›First 5 minutes workflow
›Resuscitation bay for airway risk
›Cardiac monitor and defib pads for unstable rhythm risk
›Two large bore IV lines if unstable
›Point of care glucose immediately
›Oxygen to target saturation 94 percent or higher
›Naloxone for suspected opioid toxicity
›0.04 mg IV
›Escalate every 2 to 3 minutes
›0.4 mg IV
›2 mg IV
›Maximum cumulative local protocol dependent
›If inadequate ventilation then bag valve mask
›If unable to protect airway then RSI
Antidotes and targeted therapies
›Antidotes and targeted therapies
›Acetylcysteine for acetaminophen toxicity
›Start if level above treatment line or time unknown
›Start if delayed presentation with hepatic injury and history compatible
›Dosing local protocol dependent
›Sodium bicarbonate for sodium channel blockade
›Indication QRS widening
›Bolus 1 to 2 mEq per kg IV
›Repeat bolus until QRS narrows or pH target reached
›Infusion 150 mEq in 1 L D5W
›Titrate to pH 7.50 to 7.55
›High dose insulin euglycemia therapy for beta blocker or calcium channel blocker toxicity
›Bolus regular insulin 1 unit per kg IV
›Infusion 1 unit per kg per hour
›Titrate every 10 to 15 minutes
›Dextrose infusion to maintain euglycemia
›Potassium monitoring frequent
›Glucagon for beta blocker toxicity
›3 mg IV bolus
›Repeat if response then infusion
›Nausea and vomiting common
›Calcium for calcium channel blocker toxicity
›Calcium chloride 1 g IV
›Prefer central line
›Calcium gluconate 3 g IV alternative
›Fomepizole for toxic alcohol suspicion
›Start with high anion gap metabolic acidosis and osmolar gap or convincing history
›Dosing local protocol dependent
›Hydroxocobalamin for cyanide suspected from smoke inhalation with collapse and lactic acidosis
›Dosing local protocol dependent
›Atropine for organophosphate cholinergic crisis
›Titrate to drying of secretions
›Pralidoxime adjunct local protocol dependent
›Physostigmine for severe anticholinergic delirium
›Only if QRS normal and no TCA concern
›Continuous monitoring required
Symptom control and supportive care
›Symptom control and supportive care
›Agitation
›Benzodiazepines first line for sympathomimetic and serotonin syndrome
›Midazolam 2 mg IM or IV
›Lorazepam 2 mg IV
›Seizure
›Benzodiazepines first line
›Levetiracetam 60 mg per kg IV up to 4500 mg
›Hyperthermia
›Active external cooling
›Sedation and paralysis if severe
›Hypotension
›Isotonic fluids bolus
›Norepinephrine infusion if refractory
›Hypoglycemia
›Dextrose IV
›Consider octreotide for sulfonylurea toxicity
›50 mcg subcutaneous
›Repeat every 6 hours
Decontamination decisions
›Decontamination decisions
›Activated charcoal
›Consider within 1 hour of ingestion for adsorbable agents
›Consider later for sustained release agents
›Activated charcoal contraindications
›Unprotected airway
›Caustic ingestion concern
›Bowel obstruction concern
›Whole bowel irrigation
›Polyethylene glycol electrolyte solution
›Consider for sustained release ingestion
›Consider for body packing
Monitoring and reassessment loop
›Monitoring and reassessment loop
›Reassess mental status every 15 to 30 minutes until stable
›Repeat vitals every 15 minutes if unstable
›Repeat ECG after antidote therapy and with any deterioration
›Repeat electrolytes every 2 to 4 hours when on insulin therapy
›Repeat acetaminophen and salicylate levels per kinetics and protocol
›Urine output monitoring for rhabdomyolysis and shock