esophageal intubations.29 In a study from the the patient’s ventilatory status is crucial. While clini-
Orlando, Florida EMS system, Katz and Falk report- cal indicators like chest rise or the plethysmography-
ed that 28/107 (25%) patients who had a prehospital derived respiratory rate provided by ECG lead place-
intubation arrived in the ED with an unrecognized, ment can be used, monitoring the capnographic
misplaced endotracheal tube, 18 in the esophagus waveform for hypopneic and bradypneic hypoventi-
and 9 above the vocal cords.21 However, when latory patterns provides the clinician with a quick
ambulances and aeromedical units were equipped and more accurate indication of acute respiratory
with continuous ETCO2 monitors in a follow up events.27 Burton et al reported that capnographic
study, Silvestri et al reported that the incidence of changes (defined as a change in ETCO2 level greater
unrecognized misplaced intubations was 0%, com- than 10 mmHg or intrasedation ETCO2 less than 30

Emergency Medicine Practice© 4 July 2007 •

mmHg or greater than 50 mmHg) predicted respira- be a period of prolonged hypoperfusion with cere-
tory events by up to 271 seconds.28 Often, nasal bral blood flow (CBF) reduced by as much as two-
prongs with an additional port are used to provide thirds of normal. Hyperventilation can further
continuous CO2 sampling. If commercial devices are decrease the CBF, potentially to the point of cerebral
not available, a regular nasal cannula can be modi- ischemia or by converting ischemic areas into infarc-
fied, see Figure 2. It is important to note that the CO2 tion. Evidence from in-hospital studies indicates that
waveform will show ventilatory rate and duration, prophylactic early hyperventilation can seriously
but that the vertical axis does not represent ventilato- compromise cerebral perfusion and worsen patient
ry depth (of course, it represents the amount of CO2 outcome.30 Inadvertent hyperventilation during pre-
in that ventilation). hospital transport is associated with increased mor-
Traumatic Brain Injury (TBI): Hyperventilation Several studies have demonstrated the incidence
with hypocapnea may worsen outcome in brain of induced hypocapnia during the field management
injured patients.29 Therefore, monitoring of ETCO2 is of TBI patients.29 In a retrospective study from San
emerging as a fundamental component of traumatic Diego, 59 adult severe TBI patients who were unable
brain injury management not only in the hospital but to be intubated without rapid sequence intubation
also in the prehospital arena. After TBI, there may (RSI) were matched to 177 historical non-intubated
controls. The study utilized ETCO2 monitoring and
Figure 2. Modified Nasal Cannula For Non- found an association between hypocapnia and mor-
Invasive Monitoring Of ETCO2
tality and a statistically significant association
between ventilatory rate and ETCO2. Both the low-
est and final ETCO2 readings were associated with
increased mortality versus matched controls. ETCO2
monitoring was used in 144 patients to assess
whether closer monitoring would result in a lower
rate of inadvertent severe hyperventilation (defined
as ETCO2 less than 25) after RSI. Patients with
ETCO2 monitoring had a lower incidence of severe
hyperventilation (5.6% vs. 13.4%; p = 0.035). Patients
who were severely hyperventilated had a higher
mortality rate (56% vs. 30%; p = 0.016). However, as
previously discussed, the PaCO2-ETCO2 gradient in
traumatically injured patients is unreliable, specifi-
cally in regards to low ETCO2 concentrations.
Therefore, the reliance on ETCO2 as an indicator of
hypocapnia must be further evaluated in the emer-
gency setting before it is used to guide ventilatory
management of traumatically brain injured patients
in the ED.

Prognosis Of Continued Cardiopulmonary

Resuscitation: As discussed previously, pulmonary
CO2 exchange is affected by multiple factors at the
level of the alveoli. In contrast to this, at extremely
low flow states ETCO2 is determined almost entirely
by pulmonary flow secondary to a logarithmic rela-
A nasal cannula may be quickly adapted for ETCO2 monitoring by inserting a 16 tionship between cardiac output and ETCO2 which
gauge angiocatheter into the tubing as shown. After securing in place with tape, the
angiocatheter may be connected directly to the capnometer. When utilizing a nasal exists during cardiac arrest.31 This relationship
cannula altered by this method to monitor ETCO2, it cannot be used as an oxygen
source as this will prevent the accurate sampling of exhaled CO2 by the capnometer. between pulmonary flow and ETCO2 during arrest
A second nasal cannula or an oxygen mask can be used to provide supplemental
oxygen. (Used with permission of Scott Weingart, MD) makes capnometry an important prognostic marker
during cardiopulmonary resuscitation (CPR) in • July 2007 5 Emergency Medicine Practice©

the ED. In multiple studies, an ETCO2 level of interpret, an ETCO2 concentration greater than
10 mmHg or less 20 minutes after the initiation of 40 will almost always indicate hypercapnia.
resuscitation in patients with pulseless electrical The degree of this hypercapnia may be under-
activity accurately predicted death in patients suffer- represented by the ETCO2.
ing prehospital arrest.32,33 These findings were also
supported by a small prospective trial of both in- Pulse Oximetry
and out-of-hospital arrest34 and were only minimally
affected by variations of ventilatory rate.35 However, Your asthmatic patient has become so exhausted that she is
the initial ETCO2 had no correlation with outcome or barely moving any air. She will not tolerate non-invasive
survival,32 and very low initial ETCO2 (less than 6 ventilation and it’s obvious that she needs to be intubated.
torr) has been associated with survival.35 You hand the laryngoscope to a trusted fourth year resi-
Accordingly, the 2005 ACLS guidelines state, dent. He proceeds to place the tube and states that he saw
“Intubated adults receiving CPR with ETCO2 less it pass through the cords. A few seconds later, the pulse
than 10 have poor prognosis” and they consider oximeter reading drops to 40%. You shake your head and
ETCO2 “unreliable immediately after starting CPR.”36 grab the laryngoscope. Your resident points out the yellow
color change of the end-tidal CO2 detector, but you now
notice the pulse oximeter is reading 36%. You place the
Table 1. Semi-Quantitative Colorimetric
Capnometry blade and are surprised to note that the tube is clearly
between the cords. After another minute, the pulse oxime-
ter is reading 100%.
Pulse oximeters are almost uniformly present in
US emergency departments. Noninvasive pulse
oximeters differentiate oxyhemoglobin from reduced
Colorimetric end-tidal CO2 detectors provide continuous semi-quantitative measure-
ment of end-tidal CO2 using a pH-sensitive chemical strip that changes color upon hemoglobin utilizing differing absorption compo-
exposure to the gas. The normal range of CO2 concentrations in hemodynamically
stable patients is greater than 4%.37,38 nents at the two wavelengths 660 nm and 940 nm.
The pulsatile AC component is then divided by the
ETCO2 Key Points non-pulsatile DC component to determine the arteri-
• Capnography allows for the continuous verifi- al pulse-added absorbance. This value corresponds
cation of endotracheal tube placement which to the pulse oximeter saturation estimate (SpO2).39
is essential in the unstable prehospital and ED While typically considered accurate when com-
environment in which patients are frequently pared to arterial concentrations of oxygen deter-
moved; adequate sedation can occasionally be mined by arterial blood gas co-oximetry, there are
difficult and accidental extubation is an ongo- several limitations and misconceptions regarding the
ing risk. accuracy of pulse oximetry which should be
• Continuous capnography may be superior to addressed when considering its reliability in the
qualitative CO2 detectors in detecting correct monitoring of the critically ill ED patient.
ETT placement during cardiac arrest.
Pulse Oximetry Limitations And Misconceptions
• An ETCO2 less than 10 mmHg following 20
The reliability of pulse oximetry is reduced in states
minutes of CPR is predictive of death and
of severe hypoxia. While pulse oximeters possess an
indicates that continued attempts at resuscita-
accuracy of ± 2% to one standard deviation when in
tion are likely futile.
the range of 70-100% SaO2 (oxygen saturation), their
• A rapid increase in ETCO2 concentration dur-
accuracy falls to ± 3% (SD) between 50-70% SaO2 and
ing CPR often represents the return of sponta-
are generally not considered accurate when deter-
neous circulation and can be a useful guide in
mining O2 saturations below 50%.39
determining timing of pulse checks.
The accuracy of pulse oximetry has also been
• Continuous non-invasive ETCO2 monitoring
questioned in the heterogeneous population of the
can be useful in the monitoring of patients
critically ill as a whole. The incidence of intraopera-
with tenuous respiratory status, such as those
tive pulse oximetry data failure (independently pre-
with severe reactive airway disease or conges-
dicted by hypotension and hypothermia) was found
tive heart failure.
to be 9% in a review of 9203 anesthesia records.40
• While a low ETCO2 concentration is difficult to

