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