Emergency Medicine Practice Clinical Pathways: Evidence to Improve Patient Care in Emergency Medicine

Emergency Medicine Practice Clinical Pathways: Evidence To Improve Patient Care In Emergency Medicine

BROUGHT TO YOU EXCLUSIVELY BY THE PUBLISHER OF: Emergency Medicine Practice Pediatric Emergency Medicine Practice EM Practice Guidelines Update The Lifelong Learning and Self-Assessment Study Guide EM Critical Care ED Overcrowding Solutions Table Of Contents

General Emergency Medicine Clinical Pathway For Evaluation Of Patients With Suspected Acute Hepatic Injury...... 1 Clinical Pathway For Asymptomatic Hypertension...... 2 Clinical Pathway For Symptomatic Hypertension...... 3 Clinical Pathway For Treatment Of Skin And Soft Tissue Infections...... 4 Clinical Pathway For The Management Of The Postpartum Patient With Headache...... 5 Clinical Pathway For The Management Of The Postpartum Patient With Elevated Blood Pressure (> 140 Systolic Or > 90 Diastolic)...... 6

HEENT Emergencies Clinical Pathway For Blunt Eye Trauma...... 7 Clinical Pathway For Penetrating Eye Trauma...... 8 Clinical Pathway For Treatment Of Acute Otitis Media...... 9

Hematologic Emergencies Clinical Pathway For Evaluation Of Suspected Malignant Epidural Spinal Cord Compresion...... 10 Clinical Pathway For The Management Of Hypercalcemia Of Malignancy...... 11 Clinical Pathway For Management Of Tumor Lysis Syndrome...... 12 Clinical Pathway For The Initial Management Of Neutropenic Fever...... 13

Toxicologic Emergencies Clinical Pathway For Single APAP Ingestion...... 14 Clinical Pathway For Initial Evaluation Of Toxic Alcohol Poisoning...... 15 Clinical Pathway For Management Of Methanol And Ethylene Glycol Poisoning...... 16 Clinical Pathway For Management Of Isopropanol Poisoning...... 16 Full issue available free for subscribers or for purchase for non-subscribers on our website. Full subscriptions are also available. We’d love your feedback on this iPad downloadi — please share your comments and questions in this survey. Return to the Table of Contents. Clinical Pathway For Evaluation Of Patients With Suspected Acute Hepatic Injury

AST and/or ALT > 300 U/L?

YES NO

AST > 3000 U/L? AST > 2x ALT?

YES NO YES NO

Probable toxic or ischemic ALK < 3x Upper NI? History of ethanol abuse? Not acute hepatic injury injury

NO YES YES NO

Acute hepatitis panel History of drug exposure? Alcoholic hepatitis

POSITIVE NEGATIVE YES NO

IgM anti-HAV Probable drug injury HCV exposure? NO

POSITIVE NEGATIVE YES

IgM Consider obstruction, Acute HAV NEGATIVE Anti-HCV HCV RNA anti-HBc other causes

POSITIVE POSITIVE

POSITIVE NEGATIVE

Acute HBV Previous neg?

YES NO

Possible Acute HCV acute HCV

Abbreviations: ALK, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; HAV, hepatitis A virus; HBc, hepatitis B core antigen; HBV, hepatitis B virus; HCV, hepatitis C virus; IgM, immunoglobulin M antibody; NI, normal.

CLINICAL CHEMISTRY. ONLINE by Dufour, Lott, Nolte, Gretch, Koff, Seef. Copyright 2000 by AMERICAN ASSOCIATION FOR CLINICAL CHEMIS- TRY, INC. Reproduced with permission of AMERICAN ASSOCIATION FOR CLINICAL CHEMISTRY, INC in the format Journal via Copyright Clear- ance Center.

