First 5 minutes and stabilization
›Immediate workflow
›Triage to monitored setting if instability
›Continuous pulse oximetry
›Cardiac monitoring if systemic toxicity
›IV access
›Two large bore IV lines if hypotension or sepsis concern
›Single IV line if stable
›Fluids
›If hypotension then isotonic crystalloid bolus 500 mL to 1000 mL
›Reassess after each bolus for overload risk
›Analgesia initiation
›Ketorolac IV 15 mg
›Avoid ketorolac if renal impairment or GI bleed risk
›Hydromorphone IV 0.2 mg to 0.5 mg
›Repeat every 10 to 15 minutes to effect with monitoring
›Antiemetic
›Ondansetron IV 4 mg
›Repeat once if persistent
›Antibiotics only when infection suspected
›Early antibiotics if cholecystitis with systemic features
›Immediate antibiotics if cholangitis suspected
›Workup pathway
›RUQ ultrasound first line
›Labs aligned to suspected complications
›LFTs and bilirubin for obstruction
›Lipase for pancreatitis
›Lactate for sepsis physiology
›If cholangitis suspected then urgent biliary decompression pathway
›GI or surgery consult
›ERCP access local protocol dependent
Antibiotics and source control
›Antimicrobial therapy for acute cholecystitis or cholangitis
›Community acquired without severe sepsis
›Ceftriaxone IV 1 g
›Metronidazole IV 500 mg
›Severe sepsis or healthcare associated risk
›Piperacillin tazobactam IV 4.5 g
›Dose interval local protocol dependent
›Beta lactam allergy alternatives
›Ciprofloxacin IV 400 mg
›Metronidazole IV 500 mg
›Pregnancy considerations
›Avoid fluoroquinolones when possible
›Ceftriaxone plus metronidazole generally acceptable local protocol dependent
›Source control timing
›Early surgery consultation for cholecystitis
›If unfit for surgery then percutaneous cholecystostomy pathway local protocol dependent
›Urgent ERCP for cholangitis
Symptom control and supportive care
›Supportive measures
›NPO until surgical plan clarified
›Maintenance IV fluids if ongoing vomiting
›Acetaminophen PO 1000 mg
›Maximum daily dose reduction in liver disease
›Avoid morphine if concern for sphincter of Oddi spasm is clinically relevant local practice dependent
›Reassessment schedule
›Repeat vitals every 30 to 60 minutes if unstable
›Repeat abdominal exam after analgesia
›Escalate if new peritoneal signs
›Escalate if rising bilirubin with toxicity
›Escalate if worsening hypotension despite fluids