Environmental and de escalation
›Low stimulation care
›Quiet room
›Reduce triggers
›Limit staff crowding
›Remove heat sources
›Clothing removal
›Cool ambient temperature
Sedation and agitation control
›Benzodiazepines first line
›Lorazepam IV
›1 mg to 2 mg IV
›Repeat every 5 minutes to effect
›Respiratory monitoring escalation if repeated dosing
›2 mg IM
›Repeat every 10 minutes to effect
›Consider IV access after initial control
›Midazolam IV
›2 mg to 5 mg IV
›Repeat every 5 minutes to effect
›Older adults lower initial dose
›Midazolam IM
›5 mg IM
›Repeat 5 mg IM once if needed
›Diazepam IV
›5 mg to 10 mg IV
›Repeat every 5 minutes to effect
›Longer sedation tail
›Antipsychotic adjuncts
›Droperidol IM or IV
›2.5 mg to 5 mg
›Repeat 2.5 mg to 5 mg after 10 minutes if needed
›QT monitoring if risk factors
›Haloperidol IM or IV
›2 mg to 5 mg
›Repeat every 15 minutes to effect
›Dystonia prophylaxis consideration
›Olanzapine IM
›5 mg to 10 mg
›Avoid within 1 hour of benzodiazepine IM when possible
›Orthostasis monitoring
›Severe agitation escalation
›Ketamine IM
›4 mg per kg IM
›Repeat 2 mg per kg IM once if needed
›Airway plan ready
›Ketamine IV
›1 mg per kg IV
›Repeat 0.5 mg per kg IV as needed
›Emergence reaction mitigation plan
›Rapid cooling bundle
›External cooling
›Evaporative cooling
›Mist and fan
›Continuous temperature reassessment
›Ice packs
›Axilla and groin
›Neck cooling
›Cold IV fluids
›Balanced crystalloid
›10 mL per kg bolus
›Repeat based on perfusion
›Avoid fluid overload in cardiomyopathy
›Lung ultrasound support
›BNP context
›Stop muscle activity
›Aggressive benzodiazepines
›Reduce agitation thermogenesis
›Reduce seizure activity
›If refractory hyperthermia then intubation and paralysis
›Rocuronium IV 1 mg per kg
›Continuous sedation after paralysis
›Temperature targets
›Core temperature below 39 C as early goal
›Reduce end organ injury
›Prevent DIC risk
›Continuous core temperature monitoring
›Rectal probe
›Esophageal probe if intubated
Cardiovascular management
›Chest pain and suspected vasospasm
›Aspirin PO
›160 mg to 325 mg chewable
›If no contraindication
›ACS pathway alignment
›Nitroglycerin SL
›0.4 mg SL
›Repeat every 5 minutes up to 3 doses
›Avoid if hypotension or PDE5 inhibitor use
›Nitroglycerin infusion for persistent pain or hypertension
›Start 5 microg per minute
›Titrate by 5 microg per minute every 3 minutes to 5 minutes
›Typical maximum 200 microg per minute
›Benzodiazepines adjunct
›Reduce sympathetic surge
›Improve pain
›Lower blood pressure
›Calcium channel blocker for refractory vasospasm
›Diltiazem IV
›0.25 mg per kg bolus
›Infusion 5 mg per hour to 15 mg per hour if needed
›Verapamil IV
›5 mg IV slow push
›Repeat 5 mg after 15 minutes if needed
›Hypertension and tachycardia
›First line benzodiazepines
›Treat agitation driver
›Reduce catecholamine effect
›If hypertensive emergency persists then vasodilators
›Nicardipine infusion
›Start 5 mg per hour
›Titrate by 2.5 mg per hour every 5 minutes to 15 minutes
›Maximum 15 mg per hour
›Nitroprusside infusion
›Start 0.3 microg per kg per minute
›Titrate by 0.5 microg per kg per minute to effect
›Maximum 10 microg per kg per minute
›Phentolamine IV bolus for catecholamine driven crisis
›1 mg IV to 5 mg IV
›Repeat every 5 minutes to effect
›Beta blocker cautions
›Avoid pure beta blockade in acute cocaine toxicity when possible
›Unopposed alpha concern
›Prefer benzodiazepines and vasodilators first
›If beta blockade required then mixed alpha beta agent consideration
›Labetalol IV 10 mg to 20 mg
›Repeat or infusion per local protocol
Dysrhythmias and seizures
›Wide QRS or ventricular dysrhythmia from sodium channel blockade
›Sodium bicarbonate IV
›1 mEq per kg bolus
›Repeat until QRS narrows or pH target achieved
›Target pH 7.50 to 7.55 in severe toxicity
›Bicarbonate infusion option
›150 mEq in 1 L D5W
›Rate titrated to QRS and pH
›Magnesium sulfate for torsades risk
›2 g IV over 10 minutes
›Repeat once if torsades persists
›Continuous infusion per local protocol if recurrent
›Seizure management
›First line benzodiazepines
›Lorazepam IV 4 mg
›Repeat once after 5 minutes
›Escalate if ongoing seizure
›Midazolam IM 10 mg
›If no IV access
›Transition to IV regimen after control
›Second line antiseizure
›Levetiracetam IV 60 mg per kg
›Maximum 4500 mg
›Minimal hemodynamic effect
›Fosphenytoin IV 20 mg PE per kg
›Hypotension monitoring
›Avoid in toxin induced sodium channel blockade preference
›Refractory status epilepticus pathway
›Propofol infusion
›Start 20 microg per kg per minute
›Titrate to seizure suppression
›ICU level airway management
›Mechanical ventilation
›Continuous EEG if available
Fluids and rhabdomyolysis
›Volume resuscitation
›Balanced crystalloid
›20 mL per kg initial bolus if dehydrated
›Maintenance to urine output target
›Urine output target
›1 mL per kg per hour minimum
›2 mL per kg per hour for severe rhabdo consideration
›Electrolyte management
›Hyperkalemia protocol if present
›Calcium gluconate IV
›Insulin with dextrose
›Hypocalcemia interpretation caution
›Correct only if symptomatic
›Avoid overcorrection during rhabdo phase
Evidence and guideline notes
›Evidence alignment summary
›Benzodiazepines as first line for sympathomimetic toxicity
›Consensus recommendation
›Class I expert consensus in toxicology references
›Aspirin and nitrates for cocaine associated chest pain when ACS suspected
›AHA scientific statement support
›Class I for ACS standard care
›Sodium bicarbonate for cocaine associated wide QRS
›Class IIa expert consensus
›Mechanism based therapy