Fluids and electrolyte correction
›Resuscitation and repletion
›IV fluids
›Normal saline 1 L IV bolus
›Repeat bolus based on perfusion and urine output
›Transition to maintenance fluids when improved
›Lactated Ringer 1 L IV bolus alternative
›Consider if hyperchloremia concern
›Avoid if severe hyperkalemia
›Potassium repletion
›If K 3.0 to 3.4 mmol/L
›Potassium chloride 40 mmol PO
›Repeat based on recheck
›If K below 3.0 mmol/L or unable to take PO
›Potassium chloride 10 mmol IV over 1 hour
›Repeat dosing guided by telemetry and repeat labs
›Peripheral IV max concentration per local policy
›Magnesium repletion
›If magnesium low or QT concern
›Magnesium sulfate 2 g IV over 15 to 30 minutes
›Repeat based on level and symptoms
Antiemetic and adjunct strategy
›Symptom control approach
›First-line CHS targeted agents
›Haloperidol
›Dose
›0.05 mg/kg IV once
›Maximum 5 mg
›Repeat 0.05 mg/kg once after 30 to 60 minutes if needed
›Monitoring
›Baseline ECG for QTc
›Avoid if QTc markedly prolonged
›Correct K and magnesium first when possible
›Adverse effects management
›If dystonia or akathisia, diphenhydramine 25 to 50 mg IV
›Alternative benztropine 1 to 2 mg IV or IM
›Droperidol
›Dose
›0.625 mg IV once
›Alternative 1.25 mg IV once
›Repeat dosing per response and local QT policy
›Monitoring
›ECG and electrolyte correction strategy similar to haloperidol
›Topical capsaicin
›Product
›Capsaicin cream 0.075 percent
›Alternative 0.025 percent or 0.1 percent per availability
›Application
›Thin layer to abdomen or forearms
›Repeat every 4 to 6 hours as needed
›Gloves for application
›Safety
›Avoid eyes and mucosa
›Wash hands thoroughly
›Remove with cool soapy water if intolerable burning
›Conventional antiemetics
›Ondansetron
›Dose
›4 mg IV once
›Repeat 4 mg IV once after 15 to 30 minutes if needed
›Oral disintegrating tablet 4 to 8 mg for discharge plan
›Limitation
›Reduced effectiveness in CHS common
›Metoclopramide
›Dose
›10 mg IV once
›Avoid in bowel obstruction concern
›Add diphenhydramine if EPS risk
›Promethazine
›Dose
›12.5 mg IV diluted and given slowly
›Avoid intra-arterial exposure risk
›Sedation risk counseling
›Anxiolysis and adjuncts
›Lorazepam
›Dose
›0.5 to 1 mg IV or PO
›Useful for anticipatory nausea or agitation
›Respiratory depression risk with co-ingestants
›H2 blocker or PPI if gastritis pattern
›Famotidine 20 mg IV or PO
›Alternative pantoprazole 40 mg IV or PO
Avoidances and supportive care
›Harm reduction in ED
›Opioid minimization
›Avoid opioids for functional abdominal pain pattern when possible
›Non-opioid analgesia options
›Acetaminophen 1000 mg PO
›Ketorolac 15 mg IV if renal function acceptable
›Hot water counseling
›Avoid scalding temperatures
›Burn risk warning
›Nutrition
›Oral rehydration solution once nausea controlled
›Gradual diet advancement