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Assessment for Pericardial Tamponade 2D echocardiography is useful for identifying findings consistent with pericardial tamponade (Chapter 17 Video 17 quality 120 mg sildalist. The right ventricle fills during diastole sildalist 120mgmg overnight delivery, so a collapse of the right ventricle during diastole is abnormal buy generic sildalist 120 mg. The presence of chamber compression does not in itself indicate that there is tamponade physiology sildalist 120 mg with mastercard, nor does its absence rule it out. The presence of a swinging heart within large pericardial effusion is suggestive of pericardial tamponade, as is respirophasic variation of chamber size on M-mode obtained with the sample line placed through the right ventricle and left ventricle from the parasternal long- axis view. This is manifested with respirophasic variation of mitral valve and tricuspid valve diastolic inflow velocities. A greater than 30% respirophasic variation of mitral valve E wave velocity is characteristic of pericardial tamponade measured from the apical four-chamber view. Both 2D and Doppler echocardiography are helpful in identifying the patient with pericardial tamponade. Because there are sufficient confounders, echocardiographic findings, though helpful, should never be considered diagnostic. Pericardial tamponade remains a clinical diagnosis that may or may not be supported by echocardiographic findings. Guidance of Pericardiocentesis Ultrasonography is the preferred method for safe performance of pericardiocentesis when compared to fluoroscopic guidance. Because fluoroscopy is a 2D imaging technique, the position of the liver; the relationship of the needle to the myocardium; and the relationship of the lung to the needle trajectory is less certain than with ultrasonography imaging. Pericardiocentesis performed with ultrasonographic guidance uses the same principles as those of thoracentesis and paracentesis. The fluid collection is identified, and the operator determines a safe site, angle, and depth for needle insertion while avoiding injury to adjacent anatomic structures. The operator needs to be skilled at image acquisition and interpretation, because an injury to the myocardium or coronary artery is a catastrophic complication of pericardiocentesis (Chapter 17 Video 17. Site Selection and Preparation Using ultrasonography, the best site is determined by where the most fluid is found. The best site is often found on the lateral chest using the apical four-chamber view (Chapter 17 Video 17. When the effusion is predominately posterior in location, changing the patient’s body position may distribute the fluid into a more favorable position. The left lateral decubitus position may shift the fluid for an improved apical view, whereas a semisupine position may improve the subcostal view. The distance between the site of needle penetration into the pericardium and the heart is an important determinant of safety. The heart changes in size throughout the contractile cycle; cardiac “swinging” is a common phenomenon in severe tamponade, and the respirophasic translational movement of the heart is accentuated during the respiratory cycle. As a result, the thickness of the pericardial effusion may change a major extent during cardiac movement. A reasonable approach is to require at least 1 cm of fluid depth between the heart and the planned needle entry point into the pericardial fluid. Fortunately, aerated or consolidated lung is easy to identify and therefore easy to avoid (see Chapter 11 on Lung Ultrasonography). Color Doppler examination of the planned needle trajectory is mandatory when using the parasternal approach, in order to avoid the internal mammary vessels. A pleural effusion may occur concomitantly with the pericardial effusion, and may block access to the pericardial fluid. In this situation, it is best to drain the pleural effusion, and then to determine the best approach to the pericardial effusion. Using the calipers function, the depth of needle penetration is measured from a frozen image on the ultrasound screen. This reduces the period between the final scan and needle insertion, thereby allowing the operator to maintain recent memory of the angle of approach during needle insertion. The transducer with sterile sleeve is part of the field setup, thereby allowing scanning during the procedure, because the operator may choose to reconfirm site, depth, and angle for needle insertion following sterile site preparation. The angle of needle insertion for device insertion duplicates the angle of probe angle that identified the safe trajectory for needle insertion. Confirmation of wire or catheter insertion may be accomplished by direct visualization using 2D ultrasonography. If there is a question of proper position, several milliliters of agitated saline may be injected through the catheter to document catheter position. Similar to thoracentesis and paracentesis, pericardiocentesis does not require real-time guidance with ultrasonography. However, it is important to have the transducer with sterile cover in place for immediate use throughout the procedure, in case there is a need to rescan and document successful device insertion. Pitfalls: Common and Uncommon Skin compression artifact is a common problem, because it may cause an underestimation of the depth for needle insertion. This occurs in the obese or edematous patient when the operator pushes the probe into the skin while searching for a safe needle insertion site. Measurement of needle insertion distance is made while compressing the skin and underlying soft tissue. On removal of the probe pressure, the skin rebounds, such that the