01Approach to the Critical Patient/attcp87

Immediate priorities

›Stabilization priorities

›If apnea

›Bag valve mask ventilation

›Advanced airway for persistent apnea or refractory hypoventilation

›If hypoxemia

›Supplemental oxygen

›Positive pressure ventilation as needed

›If hypotension

›Isotonic crystalloid bolus

›Vasopressor infusion if fluid refractory

›If bradycardia with instability

›Atropine per ACLS

›Transcutaneous pacing if refractory

›If hypoglycemia

›Dextrose bolus

›Continuous infusion if recurrent

›If seizure activity

›Benzodiazepines for active seizures

›Second line antiseizure therapy if refractory

›Temperature

›Active warming for hypothermia

›Passive cooling for hyperthermia from coingestants

Toxidrome recognition

›Sedative hypnotic toxidrome

›CNS depression

›Somnolence to coma

›Slurred speech

02History/hx60

Exposure characterization

›Exposure details

›Agent

›Benzodiazepine name if known

›Nonbenzodiazepine hypnotic name if known

›Barbiturate name if known

›Dose

›Tablets or mg estimate

›Maximum possible dose

›Time

›Last known well time

›Time of ingestion estimate

›Route

›Oral

›Intranasal

›Intravenous

›Formulation

›Immediate release

›Extended release

›Coingestants

›Alcohol

›Opioids

›Antidepressants

›Antipsychotics

›Antihistamines

›Muscle relaxants

›Gamma hydroxybutyrate

03Physical Exam/exam50

Core exam

›Primary survey findings

›Airway

›Gag reflex presence

›Secretions and vomitus

›Breathing

›Respiratory rate

›Work of breathing

›Breath sounds

›Circulation

›Blood pressure

›Heart rate

›Perfusion

›Disability

›GCS

›Pupillary size and reactivity

›Tone and reflexes

›Exposure

›Trauma signs

›Temperature

Toxidrome focused findings

›Sedation pattern

›Somnolence with arousability

›Dysarthria

›Ataxia

›Nystagmus

›Respiratory pattern

›Hypoventilation

04Differential Diagnosis/ddx44

Life threatening and must not miss

›Critical differentials

›Opioid toxicity

›ICD-10 T40 series poisoning

›Alcohol intoxication

›ICD-10 F10.129

›Carbon monoxide exposure

›ICD-10 T58

›Hypoglycemia

›ICD-10 E16.2

›Intracranial hemorrhage

›ICD-10 I61

›Ischemic stroke

›ICD-10 I63

›CNS infection

›ICD-10 G00, G03

›Sepsis

›ICD-10 A41

›Hypoxia or hypercapnia from COPD exacerbation

›ICD-10 J44.1

Toxin and medication mimics

›Toxicologic mimics

›Barbiturate toxicity

›ICD-10 T42.3 poisoning

›Z drug toxicity

›ICD-10 T42.7 poisoning

›Gamma hydroxybutyrate intoxication

›SNOMED CT concept for GHB poisoning

05Laboratory Tests/lt41

Core labs

›Baseline laboratory evaluation

›Point of care glucose

›Immediate correction threshold per local practice

›Electrolytes with creatinine

›Sodium mmol/l

›Potassium mmol/l

›Bicarbonate mmol/l

›Creatinine umol/l

›Venous blood gas

›pH

›pCO2 mmHg

›HCO3 mmol/l

›Complete blood count for infection or bleeding concern

›Leukocytosis interpretation caution

›Hemoglobin trend if trauma concern

Tox directed labs

›Toxicology labs

›Acetaminophen level for unknown ingestion

›Time from ingestion dependent interpretation

›Salicylate level for unknown ingestion

›Mixed respiratory alkalosis and metabolic acidosis clue