Emergency Medicine Practice© 6 July 2007 •

However, if an acceptable plethysmographic wave- gernail polish (black, blue, or green)50 but was not
form can be detected, the reliability of pulse oxime- felt to be clinically significant in mechanically venti-
try has been demonstrated over a wide range of clin- lated patients.51 Dark skin pigmentation has also
ical scenarios. When compared with invasive arteri- been suggested as a source of interference in the
al measurements, the accuracy of pulse oximetry accuracy of pulse oximetry; however, this was not
measured by finger probe was not reduced in states supported by an investigation of emergency depart-
of poor peripheral perfusion (cardiac index less than ment patients.52
2.2) or low peripheral temperature (less than 28°C).41 While motion artifact has presented a significant
Additionally, although pulse oximetry was previous- problem to oximeter design, recent advances in
ly considered inaccurate in the presence of hemoglo- motion-resistant and read-thru-motion using differ-
bin levels less than 5 g/dL, a small study of patients ent algorithms have improved accuracy and rely less
with hematocrit of less than 20% provided evidence on lengthening of signal averaging times which may
that SpO2 was accurate at hemoglobin concentrations lead to missing significant short-lived hypoxemic
as low as 2.3 g/dL.42 These results were supported events.53
by a study which showed no significant effect of
moderate anemia or acidemia on the accuracy of Pulse Oximetry Applications
SpO2.43 The presence of continuous pulse oximeters is con-
While SpO2 readings may eventually correlate sidered necessary during all phases of definitive air-
with ABG determination of blood oxygenation, there way management.54 In a study of ED patients, those
still may be significant delay associated with the monitored by pulse oximetry were found to have
detection of hypoxemia in hypothermic, vasocon- significantly fewer episodes of hypoxemia during
stricted, or low-flow states. In a study of healthy emergency intubation (27% vs. 15%), and the
volunteers, a response time of 131 seconds and 215 episodes were of shorter duration than non-moni-
seconds to hypoxic events was found during tored patients (1.4 minutes vs. 0.7 minutes).55
induced vasoconstriction or hypothermia, respective- Additionally, a systematic review of perioperative
ly. This delay was significantly reduced (22 seconds pulse oximetry in more than 20,000 patients showed
and 40 seconds) by the use of forehead reflectance a reduced incidence of hypoxemia and increased
oximetry probes.44 (However, forehead probes are incidence of both naloxone and oxygen administra-
associated with their own limitations, including dis- tion in those patients monitored with oximetry.56
tortion of findings by venous pulsation and the inci- However, the usefulness of pulse oximetry in avoid-
dence of skin burn.)45 ing hypoxemia during airway management should
Because of overlap in the absorbance of light at not by misconstrued to suggest utility in verifying
660 nm and 990 nm, dyshemoglobinemias result in a correct ET tube placement. In a series of pre-oxy-
distortion of true oxygen saturation when measured genated patients, SpO2 was unable to detect
by traditional pulse oximeters. Based on animal esophageal intubation at 30 seconds.57
studies, the presence of methemoglobinemia causes a The availability of pulse oximetry has been
significant overestimation of SpO2 by pulse oximetry. shown to substantially reduce arterial blood gas
With increasing concentration of methemoglobin, sampling in the ED without an increase in adverse
SpO2 has been found to plateau at approximately outcomes.58 Pulse oximetry can also be used to safe-
85%.46 Likewise, a carboxyhemoglobinemia level of ly and quickly titrate the FiO2 in mechanically venti-
70% results in a SpO2 of 90% while the actual meas- lated patients from potentially toxic oxygen concen-
ured SaO2 is 30%.47 In response to this limitation, a trations.59
new generation of pulse oximeters that can noninva-
sively differentiate oxyhemoglobin, deoxyhemoglo- Pulse Oximetry Key Points
bin, methemoglobin, and carboxyhemoglobin satura- • Pulse oximetry remains accurate over a wide
tion have become available.48 range of critical illness, including shock,
Ambient light has been shown to have no effect hypothermia, and significant anemia.
on the accuracy of oximetry readings in hemody- • Although pulse oximetry is necessary during
namically stable patients.49 Additionally, when stud- all phases of definitive airway management in
ied in healthy volunteers the accuracy of pulse order to reduce the length and frequency of
oximetry was decreased in the presence of dark fin- hypoxic events, it lacks sensitivity in verifying • July 2007 7 Emergency Medicine Practice©

correct ETT placement. ness by monitoring cardiac output and filling pres-
• Pulse oximetry readings may actually be show- sures using a variety of non-invasive and invasive
ing desaturations which occurred up to 1 monitoring modalities. The third and final compo-
minute in the past secondary to redistribution nent of hemodynamic monitoring is the determina-
of oxygenated blood from central to peripheral tion of overall adequacy of oxygen delivery, oxygen
circulation and prolonged signal averaging consumption, and tissue perfusion by measuring
times. This leads to the common clinical sce- central venous oxygen saturation and regional tissue
nario of a large drop in the pulse ox reading carbon dioxide and oxygen concentrations. The ben-
immediately following successful placement efits, controversy, and application of various hemo-
of the endotracheal tube. While sometimes dynamic monitoring modalities will be discussed in
terrifying, the drop often reflects the desatura- this section.
tion during the apneic period prior to the tube
placement. Arterial Pressure Monitoring

Hemodynamic Monitoring Mean arterial pressure, determined by the product of

total peripheral resistance and cardiac output, is of
A 65-year-old man, new to your emergency department, is critical importance in the maintenance of organ per-
brought in by EMS with a history of abdominal pain and fusion.60 While local autoregulatory functions pro-
vomiting for 2 days. He is obtunded, tachypneic, and vide constant blood flow over a wide range of pres-
hypotensive with a MAP of 55. His SpO2 is 90% on sures, a MAP of 60 mmHg is considered the autoreg-
100% NRB and the decision is made to intubate. Central ulatory threshold below which blood flow becomes
access is obtained, crystalloid is administered, and a point pressure dependent. Conversely, no increased blood
of care panel reveals a normal hematocrit but extremely flow occurs with mean arterial pressures greater than
low ionized calcium. His BP rebounds with an ampule of 65 mmHg.61 The principle of autoregulation is impor-
calcium chloride, and IV fluid is continued. tant because while a blood pressure greater than
The patient’s family soon arrives and explains that he 65 mmHg does not ensure acceptable organ perfu-
was well until yesterday when he began complaining of sion, a mean arterial pressure less than 65 mmHg
abdominal pain. He is an insulin-dependent diabetic and almost always represents hemodynamic inadequacy.62
suffered a myocardial infarction 1 year prior. His ECG, The importance of blood pressure as either a reflec-
chest XR, and cardiac enzymes are normal; however, his tion or a major determinant of overall function was
lipase is grossly elevated and his creatinine is 4.3. Severe recently demonstrated by a study which found that a
acute pancreatitis is assumed to be the likely cause of the single occurrence of hypotension (defined as systolic
patient’s illness and the ICU is contacted. Unfortunately, blood pressure less than 100 mmHg) conveyed a
you are told that there are no available beds in either the three-fold increased risk of in-hospital death in non-
medical or surgical ICU and there may be a significant traumatic emergency patients. Sustained hypoten-
delay before a patient can be transferred out. sion of greater than 60 minutes increased that risk an
He quickly becomes hypotensive necessitating a norepi- additional three-fold, and more significant hypoten-
nephrine drip and an intra-arterial line. You explain to the sion (systolic blood pressure [SBP] less than 80
patient’s family that he is extremely ill, but you will do mmHg) increased the risk six-fold.63
everything possible to give him the best chance to survive… Monitoring of blood pressure can be accom-
The assessment of hemodynamic status is essen- plished by several means. It was previously taught
tial in the care of the critically ill patient in order to that the presence of only a carotid pulse indicates a
ensure adequate organ perfusion and, ultimately, tis- SBP between 60-70 mmHg, the presence of carotid
sue oxygenation. Common monitoring modalities of and femoral pulses indicates a SBP of 70-80 mmHg,
three interrelated components of hemodynamic ade- and the presence of a radial pulse indicates a mini-
quacy will be reviewed. The first is the basic deter- mum SBP of 80 mmHg. However, a study compar-
mination of satisfactory organ perfusion pressure by ing physical findings with intra-arterial BP measure-
the monitoring of mean arterial pressure (MAP) uti- ments revealed that these findings consistently over-
lizing either an intra-arterial pressure transducer or estimated or did not correlate at all with the patient’s
automated blood pressure cuff. The second is the actual BP.64
estimation of cardiac function and fluid responsive- In most ED patients, the blood pressure is moni-

Emergency Medicine Practice© 8 July 2007 •

tored non-invasively by automatic blood pressure test continues to plague medical students and resi-
cuffs. Non-invasive pressure measurements are usu- dents around the world, its usefulness has been
ally provided by oscillometric pressure determina- seriously challenged. The first difficulty in the utili-
tion. This method is considered more accurate than ty of the Allen test is the inability of clinicians to
auscultatory methods, but it typically overestimates agree on what constitutes an abnormal test. In a
diastolic pressures by 4-10 mmHg, underestimates review of 15 studies, abnormal criteria for return of
systolic pressures by 0-16 mmHg, and underesti- normal hand perfusion after release of simultane-
mates MAP by 2.3-12.3 when compared to invasive ous occlusion of radial and ulnar arteries ranged
arterial catheters.65,66,67 Intermittent non-invasive from greater than 5 seconds to greater than 15 sec-
blood pressure monitors also suffer from delay in the onds.70 Additionally, inter-observer agreement of
monitoring of rapid or transitory changes in blood exam interpretation is also completely unreliable.71
pressure which could have important implications Finally, positive results do not predict the occur-
for the critically ill patient. Invasive arterial pressure rence of post cannulation hand ischemia.72
monitoring can be accomplished by arterial catheteri- Therefore, the routine use of the Allen test should
zation of the radial, brachial, axillary, dorsalis pedis, be considered misleading at best and will hopefully
or femoral artery. The two most common sites of be de-emphasized in the future.
catheterization (the radial and femoral artery) have
been found to be clinically interchangeable in the Arterial Pressure Monitoring Applications
monitoring of the critically ill in all but the most Although not an absolute indication, invasive arterial
vasoconstricted states.68 Many intensivists shy away monitoring is generally recommended when continu-
from the use of the brachial artery site as thrombosis ous infusions of vasopressors or vasodilators are being
leaves the distal upper extremity with no blood flow. utilized to target a specific blood pressure.62 Any
In terms of complications, 19,617 radial artery patient who requires frequent blood gas draws will
cannulations were reviewed; temporary occlusion of appreciate the one stick of an arterial line rather than
the radial artery was found to be the most common multiple sticks from intermittent draws. Other applica-
complication, occurring in 19.7% of cannulation tions, such as cardiac output determination derived
attempts. Temporary occlusion of the radial artery from pulse contour analysis and prediction of fluid
was defined in this review as any non-permanent responsiveness, will be reviewed later in this article.
occlusion of the artery which did not result in
ischemic damage, limb loss, necrosis, or other serious Arterial Pressure Monitoring Key Points
long lasting effects. Occlusion was diagnosed by • Non-invasive blood pressure determinations
Doppler, palpation of pulses, or inaccurate transduc- are accurate in stable patients, so long as a rea-
er readings and lasted as long as 75 days. However, sonable interval of sampling is chosen.
serious ischemic damage occurred in only 0.09%. • Intra-arterial monitoring should be considered
Hematoma formation was the second most common in patients in shock or on a continuous infu-
complication, occurring in 14.40%. Other complica- sion of vasopressors.
tions, such as pseudoaneurysm and sepsis, were
rare. Likewise, 3899 femoral artery cannulations Cardiac Output Monitoring
were reviewed and were found to be associated with
The monitoring and manipulation of cardiac output,
a much lower incidence of temporary occlusion
either directly or indirectly, is of extreme importance
(1.18%) and hematoma formation (6.1%); however,
in the care of the critically ill. Cardiac output is a
permanent ischemic damage was more frequent than
function of multiple variables, each of which plays
in radial artery procedures (0.18%). Overall, serious
an essential role in the proper functioning of the
complications of radial, femoral, and axillary cannu-
organism as a whole. Therefore, knowledge of car-
lation are considered rare.69 However, when possi-
diac output provides a sense of the overall perform-
ble, peripheral cannulation should preferably be per-
ance of the cardiovascular system. Additionally,
formed on the non-dominant limb in the unlikely
measurements of cardiovascular functionality pro-
event of serious complication.
vide the capability to monitor its normalization or
The utility of the Allen test in the prediction of
optimization, the utility of which will be discussed in
hand ischemia following radial artery cannulation
this section.
deserves mention. While the teaching of the Allen • July 2007 9 Emergency Medicine Practice©