Emergency Medicine Practice © 2010 10 EBMedicine.net • April 2010 Full issue available free for subscribers or for purchase for non-subscribers on our website. Full subscriptions are also available. We’d love your feedback on this iPad download — please share your comments and questions in this survey. 1 Return to the Table of Contents. Clinical Pathway For Asymptomatic Hypertension

Vital signs show BP elevation

Home; recheck BP Recheck BP BP normal now? YES in 1 month (Class III)

BP > 180/110 mm Hg? Home; recheck BP in NO 1 week to 1 month (Class III) YES

HYPERTENSIVE URGENCY Consider ancillary testing: CBC BMP Chest x-ray ECG

Signs of end-organ NO Contact primary care damage? provider; follow up 1 day to 1 week YES Consider starting 2-drug oral therapy, especially if BP > 200/120 mm Hg Go to the Clinical Pathway Do NOT attempt to nor- For Symptomatic Hyper- malize BP in the ED tension, next page (Class III)

Abbreviations: BMP, basic metabolic panel; BP, blood pressure; CBC, complete blood count; ECG, electrocardiogram; ED, emergency department.

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.

Class I Class II Class III Indeterminate tatives from the resuscitation • Always acceptable, safe • Safe, acceptable • May be acceptable • Continuing area of research councils of ILCOR: How to De- • Definitely useful • Probably useful • Possibly useful • No recommendations until velop Evidence-Based Guidelines • Proven in both efficacy and • Considered optional or alterna- further research for Emergency Cardiac Care: effectiveness Level of Evidence: tive treatments Quality of Evidence and Classes • Generally higher levels of Level of Evidence: of Recommendations; also: Level of Evidence: evidence Level of Evidence: • Evidence not available Anonymous. Guidelines for car- • One or more large prospective • Non-randomized or retrospec- • Generally lower or intermediate • Higher studies in progress diopulmonary resuscitation and studies are present (with rare tive studies: historic, cohort, or levels of evidence • Results inconsistent, contradic- emergency cardiac care. Emer- exceptions) case control studies • Case series, animal studies, tory gency Cardiac Care Committee • High-quality meta-analyses • Less robust RCTs consensus panels • Results not compelling and Subcommittees, American • Study results consistently posi- • Results consistently positive • Occasionally positive results Heart Association. Part IX. Ensur- tive and compelling Significantly modified from: The Emergency Cardiovascular Care ing effectiveness of community- Committees of the American wide emergency cardiac care. Heart Association and represen- JAMA. 1992;268(16):2289-2295. This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care. Copyright © 2010 EB Practice, LLC d.b.a. EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC d.b.a. EB Medicine.

Full issue available free for subscribers or for purchase for non-subscribers on our website. Full subscriptions are also available. We’d love your feedback on this iPad download — please share your comments and questions in this survey. 2 Return to the Table of Contents. Clinical Pathway For Symptomatic Hypertension

BP elevated with end-organ symptoms?

Recheck BP

Normal BP? YES Look for other causes of symptoms

Acute ischemic stroke Only treat if BP > 220/120 mm Hg to decrease BP 10% to 15% OR if tPA candidate and BP > 185/110 mm Hg (Class I*)

Acute pulmonary edema/congestive heart failure Nitrates, diuretics (Class I**) Consider positive pressure ventilation (Class II**)

Hypertensive encephalopathy Decrease MAP 20% to 25%, or to a DBP of 100-110 mm Hg (Class II)

Acute intracerebral hemorrhage Consider antihypertensives to target BP of no less than 160/90 mm Hg (Class II*)

Aortic dissection Start with β-blocker, control rate. If BP still not controlled, add a vasodilator. Target SBP: 100-120 mm Hg (Class I*)

Preeclampsia/eclampsia Target BP of 140/90 mm Hg. Consider IV labetalol, calcium channel blocker, hydralazine (Class I***)

Abbreviations: ACE, angiotensin-converting enzyme; BP, blood pressure; DBP, diastolic blood pressure; IV, intravenous; MAP, mean arterial pressure; SBP, systolic blood pressure; tPA, tissue plasminogen activator.

