Plan of DKA

Fluid bolus of isotonic crystalloid ( NS or RL) at a rate of 15 to 20 mL/kg/h during the first
.hour

After the initial bolus, administer NS at 250 to 500 mL/h in hyponatremic patients, or give
.0.45% NS at 250 to 500 mL/h for eunatremic and hypernatremic patients

.When glucose level falls to about 250 milligrams/dL, change to 5% dextrose in 0.45% NS

If serum potassium level >3.3 mEq/L, but <5.2 mEq/L (before fluid resuscitation and insulin,
coupled with urine output) calls for 20 to 30 mEq/L for at least 4 hours to keep potassium
.between 4 and 5 mEq/L

Initial hypokalemia (<3.3 mEq/L) necessitates aggressive replacement before insulin therapy.
.Give potassium IV at 20 to 30 mEq/h and hold insulin until [K+] is ≥3.5 mEq/L

.Rate no faster than 10 mEq/h via peripheral IV or 20 mEq/h via central line access

Potassium level >5.2 mEq/L, obtain an ECG immediately and check for signs of hyperkalemia.
Fluid and insulin therapy alone usually will lower the serum potassium level rapidly.
.Albuterol nebulization can provide an additional quick potassium-lowering efect

IV insulin: Administer insulin at a rate of 0.1 to 0.14 unit/kg/h with no insulin bolus once
.hypokalemia ([K+] <3.3 mEq/L) is excluded

An alternative insulin regimen is 0.1 unit/kg bolus IM, followed by a drip rate at 0.1
.unit/kg/h

Plasma glucose concentration typically decreases by 50 to 75 milligrams/dL/h, but if the

blood glucose fails to drop by 10% 1 hour after initial therapy, (assuming adequate
hydration), give a 0.14 unit/kg bolus and resume insulin drip rate. Another option is to
.increase the insulin infusion rate by 1 unit/h

Once the serum glucose is 250 milligrams/dL, add dextrose to the IV fluids and reduce the
insulin drip rate to 0.02 to 0.05 unit/kg/h. Maintain the serum glucose between 150 and 200
.milligrams/dL until the resolution of DKA

OR: SC Insulin: An initial injection of 0.3 unit/kg followed by 0.1 unit/kg every hour, or an
initial dose of 0.3 unit/kg followed by 0.2 unit/kg every 2 hours until blood glucose is <250
milligrams/dL. Then, the insulin dose is decreased by half and administered every 1 or 2
.hours until resolution of DKA

Monitor laboratory values every 1 to 2 hours to ensure that insulin is being administered in
.the desired amount

Give bicarbonate if the initial pH is <6.9, but do not give bicarbonate if the pH is ≥6.9, so
adults with a pH <6.9 can be given 100 mEq of sodium bicarbonate in 400 mL of water with
.20 mEq KCl at 200 mL/h for 2 hours until the venous pH >7.0
Transition from IV Insulin After DKA Correction. Once the patient eats, the glucose infusion
can be stopped, but it is important to overlap the IV and SC insulin for 2 to 4 hours to avoid
potential relapse to hyperglycemia or DKA
 ACUTE ASTHMA STANDARD TREATMENT.

β-ADRENERGIC AGENTS

Inhaled β2-Agonists

Albuterol

Nebulizer solution (0.63 milligram/3 mL, 1.25 milligrams/3 mL, 2.5 milligrams/3 mL, 5.0
milligrams/mL) 2.5–5 milligrams every 20 min for 3 doses, then 2.5–10 milligrams every 1–4
.h, as needed, or 10–15 milligrams/h as continuous nebulization

.MDI (90 micrograms/puff) 4–8 puffs every 20 min up to 4 h, then every 1–4 h as needed

Levalbuterol (R-albuterol)

Nebulizer solution (0.63 milligram/3 mL, 1.25 milligrams/3 mL) 1.25–2.5 milligramsevery20
.min for3doses, then 1.25–5 milligramsevery1–4 h,as needed

.MDI (45 micrograms/puff) See albuterol MDI dose

Systemic (Injected) Agents

Epinephrine

1:1000 (1 milligram/mL) 0.3–0.5 milligram every 20 min for 3 doses SC or )α- and β-agonist(
.IM

Terbutaline

2 micrograms/kg may be given over 5 min, followed by )1 milligram/mL( )β2-agonist(