needle insertion is underestimated. During actual needle insertion, the operator is appropriately concerned, if there is no fluid obtained at the depth measured from the ultrasound machine screen. The solution to this problem is to rescan the patient, confirm the angle of insertion, and estimate the compression artifact more accurately. Another cause for difficulty is movement of the mark that designates the appropriate site for needle insertion. Skin is movable, so the injudicious application of force by the operator’s hand may shift the skin mark. The needle should be inserted at the mark without any tension applied to the area that might shift the mark position. Similarly, a “dry tap” might result from inaccurate duplication of the angle at which the transducer was held, or an inaccurate skin mark. Generally, it is easier to duplicate a perpendicular transducer angle than one that is acutely angled. This favors an anterior or lateral chest wall approach (if fluid is accessible), because the transducer is often perpendicular to the chest wall when scanning in these areas. Overly vigorous probing of the anterior costal cartilage (if using a parasternal approach) may also block the needle with cartilage, causing the operator to insert the needle too deeply, with potential complications to the patient. A large anterior pericardial fat pad may be mistaken for a pericardial effusion by the inexperienced ultrasonographer. However, it is very uncommon for a consequential pericardial effusion to occur anterior to the heart without a significant posterior pericardial effusion also being present. An uncommon pitfall of pericardiocentesis occurs when the anesthesia needle penetrates the pericardium after having traversed a pleural effusion. The pericardial effusion may then drain into the pleural space through the defect in the pericardium made by the anesthesia needle. The operator is unpleasantly surprised by the lack of pericardial effusion, and the presence of a new pleural effusion. To avoid this situation, device insertion should promptly follow infiltration of the local anesthesia. Ultrasonography allows the intensivist to select a safe site, angle, and depth for needle and device insertion. Careful attention to image acquisition and interpretation allows the operator to avoid the serious complication of myocardial or coronary artery laceration. The critical care ultrasonographer is strongly encouraged to develop proficiency in ultrasound guidance of pericardiocentesis, because it is superior to subcostal fluoroscopic guidance. Permayer-Miulda G, Sagrista-Sauleda J, Soler-Soler J: Primary acute pericardial disease: a prospective study of 231 consecutive patients. Sagrista-Sauleda J, Merce J, Permanyer-Miralda G, et al: Clinical clues to the causes of large pericardial effusions. Zayas R, Anguita M, Torres F, et al: Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. The task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology.

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A greater than 30% respirophasic variation of mitral valve E wave velocity is characteristic of pericardial tamponade measured from the apical four-chamber view discount 120 mg sildalist overnight delivery. Both 2D and Doppler echocardiography are helpful in identifying the patient with pericardial tamponade sildalist 120 mg for sale. Because there are sufficient confounders cheap 120mg sildalist fast delivery, echocardiographic findings buy generic sildalist 120mgmg on-line, though helpful, should never be considered diagnostic. Pericardial tamponade remains a clinical diagnosis that may or may not be supported by echocardiographic findings. Guidance of Pericardiocentesis Ultrasonography is the preferred method for safe performance of pericardiocentesis when compared to fluoroscopic guidance. Because fluoroscopy is a 2D imaging technique, the position of the liver; the relationship of the needle to the myocardium; and the relationship of the lung to the needle trajectory is less certain than with ultrasonography imaging. Pericardiocentesis performed with ultrasonographic guidance uses the same principles as those of thoracentesis and paracentesis. The fluid collection is identified, and the operator determines a safe site, angle, and depth for needle insertion while avoiding injury to adjacent anatomic structures. The operator needs to be skilled at image acquisition and interpretation, because an injury to the myocardium or coronary artery is a catastrophic complication of pericardiocentesis (Chapter 17 Video 17. Site Selection and Preparation Using ultrasonography, the best site is determined by where the most fluid is found. The best site is often found on the lateral chest using the apical four-chamber view (Chapter 17 Video 17. When the effusion is predominately posterior in location, changing the patient’s body position may distribute the fluid into a more favorable position. The left lateral decubitus position may shift the fluid for an improved apical view, whereas a semisupine position may improve the subcostal view. The distance between the site of needle penetration into the pericardium and the heart is an important determinant of safety. The heart changes in size throughout the contractile cycle; cardiac “swinging” is a common phenomenon in severe tamponade, and the respirophasic translational movement of the heart is accentuated during the respiratory cycle. As a result, the thickness of the pericardial effusion may change a major extent during cardiac movement. A reasonable approach is to require at least 1 cm of fluid depth between the heart and the planned needle entry point into the pericardial fluid. Fortunately, aerated or consolidated lung is easy