While an in-depth discussion of cardiovascular Harold Swan in 1970, is typically inserted through
physiology is beyond the scope of this text, a brief either the internal jugular clavian vein and guided
review is necessary. Cardiac output is the product of by flow direction through the right atrium, then
stroke volume and heart rate. Stroke volume, in the right ventricle, and ultimately to the pulmonary
turn, is dependent on several variables. The first of artery. At this point, the PAC allows estimation of
these variables is preload, its value reflected by end- cardiac output by principles of thermodilution
diastolic volume of the ventricles and its effect on (injecting a solution in the right atrium and record-
cardiac output as described by the Frank-Starling ing the resultant temperature change by a thermis-
relationship. The second factor is afterload which is tor at the tip of the PAC resting in the pulmonary
determined by systemic vascular resistance. The artery).10 Two modes are available: bolus (for inter-
final factor is the intrinsic contractility of the mittent evaluation) or continuous thermodilution
myocardium.73 Each of these variables may be esti- (for continuous monitoring of cardiac output).
mated, typically by indirect means, and manipulated Studies have typically demonstrated better repro-
in order to optimize cardiac function, see Figure 3. ducibility of measurements with continuous cardiac
output estimation versus bolus methods.75
Figure 3. Hemodynamic Monitoring Insertion of pulmonary artery catheters is an
invasive procedure and, likewise, carries the risk of
serious complications. The PAC-Man trial (a
prospective trial investigating the benefit of routine
PAC use) found that PAC insertion was associated
with a 10% incidence of complications, consisting
largely of hematoma, arterial puncture, and dys-
rhythmias (including cardiac arrest) but also includ-
ing a small number of pneumothorax, hemothorax,
and the necessity of guidewire retrieval.76 Another
study demonstrated that the incidence of complica-
tions (including dysrhythmia [one fatal], subclavian
vein thrombosis, endocardial damage, and infective
endocarditis) were increased with prolonged catheter
use.77,78 Additionally, the ESCAPE trial (Evaluation
Study of Congestive Heart Failure and Pulmonary
Artery Catheter Effectiveness) demonstrated a 5%
complication rate, including infection, pulmonary
hemorrhage/infarct, catheter knotting, and ventricu-
lar tachycardia.79 While overall complications of PAC
Simultaneous monitoring of the cardiovascular, pulmonary, and hematologic systems
by various modalities provides a comprehensive approach to hemodynamic monitor-
insertion responsible for significant morbidity and
ing, allowing for the individual manipulation of each component in order to normalize mortality are considered rare, recent studies question
or optimize hemodynamic function and ultimately maintain satisfactory oxygen deliv-
ery. its utility beyond less invasive methods such as cen-
tral venous pressure and clinical exam.80
Pulmonary Artery Catheter
While pulmonary artery catheterization is not a typi- Carbon Dioxide Fick Principle
cal ED procedure, it would be impossible to discuss The Fick principle, based on the conservation of
the monitoring of cardiac output without an under- mass, observes that the amount of gas release (typi-
standing of the pulmonary artery catheter (PAC) and cally O2 or CO2) which occurs in the pulmonary cap-
the controversy regarding its use. Additionally, near- illary bed is the product of alveolar blood flow and
ly all studies evaluating alternative cardiac output the difference in gas concentration in the arterial and
monitors utilize thermodilution measured by the venous circulation. This allows for the calculation of
PAC as their criterion standard. However, the cardiac output (equivalent to alveolar blood flow) by
imprecision of pulmonary artery thermodilution is measuring or estimating the rate of carbon dioxide
well documented.74 elimination from the lungs (VCO2) over the arteri-
The pulmonary artery catheter, introduced by ovenous PaCO2 gradient.

Emergency Medicine Practice© 10 July 2007 •

Utilizing a partial carbon dioxide rebreathing mixed CO2-arterial CO2 gradient and thermodilu-
technique, the non-invasive cardiac output monitor tion, allowing for a potential minimally invasive
(NICO) applies the CO2 Fick principle to estimate method to determine CI using only a central venous
cardiac output in the intubated patient by indirectly catheter (CVC) in the superior vena cava.88
estimating CO2 elimination, venous CO2, and arterial
CO2 by changes in measured ETCO2 during the nor- Pulse Contour Analysis
mal respiratory cycle and rebreathing. However, to The contour of the arterial waveform represents the
accurately assess cardiac output by expired CO2, pul- change in intravascular pressure over the cardiac
monary capillary blood flow must also be measured. cycle and reflects the relationship between vascular
The amount of pulmonary shunting is estimated by compliance and cardiac output. By utilizing infor-
SpO2 and FiO2, thus NICO provides a non-invasive mation obtained by intra-arterial pressure transduc-
determination of cardiac output by utilizing main- ers, several novel devices allow the continuous
stream capnometry, a differential pressure pneumo- assessment of cardiac output by less invasive means
tachometer, and pulse oximetry.81 in patients in sinus rhythm.
Unfortunately, as described previously, ETCO2 is PiCCO™ calculates cardiac output from the
an unreliable estimate of PaCO2 in unstable patients change in diastolic/systolic pressure over time and
because of the variability of V/Q mismatch in the an estimate of aortic impedance. However, a direct
critically ill. This can be compensated for by estimat- determination of aortic impedance is difficult if not
ing pulmonary capillary blood flow. However, sev- impossible at the bedside, so the device must first be
eral studies demonstrate that the calculated pul- calibrated by calculating cardiac output using
monary shunt fraction by NICO differs considerably transpulmonary thermodilution to provide an accu-
from traditionally calculated shunt fraction by blood rate estimate of impedance. This requires a central
gas analysis.82,83 In light of this, cardiac output (CO) venous line and a manufacturer supplied proximal
calculated by NICO was typically considered accu- arterial (femoral or axillary) catheter.84 An ice water
rate when limited to stable patients with normal pul- bolus is injected through the central line and the
monary function or when monitoring trends.84 All resultant temperature change is recorded by the arte-
prior studies problematically compared NICO to rial catheter. This method has been found to corre-
PAC thermodilution which is not universally consid- late well with pulmonary artery thermodilution.89
ered the ‘gold standard’ of cardiac output determina- After this calibration, continuous measures of cardiac
tion.85 A recent study comparing NICO with contin- output are determined by pulse contour analysis and
uous and bolus thermodilution as well as with the have been found to correlate acceptably with ther-
true ‘gold standard’ for intraoperative cardiac output modilution.90-92 Intrathoracic blood volume (ITBV)
determination (transit time flowmetry of the ascend- can also be calculated by transpulmonary thermodi-
ing aorta) revealed comparable estimation of CO, lution as an estimate of cardiac preload, the accuracy
with a diversion in the immediate post cardiopul- of which was recently validated.93 Recalibration is
monary bypass period, with thermodilution overesti- typically recommended every 8 hours or whenever a
mating CO and NICO underestimating CO. This change in patient status occurs.90
offers a reasonable explanation of the lack of agree- LiDCO™ uses a slightly different algorithm than
ment demonstrated in previous studies,86 and pro- PiCCO™ and it calibrates using lithium bolus dilution
vides a potentially quick and simple method of in place of transpulmonary thermodilution. Unlike
determining CO in the ED. transpulmonary thermodilution, lithium dilution does
In a similar application of the CO2 Fick principle, not require central access; only peripheral intravenous
the arteriovenous carbon dioxide gradient can be and peripheral arterial catheterization are required so
used to estimate cardiac index by directly measuring it is even less invasive. Cardiac output determined by
the mixed venous CO2 and arterial PaCO2 gradient.87 lithium dilution correlates well with pulmonary artery
However, the calculation of this gradient requires thermodilution,94 as does the pulse contour algorithm
mixed venous CO2 samples from the pulmonary used by the continuous monitoring device.95 Like
artery and, therefore, a PAC. Recently, a study PiCCO™, LiDCO™ requires recalibration every 8
demonstrated that the central venous CO2-arterial hours to remain accurate.96
CO2 gradient also correlates well with cardiac index FloTrac™, a newly introduced cardiac output
(CI = CO/body surface area) determined by both monitor, requires only a peripheral arterial catheter • July 2007 11 Emergency Medicine Practice©

