Overdose Order Set - Managment of Acute Overdose



Initial Assessment FORMCHECKBOX Check Airway, Breathing, Circulation (If abnormal vitals contact MD immediately) FORMCHECKBOX IV / O2 / Cardiac Monitoring / AccucheckOrders FORMCHECKBOX Overdose Order Protocol FORMCHECKBOX Urine Specimen FORMCHECKBOX Urine Drug ScreenAdditional Labs: FORMCHECKBOX ECG FORMCHECKBOX CXR FORMCHECKBOX Other investigations: Vitals FORMCHECKBOX Vitals: HR, RR, BP, SpO2 q15minsNeurovitals FORMCHECKBOX Neurovitals q15 min and PRN FORMCHECKBOX If change in level of consciousness, notify MD immediatelyMonitoring FORMCHECKBOX Continuous Cardiac/SpO2 FORMCHECKBOX Glasgow Coma Scale q4h and PRN FORMCHECKBOX Intake and Output q1hOverdose Management FORMCHECKBOX Known Ingestant(s): FORMCHECKBOX Unknown IngestantTreatment (see protocol below FORMCHECKBOX Lipid 20% FORMCHECKBOX Injectable NaHCO3 FORMCHECKBOX N-Acetylycysteine (NAC) FORMCHECKBOX Glucagon FORMCHECKBOX CaCl2 FORMCHECKBOX Naloxone (Narcan)Tubes/RespiratoryNasogastric Tube FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Contact Poison Control (P: 1-800-268-9017 ext.268) Advice Given: Urinary CatheterInsert Foley Catheter and initiate Indwelling Urinary Catheter (Short Term) Protocols FORMCHECKBOX Yes FORMCHECKBOX NoRespiratory (no ventilation) FORMCHECKBOX Titrate O2 to keep SpO2 greater then 92% and less than 96%. If SpO2 greater than 96% discontinue O2 FORMCHECKBOX Patient with known chronically elevated PaCO2: Titrate O2 to keep SpO2 between 88% and 92% FORMCHECKBOX O2L/min via nasal prongs or Diet FORMCHECKBOX NPO, no PO medications FORMCHECKBOX Other: FORMCHECKBOX GI Decontamination: FORMCHECKBOX Activated Charcoal (50 g) x 1 dose FORMCHECKBOX PO OR FORMCHECKBOX NG THEN FORMCHECKBOX Activated Charcoal 25 g q4h stop when stool contains charcoal FORMCHECKBOX Activated Charcoal 50 g (225 mL) q4h stop when stool contains charcoal FORMCHECKBOX Whole Bowel Irrigation –Stock Electrolyte Lavage at 500 mL/h NG until stool is liquidLipid 20% Protocol (recommended for overdose of lipid soluble medications: i.e. psychotropic drugs (TCA’s, SSRI’s, Atypical Antipsychotics, Anticonvulsants, Buproprion), calcium channel blockers, beta blockers, herbicides/pesticides FORMCHECKBOX 20% Lipid Emulsion 1.5 mL/kg (lean body mass) over 1 minute, then infuse 0.25 mg/kg/minute Repeat bolus dose x 1-2 if persistent cardiovascular collapse Continue infusion for at least 10 minutes after achieving circulatory stability If blood pressure remains low, increase infusion rate to 0.50 mg/kg/minute**Recommend upper limit: approximately 10-12 mL/kg over the first 30 minutes (as per The American Society of Regional Anesthesia guidelines [Attached])NAC Protocol21 Hour N-acetylcysteine IV Infusion Regimen(If within 10 hours of acetaminophen ingestion)21 Hour N-acetylcysteine IV Infusion Regimen (Total 3 doses; total dose delivered 300 mg/kg)*** Recommended for patients intolerant to PO intake or with hepatic failure****** Fluid volume should be reduced in patients weighing less than 40 kg***Loading Dose FORMCHECKBOX N-acetylcysteinemg IV over 60 minutes (150 mg/kg) (max 15 g)Second Dose FORMCHECKBOX N-acetylcysteinemg IV over 4 hours (50 mg/kg) (max 5 g)Third Dose FORMCHECKBOX N-acetylcysteinemg IV over 16 hours (100 mg/kg) (max 10 g) FORMCHECKBOX Notify MD to reassess need for further N-acetylcysteine 2 hours prior to end of regimenNaHCO3 ProtocolSodium Bicarbonate 150 mmol in 1 litre D5W bolus______ mL over _____minutes, thenInfuse at 150 mL/h or ______ mL/h IV infusion (goal pH 7.45-7.55) when goal is achieved, notify MDGlucagon ProtocolRefer to ACLS guidelines (attached) FORMCHECKBOX