to identify and therefore easy to avoid (see Chapter 11 on Lung Ultrasonography). Color Doppler examination of the planned needle trajectory is mandatory when using the parasternal approach, in order to avoid the internal mammary vessels. A pleural effusion may occur concomitantly with the pericardial effusion, and may block access to the pericardial fluid. In this situation, it is best to drain the pleural effusion, and then to determine the best approach to the pericardial effusion. Using the calipers function, the depth of needle penetration is measured from a frozen image on the ultrasound screen. This reduces the period between the final scan and needle insertion, thereby allowing the operator to maintain recent memory of the angle of approach during needle insertion. The transducer with sterile sleeve is part of the field setup, thereby allowing scanning during the procedure, because the operator may choose to reconfirm site, depth, and angle for needle insertion following sterile site preparation. The angle of needle insertion for device insertion duplicates the angle of probe angle that identified the safe trajectory for needle insertion. Confirmation of wire or catheter insertion may be accomplished by direct visualization using 2D ultrasonography. If there is a question of proper position, several milliliters of agitated saline may be injected through the catheter to document catheter position. Similar to thoracentesis and paracentesis, pericardiocentesis does not require real-time guidance with ultrasonography. However, it is important to have the transducer with sterile cover in place for immediate use throughout the procedure, in case there is a need to rescan and document successful device insertion. Pitfalls: Common and Uncommon Skin compression artifact is a common problem, because it may cause an underestimation of the depth for needle insertion. This occurs in the obese or edematous patient when the operator pushes the probe into the skin while searching for a safe needle insertion site. Measurement of needle insertion distance is made while compressing the skin and underlying soft tissue. On removal of the probe pressure, the skin rebounds, such that the needle insertion is underestimated. During actual needle insertion, the operator is appropriately concerned, if there is no fluid obtained at the depth measured from the ultrasound machine screen. The solution to this problem is to rescan the patient, confirm the angle of insertion, and estimate the compression artifact more accurately. Another cause for difficulty is movement of the mark that designates the appropriate site for needle insertion. Skin is movable, so the injudicious application of force by the operator’s hand may shift the skin mark. The needle should be inserted at the mark without any tension applied to the area that might shift the mark position. Similarly, a “dry tap” might result from inaccurate duplication of the angle at which the transducer was held, or an inaccurate skin mark. Generally, it is easier to duplicate a perpendicular transducer angle than one that is acutely angled. This favors an anterior or lateral chest wall approach (if fluid is accessible), because the transducer is often perpendicular to the chest wall when scanning in these areas. Overly vigorous probing of the anterior costal cartilage (if using a parasternal approach) may also block the needle with cartilage, causing the operator to insert the needle too deeply, with potential complications to the patient. A large anterior pericardial fat pad may be mistaken for a pericardial effusion by the inexperienced ultrasonographer. However, it is very uncommon for a consequential pericardial effusion to occur anterior to the heart without a significant posterior pericardial effusion also being present. An uncommon pitfall of pericardiocentesis occurs when the anesthesia needle penetrates the pericardium after having traversed a pleural effusion. The pericardial effusion may then drain into the pleural space through the defect in the pericardium made by the anesthesia needle. The operator is unpleasantly surprised by the lack of pericardial effusion, and the presence of a new pleural effusion. To avoid this situation, device insertion should promptly follow infiltration of the local anesthesia. Ultrasonography allows the intensivist to select a safe site, angle, and depth for needle and device insertion. Careful attention to image acquisition and interpretation allows the operator to avoid the serious complication of myocardial or coronary artery laceration. The critical care ultrasonographer is strongly encouraged to develop proficiency in ultrasound guidance of pericardiocentesis, because it is superior to subcostal fluoroscopic guidance. Permayer-Miulda G, Sagrista-Sauleda J, Soler-Soler J: Primary acute pericardial disease: a prospective study of 231 consecutive patients. Sagrista-Sauleda J, Merce J, Permanyer-Miralda G, et al: Clinical clues to the causes of large pericardial effusions. Zayas R, Anguita M, Torres F, et al: Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. The task force on the diagnosis and management of pericardial diseases of the European Society of Cardiology. Competence in the performance of transvenous pacing also requires the operator to have training in central venous access (Chapter 6) and hemodynamic monitoring (Chapter 28) [2]. Tachyarrhythmias Temporary cardiac pacing is used less often for the prevention and termination of supraventricular and ventricular tachyarrhythmias. Pacing termination of atrial flutter in cardiac surgery patients with epicardial leads may be preferable to synchronized cardioversion, which carries the risk associated with sedation.