and does not need calibration. Cardiac output is cal- again demonstrated somewhat reduced accuracy in
culated by the FloTrac™ device from pulsatility and patients with extensive pulmonary edema, pleural
an estimation of resistance/compliance based on effusions, chest wall edema, or chest tubes parallel
age/gender/weight/height.97 There are currently with the aorta.102 More recently, a study utilizing cur-
limited data reflecting the reliability of FloTrac™, rent generation TEB demonstrated good correlation
and studies are conflicting. In one study, comparable with thermodilution in both hemodynamically stable
bias and precision were found when compared to and unstable cardiac surgery patients103 and was
continuous cardiac output thermodilution.98 found to correlate well with CI measured by PAC in
However, another investigator concluded that there a large study of trauma patients with TEB initiated
was unacceptable agreement with thermodilution, while in the ED.104
although this study was performed using the first
generation FloTrac™ and interval improvements of Esophageal Doppler
the analytic algorithm have been incorporated since Esophageal Doppler is another minimally invasive
the study was completed.99 monitor of cardiac output which estimates stroke
volume by recording the velocity of blood flow in
Transthoracic-Electrical Bioimpedance the descending aorta by means of an ultrasound
Transthoracic-electrical bioimpedance (TEB) moni- probe, roughly the size of a gastric tube, placed
tors operate by measuring resistance in the thorax to nasally or orally. In order to accurately assess stroke
high frequency, low magnitude current to estimate volume from flow, esophageal Doppler measurement
changes in total thoracic fluid content over the car- makes several assumptions. The first is that there is
diac cycle which allows for the calculation of cardiac stable cephalic-caudal blood flow; this flow may be
output. This is accomplished quickly and non-inva- inconsistent in the critically ill. The second assump-
sively with several skin electrodes (similar to those tion is the existence of a constant cross sectional area
utilized by ECG) applied to the neck and thorax.100 of the aorta. This aortic measurement is either esti-
Unfortunately, TEB is unable to accurately assess car- mated by calculations based on height/weight/age
diac output in the presence of dysrhythmias (such as or directly measured by integrated real-time M-
atrial fibrillation or atrial flutter)84 and provides no Mode echocardiographic capabilities of some
direct preload assessment. esophageal Doppler models.105 The utilization of the
In terms of reliability, a meta-analysis comparing esophageal Doppler is a learned skill, but a study
154 studies revealed good correlation with cardiac suggests that no more than 12 placements are needed
output estimated by thermodilution; however, in to become adept.106
their analysis, accuracy was diminished in cardiac The reliability of esophageal Doppler was dis-
patients.101 A study of critically ill emergency depart- cussed in a systematic review of 11 validation papers
ment patients echoed the accuracy of TEB overall but that revealed low bias but limited agreement in

Table 2. Cardiac Output Monitors

Emergency Medicine Practice© 12 July 2007 •

absolute CO values when compared to PAC ther- ing to optimize cardiac output. Because CO moni-
modilution but high clinical agreement when follow- toring historically required PAC placement in the
ing trends. However, the authors concluded that ICU, most non post-operative studies only investi-
there were an inadequate number of studies review- gated patients optimized late (more than 24 hours) in
ing the accuracy of the esophageal Doppler with their hospital course. These studies were disappoint-
integrated M-Mode aortic measurement capabili- ing, demonstrating no difference in mortality111 or
ties.107 A recent study comparing esophageal even increased mortality for supranormal target val-
Doppler with direct echocardiographic aortic meas- ues.112 However, a meta-analysis of early hemody-
urement to PAC thermodilution and PiCCO™ namic optimization with PACs found supranormal
revealed good agreement between all methods.92 target values (defined as CI greater than 4.5
Additionally, esophageal Doppler allows preload L/min*m², pulmonary artery occlusion pressure less
estimation with more accuracy than pulmonary than 18 mmHg, oxygen delivery (DO2) greater than
artery perfusion pressure (PAOP) using corrected 600 mL/min*m² and oxygen consumption (VO2)
flow time (FTc) and contractility estimation from greater than 170 mL/min*m²) were associated with
peak velocity (PV) of aortic blood flow.108 decreased mortality in studies with high control
group mortality (greater than 20%). In this systemat-
Cardiac Output Monitoring Applications ic review, early hemodynamic optimization was
Currently, all studies which have investigated the defined as therapy occurring within the first 12
benefit of cardiac output monitoring in the critically hours after surgery, less than 24 hours after trauma,
ill utilize pulmonary artery catheterization in their before the onset of organ failure, or less than 4 hours
experimental group. Therefore, it is necessary to after the diagnosis of sepsis. Additionally, therapy
briefly outline the controversy which surrounds the was only considered effective when it resulted in dif-
use of pulmonary artery catheterization in the rou- ferences in DO2 between protocol and control
tine management of patients in the intensive care groups.113 Of note, one study initiating early opti-
unit. Although the validity of the routine utiliza- mization of severe trauma patients in the emergency
tion of the pulmonary artery catheter in the care of department by utilizing transthoracic electrical
the critically ill has long been questioned, the SUP- bioimpedance and changing to PAC in the ICU
PORT investigators were the first to provide prelim- found no difference in mortality between groups.
inary data that the use of PACs may in fact be However, there was also no difference in oxygen
counter productive. In a large retrospective study delivery between control and protocol groups in
of 5735 critically ill patients, they found an those who died because optimal values could not be
increased 30 day mortality, increased hospital cost, obtained. Ultimately, there was no difference in
and increased length of ICU stay associated with treatment between study groups; therefore, it is not
the use of PACs.109 The lack of benefit was later surprising that there was no difference in outcome.
confirmed by several prospective trials, including This study has also been criticized for the low mor-
the PAC-Man trial which demonstrated that the tality rate of the control group (less than 15%).114
routine placement of PACs had no effect on morbid-
ity or mortality.76,110 Additionally, the ESCAPE trial Recognition Of Hemodynamic Instability: The iden-
found no difference in mortality or length of hospi- tification of the hemodynamically unstable patient
tal stay when PAC parameters were compared with can be difficult, and reliance solely upon clinical indi-
clinical assessment in the management of severe cators is considered inadequate. Blood pressure
CHF patients.79 However, none of the trials utilized (MAP) has been demonstrated to be an unreliable
clearly defined treatment endpoints or therapies predictor of blood flow and cardiac output,115 and
based on the measurements obtained from the PAC, while shock index (HR/systolic BP greater than 0.9)
instead relying only on the discretion of the indi- fares better, it's not sensitive in identifying critical ill-
vidual intensivist in determining their usage and ness.116 Furthermore, a large portion of critically ill
interpretation. patients with significant global tissue hypoxia (identi-
fied by elevated lactate and decreased central venous
Targeted Resuscitation: While routine use of pul- oxygenation) will present with normal MAP, HR, and
monary artery catheters is now considered unbenefi- SI and, likewise, demonstrate no change in vital signs
cial, interest remains in using PAC or other monitor- despite trends of systemic improvement.117 While the • July 2007 13 Emergency Medicine Practice©

usefulness of high serum lactate levels in identifying patient will require before you begin overloading an
high-risk patients is well established,118 the require- already diseased heart and a patient with likely acute
ment of serial blood draws (and possibly significant tubular necrosis. You connect the patient’s existing arte-
laboratory turn around time in the absence of depart- rial line to a pulse contour cardiac output monitor and
mental point of care measurement devices) makes for note that his cardiac index is low and his stroke volume
potentially significant delays in the identification of varies considerably with his respiratory cycle indicating
patients with declining hemodynamic status. inadequate preload. You administer another 2 liters of
However, the application of non-invasive or invasive IVF and observe as his cardiac index begins to rise…
hemodynamic monitors may improve the clinician's While measures of cardiac output offer a com-
ability in the early identification of the critically ill posite of heart rate, preload, inotropy, and afterload,
prior to overt decompensation. A recent study it is often necessary to determine whether the patient
demonstrated that hemodynamic trends in CI, oxy- needs additional volume. Measures of preload have
gen delivery and consumption, and tissue perfusion traditionally (and only somewhat successfully) been
obtained by completely non-invasive monitoring used to answer this question.
modalities (TEB, SpO2, and transcutaneous oxygen
and carbon dioxide monitors) predicted non-survival Pulmonary Artery Perfusion Pressure
in severe trauma patients.104 Additionally, when By ‘wedging’ the distal balloon of the PAC into small-
blunt and abdominal trauma patients were evaluated er branches of the pulmonary artery, the pulmonary
with the addition of a stochastic analysis/mathemat- artery occlusion pressure (PAOP) can be measured.
ical search and display program to calculate survival The PAOP is an estimate of left ventricular end-dias-
probabilities utilizing measurements from the same tolic pressure (LVEDP) in the absence of disturbances
non-invasive modalities, a further increase in the of the pulmonary vasculature, the left atrium, or the
ability to avoid misclassification of non-survivors mitral valve and an estimate of left ventricular end-
and survivors was noted.119 diastolic volume (LVEDV) in the absence of abnormal
ventricular compliance. If no alterations present,
Cardiac Output Monitoring Key Points LVEDV can then be used as an estimate of preload.120
• Minimally invasive cardiac output monitors A newer volumetric PAC allows the estimation of
allow for time efficiency in the ED setting and right ventricular end-diastolic volume (RVEDV) by
provide valuable information regarding the thermodilution, which may be superior to PAOP in
overall cardiovascular status of the patient. the assessment of preload.121 However, PACs are not
• A declining cardiac index in the critically ill routinely placed in the ED; given the complications
patient indicates a necessity for aggressive mentioned in the previous section, this is not likely to
clinical re-evaluation and intervention. In the change in the future.
traumatically injured patient, for example,
sources of potential ongoing blood loss must Central Venous Pressure
be investigated. Measured in the superior vena cava by the distal
• Early hemodynamic optimization may be ben- port of central venous catheter or the proximal port
eficial in the critically ill ED patient. Although of a pulmonary artery catheter, central venous pres-
further prospective trials need to be per- sure (CVP) is a representation of right atrial pressure
formed, maintaining CI greater than (RAP). RAP can provide an estimate of venous
4.5 L/min*m², oxygen delivery (DO2) greater return and a very rough estimation of preload. The
than 600 mL/min*m² and oxygen consump- estimation is rough because it is also affected by
tion (VO2) greater than 170 mL/min*m² may right ventricular compliance, pericardial disease,
provide additional survival benefits in condi- valvular disease, and factors that affect intrathoracic
tions with high patient mortality. pressure (such as positive pressure ventilation, posi-
tive end-expiratory pressure, and normal respiratory
Preload Monitoring variation).62 Thus static CVP measurements rely on a
complex interaction of variables and are typically
Your patient with severe acute pancreatitis has now considered poor indicators of preload and volume
received 6 liters of crystalloid but still lacks any output status,122 see Figure 4. While the normal CVP range
from his Foley catheter. You question how much fluid this is between 4-6 mmHg,123 significant hypervolemia or

Emergency Medicine Practice© 14 July 2007 • • July 2007 15 Emergency Medicine Practice©
Figure 4. CVP Waveform Interpretation cussed below, CVP’s role in the emergency popula-
tion remains somewhat nebulous.