.continuous infusion of 5 micrograms/kg/h

Anticholinergics/Combinations

Ipratropium bromide

Nebulizer solution (0.25 milligram/mL) 0.5 milligram every 20 min for 3 doses, then as
.needed

.MDI (18 micrograms/puff) Eight puff severy20 min, as needed, up to 3 h

Ipratropium with albuterol

Nebulizer solution (each 3-mL vial contains 0.5 milligram of ipratropium bromide and 2.5
.milligrams of albuterol) 3 mLevery20 min for 3 doses, then as needed

MDI (each puff contains18 micrograms of ipratropium bromide and 90 micrograms of

.albuterol) Eight puffs every20 min as needed up to 3 h

Systemic Corticosteroids

Prednisone

For inpatients: oral “burst,” use 40–80 milligrams/d in 1 or 2 divided doses until PEFR
.reaches70% of predicted or personal best

Methylprednisolone IV

.milligram/kg every4–6 h 1

Prednisolone

.milligrams/kg/d for 5–10 d; may be divided twice daily 2–1

TREATMENT OF STATUS EPILEPTICUS

 Status epilepticus is a single seizure ≥5 minutes in length or two or more seizures without
.recovery of consciousness between seizures

Establish large-bore IV access and determine a bedside glucose. Administer normal

saline.The patient should be protected from injury related to uncontrollable convulsions
and, if possible, placed in a lateral decubitus position to reduce aspiration risk. Intermittent
suctioning of oral secretions must be performed with caution. Place the patient on oxygen, a
.cardiac monitor, pulse oximeter, and end-tidal capnography

consider endotracheal intubation for airway protection, oxygenation, and ventilation.

.Arrange for continuous EEG monitoring

Initial laboratory evaluation includes blood glucose, a metabolic panel including calcium and
magnesium, lactate, and if appropriate, a pregnancy test, a toxicology screen, and
.anticonvulsant levels

.Administer glucose IV if hypoglycemia is suspected or confirmed

.Monitor temperature, treat hyperthermia with passive cooling

Place a urinary catheter to monitor urine output and insert a nasogastric tube to help
.prevent aspiration

If toxic ingestion is suspected as the cause of seizures, proceed with GI decontamination (as
.appropriate)

ANTICONVULSANT DRUGS IN STATUS EPILEPTICUS

IV lorazepam 0.1 mg/kg IV over 1–2 min (2 to 4 milligrams) and IV diazepam 0.15–0.2 mg/kg
IV over 1–2 min max 10 mg per dose (5 to 10 milligrams) have equal efficacy in controlling
.status epilepticus

.midazolam 0.2 mg/kg IV over 1–2 min, IM, IN (max of 10 mg per dose )

If IV line is not available give IM midazolam for adults , rectal diazepam gel and buccal
.midazolam for children, buccal midazolam (0.5 milligram/kg, up to 10 milligrams)

:follow benzodiazepines with longeracting antiepileptic agents

Fosphenytoin: The loading dose is 20 phenytoin equivalents/kg, which can be infused at 150
.phenytoin equivalents/min over 10 to 15 minutes, can also be given IM

phenytoin: The loading dose for phenytoin is 20 milligrams/kg IV, infused no faster than a
rate of 25 milligrams/min (taking about 1 hour to administer).Place patients on a cardiac
.monitor, with blood pressure assessments. Shouldn't be given IM

Valproic acid: is effective but has serious side effects. should not be administered along with
.phenytoin. The dose is 20 to 40 milligrams/kg IV

Levetiracetam: is very effective, The dose is 20 to 60 milligrams/kg IV

 .Lacosamide: the dose is 200 milligrams IV given over 15 minutes

REFRACTORY STATUS EPILEPTICUS

is defined as persistent seizure activity despite the IV administration of adequate amounts of

.two antiepileptic agents and usually exceeds 60 minutes

Propofol: can be started as an infusion at typical rates of 2 to 10 milligrams/kg/h and titrated

.up to effect of seizure cessation

Midazolam: can be started at 0.05 to 0.4 milligram/kg/h and is titrated up to seizure

.cessation

phenobarbital: (up to 20 milligrams/kg IV)

ketamine: can be administered as a bolus dose of 0.5 to 4.5 milligrams/kg or as an infusion

