›0.1 mg/kg IV (typical adult dose 2–4 mg)
›Repeat every 5 minutes to max 0.2 mg/kg
›Preferred in hospital setting for seizure termination
›Diazepam IV
›0.2 mg/kg IV (typical adult dose 5–10 mg)
›Rectal or IM route if IV access unavailable
›Midazolam IM
›10 mg IM for adults if no IV access
›Pediatric dose 0.2 mg/kg IM
›Refractory status epilepticus protocol
›Levetiracetam IV
›60 mg/kg IV over 15 minutes (max 4500 mg)
›Avoid phenytoin as first add-on (mechanism does not address GABA deficit)
›Phenobarbital IV
›20 mg/kg IV at 50–100 mg/min
›Respiratory depression monitoring required
›Propofol infusion for refractory status
›1–2 mg/kg IV bolus then 20–200 mcg/kg/min infusion
›Requires intubation and mechanical ventilation
›EEG monitoring for burst suppression endpoint
Hepatotoxicity management
›N-acetylcysteine (NAC)
›Empiric consideration for hepatoprotection
›No controlled data specific to gyromitrin toxicity
›Extrapolated from acetaminophen hepatotoxicity and other oxidant hepatic injuries
›Low risk profile supports empiric use when hepatotoxicity present
›IV protocol (if using)
›Loading dose 150 mg/kg IV over 60 minutes
›Maintenance 50 mg/kg IV over 4 hours then 100 mg/kg over 16 hours
›Continue until hepatic function improving or transplant undertaken
›Coagulopathy management
›Vitamin K
›10 mg IV or SC daily for 3 days
›Ensures adequate substrate for coagulation factor synthesis
›Fresh frozen plasma
›Reserve for active bleeding or INR > 2 with planned invasive procedure
›Do not give prophylactically — obscures INR trend used for prognosis
›Cryoprecipitate
›For fibrinogen < 1.5 g/L with active bleeding
›Dose: 1 unit per 10 kg body weight
›Hepatic encephalopathy management
›Lactulose
›30–45 mL PO or NG every 1–2 hours until bowel movement then every 8–12 hours
›Target 2–4 soft stools daily
›Rifaximin
›550 mg PO twice daily as adjunct for grade II or higher encephalopathy
›Avoid sedatives, opioids, and hepatotoxic medications
›Liver transplant evaluation
›Early referral if meeting King's College Criteria or MELD > 25
›Ideally within 24 hours of acute liver failure diagnosis
›Contraindications: active infection, multi-organ failure without hepatic basis
Methemoglobinemia treatment
›Methylene blue
›Indications
›Methemoglobin level > 20% or symptomatic at lower levels
›Symptoms: cyanosis, dyspnea, altered mental status despite adequate SpO2
›Dosing
›1–2 mg/kg IV over 5 minutes
›Repeat in 1 hour if inadequate response
›Maximum cumulative dose 7 mg/kg
›Contraindications
›G6PD deficiency — methylene blue may worsen hemolysis
›Serotonin syndrome risk if serotonergic medications present
›Fluid and electrolyte resuscitation
›IV crystalloid for volume depletion from GI losses
›Isotonic saline or balanced crystalloid
›Titrate to hemodynamic response and urine output >= 0.5 mL/kg/h
›Electrolyte replacement
›Potassium replacement for hypokalemia (maintain K+ 3.5–5 mmol/l)
›Magnesium 2 g IV if hypomagnesemia or refractory hypokalemia
›Glucose management
›Dextrose 10% infusion if hypoglycemia from hepatic failure
›Target glucose 4–10 mmol/l
›Antiemetics
›Ondansetron 4–8 mg IV every 6–8 hours for nausea and vomiting
›QTc monitoring if prolongation risk present
›Metoclopramide 10 mg IV as alternative
›Hemolysis management
›Packed red blood cells if hemoglobin < 70 g/L or symptomatic anemia
›Hemolysis occurs in approximately 2.5% of cases
›Adequate IV hydration to prevent hemoglobin precipitation in renal tubules
›Renal protection
›Avoid nephrotoxic medications: NSAIDs, aminoglycosides, IV contrast
›Hepatorenal syndrome management with nephrology input if creatinine rises
›Continuous renal replacement therapy if severe acute kidney injury