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Symptoms rarely last more than several hours sildalist 120 mg without prescription, and acute renal toxicity is almost always reversible over a period of a few days to weeks 120mg sildalist amex. Metabolic acidosis 120mg sildalist with visa, coma discount sildalist 120 mg with amex, seizures, hepatic dysfunction, hypotension, and cardiovascular collapse are relatively frequent after phenylbutazone overdose [60,61,64–66]. Uncommonly, coma, hyperactivity, hypothermia, seizures, metabolic acidosis, acute renal insufficiency, thrombocytopenia, acute respiratory distress syndrome, upper gastrointestinal tract bleeding, and respiratory depression are seen in ibuprofen poisoning [39,66–69]. Little correlation was found between the amount of ibuprofen reportedly ingested and symptoms in adults [65]. In the pediatric population, however, the mean amount ingested was much greater in symptomatic patients (440 mg per kg) than asymptomatic ones (114 mg per kg) [67]. Elderly patients are at increased risk of developing toxicity with both therapeutic doses and overdoses. Physical examination should focus on vital signs, neurologic and cardiopulmonary function, and assessment of the state of hydration. Vital signs should include an accurate temperature and respiratory rate and, if possible, orthostatic measurements of pulse and blood pressure. Patients with moderate-to-severe salicylate poisoning should also have serum calcium, magnesium, and ketones, liver function tests, coagulation profile, electrocardiogram, and chest radiograph. The ferric chloride spot test can be used to rapidly detect the presence of salicylate in urine or commercial products [72]. A positive urine test indicates exposure but not overdose, because positive results are seen with therapeutic dosing. False-positive reactions may be caused by acetoacetic acid, phenylpyruvic acid, phenothiazines, and phenylbutazone. Diflunisal may result in falsely elevated serum salicylate levels when measured by fluorescence polarization immunoassay or the Trinder colorimetric assay [73]. At similar salicylate concentrations, patients with chronic poisoning tend to be more ill than those with acute poisoning [29,45,46]. Conversely, with chronic overdosage and late in the course of an acute overdose, moderate or severe toxicity may be present despite serum salicylate concentrations in or just above the high therapeutic range. At similar salicylate concentrations, children, the elderly, and those with underlying disease tend to be more ill than otherwise healthy adults [29,44,58,74]. Poisoning in such patients, particularly if chronic, can occasionally be seen with therapeutic salicylate levels. Hence, as noted previously, the severity of poisoning is ultimately determined by acid–base status and clinical findings. Serial salicylate levels are necessary for confirming the diagnosis and monitoring the efficacy of treatment, but do not obviate the need for continued clinical and metabolic monitoring. Depending on the severity and course of poisoning, drug levels and other laboratory tests should initially be repeated at 2-hour intervals. Because of delayed and erratic absorption, it is imperative to demonstrate a falling and near-zero salicylate concentration to exclude significant ongoing absorption after overdose, which generally requires at least 12 hours even in mild overdoses [19]. These patients are typically elderly, have a variety of presenting complaints and underlying illnesses, and have been taking aspirin with therapeutic intent. To avoid missing the diagnosis, all patients should be asked specifically about the use of nonprescription drugs. Asking about tinnitus or hearing distortion, which occurs with salicylate levels in the high end of the therapeutic range (i. Occult salicylate poisoning should be considered in any patient with an unexplained acid–base disturbance, altered mental status, hyperthermia, diaphoresis, dyspnea, vomiting, or pulmonary edema [28,59]. Hemodynamic, autonomic, and laboratory manifestations of severe poisoning resemble the systemic inflammatory response syndrome and may be mistaken for sepsis [51,55,75]. Salicylate poisoning has also been misdiagnosed as alcohol intoxication, alcohol withdrawal, dementia, diabetic ketoacidosis, impending myocardial infarction, hepatic encephalopathy, and viral encephalitis. It may be particularly difficult to distinguish from Reye’s syndrome, because they are not only similar in presentation but appear to be interrelated [76,77]. Radiopaque densities in the stomach on abdominal radiograph suggest the possibility of an