›Continuous glucose infusion if refractory hypoglycemia
Electrolyte and nutritional repletion
›Deficiency correction
›Magnesium sulfate
›2 g IV over 20 minutes for documented hypomagnesemia
›4 g IV if concurrent seizure activity
›Hypomagnesemia impairs potassium correction
›Potassium
›Target serum K+ >3.5 mmol/L
›10–20 mmol/hr IV via peripheral line (max 40 mmol/hr central)
›Oral repletion when tolerating PO
›Phosphate
›Sodium phosphate 15 mmol IV over 2 hours for severe hypophosphatemia
›Refeeding risk in malnourished patients
›Folate
›1 mg PO or IV daily — deficiency common in chronic drinkers
›Required for red cell production and neurological function
›Nausea and vomiting management
›Ondansetron
›4 mg IV over 2 minutes — first-line antiemetic
›Monitor QTc; avoid with prolonged QTc or Class IA/III antiarrhythmics
›May repeat once after 4–8 hours
›Metoclopramide
›10 mg IV over 15 minutes — alternative antiemetic
›Extrapyramidal side effects — monitor for akathisia and dystonia
›Avoid in Parkinson disease and with phenothiazines
›Droperidol
›1.25–2.5 mg IV for refractory nausea — also effective for agitation
›QTc monitoring required; do not use if QTc >500 ms
›Level B ACEP recommendation for nausea management
›Pharmacological sedation for agitated patient
›Non-pharmacological first
›De-escalation techniques and calm environment
›Verbal reassurance — reduce stimulation
›Avoid physical restraints unless immediate safety risk
›Droperidol
›2.5–5 mg IM or IV — preferred agent for acute agitation in intoxication
›Onset 5–10 minutes IM, 2–5 minutes IV
›ECG required; QTc monitoring
›Haloperidol
›5 mg IM — alternative for agitation management
›Onset 15–30 minutes IM
›Avoid in prolonged QTc or suspected tricyclic co-ingestion
›Avoid benzodiazepines during active intoxication
›Additive respiratory depression with ethanol
›Reserve for concurrent alcohol withdrawal treatment only
›Exception: concurrent benzodiazepine withdrawal
Toxic alcohol antidote protocol
›Fomepizole therapy
›Indications
›Suspected methanol or ethylene glycol ingestion
›Osmolal gap >10 with high anion gap metabolic acidosis
›Visual complaints or crystalluria
›Dosing protocol
›Loading dose: 15 mg/kg IV over 30 minutes
›Maintenance: 10 mg/kg IV every 12 hours for 4 doses
›Then 15 mg/kg IV every 12 hours until methanol/ethylene glycol undetectable
›Adjunctive therapy
›Folate 50 mg IV every 4 hours for methanol — enhances formic acid elimination
›Pyridoxine 100 mg IV for ethylene glycol — promotes non-toxic metabolite
›Thiamine 100 mg IV for ethylene glycol — similar rationale
›Hemodialysis criteria
›Methanol or ethylene glycol level >15 mmol/L
›Severe metabolic acidosis pH <7.1
›Visual impairment from methanol
›Renal failure from ethylene glycol
Naloxone for opioid co-ingestion
›Opioid reversal
›Naloxone indications
›Respiratory depression with miosis — high suspicion for opioid co-ingestion
›SpO2 <92% with suspected opioid toxidrome
›Dosing
›0.4–2 mg IV, IM, or IN — titrate to respiratory improvement
›Repeat every 2–3 minutes to maximum 10 mg if no response
›Infusion: 2/3 of reversal dose per hour for sustained opioid effect
›Cautions
›Avoid large bolus in opioid-dependent patient — precipitates withdrawal
›Opioid half-life may exceed naloxone duration — rebound sedation risk
›Duration of naloxone 30–90 minutes versus fentanyl up to 12 hours
Alcohol withdrawal prophylaxis and treatment
›Withdrawal prevention
›CIWA-Ar directed therapy
›Score 8–14: oral benzodiazepine as needed
›Score >=15 or parenteral required: IV or IM benzodiazepine
›Diazepam — preferred for smooth tapering due to long half-life
›10 mg IV or PO every 5–10 minutes until CIWA-Ar <8
›Long-acting — prevents breakthrough seizures
›Avoid in severe hepatic dysfunction
›Lorazepam — preferred in hepatic impairment or elderly
›2–4 mg IV or IM every 5–15 minutes as needed
›Shorter acting — accumulation reduced in liver disease
›IM absorption reliable — useful if no IV access
›Phenobarbital
›10–15 mg/kg IV for severe refractory withdrawal or benzodiazepine failure
›Class II evidence — increasingly used in severe cases
›Loading: 260 mg IV every 15–20 minutes to clinical effect