*American Heart Association guidelines **European Society of Intensive Care Medicine guidelines ***Royal College of Obstetricians and Gynaecologists guidelines

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Skin and soft tissue infection

• Toxic-appearing? • Begin resuscitation efforts • Sepsis? • Seek surgical consultation YES • Possible necrotizing • Begin empiric broad-spectrum antibiotics with CA-MRSA infection? coverage NO • Admit patient (Class II) NO

Abscess Cellulitis

Perform incision and • Systemic signs and symptoms? drainage • Comorbidities? • Critical anatomic location? • Purulent discharge?

• Systemic signs and symptoms? YES NO • Comorbidities? • Critical anatomic location? • Surrounding cellulitis? • Consider empiric antibiotic • Consider empiric • Large size? coverage for S pyogenes +/- antibiotic coverage CA-MRSA for S pyogenes +/- • Consider the need for IV NO YES CA-MRSA administration of antibiotics • Consider oral admin- and patient admission istration of cepha- • Begin empiric antibiotic • Begin incision and drainage lexin or dicloxacillin No antibiotics are indicated coverage for CA-MSRA if needed • For CA-MRSA (Class II) • Consider the need for IV • Consider oral administration coverage, add oral administration of antibiot- of cephalexin or dicloxacillin TMP-SMX or use ics and patient admission • Consider IV administration clindamycin alone* • Consider empiric coverage of cefazolin or ampicillin- (Class II) of S pyogenes (extensive sulbactam cellulitis or abnormal vital • For CA-MRSA coverage, *Beware of resistance signs) add oral TMP-SMX or doxy- • Consider oral administra- cycline/minocycline,* or use tion of TMP-SMX, clinda- clindamycin alone* mycin,* or doxycycline/ • Consider IV administration minocycline* of vancomycin alone or • Consider IV administration clindamycin alone* of vancomycin (Class II) (Class II) *Beware of resistance *Beware of resistance

Abbreviations: CA-MRSA, community-acquired methicillin-resistant Staphylococcus aureus; IV, intravenous; S pyogenes, Streptococcus pyogenes; TMP-SMX, trimethoprim-sulfamethoxazole.

Full issue available free for subscribers or for purchase for non-subscribers on our website. Full subscriptions are also available. We’d love your feedback on this iPad download — please share your comments and questions in this survey. 4 EmergencyReturn Medicineto the Table Practice of Contents © 2010 . 10 EBMedicine.net • October 2010 Clinical Pathway For The Management Of The Postpartum Patient With Headache

Does the patient have elevated blood pressure: > 140 systolic or > 90 diastolic? YES NO

Go to “Clinical Pathway for the Postpartum Patient with Elevated Does the patient have altered mental status, papilledema, Blood Pressure” or abnormal neurologic examination?

YES NO

• Check glucose, obtain Did the patient have epidural CBC and metabolic anesthesia for delivery? profile • Obtain CT of brain • Consult Neurology and Ob/Gyn NO YES • Admit to hospital (Class II)

Treat headache with analgesics. (Class II) Refer for follow-up to PCP or Ob/Gyn. Consult Anesthesia for consideration of blood patch Consider lumbar puncture in treatment. (Class II) patients for whom meningi- tis, encephalitis, or SAH is a consideration. (Class I)

Abbreviations: CBC, complete blood count; CT, computed tomography; Ob/Gyn, obstetrician/gynecologist; PCP, primary care provider; SAH, subarachnoid hemorrhage.

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.