Preload Monitoring Applications

Preload monitoring is typically utilized to determine
whether or not a patient would benefit from addi-
tional volume. However, while the primary applica-
tion of preload monitoring is to assess fluid respon-
siveness, the utilization of static cardiac filling pres-
sures like CVP and PAOP to predict volume
response is problematic, as discussed further.
The c wave on the CVP tracing represents the AV valves movement back into the
atrium during the onset of ventricular contraction. The base of the c wave is the best
estimate of final ventricular filling pressure and, therefore, RV preload. Alternatively, Fluid responsiveness: A discussion of fluid respon-
the base of the a wave, which immediately follows the p wave on the cardiac moni-
tor, can be used when the c wave is not evident. The effect of respiration on trans- siveness must begin with its differentiation from
mural pressure must also be taken into account when interpreting the CVP wave-
form. End-Expiration represents the point at which pleural pressure most closely preload. While preload reflects end-diastolic volume
approximates atmospheric pressure and is the point at which measurements should
be taken in both spontaneously breathing and mechanically ventilated patients. of the ventricles (typically estimated by filling pres-
(Used with permission of Chad Meyers, MD)178
sures measured by invasive and minimally invasive
methods) it provides no information regarding
hypovolemia may exist in patients within this range,
where on the Frank-Starling curve the heart is oper-
and caution must be used in the interpretation of this
ating and, therefore, can be difficult to interpret.
value by itself.
However, fluid responsiveness, while dependent on
In terms of practical aspects of CVP monitoring,
preload, describes the ability to increase cardiac out-
while placement of catheters via the SVC or IJ is typ-
put by infusing volume, see Figure 5. Predicting
ically considered preferable, CVP measurements by
femoral line are, on average, 0.5 mmHg lower and
Figure 5. Frank-Starling Curve Predicts Fluid
may be reliable as an alternative when line place- Responsiveness
ment supradiaphragmatically is difficult or con-
traindicated.124 Additionally, saline administered
through a multi-lumen CVC did not affect CVP
when measured through the distal port, regardless of
the rate of infusion.125 CVP can also be measured by
external jugular vein examination, see Table 3.
Despite these limitations, CVP has an important
role in the monitoring of critical patients. Because
our patients are evaluated pre-resuscitation and
often before the onset of volume overload and
edema, the CVP may be more accurate in the ED
population as compared to the ICU patient.
However, because little literature exists apart from Used with permission of Chad Meyers, MD

one well-performed randomized control trial dis-

TABLE 3 – Estimation Of CVP By External Jugular Vein Examination

1. Position the patient at a 30° – 45° angle.

2. Identify the external jugular vein (EJV). If not readily identifiable, increasing intrathoracic pressure by Valsalva maneu-
ver or occluding the EJV at the base of the neck may help distend the vein.
3. Identify the apex of venous pulsations in the EJV by stripping. This is accomplished by placing one finger at the top of
the venous column and spreading another finger along the vein’s course to its base. When the lower finger is
released, the EJV will refill in a retrograde fashion and identification of the venous pulsation may be more clearly
4. Measure the height of the EJV from the patient’s angle of Louis located at the 2nd intercostal cartilage on the sternum.
5. Add 5 centimeters of water to this measurement to account for the distance between the angle of Louis and the right
6. This value is the CVP in cm of water. Multiply by 0.75 to obtain CVP in mm Hg.177

Emergency Medicine Practice© 16 July 2007 •

volume response is critically important in hemody- patients and was found to be as accurate as DPP and
namically unstable patients, as fluid infusion in an allows for completely non-invasive determination of
already volume overloaded patient may result in fluid response with only pulse oximetry/plethys-
volume overloaded patient may result in worsening mography.133
of overall condition without any increase in cardiac In spontaneously breathing patients, the
output. prediction of fluid response is more difficult.
The method used to identify fluid responsive- A single study found that a drop in right atrial
ness depends on whether the patient is breathing pressure/ CVP greater than 1 mmHg during inspi-
spontaneously or is deeply sedated/paralyzed and ration predicted fluid response in spontaneously
not triggering the mechanical ventilator. In both breathing patients;126 these findings were not sup-
spontaneously breathing and mechanically ventilat- ported by a more recent study which also demon-
ed patients, static cardiac filling pressures such as strated no correlation with stroke volume variation
right atrial pressure (equivalent to CVP in the and fluid response in spontaneously breathing
absence of vena-caval occlusive disease), PAOP, patients.134
RVEDVI, and ITBVI are consistently unable to pre- When used in conjunction with cardiac output
dict fluid responsiveness despite their ability to mon- monitoring, a fluid challenge may also be utilized to
itor preload. 126-130 determine volume responsiveness. Volume is infused
Dynamic measurements are much more promis- until CVP is increased by 2 mmHg; if cardiac output
ing in their ability to predict fluid response and rely subsequently increases by 300 mL/min or more then
on the physiologic relationship between respiratory the patient is likely operating on the ascending por-
variation and right ventricular function. A demon- tion of the Frank-Starling curve and is considered
stration of this concept is provided by explaining fluid responsive.123 Relying on a similar concept but
the variation of blood pressure observed in intubat- increasing central venous return by physical maneu-
ed patients. A positive pressure (mechanical) breath vers instead of by infusing additional volume, a
decreases venous return which then decreases right novel dynamic predictor of fluid response measuring
ventricular filling and ejection fraction which in turn change in aortic blood flow (ABF) using esophageal
causes a decrease in left ventricular ejection fraction Doppler found that increased ABF greater than 10%
a few beats later during expiration and ultimately during passive leg raise (45°) predicted volume
results in a decrease in systolic pressure. The mag- response in both spontaneously breathing and
nitude of variation is exaggerated in volume deplet- mechanically ventilated patients. Additionally, this
ed individuals and can be utilized to predict fluid method may prove to be even more versatile as it is
response. In several studies, systolic pressure varia- not affected by the presence of non-sinus rhythm, a
tion (SPV) has been found to correlate well with vol- limitation of other dynamic measurements.135
ume responsiveness in mechanically ventilated While the use of dynamic markers to predict
patients.127,131 Similarly, delta pulse pressure (DPP) fluid response seems promising, prospective trials
greater than 13% (defined as the difference between that demonstrate their ability to affect outcome do
the maximum pulse pressure during inspiration and not exist at this time. Interestingly, despite the well
the minimum pulse pressure during expiration) was
found to be more sensitive than SPV in predicting Figure 6. Delta Pulse Pressure
fluid response,131 see Figure 6. Utilizing pulse con-
tour analytic devices such as PiCCOTM to assess
stroke volume variation (SVV) in cardiac surgery
patients has also been shown to correlate well with
volume responsiveness while re-demonstrating the
limitations of static CVP measurements.129,132 Pre-
ejection period variation (defined as respiratory
variation of the time interval between the beginning
of the R wave on the ECG and the upstroke of the Changes in pulse pressure over the respiratory cycle (delta PP) are calculated as
the difference between Ppmax and Ppmin divided by the mean of the two values. A
radial artery pressure curve [PEPkt] or pulse value of 13% or greater accurately predicted fluid responsiveness in mechanically
ventilated patients without spontaneous breathing. (Used with permission of Chad
plethysmographic waveform [PEPlet]) corresponds Meyers, MD)131
with fluid responsiveness in mechanically ventilated • July 2007 17 Emergency Medicine Practice©