›Ethanol level when available

›Additive CNS depression risk

›Urine drug screen

›Limited utility for acute management

›False positives and false negatives

›Creatine kinase for prolonged down time concern

06Diagnostic Tests/dt36

Scoring Systems

›Clinical scales

›Glasgow Coma Scale

›Trend over time for trajectory

›Intubation consideration trigger when declining

›Richmond Agitation Sedation Scale

›Sedation depth monitoring

›Target for safe observation

›Clinical Opioid Overdose suspicion score surrogate

›Miosis

›Bradypnea

›Response to naloxone

MRI

›MRI brain indications

›Persistent altered mental status without clear tox explanation

›Focal neurologic deficit

›Suspected posterior circulation stroke with nondiagnostic CT

›Seizure with persistent deficit

›MRI constraints

›Unstable airway or ventilation

›Need for continuous monitoring compatibility

CT

›CT head indications

›Head trauma or unwitnessed fall

›Anticoagulant use

›Persistent coma beyond expected drug kinetics

›Focal neurologic findings

›CT chest indications

07Disposition/dispo31

Level of care decisions

›ICU indications

›Ongoing ventilatory support

›Recurrent apnea

›Persistent hypercapnia despite support

›Hemodynamic instability

›Refractory hypothermia

›Ward or monitored bed indications

›Moderate sedation requiring prolonged observation

›Long acting ingestion with delayed peak concern

›Aspiration pneumonitis requiring oxygen

›ED observation indications

›Stable vital signs

›Improving mental status trend

›No coingestant red flags

Discharge criteria

›Safe discharge criteria

›Awake and oriented at baseline

›Ambulation at baseline

›Tolerating oral intake

›Normal ventilation without supplemental oxygen

›No delayed effect concern based on agent and time

›Reliable supervision and follow up

Consultation and transfer

›Consultation triggers

›Poison center or clinical toxicology consult

›Mixed ingestion concern

›Flumazenil consideration

08Treatment/t82

Supportive care

›Core supportive treatment

›Airway positioning

›Lateral recovery position for vomiting risk

›Suction setup

›Oxygen and ventilation support

›Nasal cannula for mild hypoxemia

›Noninvasive ventilation for hypercapnia with intact airway reflexes

›Intubation for apnea or inability to protect airway

›Fluids and hemodynamics

›Isotonic crystalloid bolus

›Norepinephrine infusion for shock

›Start low dose per local protocol

›Titrate to MAP target

›Central access if escalating dose

›Temperature management

›Active warming for hypothermia

›Warmed IV fluids if moderate to severe hypothermia

Decontamination

›Gastrointestinal decontamination

›Activated charcoal considerations

›Within 1 hour for substantial ingestion with protected airway

›Avoid if altered mental status without protected airway

›Avoid if imminent intubation not planned

›Whole bowel irrigation

›Rare role

›Consider only for massive sustained release coingestion with toxicology guidance

Antidotes and reversal agents

›Flumazenil

›Indications

›Iatrogenic benzodiazepine sedation with clinically significant respiratory depression