Emergency Medicine Practice © 2010 8 EBMedicine.net • August 2010 Full issue available free for subscribers or for purchase for non-subscribers on our website. Full subscriptions are also available. We’d love your feedback on this iPad download — please share your comments and questions in this survey. 5 Return to the Table of Contents. Clinical Pathway For The Management Of The Postpartum Patient With Elevated Blood Pressure (> 140 Systolic Or > 90 Diastolic)

Does the patient have headache and/or nausea and/or abdominal pain and/or blurry vision? YES NO

Obtain urinalysis, CBC, and metabolic profile and check reflexes. Recheck blood pressure. Is blood pressure still elevated? Does patient have proteinuria or hyperreflexia?

YES NO YES NO

Begin magnesium sulfate Begin labetalol or therapy (4-6 gm IV bolus over Begin labetalol 10 mg IV, or hydralazine by mouth. Refer for follow-up to PCP 10-20 minutes followed by a hydralazine 5 mg IV. (Class II) or Ob/Gyn for BP check in drip at 2 g/hr) and labetalol 10 (Class II) 1-2 days. mg IV, or hydralazine 5 mg IV. Refer for follow-up to PCP or (Class II) (Class I) Consult Ob/Gyn. Ob/Gyn in 1-2 days. Consult Ob/Gyn for admission.

Abbreviations: BP, blood pressure; CBC, complete blood count; IV, intravenous; Ob/Gyn, obstetrician/gynecologist; PCP, primary care provider.

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History (how, when, where, No further examination and what) Place eyeshield Call for ophthalmology consult Obvious globe rupture? Consider CT scan STOP! YES Send to OR (Class I)

Perform lateral canthotomy Bedside ultrasound / CT Call for ophthalmology Proptosis? YES Retrobulbar hematoma scan consult Send to OR (Class I) NO

Entrapment of ocular Primary or delayed repair muscles? YES CT scan Orbital fracture (Class II)

Traumatic miosis Pupillary abnormality? YES Traumatic mydriasis Refer to ophthalmologist Anterior uveitis Iridodialysis NO

Rapid afferent pupillary Optic nerve injury YES Urgent ophthalmologic defect? Large retinal tear consult Large vitreous injury

NO Provide supportive care (Class II) Anterior chamber injury? YES Hyphema Administer topical steroids Observe for rebleeding Consult ophthalmology NO

Traumatic cataract Dislocated lens Urgent ophthalmologic Abnormal vision? YES Vitreous hemorrhage consult Retinal detachment NO

HIGH Acute glaucoma Intraocular pressure? Emergent ophthalmologic Hemorrhage within globe LOW consult for medical treatment and/or possible surgery (Class I) Ruptured globe

Fundoscopy

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History (how, when, where, and what)

Impaled object? YES STOP! Stabilize object Call for ophthalmology consult NO Remove object in OR (Class II)

Full eye examination

Call for ophthalmology Evaluate for canalicular consult Lid laceration? YES injury Repair within 24 to 48 hours (Class II) NO

Call for ophthalmology consult Corneal laceration? YES Seidel test Perform emergent repair (Class II)

Intraocular foreign body? Metallic? YES CT scan

Ophthalmology consult To OR for removal and Vegetal? MRI repair Class II

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.

Full issue available free for subscribers or for purchase for non-subscribers on our website. Full subscriptions are also available. We’d love your feedback on this iPad download — please share your comments and questions in this survey. 8 Return to the Table of Contents. Clinical Pathway For Treatment Of Acute Otitis Media

Age 2 months to 12 years with high probability of AOM: • Acute onset • Middle ear effusion • Middle ear inflammation

Pain control as appropriate (Class I)

Age?

≤ 2 years > 2 years

Certain Uncertain diagnosis or diagnosis and Well-appearing: severe illness well-appearing Treat with wait-and-see prescription Severe illness: (Class I) Treat with 10 days of high-dose OR amoxicillin Treat with 5-7 days of high-dose (Class I) 10 days of high-dose amoxicillin amoxicillin (10 days if < 5 years old) (Class I)

If patient presents to ED with no improvement within 48 to 72 hours: • Begin treatment with high-dose (80–90 mg/kg) amoxicillin, if not already treated (Class I) • Switch to amoxicillin/clavulanate if patient is on amoxicillin (Class I) • Refer or consult as appropriate (Class II)

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.

