› ! Hepatitis (acute) → › ! Choledocholithiasis and cholangitis → › Cholecystitis → › Hepatic encephalopathy → First 5 minutes and stabilization
› Immediate priorities
› Resuscitation bay if hypotension or altered mental status
› Cardiac monitor and pulse oximetry
› Two large bore IV access if septic or bleeding concern
› Point of care glucose
› If glucose low, dextrose IV
› Sepsis pathway when indicated
› IV fluids
› 20 mL per kg crystalloid for hypotension or lactate elevation
› Reassess after each bolus
› Antibiotics if cholangitis suspected
› Piperacillin tazobactam IV 4.5 g every 6 hours
› Ceftriaxone IV 2 g daily plus metronidazole IV 500 mg every 8 hours
› Vasopressors if refractory shock
› Norepinephrine IV start 0.05 microgram per kg per minute
› Titrate every 2 to 5 minutes to MAP 65 mmHg
› Core testing sequence
› Hepatic panel plus INR and glucose
› CBC and electrolytes including creatinine
› Pregnancy test when applicable
› Acetaminophen level with any uncertainty
› Imaging sequence
› Right upper quadrant ultrasound early
› MRCP when cholestatic pattern and ultrasound nondiagnostic
› CT abdomen when mass or alternate diagnosis concern
› Acetaminophen toxicity pathway
› Start N acetylcysteine if overdose suspected or aminotransferases very high with unclear history
› N acetylcysteine IV protocol local protocol dependent
› Weight based loading dose
› Maintenance infusion phases
› Symptom control
› Antiemetic
› Ondansetron ODT 4 mg once
› Ondansetron IV 4 mg once
› Pruritus in cholestasis
› Cholestyramine 4 g once to twice daily
› Separate from other meds by at least 4 hours
› Pain control
› Avoid NSAIDs with significant coagulopathy
› Avoid sedatives with encephalopathy concern
Monitoring and reassessment loop
› Serial reassessment targets
› Mental status every 30 to 60 minutes when encephalopathy concern
› Vitals every 15 minutes when unstable
› Urine output monitoring when septic or AKI risk
› Repeat labs timing
› INR and glucose every 4 to 6 hours when acute liver failure concern
› AST and ALT trend every 6 to 12 hours when severe
Consultation and escalation
› Early consultation triggers
› GI for suspected biliary obstruction
› Surgery for complicated cholecystitis concern
› Toxicology for suspected ingestion
› ICU for acute liver failure or septic shock
› Transfer considerations
› Liver transplant center for acute liver failure
› ERCP capable center for acute cholangitis
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