enteric-coated or sustained-release formulation or a magnesium or bismuth salt of salicylate. It is critically important to remember that, should endotracheal intubation be necessary, hyperventilation must be accomplished before, during, and after this procedure to prevent worsening acidemia, which increases the fraction of nonionized salicylic acid available for tissue distribution, thereby enhancing toxicity. The administration of respiratory depressants or failure to adequately hyperventilate unconscious or paralyzed patients can result in rapid deterioration and death of severely poisoned patients [52,56,78]. It is also prudent to administer sodium bicarbonate to patients who have seizures, as acidemia is likely to worsen. Hyperthermia should be treated with cooling blankets, ice packs, and evaporative methods (see Chapter 185). Central venous pressure monitoring may be necessary for optimal treatment of hypotension, especially if there is evidence of heart failure or pulmonary edema. Patients with noncardiac pulmonary edema should be treated with positive pressure ventilation rather than diuretics. Again, maintaining hyperventilation and reducing acidemia are critical in patients with compromised pulmonary function. The degree of dehydration parallels the severity of poisoning [54], but it is often unappreciated, underestimated, or undertreated. Patients with mild, moderate, or severe poisoning typically have volume deficits of 1 to 2, 3 to 4, or 5 to 6 L (20, 40, and 60 mL per kg in children), respectively. In the presence of acidemia, hypokalemia is more severe than indicated by the serum potassium level (by approximately 0. In addition, the goal of therapy is to limit the tissue distribution of salicylates by increasing the serum pH. The dose of bicarbonate needed may be substantial, and is typically 200 to 300 mEq in an adult with severe poisoning. Tetany should be treated with intravenous calcium chloride or calcium gluconate (10 mL of a 10% solution over 5 to 10 minutes). Fresh-frozen plasma, red blood cell, and platelet transfusions may be required for patients with active bleeding or significant blood loss. Gastrointestinal decontamination should be performed in all patients with intentional overdoses and those with accidental ingestions of greater than 150 mg per kg. Because of delayed absorption, decontamination may be effective for as long as 24 hours after overdose, even in patients with spontaneous vomiting [18]. Considerable diversity of opinion exists, however, regarding the optimal method of decontamination [80]. Multiple oral doses of charcoal [81] or gastric lavage preceded and followed by activated charcoal may be even more effective for preventing the absorption of large overdoses [82]. Repeated doses of activated charcoal or whole-bowel irrigation may be effective for patients who have ingested enteric-coated or sustained-release formulations and those with serum drug levels that continue to rise despite other decontamination measures [83]. The efficacy of multiple-dose charcoal therapy in enhancing salicylate elimination may depend on the formulation. Increases in serum salicylate elimination reported using an effervescent preparation containing bicarbonate [84] could not be replicated with multiple doses of noneffervescent charcoal in simulated overdose (i. Oral charcoal did not substantially accelerate the elimination of intravenously administered salicylic acid, discounting the role of gut dialysis or enterohepatic circulation [89]. Salicylate elimination can be enhanced by urine alkalinization and diuresis [24,25,29,92], extracorporeal removal [93], and perhaps by glycine administration [44]. It should be emphasized that alkalinizing the serum and urine, and establishing a urine output of 1 to 2 mL/kg/h are critically important goals in the management of patients with salicylate toxicity [30,94]. Moreover, alkalinization of the urine is difficult to achieve in patients with acidemia and aciduria (i. Theoretical concerns regarding pulmonary or cerebral edema should not preclude aggressive fluid therapy, as administering only maintenance fluids intravenously is insufficient treatment for a patient with salicylate poisoning. Indications for urine alkalinization and alkaline diuresis include acid– base abnormalities and systemic symptoms with a salicylate level that is greater than 30 mg per dL after an acute overdose. All patients treated with alkaline diuresis need close monitoring in an intensive care unit or step down setting. Bladder catheterization is essential in those with moderate or severe poisoning, as hourly monitoring of urine output and pH is required.