Full issue available free for subscribers or for purchase for non-subscribers on our website. Full subscriptions are also available. We’d love your feedback on this iPad download — please share your comments and questions in this survey. 9 Return to the Table of Contents. Clinical Pathway For Evaluation Of Suspected Malignant Epidural Spinal Cord Compression

Patient with back pain and history of malignancy

Normal neurological exam Abnormal neurological exam

Low suspicion of ESCC High suspicion of ESCC

Administer empiric steroids Excellent follow-up Unreliable follow-up (Class II)

Outpatient MRI or CT myelogram within Emergent MRI or CT myelogram 24 hours (Class III) (Class I)

No ESCC ESCC

Consider alternate diagnosis Admit; consult oncology, neurosurgery, and radiation oncology as appropriate

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.

Class I Class II Class III Indeterminate tatives from the resuscitation • Always acceptable, safe • Safe, acceptable • May be acceptable • Continuing area of research councils of ILCOR: How to De- • Definitely useful • Probably useful • Possibly useful • No recommendations until velop Evidence-Based Guidelines • Proven in both efficacy and • Considered optional or alterna- further research for Emergency Cardiac Care: effectiveness Level of Evidence: tive treatments Quality of Evidence and Classes • Generally higher levels of Level of Evidence: of Recommendations; also: Level of Evidence: evidence Level of Evidence: • Evidence not available Anonymous. Guidelines for car- • One or more large prospective • Non-randomized or retrospec- • Generally lower or intermediate • Higher studies in progress diopulmonary resuscitation and studies are present (with rare tive studies: historic, cohort, or levels of evidence • Results inconsistent, contradic- emergency cardiac care. Emer- exceptions) case control studies • Case series, animal studies, tory gency Cardiac Care Committee • High-quality meta-analyses • Less robust RCTs consensus panels • Results not compelling and Subcommittees, American • Study results consistently posi- • Results consistently positive • Occasionally positive results Heart Association. Part IX. Ensur- tive and compelling Significantly modified from: The Emergency Cardiovascular Care ing effectiveness of community- Committees of the American wide emergency cardiac care. Heart Association and represen- JAMA. 1992;268(16):2289-2295. This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care. Copyright © 2010 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC.

EmergencyFull issue Medicine available Practice free ©for 2010 subscribers or for purchase4 for non-subscribersEBMedicine.net on our •website. February 2010 Full subscriptions are also available. We’d love your feedback on this iPad download — please share your comments and questions in this survey. 10 Return to the Table of Contents. Clinical Pathway For The Management Of Hypercalcemia Of Malignancy

Hypercalcemia (Using correcteda or ionized serum calcium level)

10.3-11.2 mg/dL 11.3-13.5 mg/dL 13.5-17.9 mg/dL >18 mg/dL or >13.5 with neurological symptoms, renal failure, or CHF

No No Symptoms? Symptoms? symptoms? symptoms?

Contact oncology and discharge Initiate treatment with IVF, Begin treatment and contact Arrange emergent hemodialysis home (Class III) consider discharge home (Class II) oncology (Class III)

Aggressive IVF (Class II); Loop diuretics when euvolemic (Class III); Consider bisphosphonate (Class I)

aCorrected calcium level = Measured calcium level + 0.8 x (4.0 - Serum albumin level) Abbreviations: CHF, congestive heart failure; IVF, intravenous fluids.

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.

