›Metoclopramide 10 mg IV over 1 to 2 minutes
›Maximum 10 mg per dose and 0.5 mg/kg per day; reduce by half when creatinine clearance is below 40 ml/min
›Contraindicated in bowel obstruction and perforation
›Extrapyramidal and tardive dyskinesia risk; limit courses to under 5 days and use lower doses in older adults
›Erythromycin 3 mg/kg IV, about 250 mg, as a motilin-agonist prokinetic before urgent endoscopy
›Prolongs the QT interval and interacts with CYP3A4 substrates
›A normal-appearing response to a prokinetic does not confirm an empty stomach; confirm with ultrasound
Procedural sedation strategy
›Prefer to avoid elective procedural sedation in a patient with a likely full stomach
›Delay, use local or regional anaesthesia, or proceed to a definitive airway instead
›When sedation is unavoidable, keep it as light as possible and preserve protective reflexes
›Titrate to the minimum effective depth with the patient head-up
›Continuous capnography, pulse oximetry, and cardiac monitoring, with observations at least every 5 minutes and continuously during titration
›A dedicated clinician for the airway, separate from the proceduralist
›Suction, advanced airway equipment, and reversal agents at the bedside
›Ketamine 1 to 2 mg/kg IV over 1 to 2 minutes, or 4 to 5 mg/kg IM
›Relatively preserves airway tone but does not protect against aspiration
›Laryngospasm and hypersalivation are risks; keep suction ready
›Propofol 0.5 to 1 mg/kg IV, then 0.5 mg/kg every 1 to 3 minutes
›Causes apnea, loss of airway reflexes, and hypotension, and abolishes protection against aspiration
›Omit or reduce the initial bolus and titrate slowly if volume-depleted or hypotensive
›Etomidate 0.1 to 0.15 mg/kg IV for brief procedures
›Myoclonus can complicate the procedure and there is still no airway protection
›Dexmedetomidine 1 microgram/kg IV over 10 minutes, then 0.2 to 0.7 microgram/kg per hour
›Less respiratory depression but causes bradycardia and hypotension
›Reassess blood pressure and heart rate every 5 minutes during the load and after each rate change
›Reverse opioid or benzodiazepine co-sedation if airway compromise develops
›Naloxone 0.04 to 0.4 mg IV titrated for opioid-related hypoventilation
›Flumazenil 0.2 mg IV is generally avoided when seizures or chronic benzodiazepine use are possible
›If vomiting occurs during sedation, stop the procedure, suction, position head-down and lateral, and reassess the airway
Rapid sequence intubation technique
›Indicated when a full-stomach patient needs a definitive airway or cannot tolerate a required procedure awake
›Preferred over deepening sedation in a patient with retained gastric contents
›Preoxygenate without inflating the stomach
›3 minutes of tidal breathing on a tight reservoir mask, or 8 vital-capacity breaths
›Apneic oxygenation by nasal cannula at 15 l/min
›Head-up or ramped position, and reverse Trendelenburg if not hypotensive
›Induction agent chosen for haemodynamics
›Ketamine 1.5 to 2 mg/kg IV, reduced to 1 mg/kg IV if shock
›Etomidate 0.3 mg/kg IV as an alternative
›Propofol 1.5 to 2.5 mg/kg IV only if haemodynamically stable
›Neuromuscular blockade for optimal first-pass conditions
›Rocuronium 1.2 mg/kg IV
›Keep sugammadex 16 mg/kg IV immediately available
›Succinylcholine 1.5 mg/kg IV if there is no contraindication
›Avoid with hyperkalaemia, major burns beyond 24 hours, denervating injury, or malignant hyperthermia history
›Routine cricoid pressure is optional and should be released if it worsens the laryngeal view
›Video laryngoscopy for the best first-pass success and a shorter apneic time
›Immediate post-intubation orogastric tube to decompress the stomach
›Have a suction-assisted airway decontamination approach ready for massive regurgitation
Aspiration pneumonitis and associated pulmonary care
›Immediate management of a witnessed aspiration
›Head-down and lateral, suction the pharynx, then suction the airway once it is secured
›Do not perform routine bronchoalveolar lavage or repeated saline instillation and suction
›Bronchoscopy only to remove a large particulate obstruction
›Oxygenation and ventilation support