Glucagon mg (0.05-0.15 mg/kg) IV bolus, then infuse at mg/hour (0.05-0.1 mg/kg/hour) Titrate infusion rate to achieve adequate hemodynamic responseCaCl2 Protocol (100 mg/mL)For Beta blocker overdose refractory to Glucagon: FORMCHECKBOX 20 mg/kg IV over 5-10 minutes, then 20 mg/kg/hour infusion (titrating based on hemodynamic response) For Calcium Channel Blocker overdose: (as per Lexicomp) FORMCHECKBOX Initial: 1000-2000 mg over 5 minutes; may repeat every 10-20 minutes with 3-4 additional doses or 1000 mg every 2-3 minutes until clinical effect is achieved (DeWitt, 2004); if favorable response obtained, consider I.V. infusion, then: Infusion: 20-40 mg/kg/hour (DeWitt, 2004; Salhanick, 2003)Naloxone ProtocolAdultIV/IM/SC: 0.1-0.4mg (single max. dose of 2mg), repeat q2-3 minutes until reversal is seen (if no response is observed after 10mg, there may be another cause of respiratory depression) OR IV infusion: 2mg in 500mL D5W/NS (0.004mg/mL = 4mcg/mL) Administer two-thirds of bolus dose that resulted in reversal each hr., ie. If 0.4mg bolus resulted in reversal, run drip 0.27mg/hr = 67mL/hr. Titrate to effect. If no reversal with bolus, start drip at 0.4mg/hr. and titrate to effect.Children0.01mg/kg IV/IM/SC q2-3 min. for 2-3 dosesBolus Administration FORMCHECKBOX Naloxone (0.4-2mg) IV bolus, repeat q2-3 minutes if necessary. (if no response after 10mg, consider other causes for respiratory depression)Continuous Infusion (for use with exposure to long-acting opioids or extended release products) FORMCHECKBOX Infuse 2/3 of the initial effective bolus naloxone dose on an hourly basis; administer ? of the initial effective bolus naloxone dose within 15 minutes of starting the infusion. Adjust infusion rate as needed to ensure adequate ventilation and prevent withdrawal symptoms. (As per Lexicomp) FORMCHECKBOX Attempt to Identify Toxidromes:Anticholinergic (hyperthermia, dilated pupils, dry skin, flushing, agitation/hallucinations)Sympathomimetic (tachycardia, hypertension, diaphoresis, piloerection, seizures, hyperthermia, dilated pupils)Opiate/Sedative (miosis, nausea, vomiting, respiratory depression, hypothermia)Cholinergic (salivation, lacrimation, urination, defecation, GI distress, emesis)Serotonin Syndrome (agitation, diarrhea, tachycardia, hallucinations, hyperthermia, nausea, vomiting)Ethanol Posioning (confusion, vomiting, seizures, respiratory depression, hypothermia, cyanosis, unconciousness) Add protocol FORMCHECKBOX Management of Identified toxidrome(s): ____________________________________ Seizure ControlAvoid phenytoin in TCA overdose*** FORMCHECKBOX Lorazepam 4mg slow IV over 1-2 minutes (max rate 4mg/min) q 10-15mins prn if necessary (max dose usually 8 mg) FORMCHECKBOX Diazepam 5-10 mg IV given over <5 mg/min q5-10min prn (max dose: 30 mg)Intubation ProtocolPre Intubation Etomidate _____ mg IV fentaNYL _____ micrograms IV Ketamine _____ mg IV Midazolam _____ mg IV Propofol _____ mg IV Rocuronium _____ mg IV Succinylcholine _____ mg IV Other: _________________________________________________________ Post Intubation fentaNYL _____ micrograms IV q _____ minutes PRN (max _____ micrograms) Morphine _____ mg IV q _____ minutes PRN (max _____ mg) Midazolam _____ mg IV q _____ minutes PRN (max _____ mg) Phenylephrine ___ micrograms IV q2minutes PRN if Systolic BP less than ____ (max ___mcgRocuronium _____mg IV q____ minutes PRN (max _____ mg) Maintain sedation if patient paralyzed with Rocuronium Other: _________________________________________________________ FORMCHECKBOX DispositionAdditional Orders ................
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