FullEmergency issue Medicineavailable Practice free for © 2010 subscribers or for purchase16 for non-subscribersEBMedicine.net on our website. • March 2010 Full subscriptions are also available. We’d love your feedback on this iPad download — please share your comments and questions in this survey. 11 Return to the Table of Contents. Clinical Pathway For Management Of Tumor Lysis Syndrome

Suspected clinical tumor lysis syndrome? Signs/symptoms: seizure, lethargy, vomiting, dysrhythmia, dehydration, oliguria Risk factors: lymphoproliferative or chemosensitive malignancy, large tumor bur- den, recent antitumor therapy, preexisting acute kidney injury, or hyperuricemia

YES

Perform the following diagnostic studies: chemistries; ionized calcium, uric acid, phosphate, LDH, and lactate levels; complete blood cell count, peripheral smear; urinalysis; ECG

Acute kidney injury Hypocalcemia Hyperphosphatemia Hyperuricemia Hyperkalemia (GFR < 60 mL/min or (≤ 7 mg/dL or 25% (≥ 4.5 mg/dL or 25% ≥ 8 mg/dL or 25% (≥ 6 meq/L or 25% creatinine > 1.5 mg/dL) decrease from baseline) increase from baseline; increase from baseline increase from baseline) ≥ 6.5 mg/dL in children)

Volume overload? Calcium gluconate Consult with oncologist Changes on ECG? (50-200 mg IV; Aluminum hydroxide to consider allopurinol (10 mg/kg/d orally NO NO only treat if patient is (50-150 mg/kg orally) symptomatic) Consider dialysis if divided q8 or 200-400 YES 2 (Class II) medically refractory mg/m IV, divided q12; Regular insulin (10 U) (Class II) renally dosed) with 50% dextrose Closely monitor Rasburicase (0.05-0.2 (50-100 mL, IV) urine output mg/kg IV; first discuss Consult a nephrologist Check finger stick Saline bolus (1-2 L) with oncologist) for dialysis before and after initially, then fluids (Class II) (Class II) Sodium bicarbonate with goal urine (50 mEq, IV) output > 3 L/day Albuterol (2.5-5.0 mg, unless patient has YES nebulized) congestive heart Sodium polystyrene failure or oliguric Calcium chloride (100- to (15-30 g orally /PR) renal insufficiency 200-mg IV push; repeat Dialysis (if refrac- (Class II) as needed) tory to medical (Class II) treatment) (Class II)

Abbreviations: ECG, electrocardiogram; IV, intravenously; PR, per rectum.

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.

EmergencyFull issue Medicine available Practice free ©for 2010 subscribers or for purchase12 for non-subscribersEBMedicine.net on our website. • March 2010 Full subscriptions are also available. We’d love your feedback on this iPad download — please share your comments and questions in this survey. 12 Return to the Table of Contents. Clinical Pathway For The Initial Management Of Neutropenic Fever

Fever (temperature ≥ 38.3°C [≥ 101ºF]) plus neutropenia (ANC < 500 cells/μL)

At risk for severe infection? (Class II)

YES NO

IV monotherapy NO Tolerates oral medications? (Class I)

YES

Vancomycin indicated? Meets MASCC criteria for outpatient management? NO (Class I)

YES NO YES

Add vancomycin Is patient critically ill or at Consider outpatient management with oral ciprofloxacin and (Class I) risk for multidrug-resistant amoxicillin/clavulanate organisms? (Class I)

YES NO

Add an aminoglycoside or a fluoroquinolone Admit (Class II)

Adapted with permission from Hughes et al, 2002 Guidelines for the Use of Antimicrobial Agents in Neutropenic Patients With Cancer, ©The University of Chicago Press.

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.

Full issue available free for subscribers or for purchase for non-subscribers on our website. Full subscriptions are also available. We’d love your feedback on this iPad download — please share your comments and questions in this survey. 13 Return to the Table of Contents. Clinical Pathway For Single APAP Ingestion

APAP ingestion

> 150 mg/kg* or < 150 mg/kg* Dose taken? unknown

If sure, discharge patient if no other medical clear- When taken? ance, psychiatric (eg, suicidality) concerns (Class II)

> 24 hr or < 1 hr 1-4 hr 4-8 hr 8-24 hr unknown time

Give single dose of Wait until 4 hr post Check serum APAP Start treatment with Check APAP, BMP, LFTs, AC (Class I) ingestion (Class I) level (Class I) NAC (Class I) coagulation levels

Will level be Abnormal labs? Check APAP, BMP, available < 8 hr post Symptomatic NO LFTs, coag levels ingestion? patient?