›Titrate oxygen to SpO2 at or above 94 percent, or 88 to 92 percent in chronic hypercapnia
›Lung-protective ventilation with a tidal volume of 6 ml/kg predicted body weight if intubated
›Non-invasive ventilation only in a fully alert patient who can protect the airway
›Antibiotics are not given routinely for chemical pneumonitis
›Start if there is no improvement within 48 hours, with shock, or with a clear aspiration of infected material
›Ceftriaxone 2 g IV every 24 hours, or ampicillin-sulbactam 3 g IV every 6 hours
›Add anaerobic cover such as metronidazole 500 mg IV every 8 hours only for lung abscess, empyema, or necrotising pneumonia
›Corticosteroids are not recommended
›Historical high-dose regimens such as methylprednisolone 30 mg/kg IV showed no benefit and possible harm
›Bronchodilators only for demonstrable bronchospasm
›Salbutamol 2.5 to 5 mg nebulised, repeated as needed for wheeze
Antiemetics and management of associated complications
›Antiemetic therapy for vomiting and to reduce the aspiration load
›Ondansetron 4 mg IV every 8 hours as needed
›Maximum single intravenous dose 16 mg because of QT prolongation
›Obtain an ECG and correct potassium above 4.0 mmol/l and magnesium above 1.0 mmol/l before repeat dosing in at-risk patients
›Metoclopramide 10 mg IV, with dosing and cautions as above, and avoided in obstruction
›Prochlorperazine 10 mg IV or IM every 6 to 8 hours, maximum 40 mg per day; extrapyramidal and QT effects
›Haloperidol 0.5 to 1 mg IV for refractory nausea; QT prolongation, obtain an ECG
›Droperidol 0.625 to 1.25 mg IV; QT-prolongation warning, ECG and telemetry
›If vomiting persists despite two agents from different classes, reassess for obstruction, raised intracranial pressure, or another untreated cause
›Rehydration and electrolyte repletion
›Balanced isotonic crystalloid; 500 ml boluses in adults, reassessed clinically after each
›Paediatric bolus 10 to 20 ml/kg isotonic crystalloid, reassessed after each
›Verify against current paediatric guideline before use
›Replace potassium and magnesium guided by levels and the ECG
›Acute pancreatitis
›Goal-directed moderate fluid resuscitation with lactated Ringer's, about 1.5 ml/kg per hour after a modest initial bolus
›Avoid aggressive high-volume resuscitation, which increased fluid overload without benefit in a randomised trial
›Analgesia with fentanyl 25 to 50 micrograms IV every 5 to 10 minutes titrated, or hydromorphone 0.2 to 0.5 mg IV every 2 to 3 hours
›Antiemetic and early enteral nutrition as tolerated, and withhold the GLP-1 agonist
›ERCP within 24 hours only for gallstone pancreatitis with cholangitis or biliary obstruction
›Bowel obstruction or severe ileus
›Nil by mouth, nasogastric decompression, isotonic fluid, and electrolyte correction
›Early surgical consultation, with CT to define the level and identify ischaemia
›Withhold the GLP-1 agonist and other gut-slowing drugs
›Gallstone disease
›Analgesia and antiemetics
›Ceftriaxone 2 g IV every 24 hours plus metronidazole 500 mg IV every 8 hours for acute cholecystitis or cholangitis
›Surgical and biliary referral, with ERCP for cholangitis or a retained stone
›Hypoglycaemia when on insulin or a sulfonylurea
›Dextrose 25 g IV, that is 250 ml of 10 percent dextrose, if unable to take oral carbohydrate
›Paediatric dextrose 0.25 g/kg IV, that is 2.5 ml/kg of 10 percent dextrose
›Verify against current paediatric guideline before use
›Glucagon 1 mg IM if there is no IV access, expecting a reduced response if glycogen-depleted
›Octreotide 50 micrograms subcutaneously every 6 hours for sulfonylurea-induced recurrent hypoglycaemia
›Recheck glucose every 15 to 30 minutes and target above 4.0 mmol/l
›Acute kidney injury
›Restore volume with isotonic crystalloid, hold nephrotoxins and the GLP-1 agonist, and minimise iodinated contrast
›Euglycaemic ketoacidosis when a co-prescribed SGLT2 inhibitor is present
›Intravenous fluid, an insulin infusion with concurrent dextrose to allow ketone clearance at near-normal glucose, and electrolyte replacement
›Compounded-product overdose