The United States has approximately 62 buy 120 mg sildalist,000 full-feature ventilators generic 120mg sildalist with mastercard, or 20 of these per 100 discount sildalist 120mg free shipping,000 residents discount sildalist 120mgmg, plus an additional 100,000 ventilators with fewer features but which could be used during a disaster [27]. Thus, in preparing to provide mechanical ventilation to a large number of critically ill disaster casualties, planners need to consider other options, such as high-flow nasal cannula oxygenation or noninvasive positive-pressure ventilation for selected patients. Anesthesia machines and transport ventilators could serve as additional options, although these could be similarly limited by the number of trained personnel and have disadvantages with regard to infection control [29–32]. The provision of critical care during a disaster will also require that a large quantity of supplies and pharmaceuticals be on hand and readily available to critical care providers. The Joint Commission currently requires that accredited hospitals plan for 96 hours of autonomous function, without external resupply, in the event of disaster (although 96 hours of supplies and the ability to function at full capacity are not required). In 2005, during the Hurricane Katrina disaster in New Orleans, the lack of available supplies, pharmaceuticals, and operational equipment forced the dedicated staff at Charity Hospital to improvise critical care practices and deviate from the usual standards of care prior to final evacuation of the hospital [33]. Hospitals in areas affected by the Great East Japan Earthquake and subsequent tsunami of 2011 and by Hurricane Sandy in 2012 showed comparable experiences. In Miyagi Prefecture in Japan, for example, six out of 14 of hospitals had less than 1 day of food on hand at the time of the quake, and another six hospitals had less than 1 day of medical supplies. Just-in-time supply practices at New York City hospitals produced some similar shortages, offset in part by supplies available from elsewhere in the city [34,35]. Shortages of intensivists, critical care nurses, respiratory therapists, critical care pharmacists, and other specially trained personnel may be a limiting factor in caring for large numbers of critically ill patients. In infectious outbreaks or natural disasters, hospital staff may themselves be victims, further decreasing the institution’s ability to respond [36,37]. These recommendations state that experienced providers should perform direct patient care, when feasible. Finally, systematic procedures (such as protocols) should be instituted and understood by all critical care providers, in order to standardize processes, maximize good outcomes, and maximize safety to patients and staff during a disaster. During contigency and crisis surge conditions, intensivists will need to focus part of their effort on supervising cross-trained physicians from other specialties. Nonintensivist physicians who are skilled in proving hands-on care, such as hospitalists, emergency physicians, general surgeons, or anesthesiologists, could be assigned six patients each (assuming that other urgent clinical duties do not take precedence). Intensivists could supervise four to eight such providers, thereby extending their critical care coverage to almost 50 patients. Training for such processes will become necessary for prolonged events that will severely strain staff resources during a major disaster [25,38]. During a major disaster, space limitations may require that critical care be provided in other areas of a hospital [24,39]. In the initial phases of a surge requirement, hospitals should be able to accommodate up to a 20% increase of critically ill patients with minimal impact, assuming that supplies and staff are available and the hospital is not at maximum capacity. As an emergency mass critical care event progresses, formal critical care space will need to expand into other areas of the hospital, with the hospital continuing to make room for critically ill patients by transferring the most stable inpatients elsewhere. Critical care has been provided in such settings before, with recent experience in New York City following the damage to Bellevue Hospital by Hurricane Sandy as well as during humanitarian international missions or military operations [25,40,41]. However, because of the logistical requirements for specialized equipment, infection control support, and the relocation of trained personnel, critical care should only be provided in “field” settings as a last resort. For most major disaster situations, such facilities can be best used for the management of noncritically ill patients who are transferred from hospitals in order to free up space for the management of the critically ill. Critical care providers and institutions should strive to manage resources within their own facility and region with the goal of providing usual critical care practices to the extent possible. However, in a major disaster, because resources become increasingly limited, health care providers and leaders must have a plan in place to change the focus of critical care from the needs of the individual to the needs of the population as a whole. Ethical and Legal Principles Utilitarian principles guide the theory of the “greatest good for the greatest number. Those who are unlikely to recover or improve with the available care are not abandoned, but are provided with appropriate palliative