Approach to the critical patient
›First 5 minutes workflow
›Airway and aspiration risk
›Suction readiness
›Lateral positioning if actively vomiting
›Monitoring
›Continuous pulse oximetry
›Cardiac monitor if severe electrolyte derangement or QT risk
›IV access and fluids
›Two IVs if shock or severe dehydration
›Isotonic crystalloid bolus if hypovolemia
›Time critical tests
›Point of care glucose early
›Pregnancy test early in patients with pregnancy potential
›Reassessment loop
›Symptom reassessment every 30 to 60 minutes while in ED
›Repeat vitals after fluids and antiemetics
›Repeat electrolytes after repletion if severe derangements
›Escalate level of care for persistent instability
Fluids and electrolyte correction
›Volume resuscitation
›Normal saline or balanced crystalloid IV
›Bolus 10 to 20 mL per kg for significant dehydration local protocol dependent
›Maintenance IV fluids after bolus based on ongoing losses
›Potassium repletion
›If potassium less than 3.0 mmol per L IV replacement with cardiac monitoring
›Typical IV potassium chloride 10 to 20 mEq per hour
›Avoid dextrose containing fluids if worsening hypokalemia risk
›Magnesium repletion
›If magnesium low or QTc prolonged
›Magnesium sulfate IV 1 to 2 g
›Metabolic derangements
›If ketoacidosis suspected treat per DKA or starvation ketosis pathway
›If severe alkalosis and ongoing vomiting prioritize volume and chloride repletion
Antiemetics and symptom control
›Standard antiemetics
›Ondansetron IV 4 mg
›Repeat dosing based on response local protocol dependent
›QTc caution in prolonged QT
›Dopamine antagonists for CHS
›Haloperidol IV 0.05 mg per kg
›Typical adult dose 2.5 to 5 mg
›Dystonia risk
›Diphenhydramine IV 25 to 50 mg for dystonia treatment
›QTc and torsades risk
›Avoid if markedly prolonged QTc or severe hypokalemia until corrected
›Droperidol option where available
›Droperidol IV 0.625 to 1.25 mg
›QTc monitoring local protocol dependent
›Sedation monitoring
›Topical capsaicin
›Capsaicin 0.025 percent to 0.1 percent topical to abdomen or arms
›Application with gloves
›Burning sensation counseling and skin irritation monitoring
›Benzodiazepines adjunct
›Lorazepam IV 0.5 to 1 mg for anxiety and refractory nausea
›Avoid oversedation especially with co ingestion
›Pain management cautions
›Avoid opioids when possible
›Acetaminophen if mild pain and no liver injury concern
Cannabis cessation pathway
›Definitive management
›Cannabis cessation as key intervention
›Symptom resolution timeline days to weeks after cessation
›Withdrawal management
›Sleep disturbance
›Irritability
›Nausea during withdrawal
›Referral and supports
›Substance use counseling referral
›Primary care follow up for cessation plan