documented limitations of static measurements in tral venous oxygen saturation is 60%. You recheck for
the prediction of fluid response, in a study that will stroke volume variation on the cardiac output monitor but
be discussed at greater length later in this review, he now lacks any indication of fluid response. You begin a
Rivers et al utilized a target CVP greater than dobutamine infusion and an hour later, you re-sample his
8 mmHg in spontaneously breathing patients or a central venous blood, and his ScvO2 is 71%. His toes are
CVP greater than 12 mmHg in mechanically ventilat- now warm, and 80 cc of urine is present in his Foley bag.
ed patients with severe sepsis or septic shock and Months later, you hear from your ICU colleagues that
found a significant reduction in mortality when the patient had a long complicated hospital course includ-
treatment was combined with other hemodynamic ing numerous pancreatic necrosectomies. Against all
goals.136 However, the utility of CVP in the manage- odds, he eventually left the hospital for a rehabilitation
ment of fluid resuscitation in septic patients does not facility a few weeks prior and is now doing well.
seem to extend to the ICU. In a recent study, a CVP Perhaps the most important purpose to hemo-
of 8 mmHg or less in spontaneously breathing dynamic monitoring is to provide the answer to
patients or 12 mmHg or less in mechanically venti- one question: “Are we getting oxygen to the tis-
lated patients after 6 hours of resuscitation was not sues?” All of the markers we have discussed up
predictive of fluid response (defined as an increase in until now answer this question only indirectly.
cardiac index of 15% or more). Additionally, no cor- Tissue oxygen balance is dependent on two vari-
relation was demonstrated when CVP measurements ables: oxygen delivery (DO2) and oxygen consump-
were combined with PAOP or a pre-volume chal- tion (VO2). Both variables are a function of cardiac
lenge reduced stroke volume index.137 Thus, pre- output, oxygen carrying capacity, and oxygen satu-
resuscitation CVP values alone may have a positive ration. If the body’s metabolic requirements for
predictive value of volume status and fluid response oxygen exceed oxygen delivery cellular dysoxia
when less than 8 mmHg; however, this inference has occurs, and if this dysoxia induces organ dysfunc-
not been evaluated objectively. tion then a state of shock exists. By varying the
ratio of oxygen extraction, the quantity of oxygen
Preload Monitoring Key Points delivered to the microcirculation is held constant
• Dynamic markers of fluid responsiveness over a wide range of hemodynamic states.
allow the clinician to appropriately administer However, a critical DO2 value exists below which
volume in both the hemodynamically stable VO2 becomes supply dependent; any further
and unstable patient thereby avoiding volume decreases in cardiac output, oxygen carrying capaci-
overload and potentially worsening the ty, or arterial oxygen content that lower delivery
patients overall clinical status. below this point will result in further decreases in
• In a patient with a low cardiac output, markers VO2 and the likelihood of organ dysfunction and
indicating no fluid responsiveness should lead shock increases,73 see Figure 7.
to the initiation of inotropic support to main-
tain adequate tissue perfusion.
Figure 7. Critical Supply Dependent Oxygen
• In the severely septic or septic shock patient, a
CVP of 8 mmHg or less in the spontaneously
breathing patient or 12 mmHg or less in the
mechanically ventilated patient indicates the
requirement for additional volume administra-

Tissue Perfusion Monitoring

Back to the patient suffering from severe acute pancreati-

tis: his mean arterial pressure is now stable and his car-
diac index has normalized; however, his extremities
remain mottled and cold and he has not yet produced any
urinary output. You obtain a blood gas sample from his Used with permission of Chad Meyers, MD

subclavian central venous catheter and note that his cen-

Emergency Medicine Practice© 18 July 2007 •

Central Venous and Mixed-Venous Oxygenation that ROSC has likely already occurred.139 In the post
arrest patient, venous hyperoxia (ScvO2 greater than
Mixed-venous oxygenation (SvO2) represents the
75%) was associated with non-survival in those with
oxygen saturation of blood in the pulmonary artery
coincident lower range DO2 values. Non-survivors
which consists of blood returning from the SVC,
had higher ScvO2, higher lactate, and lower VO2 at
IVC, and coronary sinuses. Therefore, SvO2 is an
the same DO2 as survivors. This derangement in VO2
admixture of the venous return from the whole body.
and oxygen extraction is hypothesized to be the result
In contrast, central venous oxygenation (ScvO2) rep-
of microcirculatory abnormalities146 or large doses of
resents the oxygen saturation of blood in the SVC
epinephrine given during resuscitative measures.147
alone. A normal SvO2 in most individuals is
65-75% 138,139 -- but ScvO2 is typically lower than SvO2
Targeted Resuscitation: As previously discussed, the
in healthy individuals and 5-10% higher in critically
benefit of resuscitation strategies is likely a function
ill patients. Despite this, there is still good correla-
of time at which protocol is started, and, not surpris-
tion in measurements as well as trends between the
ingly, a targeted SvO2 greater than 70% has not been
two values.140,141 ScvO2 can be measured either con-
shown to reduce mortality when applied to ICU
tinuously by specially designed central venous
patients if initiated late in these patients’ hospital
catheters utilizing fiberoptic reflectance spectropho-
course.111 However, in a landmark study investigat-
tometry or periodically by intermittent blood draws
ing the effects of early hemodynamic optimization of
and blood gas analysis.139
severely septic patients in the first 6 hours of their
Central and mixed-venous oxygen saturation
hospital course, Rivers et al were able to demonstrate
are important because they provide a global indica-
an overall reduction in mortality from 46.5% to 30%
tor of tissue perfusion and whole-body O2 balance,
(ARR 16.5%), yielding a number needed to treat of 6.
which is difficult (if not impossible) to determine by
In their study, patients identified as suffering from
clinical indicators. For instance, Rady et al demon-
septic shock or severe sepsis with SBP less than
strated the presence of signs of global ischemia rep-
90 mmHg despite fluid therapy or lactate greater
resented by decreased ScvO2 and elevated lactate in
than 4 mmol/L, respectively, were treated with liber-
absence of traditional clinical indicators of shock
al fluid therapy targeting CVP greater than 8 mmHg,
(such as elevated HR, decreased BP, or elevated
and maintenance of MAP between 65 and 90 mmHg
shock index).117 Likewise, an ScvO2 less than 65%
using vasopressors or vasodilators, see the Severe
predicted hemorrhage and was found to be more
Sepsis Clinical Pathway insert. If patients contin-
accurate than vital signs in traumatically injured
ued to demonstrate global oxygen deficit (defined as
patients.142 In another study, ScvO2 was able to dif-
decreased ScvO2 less than 70%) then hemodynamic
ferentiate occult cardiogenic shock in patients with
optimization of oxygen delivery was attempted by
known EF less than 30% who were otherwise clini-
inotropic support and/or blood transfusion as well
cally indistinguishable.143
as the minimization of metabolic oxygen require-
ments by mechanical ventilation.136 The Early Goal
Tissue Perfusion Monitoring Applications
Directed Therapy (EGDT) protocol has since been
Cardiac Arrest: Although not typically considered a
incorporated into the international Surviving Sepsis
primary indication for placement of a ScvO2 catheter,
Campaign,148 and the findings have been supported
an existing continuous ScvO2 monitor may provide
by numerous studies demonstrating the feasibility
useful information in regards to the prognosis and
and benefit of its implementation.149-151
adequacy of cardiopulmonary resuscitation. In one
study, all patients with ScvO2 greater than 70%
demonstrated return of spontaneous circulation Regional Perfusion
(ROSC), while no patient with a maximal ScvO2 less Sublingual Capnometry
than 30% attained ROSC.144 Additionally, adequate Unlike other shock states, microvascular flow pat-
chest compressions may be reflected by an increase in terns are deranged and heterogeneous in septic
ScvO2 greater than 40%.145 ScvO2 values between 40- shock leading to regional dysoxia despite resuscita-
72% indicate progressively increasing chances of tive measures aimed at restoring global oxygena-
ROSC. ScvO2 values greater than 60% indicate that tion. This phenomenon, termed microcirculatory
ROSC is likely and values greater than 72% indicate and mitochondrial distress syndrome (MMDS), has • July 2007 19 Emergency Medicine Practice©

been demonstrated by direct visualization of the in sepsis but have not yet been correlated with
microvasculature by orthogonal polarization spec- PslCO2.161 Although these studies are promising,
tral (OPS) imaging.152 Microvascular shunting in none have been evaluated for their benefit on mortal-
sepsis can lead to lower tissue PO2 values than ity or morbidity.
venous PO2 or a PO2 gap that could result in appar-
ent normal or high values of global oxygenation Percutaneous O2 and CO2
(such as SvO2/ScvO2) despite significant regional
tissue dysoxia.153 These microvascular derangements Percutaneous O2/CO2 can be noninvasively moni-
have important implications and when compared to tored by heated probes placed on the skin. The mon-
survivors of sepsis, microcirculatory alterations pre- itor requires approximately 15 minutes to equilibrate
dicted non-survival in patients despite similar indi- and the probes must be moved every 4 hours to
cators of global perfusion (SvO2, lactate) in both avoid skin burns. While PtcO2 correlates with PO2 in
groups.154 normal patients, it significantly overestimates PO2 in
Estimation of microcirculatory competency can low flow states. This is reflected by the relationship
be accomplished non-invasively by the measurement between low PtcO2/FiO2 ratio and the incidence of
of CO2 in the tissue. This is based on the observation shock.162 Similarly, PtcCO2 levels climb and diverge
that CO2 accumulation in the tissue reflects low from PaCO2 in states of low cardiac output.163 In
blood flow and decreased CO2 washout.155 Tissue trauma patients, percutaneous measurement of
CO2 can be measured by a variety of methods, O2/CO2 has been shown to be a predictor of mortali-
including gastric tonometry, sublingual capnometry, ty with PtcCO2 values of greater than 90 torr, PtcCO2
or buccal capnometry. Sublingual capnometry non- remains greater than 60 torr for 30 minutes or PtcO2
invasively measures CO2 by sublingual optode and remains less than 50 torr for 60 minutes.164 In another
has largely replaced gastric tonometry due to its rela- trial studying the predictive value of percutaneous
tive ease of insertion and greater reliability in certain measurements in trauma patients, an increased
patient populations.156 Sublingual CO2 difference PtcCO2 and decreased PtcO2/FiO2 ratio correlated
(PslCO2–PaCO2) was found to correlate well with well with non-survival.104
microvascular circulation determined by OPS, sug-
gesting that the main determinant of PslCO2 was Tissue Perfusion Key Points
microcirculatory flow.157 • ScvO2 less than 70 mmHg or greater than
80 mmHg represents inadequate global perfu-
Sublingual Capnometry Applications sion and, therefore, oxygenation. During early
The minimal invasiveness of sublingual capnometry supply dependent stage of resuscitation, these
has the potential to create a useful triage tool for the findings should prompt a diligent attempt to
identification and stratification of the critically ill normalize oxygen balance by correcting ane-
patient in the ED. A PslCO2 greater than 70 mmHg mia, optimizing cardiac index, and minimiz-
was found to correlate with circulatory shock and ing oxygen consumption.
decreased likelihood of hospital survival, with nor- • Sublingual capnometry is a non-invasive and
mal values ranging between 43 to 47 mmHg and quick method of determining regional perfu-
averaging 45.2 ± 0.7 mmHg.158 In a more recent sion. PslCO2 greater than 70 mmHg or a
study, an initial PslCO2-PaCO2 difference greater
PslCO2-PaCO2 gap greater than 25 mmHg cor-
than 25 mmHg had a PPV of 79% and a NPV of 73%
relate with non-survival and severity of criti-
of non-survival.159
cal illness and signal the potential necessity
Additionally, by functioning as a surrogate
for aggressive management and resuscitative
marker of microcirculatory flow, PslCO2 could poten-
tially be utilized to monitor therapies directed at
• Percutaneous CO2 greater than 90 torr or
microvascular recruitment. Dobutamine has been
remaining greater than 60 torr for 30 minutes
shown to have a positive effect on microvascular
and percutaneous O2 remaining less than
flow in sepsis separate from its effect as an inotrope
50 torr for 60 minutes are predictors of mortal-
as determined by both OPS160 and PslCO2.162 Other
ity in the critically ill trauma patient.
recruitment strategies, such as nitroglycerin infusion
after adequate fluid loading, have also been found to
have a positive effect on microvascular flow by OPS