›Mainly supportive: antiemetics, rehydration, glucose monitoring, and a prolonged observation period because the effect is long-acting
Iatrogenic risks to anticipate and prevent
›Procedural sedation and general anaesthesia
›The central hazard: induction or deep sedation removes airway protection and retained gastric contents are regurgitated and aspirated
›Mitigate with gastric ultrasound, delay when possible, a rapid sequence technique, and head-up positioning
›Airway management
›Vigorous bag-mask ventilation insufflates the stomach and increases regurgitation; use low pressures and a gastric tube
›Extubate awake, with the stomach decompressed and suction ready
›Intravenous fluids
›Under-resuscitation misses hypovolaemia and acute kidney injury from vomiting and diarrhea
›Over-resuscitation causes pulmonary oedema and worsened outcomes in acute pancreatitis; give goal-directed moderate volumes
›Oxygen and non-invasive ventilation
›Non-invasive positive pressure in an obtunded, vomiting patient distends the stomach and risks aspiration; reserve it for the alert patient
›Vasopressors
›Treating induction hypotension with pressors alone while ignoring volume depletion delays correction; give crystalloid and use norepinephrine 0.05 to 0.5 microgram/kg per minute as a bridge, titrated to mean arterial pressure with blood pressure checked at least every 5 minutes
›Phenylephrine 50 to 200 micrograms IV bolus for transient hypotension
›Mechanical circulatory support
›Intra-aortic balloon pump and other mechanical circulatory support have no role here; do not let an obesity cardiomyopathy work-up delay airway protection
›Anticoagulation and antiplatelet therapy
›Not contraindicated by the drug itself, but hold for active upper GI bleeding from forceful vomiting such as a Mallory-Weiss tear, and follow standard periprocedural rules
›Delayed gastric emptying can slow the absorption of oral anticoagulants
›Fibrinolysis
›No therapeutic role in this topic; recent forceful vomiting with possible oesophageal injury is a bleeding hazard if another indication is considered
›Analgesia
›Opioids further slow gastric emptying and worsen nausea and retained contents; prefer acetaminophen 1 g IV or orally every 6 hours, maximum 4 g per day
›Ketorolac 15 to 30 mg IV every 6 hours, maximum 120 mg per day, is opioid-sparing but avoid it in acute kidney injury, volume depletion, and acute pancreatitis
›Do not withhold opioid analgesia when it is genuinely needed, as in acute pancreatitis; anticipate more nausea and slower emptying
Resuming GLP-1 therapy and outpatient adjustment
›Agent identification and usual maintenance dosing, for reconciliation and not for ED initiation
›Semaglutide subcutaneous: start 0.25 mg once weekly for 4 weeks, then 0.5 mg, may increase to 1 mg, maximum 2 mg once weekly
›Oral semaglutide: 3 mg once daily for 30 days, then 7 mg, maximum 14 mg once daily
›Semaglutide 2.4 mg once weekly subcutaneously is the weight-management target dose
›Tirzepatide subcutaneous: start 2.5 mg once weekly for 4 weeks, increase by 2.5 mg every 4 weeks as tolerated, maximum 15 mg once weekly
›Dulaglutide subcutaneous: 0.75 mg once weekly, may increase to 1.5 mg then 3 mg, maximum 4.5 mg once weekly
›Liraglutide subcutaneous: start 0.6 mg once daily for 1 week, then 1.2 mg, maximum 1.8 mg once daily for diabetes, and up to 3 mg once daily for weight management
›Exenatide: immediate-release 5 microgram subcutaneously twice daily within 60 minutes before meals, may increase to 10 microgram twice daily after 1 month; extended-release 2 mg subcutaneously once weekly
›Do not restart the agonist until vomiting has resolved and oral intake is reliable
›After pancreatitis, ileus, or obstruction attributable to the drug, do not resume it and document the reaction
›After an isolated compounded-product dosing error, counsel on device use and switch to a licensed product
›Communicate any planned procedure to the prescriber so the hold can be scheduled
›Arrange endocrinology or primary care follow-up for glycaemic and weight-management alternatives
›Bridge with insulin or other agents if diabetes control is lost during a prolonged hold