care. This fundamental principle guides the implementation of a mass-casualty triage system during major disasters [42,43]. It mandates a fair and just rationing of resources, based on objective information and decision-making, in order to benefit the population as a whole, rather than individual patients. Such a shift in health care priorities requires active community involvement and an open, transparent decision-making processes. Ideally, plans for the fair and just rationing of critical care resources during periods of overwhelming demand should be developed prior to the disaster. Importantly, in order to implement such processes, providers must feel secure in their legal protection. Hence, providers should be legally protected from local and state law if there is a need to deviate from the usual standards of care during periods of scarce resources. The need for such legal protection was poignantly highlighted in New Orleans during the Hurricane Katrina disaster, as palliative care was provided to some patients as evacuation attempts were repeatedly delayed and hospital capabilities were overwhelmed [44]. In response to these events, New York State has developed ventilator allocation guidelines for pandemics and other mass-casualty events, with other states now following its lead [45]. Critical Care Triage There remains debate about the preferred method of triage during a major disaster where patient needs have exceeded critical care resources. Although each of these concepts has its merits; none have been prospectively evaluated in a disaster setting. Such triggers would include a lack of critical equipment or medical supplies, inadequate critical care spaces, inadequate staff, and inadequate capability to transfer noncritically ill patients to other facilities. Once the requirement to triage care has been directed, critical care providers must determine which patients should receive critical care and which patients should not. This process needs to be carefully planned and evaluated with community involvement prior to a catastrophic event. If, for example, a health care system or region proposes to exclude critical care to the very elderly during a major disaster, then community representatives from the elderly population would need to be included in such decisions. That is, the elderly would participate in advance planning with providers on how to triage the elderly during future mass-casualty emergencies. However, all have similar limitations in that they have not been rigorously evaluated in emergency mass critical care scenarios. A triage team, consisting of an experienced intensivist and another acute care physician, may be preferable to a single triage officer, given the emotional burden and the utility of a second “set of eyes” during a crisis. This group, operating independently from the bedside clinicians, would gather periodic patient data to determine the severity of illness and document improvement, stability, or deterioration of critically ill patients over time. The patients who deteriorate or fail to improve over time would have their critical care resources reallocated to other patients. The availability of an experienced critical care triage team has the advantage of removing the burden of triage decisions from busy clinicians who are providing critical care at the bedside. This team also removes some of the inherent bias that providers may have when making decisions for patients personally known to them. This committee, distinct from the triage team, would: Work with regional planners and maintain situational awareness of the community and state, regarding the ongoing use and need of triage protocols. Review the implementation of the local triage protocol, to ensure compliance and integrity of triage operations. Serve as a forum for appeals by patients, families, and staff regarding the accurate and ethical implementation of the triage tool. Ideally, hospitals are the optimal setting to provide critical care for severely ill and injured patients. During major disasters, hospitals should coordinate with community medical response systems to offload patients with minor injuries or illnesses so that hospital resources can be focused on the care of critically ill patients. Predisaster planning and training are essential for mitigating the adverse effects of an overwhelming disaster on hospitals and their communities. Carefully developed plans for surging critical care resources will facilitate continuation of usual hospital processes for the largest number of the patients. However, when surge procedures fail to meet the critical care demands of an overwhelming patient influx, processes to triage and alter the usual standards of critical care must be implemented. These planning concepts and guidelines can help guide critical care practitioners to care for their patients under the challenging conditions of a catastrophic disaster. The opinions and assertions contained herein are those of the authors and do not necessarily reflect the views or position of the Department of the Navy, Department of Defense, Department of Veterans Affairs, the United States Government, nor of the academic institutions with which the authors are affiliated. Medicare and Medicaid Programs: Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. Fiscal Year 2016 Public Health and Social Services Emergency Fund—Justification of Estimates for Appropriations Committees. Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care.