Emergency Medicine Practice© 20 July 2007 •

TBI patients,171 they are typically inadequate when
Neurologic Monitoring
excluding injury or radiographic abnormalities in
Because the management of the critically ill often those patients with normal or near-normal physical
necessitates aggressive control of the airway and exam.172 In a single study of closed head injury
subsequent deep sedation, clinical assessment of patients, an initial BIS greater than 95 excluded all
neurologic function is difficult if not impossible. patients with poor outcomes regardless of radi-
Typically, complex monitoring devices such as elec- ographic findings, while, conversely, all patients with
troencephalography (EEG) are beyond the scope of poor outcomes had an initial BIS less than 95, includ-
most emergency physician’s practice; however, the ing patients with normal physical and radiographic
development of bispectral electroencephalographic examination. In this study, poor outcome was
monitors provides the non-specialist with a simpli- defined as death, persistent vegetative state, or dis-
fied tool to assess a patient’s cortical activity. charge to long term care facility for neurologic dis-
abilities; these results need prospective validation
Bispectral Electroencephalographic Monitors before any clinical use.173

The bispectral index (BIS) is derived from bispectral

BIS Monitoring Key Points
EEG signal processing of bioelectric potentials
• Bispectral index monitoring allows for a non-
obtained by forehead leads and displayed as a
invasive assessment of cortical activity. While
numerical value ranging from 0 (representing corti-
BIS usage intraoperatively has been shown to
cal silence) to 100 (representing full alertness). Its
be accurate in predicting adequate sedation,
primary clinical use has been in the operating room
no correlation between clinical markers of
to assess adequate sedation and minimize anesthetic
sedation and BIS have been found in mechani-
usage. Recent studies have attempted to demonstrate
cally ventilated patients in the ED.
benefit in other settings, such as the emergency
• Although not prospectively validated, an ini-
tial BIS less than 95 may predict potential poor
neurologic outcome in patients suffering from
Bispectral Electroencephalographic Monitors Applications
closed head injury.
Determining the level of adequate sedation in
mechanically ventilated patients in the ED is difficult,
and the accuracy of various clinical scoring systems is
considered inadequate.166 Therefore, a monitoring The availability of less invasive monitoring devices
device with the ability to objectively determine seda- has already and will continue to change the land-
tion for our critically ill patients might be helpful. scape of critical care in the emergency department.
Although findings concerning the use of the BIS as a However, the necessity of such devices and the
method of continuous assessment of adequate seda- potential requirements they mandate of emergency
tion in mechanically ventilated patients in the ICU physicians is a source of considerable controversy. In
were initially encouraging,167 recent studies in a more a questionnaire distributed to academic emergency
heterogeneous surgical ICU population and the emer- departments in July of 2004, a dismal 7% of depart-
gency department have not shown any correlation ments implemented EGDT in the care of patients
between BIS and clinical measures of sedation.168,169 demonstrating signs of severe sepsis or septic shock.
Despite these findings, a prospective observational The lack of specialized monitoring devices was listed
study in the ED found good correlation between a as the reasoning in 75% of institutions questioned.174
consistent BIS less than 70 and lack of recall concern- The benefit of the early hemodynamic optimiza-
ing intubation, suggesting the possibility of some tion of the critically ill, a concept encapsulated by
utility of BIS in the prediction of amnesia and its EGDT, applies regardless of the presence or absence
dependence on adequate level of sedation in the of specialized monitors. While the use of continuous
ED.170 monitoring may be preferable, “low-tech” alterna-
BIS may be useful in the initial assessment of tives do exist when they are unavailable. For exam-
traumatically brain injured patients with relatively ple, the measurement of central venous pressure is
normal clinical exams. While prior studies have possible without the use of a pressure transducer.
shown that clinical indicators such as low Glasgow Using an infusion line on an existing central venous
Coma Scale are associated with poor outcomes in • July 2007 21 Emergency Medicine Practice©

catheter, the stopcock is held at the patient’s phlebo- ed to mmHg by multiplying by 0.75. If this level of
static axis (mid axillary line, 4th intercostal space in invasiveness is still too much, the CVP can be esti-
the supine patient), a length of saline filled extension mated by examination of the external jugular vein,
tubing is attached, and the stopcock is opened to the see Table 3 on page 16.
new tubing. At this point, a column of fluid exists In the absence of continuous ScvO2 monitors,
from the level of the right atrium to the meniscus in intermittent samples of blood drawn from the central
the extension tubing and as the patient breathes, the venous catheter may be sent for blood gas analysis.
meniscus of the column will rise and fall. The height However, another simple bedside clinical sign can
of the column measured from the phlebostatic axis to also be of significant benefit in the identification of
the meniscus represents the central venous pressure perfusion abnormalities. In an eloquent study pub-
in centimeters of water. This number can be convert- lished by Joly et al in 1969, the temperature of the

Risk Management Pearls

1. Relying on clinical indicators of hemodynamic insta- 6. Utilizing CVP as an estimate of preload in the resus-
bility to rule out critical illness. citated patient.

While vital signs are valuable tools if abnormal, 50% The utility of CVP as a measure of preload and fluid
of critically ill patients may present with normal blood responsiveness has never been validated in patients
pressure and heart rate. Indicators of global or region- after 6 hours of resuscitation. Reliance on CVP to
al perfusion (e.g., lactate, ScvO2, sublingual capnome- monitor volume status after this period may be mis-
try) or cardiac index are considered more reliable. leading.

2. Estimating blood pressure through physical exam. 7. Being reassured by a very high ScvO2.

Palpating various peripheral pulses for blood pressure ScvO2 greater than 80% reflects decreased oxygen uti-
determination is both unreliable and misleading. lization by the tissues. In septic shock, this can be a
Utilize intermittent automated cuff pressure or contin- sign of microcirculatory abnormalities and mitochon-
uous intra-arterial monitoring to determine blood drial dysfunction.
pressure in the critically ill.
8. Being reassured by a normal SpO2 following smoke
3. Leaving the automated blood pressure cuff set to inhalation.
record at 30 minute intervals.
The presence of carboxyhemoglobinemia following
Often, default recording times for blood pressure smoke inhalation may mask significant hypoxia due to
measurement are set at lengthy time intervals. This the limitations of traditional pulse oximetry caused by
will invariably lead to significant delay in appropriate the overlap of light absorbance between oxyhemoglo-
intervention or missing transient episodes of hypoten- bin and carboxyhemoglobin.
sion, which may have significant implications in the
critically ill. 9. Being reassured by a high non-invasive blood pres-
sure measurement in the initial resuscitation of
4. Utilizing normal SpO2 as an indicator of correct severe trauma.
endotracheal tube placement.
Because of high endogenous catecholamine levels, the
While pulse oximetry is a valuable tool in preventing initial cuff blood pressure measurement in the arm of
hypoxic events, because of the shape of the oxyhemo- a patient with large amounts of blood loss may read a
globin dissociation curve, significant desaturation may high value even though the actual central arterial
occur before changes in SpO2 are evident. pressure is low. The most accurate blood pressure
readings in these patients are obtained from a femoral
5. Relying on ETCO2 as an estimate of PaCO2. intra-arterial line. The readings between this catheter
and the cuff measurements will often be widely dis-
While ETCO2 may reflect PaCO2 in hemodynamically crepant.
stable healthy volunteers, its relationship is unpre-
dictable and unreliable in patients who are unstable or 10. Relying on monitoring devices over clearly contra-
with abnormal pulmonary function. For example, dictory clinical judgment.
monitoring of the decompensated COPD patient for
hypercapnia by ETCO2 alone may lead to overconfi- Since all monitoring devices are sometimes inaccurate,
dence in clinical status and the overlooking of signifi- clinical gestalt still plays a large role in the evaluation
cant clinical deterioration (i.e., an ETCO2 of 30 mmHg of a critically ill patient. If a patient looks much sicker
may actually reflect a PaCO2 of 95 mmHg due to sig- than a monitoring device indicates, continued vigi-
nificant pulmonary shunting). lance is often rewarded.

