Underlying cause directed therapy
› Sepsis management
› Antibiotics within 1 hour of sepsis recognition
› Broad spectrum coverage selection per source
› Blood cultures before antibiotics when feasible
› Fluid resuscitation
› 30 mL/kg IV crystalloid for septic shock
› Reassess hemodynamics after each bolus
› Vasopressors when MAP <65 mmHg despite fluids
› Norepinephrine 0.01 to 3 mcg/kg/min IV first-line
› Titrate to MAP >= 65 mmHg
› Class I recommendation for norepinephrine as first-line vasopressor
Salicylate toxicity management
› Salicylate poisoning protocol
› IV sodium bicarbonate for urinary alkalinization
› Target urine pH 7.5 to 8.0
› 1 to 2 mEq/kg IV bolus then 100 to 150 mEq in 1 L D5W at 150 to 250 mL/hour
› Enhances urinary salicylate excretion by ion trapping
› Potassium supplementation essential
› Hypokalemia prevents urinary alkalinization
› Replace to K+ >4.0 mmol/L before sodium bicarbonate efficacy
› Hemodialysis indications
› Salicylate level >7.2 mmol/L
› Renal failure preventing elimination
› Altered mental status or seizures
› Pulmonary edema
› Avoid intubation when possible
› Respiratory alkalosis is compensatory for metabolic acidosis
› Intubation removes compensatory hyperventilation
› If intubation required, match pre-intubation minute ventilation
Hyperventilation syndrome management
› Anxiolytic therapy
› Benzodiazepines for acute panic-driven hyperventilation
› Lorazepam 1 to 2 mg IV or IM
› Diazepam 5 to 10 mg IV
› Caution: rule out organic cause first
› Reassurance and breathing retraining
› Slow diaphragmatic breathing instruction
› Paced respiration targeting RR 12 to 16 per minute
› Avoid paper bag rebreathing
› Can worsen hypoxemia if organic cause present
› Risk outweighs benefit in undifferentiated patient
› Anxiolytic dosing
› Lorazepam 1 mg IV
› Repeat in 5 minutes if insufficient effect
› Maximum 4 mg IV in acute setting
› Diazepam 5 mg IV
› Titrate every 5 minutes
› Maximum 20 mg in acute setting
› Anticoagulation for PE
› Unfractionated heparin for hemodynamically unstable PE
› 80 units/kg IV bolus followed by 18 units/kg/hour infusion
› Target aPTT 60 to 100 seconds
› Class I recommendation
› Low molecular weight heparin for stable PE
› Enoxaparin 1 mg/kg SQ every 12 hours
› Dose adjust for CrCl <30 mL/min
› Systemic thrombolysis for massive PE
› Alteplase 100 mg IV over 2 hours
› Reserved for hemodynamic compromise
› Class IIa recommendation when SBP <90 mmHg
› Electrolyte management
› Potassium replacement
› Oral KCl 20 to 40 mEq for mild hypokalemia
› IV KCl 10 to 20 mEq/hour for moderate to severe hypokalemia
› Continuous cardiac monitoring during IV replacement
› Calcium for symptomatic hypocalcemia
› Calcium gluconate 1 to 2 g IV over 10 minutes for tetany
› Ionized calcium target >1.0 mmol/L
› Phosphate replacement when severe
› Sodium phosphate or potassium phosphate 0.08 to 0.16 mmol/kg IV over 6 hours
› Recheck phosphate level after replacement
Mechanical ventilation considerations
› Ventilator settings in respiratory alkalosis
› Permissive hypercapnia strategy
› Reduce tidal volume or respiratory rate to allow PaCO2 normalization
› Target pH >7.20 as minimum acceptable
› Avoid aggressive hyperventilation
› Iatrogenic respiratory alkalosis common in mechanically ventilated
› Cerebral vasoconstriction worsens outcome
› Dead space reduction
› Minimize circuit dead space
› Optimize PEEP to reduce dead space ventilation
Show 53 more ▾