YES Start treatment with Toxic APAP level? NO NAC (Class I) Abnormal labs?

Once APAP level Is the patient is available, plot it symptomatic? on R-M Nomogram (Class I)

Toxic APAP concentration? Abnormal labs?

YES NO NO YES YES NO YES

Stop NAC and obtain Start/continue NAC psychiatric evaluation. Continue NAC Psychiatric Start NAC (Class II) (Class I) Discharge patient if (Class I) evaluation (Class III) cleared. (Class II)

*If patient is at a higher baseline risk for hepatotoxicity, use a value of 75 mg/kg.

Abbreviations: AC, activated charcoal; BMP, basic metabolic panel; LFT, liver function tests; NAC, N-acetylcysteine; R-M, Rumack-Matthew.

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Altered mental status or suspicion of toxic alcohol ingestion

1. Check ABCs 2. Provide IV line and oxygen as needed 3. Check fingerstick blood glucose 4. Question EMTs, family, and friends 5. Order toxicology consult or call local poison control center (1-800-222-1222)

Check serum osmolality, ethanol level, electrolytes, renal function, ABG, and methanol, isopropanol, and ethylene glycol levels (Class II)

See Clinical Pathway For Management High suspicion of isopropanol ingestion? YES Of Isopropanol Poisoning, on next page

See Clinical Pathway For Management Of Methanol And Ethylene Glycol Poisoning on next page

Abbreviations: ABCs, airway, breathing, circulation; ABG, arterial blood gas; EMT, emergency medical technician; IV, intravenous.

Class Of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.

Full issue available free for subscribers or for purchase for non-subscribers on our website. Full subscriptions are also available. We’d love your feedback on this iPad download — please share your comments and questions in this survey. 15 Return to the Table of Contents. Clinical Pathway For Management Of Methanol And Ethylene Glycol Poisoning

One or more of the following 1. Administer fomepizole 15 mg/ criteria?: kg (Class III) 2. Work up other reasons for • Anion gap > 12 presentation No, or toxic alcohol levels • Osmolar gap > 10 3. Consider isopropanol ingestion not readily available • Ethylene glycol > 20 mg/dL if there is ketosis and osmolar • Methanol > 20 mg/dL gap without other apparent • Evidence of metabolic acidosis cause (particularly without aci- • Evidence of renal failure dosis). See Clinical Pathway For Management Of Isopropa- YES nol Poisoning. 4. Admit to ICU

Administer fomepizole 15 mg/kg (Class II)

Ethylene glycol Methanol

1. Administer thiamine 100 mg IV 1. Administer folinic acid (leucov- AND administer pyridoxine 100 orin) 50 mg IV OR administer mg IV (Class III) folic acid 50 mg IV (Class III) 2. Order renal consult if 2. Order ophthalmologic consult • presentation is delayed, 3. Consider renal consult for • patient is acidemic, or potential hemodialysis if • there are signs of renal • ingestion is large, insufficiency • presentation is delayed, 3. Admit to ICU or • there are visual distur- bances 4. Admit to ICU

Clinical Pathway For Management Of Isopropanol Poisoning

Isopropanol ingestion

1. Administer proton-pump inhibitor (Class III) Is patient symptomatic? NO 2. Clear from a toxicologic standpoint

YES

1. Administer proton-pump inhibitor (Class III) 2. Admit to ICU vs general medical floor if • persistent CNS depression or • hemorrhagic gastritis

Abbreviations: CNS, central nervous system; ICU, intensive care unit; IV, intravenous.

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