.up to 5 milligrams/kg/h

Treatment of Hypertensive Emergencies by Diagnosis

 : Aortic dissection

Therapy Goals : Reduce shear forces by decrease BP and PR Lower SBP to 100–120 mm Hg,
PR ≤60

beats/min

,Agents: Esmolol* IV bolus, then continuous infusion

,OR Labetalol* IV bolus or continuous infusion

,Nicardipine IV continuous infusion (after β-blocker)

.Nitroprusside continuous infusion (after β-blocker)

: Acute hypertensive pulmonary edema

Therapeutic effect : Reduce BP by 20%–30%; diuresis through vasodilation; symptomatic

relief

Agents : Nitroglycerin* SL, topical, or IV continuous infusion

Clevidipine IV continuous infusion

Nitroprusside IV continuous infusion

Enalaprilat IV

: Acute myocardial infarction

Therapeutic effect: Reduce ischemia; avoid ≤25% reduction of MAP

Agents: Nitroglycerin*SL, aerosol, or IV continuous infusion

 Esmolol* IV continuous infusion

.Labetalol or metoprolol IV bolus

Nicardipine IV continuous infusion Nesiritide IV

: Acute sympathetic crisis (cocaine, amphetamines, MAOI toxicity)

Therapeutic effect : Reduce excessive sympathetic drive and symptomatic relief

Aim for SBP <140 mm Hg in the first hour

Agents : Benzodiazepine* IV bolus

Nitroglycerin SL, topical, or IV continuous infusion

Phentolamine* IV or IM

.Nicardipine or clevidipine IV continuous infusion

: Acute renal failure

Therapeutic effect : Reduce BP by no more than 20% acutely

Agents : Fenoldopam IV continuous infusion

Nicardipine IV continuous infusion

.Clevidipine IV continuous infusion

Eclampsia, preeclampsia

Aim for SBP <140 mm Hg in the first hour

Agents : Hydralazine* IV bolus

 Labetalol* IV bolus

Nifedipine* oral

: Hypertensive encephalopathy

Therapeutic effect : Decrease MAP 20%–25% in the first hour of presentation; more
aggressive lowering

may lead to ischemic infarction

Agents : Labetalol IV bolus or continuous infusion

Nicardipine IV continuous infusion

Clevidipine IV continuous infusion

Hypertensive encephalopathy

Therapeutic effect : Decrease MAP 20%–25% in the first hour of presentation; more
aggressive lowering

may lead to ischemic infarction

Agents : Labetalol IV bolus or continuous infusion

Nicardipine IV continuous infusion

.Clevidipine IV continuous infusion

Intracerebral hemorrhage

Therapeutic effect : If SBP >220 mm Hg, consider aggressive management with IV infusion
If SBP 150–220 mm Hg, IV boluses of antihypertensive medications should be used to acutely
lower SBPto 140 mm Hg

Agents : Labetalol IV bolus or continuous infusion

,Nicardipine IV continuous infusion

.Esmolol IV bolus, then continuous infusion

Acute ischemic stroke, rtPA candidate (BP ≤185/110 mm Hg)

: Therapeutic effect

measurements

If fibrinolytic therapy planned, treat if BP remains >185/110 mm Hg after 3

Agents : The following antihypertensive recommendations (agents section)

are for immediate BP control prior to reperfusion; BP management during and after
reperfusion therapy

is outlined in comments section

Labetalol* 10–20 milligrams IV over 1–2 min; may repeat once

Nicardipine* 5 milligrams/h IV infusion, titrate up by 2.5 milligrams/h every 5–15 min until
desired BP is

reached; maximum 15 milligrams/h

Clevidipine* 1–2 milligrams/h IV infusion, double the dose every 2–5 min until desired BP is
;reached

maximum 21 milligrams/h
 .Nitroprusside may be used if BP is not controlled with above agents or DBP >140 mm Hg

Acute ischemic stroke, hypertension excludes reperfusion therapy

Therapeutic effect : Treat if ≥220/120 mm Hg on third of 3 measurements, spaced 15 min

apart; BP

should be reduced by ~15% in the first 24 h

Early treatment of hypertension is indicated if required by other comorbid conditions (i.e.,

acute

coronary syndrome, aortic dissection, preeclampsia/eclampsia). Lowering by 15% acutely is

probably

safe

Same agents and doses as above acute ischemic stroke rtPA candidate