› Airway decision algorithm
› GCS <= 8 — endotracheal intubation
› RSI preferred: succinylcholine 1.5 mg/kg IV
› Alternative: rocuronium 1.2 mg/kg IV
› Avoid long-acting neuromuscular blockade — masks seizure activity
› Ketamine for induction (sedative-hypnotic toxicity with hemodynamic instability)
› 1–2 mg/kg IV
› Maintains hemodynamic stability
› Etomidate alternative
› 0.3 mg/kg IV for induction
› Bag-valve-mask ventilation for apnea prior to intubation
› 2-person technique with oral airway adjunct
› Target SpO2 > 94% prior to laryngoscopy
Flumazenil (benzodiazepine reversal agent)
› Flumazenil dosing protocol
› Initial dose: 0.2 mg IV over 30 seconds
› Repeat 0.3 mg IV at 1 minute if insufficient response
› Subsequent doses 0.5 mg IV every 1 minute
› Maximum cumulative dose 3 mg in overdose setting
› Onset of action 1–2 minutes; duration 45–90 minutes
› Re-sedation expected if long-acting benzodiazepine taken
› Monitor minimum 2 hours after last dose for re-sedation
› Flumazenil contraindications
› Chronic benzodiazepine dependence — precipitates acute withdrawal and seizures
› TCA or sodium channel blocker co-ingestion — refractory seizures and dysrhythmias
› Epilepsy with benzodiazepine use for seizure control
› Undifferentiated coma of unknown etiology — do not use empirically
› Elevated ICP or head injury history
› Appropriate use scenarios
› Iatrogenic procedural sedation reversal — safest application
› Pediatric exploratory ingestion of known benzodiazepine (no chronic use, no TCA)
› Diagnostic use in monitored setting when diagnosis uncertain and benefit high
› Respiratory support
› Supplemental oxygen for SpO2 < 94%
› Nasal airway adjunct for obtunded patient maintaining spontaneous respirations
› Positioning — lateral decubitus (recovery position) to reduce aspiration risk
› High-flow nasal cannula (HFNC) for moderate hypoxemia
› Flow rate 20–60 L/min; FiO2 titrated to SpO2 target
› Hemodynamic support
› IV crystalloid bolus for hypotension
› Normal saline or Ringer's lactate 500–1000 mL
› Repeat as needed targeting MAP > 65 mmHg
› Norepinephrine for vasopressor-requiring hypotension
› Initial rate 0.1–0.2 mcg/kg/min
› Titrate to MAP > 65 mmHg
› Maximum 1–2 mcg/kg/min
› Vasopressin 0.03–0.04 units/min as adjunct for refractory hypotension
› Temperature management
› Passive rewarming for mild hypothermia (35–36 C)
› Warm blankets, remove wet clothing
› Active external rewarming for moderate hypothermia (32–35 C)
› Heating blankets, warmed IV fluids
› Active internal rewarming for severe hypothermia (< 32 C)
› Warmed humidified O2
› Warmed IV fluids 38–42 C
› ICU level care
Enhanced elimination (barbiturates)
› Urinary alkalinization for phenobarbital
› Sodium bicarbonate 1–2 mEq/kg IV bolus then 150 mEq/L in D5W at 250 mL/hr
› Target urine pH 7.5–8.0
› Enhances renal excretion of ionized phenobarbital
› Monitor serum potassium — hypokalemia limits alkalinization efficacy
› Hemodialysis for severe barbiturate poisoning
› Indication: phenobarbital level > 430 mmol/l (100 mcg/mL) with clinical deterioration
› Hemoperfusion or intermittent hemodialysis are effective modalities
› Reduces drug half-life from 100 hours to 8–10 hours
› Consult nephrology early in severe cases
› Multidose activated charcoal (MDAC) for phenobarbital
› 25 g activated charcoal every 4 hours
› Interrupts enterohepatic circulation
› Airway protection required; contraindicated if intubation not possible
Rhabdomyolysis management
› Rhabdomyolysis protocol
› Aggressive IV hydration: normal saline 1–1.5 L/hr initially
› Target urine output 1–2 mL/kg/hr
› Monitor urine color and CK every 6 hours
› Urinary alkalinization controversial but commonly used
› Sodium bicarbonate in IV fluids to target urine pH > 6.5
› Hemodialysis if acute kidney injury with oliguria progresses
› Compartment syndrome — early surgical consultation if pressures > 30 mmHg
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