Approach to the critical patient
›First 5 minutes
›Monitoring
›Cardiac monitor
›Pulse oximetry
›Capnography if hypoventilation risk
›IV access
›At least 1 large bore IV if moderate or severe
›2 large bore IV if shock or major trauma concern
›Glucose
›Immediate point of care glucose
›If low, dextrose immediately
›Oxygenation and ventilation
›Supplemental oxygen if SpO2 under 92 percent
›Bag valve mask ventilation if hypoventilation
›Airway escalation
›If GCS 8 or less, prepare for airway management
›If recurrent vomiting with poor reflexes, prepare for airway management
›Hypoglycemia treatment
›Dextrose IV
›Adult D50W 25 g IV
›If ongoing risk, D10W infusion titrated to euglycemia
›Thiamine timing
›Thiamine IV before or with glucose in malnutrition risk
›Thiamine for Wernicke risk
›Thiamine IV
›200 mg to 500 mg IV local protocol dependent
›Repeat dosing schedule local protocol dependent
›Magnesium replacement support
›If low magnesium, replete
›Repletion may improve thiamine responsiveness
›Opioid toxicity overlap
›Naloxone trial if bradypnea
›0.04 mg IV
›Titrate every 2 to 3 minutes to RR over 10
›Maximum dose pathway local protocol dependent
›Fluids
›Isotonic crystalloid if hypovolemia
›500 mL to 1000 mL bolus
›Reassess after each bolus
›Nausea and vomiting
›Ondansetron 4 mg IV
›Metoclopramide 10 mg IV
›Nonpharmacologic de escalation
›Low stimulation environment
›Staff safety plan
›Sedation when required for safety
›Benzodiazepines
›Lorazepam 1 mg to 2 mg IV
›Repeat every 10 to 15 minutes to target
›Antipsychotics
›Haloperidol 2 mg to 5 mg IM
›QTc risk consideration
›Avoid oversedation
›If concurrent alcohol plus sedatives, higher respiratory depression risk
›Capnography preferred when sedating
›Scheduled reassessment
›Neuro checks every 30 to 60 minutes until improving
›Vital signs every 30 to 60 minutes until stable
›Triggers to broaden workup
›No improvement over expected time window
›New focal deficit
›Persistent hypoxia
›Worsening acidosis
›Aspiration management triggers
›New cough with hypoxia
›Fever after vomiting episode