›Known isolated benzodiazepine ingestion with high confidence

›Contraindications

›Chronic benzodiazepine use or dependence

›Seizure disorder

›Mixed ingestion with proconvulsants

›Tricyclic antidepressant exposure concern

›Adult dosing

›Initiate 0.2 mg IV over 15 seconds

›Repeat 0.2 mg IV every 1 minute if needed

›Maximum 1 mg total for initial reversal attempt

›Pediatrics dosing

›Initiate 0.01 mg/kg IV

›Maximum 0.2 mg per dose

›Repeat every 1 minute if needed

›Maximum 0.05 mg/kg or 1 mg total

›Post reversal monitoring

›Resedation risk

›Observation length based on agent half life

›Repeat dosing requirement evaluation

›Seizure readiness

›Immediate seizure management plan

›Naloxone for suspected opioid coingestion

›Trial dosing

›Low dose IV titration for ventilation improvement

›Escalate dosing if no response and high suspicion

›Monitoring after response

›Renarcotization risk with long acting opioids

Seizure and agitation management

›Seizure management

›Benzodiazepine first line for active seizures

›Lorazepam IV dosing per local protocol

›Midazolam IM or IN if no IV access

›Second line agents

›Levetiracetam dosing per local protocol

›Valproate avoidance in pregnancy when possible

›Refractory status epilepticus

›Intubation with continuous infusion sedatives per ICU protocol

›Agitation paradoxical reaction

›Nonpharmacologic deescalation

›Antipsychotic use with QT monitoring when needed

Barbiturate specific pathway

›Barbiturate toxicity pathway

›Alkalinization for phenobarbital with toxicology guidance

›Sodium bicarbonate infusion

›Titrate urine pH target per protocol

›Potassium repletion to enable alkalinization

›Extracorporeal removal consideration

›Hemodialysis for severe phenobarbital with shock or coma

›Toxicology consult for thresholds

Monitoring during treatment

›Reassessment cadence

›Frequent respiratory reassessment

›Capnography trend

›VBG repeat if worsening ventilation

›Aspiration monitoring

›Lung exam trend

›Imaging if hypoxemia or fever develops

09Special Populations/sp32

Pregnancy

›Pregnancy considerations

›Maternal resuscitation priority

›Oxygenation and ventilation optimization

›Left lateral uterine displacement if late pregnancy

›Medication safety

›Flumazenil use only with strong indication and toxicology input

›Avoid valproate for seizures when alternatives available

›Fetal considerations

›Continuous fetal monitoring when viable gestational age and maternal instability

›Obstetrics consult for significant overdose

Geriatric

›Geriatric considerations

›Increased sensitivity

›Lower doses causing deeper sedation

›Higher fall risk

›Delayed clearance

›Hepatic metabolism reduction

›Drug accumulation with long acting agents

›Disposition bias toward observation

›Baseline cognitive impairment confounding

›Higher aspiration risk

Pediatrics

›Pediatric considerations

›Small ingestion risk

›Single tablet potentially significant in toddlers

›Paradoxical agitation

›Disinhibition

10Background/b35

Epidemiology

›Epidemiology

›Benzodiazepines common contributor to polysubstance sedation presentations

›Severe outcomes more likely with coingestants

›Alcohol

›Opioids

›Older adults higher risk of falls and delirium with benzodiazepines

Pathophysiology

›Pathophysiology

›Benzodiazepines

›Positive allosteric modulation of GABA A receptor

›Increased chloride conductance

›Enhanced inhibitory neurotransmission

›Z drugs

›GABA A receptor effects with relative selectivity

›Similar sedation and amnesia profile

›Barbiturates

›GABA A receptor agonism

›Greater respiratory depression risk than benzodiazepines

›Additive depression with other CNS depressants

›Synergistic respiratory depression with opioids and alcohol

Therapeutic Considerations

›Treatment principles

›Supportive care as mainstay for isolated benzodiazepine exposure

›Airway and ventilation support prevents morbidity

›Flumazenil risk benefit balance

›Reversal benefit in select iatrogenic cases

›Seizure and withdrawal risk in dependence or mixed ingestion

11Patient Discharge Instructions/pdi27

copy discharge instructions

›Discharge instructions

›Diagnosis explanation

›Sedative medication exposure with slowed thinking and breathing risk

›Next 24 hours safety

›No driving

›No alcohol

›No cannabis

›No sedating medications unless prescribed and reviewed

›Responsible adult observation if available

›Hydration and nutrition

›Fluids as tolerated

›Light meals as tolerated

›Return to ED now for

›Trouble breathing

›Blue lips or severe sleepiness

›Repeated vomiting

›Chest pain

›Fever or worsening cough

›Confusion that worsens

›Fainting or new weakness

›Seizure

›Follow up

›Primary care within 1 to 3 days

›Medication review for sedatives and interactions

›Prevention

›Keep medications locked and out of reach

›Avoid mixing sedatives with alcohol or opioids

12References/r8

Clinical guidelines and consensus

›Core guidance sources

›American College of Medical Toxicology position statements on antidote use and toxicology consultation

›American Academy of Clinical Toxicology guidance on GI decontamination and activated charcoal

›Resuscitation council ACLS guidance for airway and hemodynamic instability management

Evidence based sources

›Key evidence base

›Reviews on flumazenil adverse events and seizure risk in mixed ingestion and benzodiazepine dependence

›Clinical toxicology textbooks on sedative hypnotic toxidromes and management

›Emergency medicine toxicology chapters on benzodiazepine and barbiturate overdose evaluation

Evidence & Review

Evidence & Review