Emergency Medicine Practice© 22 July 2007 •

ventrum of the great toe was found to be closely cor- ments of critical care will also undoubtedly further
related with cardiac index and global perfusion. They strain the staff of already overcrowded emergency
observed that if the temperature of the great toe was departments. Thus, the development of minimally
less than 27 degrees Celsius after 3 hours of admis- and completely non-invasive monitoring modalities
sion, the likelihood of death was 67%.175 Familiarity is crucial, not only to guide treatment of the critically
with this concept has led many venerable surgeons to ill more effectively but also more efficiently and
make laying their hands on the feet the first physical quickly. Additionally, the availability of advanced
exam assessment in a critically ill patient. monitoring devices will potentially increase the diag-
The dependence of clinicians on technologically nostic acumen of the emergency physician, minimiz-
advanced and often expensive monitoring method- ing the misidentification of the less severely ill and
ologies was recently challenged by Dr. Stephen Streat limiting the misappropriation of valuable resources.
on the Critical Care Medicine Listserv (CCM-L). His Ideally, by enhancing the ability of the emergency
approach to the management of severe sepsis and physician to initiate optimal care of the critically ill,
shock entails an aggressive utilization of basic effective monitoring will play an important role in
resources, such as the necessity of early airway man- the integration of our specialty in the continuum of
agement, inotropes, vasopressors, fluids, and often critical care. A continuum which begins in the emer-
times surgery for source control. By carefully moni- gency department and inarguably has an indelible
toring clinical parameters of hemodynamic optimiza- impact on the outcome of the most fragile patients.
tion, he approximates the targeted end points of the
Rivers trial, see the Sepsis Protocol Clinical References
Pathway on page 15. However, this approach does
Evidence-based medicine requires a critical appraisal
not imply a hands-off approach to the management of the literature based upon study methodology and
of the severely septic patient but instead highlights number of subjects. Not all references are equally
the often unavoidably labor intense requirements of robust. The findings of a large, prospective, random-
care of the critically ill. As he states simply and ized, and blinded trial should carry more weight
articulately, “It is not the technology that makes than a case report.
To help the reader judge the strength of each ref-
intensive care work – it is the people who intensively
erence, pertinent information about the study, such
care.”176 as the type of study and the number of patients in
the study, are included in bold type following the
Introductory Case Conclusion reference, where available.

Several hours after your pneumonia patient from yester- 1. Nelson, M., et al. Critical care provided in an urban emergency depart-
ment. Am J Emerg Med 1998;16(1):56-9. (Prospective, observational, 340
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2. Hospital-Based Emergency Care: At the Breaking Point. Future of
short of breath and hypoxemic requiring intubation. A Emergency Care, ed. C.o.t.F.o.E.C.i.t.U.S.H. System 2006 The National
subsequent arterial blood gas revealed a lactate of 7.8 Academies Press. (Review)
3. Kline, J.A., et al. Diagnostic accuracy of a bedside D-dimer assay and
mmol/L, and she continued to have no urine output. alveolar dead-space measurement for rapid exclusion of pulmonary
embolism: a multicenter study. Jama 2001;285(6):761-8. (Prospective,
Liberal IV fluid was administered through a central observational, 380 patients)
4. Verschuren, F., et al. Volumetric capnography as a screening test for
venous catheter along with vasopressors. Despite the pulmonary embolism in the emergency department. Chest
aggressive management of the floor team, she coded later 2004;125(3):841-50. (Prospective, observational, 45 patients)
5. Nunn, J.F. and D.W. Hill. Respiratory dead space and arterial to end-
that morning and subsequently died as a consequence of tidal carbon dioxide tension difference in anesthetized man. J Appl
Physiol 1960;15:383-9. (Prospective, observational, 12 patients)
septic shock. When the case was presented at the hospital’s 6. Wahba, R.W. and M.J. Tessler, Misleading end-tidal CO2 tensions. Can
J Anaesth 1996;43(8):862-6. (Review)
M&M conference, a copy of the River’s study on EGDT 7. Yamanaka, M.K. and D.Y. Sue. Comparison of arterial-end-tidal PaCO2
was distributed and you are left wondering if the patient’s difference and dead space/tidal volume ratio in respiratory failure.
Chest 1987;92(5):832-5. (Prospective, observational, 17 patients)
outcome could have been different. 8. Yosefy, C., et al. End tidal carbon dioxide as a predictor of the arterial
PaCO2 in the emergency department setting. Emerg Med J
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ments be predicted? Crit Care 2006;10(4):R102. (Prospective, 21 1981;9(10):752-5. (Prospective, observational, 44 patients)
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135. Monnet, X., et al. Passive leg raising predicts fluid responsiveness in warning of tissue hypoxia and hemodynamic shock in critically ill
the critically ill. Crit Care Med 2006;34(5):1402-7. (Prospective, 71 emergency patients. Crit Care Med 2000;28(7):2248-53. (Prospective,
patients) observational, 48 patients)
136. Rivers, E., et al. Early goal-directed therapy in the treatment of severe 165. Stanski, D.R.S., Steven L. Monitoring the Depth of Sedation, in Miller’s
sepsis and septic shock. N Engl J Med 2001;345(19):1368-77. Anesthesia. R.D. Miller, Editor 2005 Churchill Livingstone (Review,
(Prospective, randomized, semi-blind, 263 patients) text)
137. Osman, D., et al. Cardiac filling pressures are not appropriate to pre- 166. De Jonghe, B., et al. Using and understanding sedation scoring sys-
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2007;35(1):64-8. (Retrospective, 96 patients) (Systematic review, 25 studies)
138. Nelson, L.D. Continuous venous oximetry in surgical patients. Ann 167. Riker, R.R., et al. Validating the Sedation-Agitation Scale with the
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2004;30(8):1572-8. (Prospective, observational, 32 patients) patients)
141. Dueck, M.H., et al. Trends but not individual values of central venous 169. Gill, M., et al. Can the bispectral index monitor the sedation adequacy
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Emergency Medicine Practice© 26 July 2007 •

CME Questions 8. Pulse oximetry has a vital role during intubation and
airway management; it can be used to:
1. End-tidal CO2 monitoring has been shown to: a. confirm endotracheal tube placement.
a. verify correct tube placement after RSI and b. always obtain accurate arterial oxygenation moni-
throughout intubation. toring immediately following placement of the
b. predict adverse respiratory events in procedural tube.
sedation. c. provide a reasonable approximation of PaO2 dur-
c. guide pulse checks and demonstrate ROSC during ing ventilation of an intubated patient.
CPR. d. none of the above
d. all of the above
9. The pulmonary artery catheter’s:
2. The reliability of pulse oximetry is affected by: a. benefits on patient mortality are clearly estab-
a. severe anemia. lished in numerous studies.
b. poor peripheral perfusion. b risks may outweigh its benefits.
c. poor waveform. c. main use is to obtain accurate MAP measure-
d. A and B ments.
d. should be abandoned for new, non-invasive out-
put monitors which have clearly proven their util-
3. CVP in the setting of sepsis: ity.
a. is reliable only when obtained by internal jugular
or subclavian central venous catheters.
b. when decreased, may represent hypervolemia. 10. The utilization of cardiac output measurements
c. when decreased, always represents hypovolemia. determined by pulmonary artery catheterization to
c. when decreased, can be utilized to predict fluid guide therapy:
responsiveness in ICU patients. a. has no benefit on patient morbidity.
b. has been shown to benefit patients in decompen-
sated congestive heart failure.
4. Central venous oxygenation: c. is more reliable than CVP to guide fluid resuscita-
a. if less than 70%, represents global perfusion tion.
abnormalities. d. has demonstrated benefit in patient groups with
b. if greater than 90%, represents adequate resuscita- high mortality when initiated early in their hospi-
tion of septic shock. tal course.
c. if greater than 75%, represents good prognosis in
patients with ROSC.
d. A and B 11. Mixed venous oxygen saturation (SvO2):
a. refers to a sample taken from the tip of a central
venous catheter.
5. In the critical care literature, which of the following b. requires the lab to mix a sample from a PAC with
has been associated with improved mortality? a sample from an aterial puncture.
a. accurate determination of patients who are vol- c. refers to a mixture of blood from the SVC, IVC,
ume responsive and coronary sinuses.
b. late hemodynamic optimization of severely septic d. is best obtained from the subdiaphragmatic
patients upon admission to the ICU femoral vein.
c. increasing cardiac output to supranormal levels to
increase oxygen delivery in certain high risk
patients 12. An ETCO2 of less than 10 during arrest:
d. all of the above a. predicts dismal outcome at any point during car-
diac arrest.
b. indicates that the respiratory therapist should
6. Bispectral electroencephalographic monitoring: decrease ventilation frequency.
a. allows for determination of mechanically ventilat- c. always indicates a poorly positioned ET tube.
ed patients’ level of sedation in the operating d. predicts no ROSC 20 minutes after PEA arrest.
b. allows for determination of mechanically ventilat-
ed patients’ level of sedation in the emergency 13. In Early Goal Directed Therapy (EGDT):
room. a. inotropes should always be started before volume
c. allows for determination of mechanically ventilat- loading to prevent edema.
ed patients’ level of sedation in the ICU. b. an endpoint is an ScvO2 between 70 and 80.
d. none of the above c. requires vasopressors regardless of blood pres-
d. resulted in a mortality reduction of only 2%.
7. Microvascular flow and regional perfusion abnor-
a. correlate with markers of global perfusion such as 14. Critically ill emergency department patients in shock
central venous oxygen. may benefit from:
b. are typically heterogenous in states of traumatic
hemorrhagic shock. a. intra-arterial blood pressure monitoring to meas-
c. are typically homogenous in states of severe sepsis ure accurate MAP.
and septic shock. b. CVP monitoring to help guide pre-resuscitation
d. can be responsible for significant regional oxygen volume optimization.
debt in the presence of elevated central venous c. continuous capnography to ensure continued
oxygen levels. endotracheal tube placement and early detection
of hypercapnia.
d. all of the above • July 2007 27 Emergency Medicine Practice©

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Critical Care Monitoring In The Emergency Department • July 2007 Emergency Medicine Practice©