Indicated in pheochromocytoma hypertensive crisis, extravasation of norepinephrine/epinephrine, hypertensive emergency with end organ damage secondary to cocaine toxicity not responsive to appropriate sedation
Concerns: hypotension, medication safety
Levocarnitine
Antidote to valproic acid
Give when: moderate to severe hyperammonemia, valproate level >450, CNS depression, severe hepatotoxicity
Naloxone for clonidine reversal
Big doses- 10mg
Consider for reversal of CNS depression
Fluids and vasopressors may also be required
Benzodiazepines
Midazolam: IV onset of action 2 min
Lorazepam: onset of action 5-20 minutes
Physostigmine
Reversal of anticholinergic toxicity
Primarily for agitation and delirium reversal
MOA: inhibits acetylcholinesterase and prolongs the central and peripheral effects of acetylcholine
Have physician and atropine at bedside
No significant risk of seizures
Low dose, push slow
Flumazenil
Benzodiazepine overdose or reversal only
Competitively inhibits activity of BZ receptor site on GABA/BZ receptor complex
Not effective on other medications that affect GABA
Concerns
Could precipitate withdrawal seizures if patient regularly uses benzos
Seizure history outside of withdrawal seizures
Risk vs benefit–goal of therapy
Project ECHO
Optimal Aging Clinic will be added to discharge follow up options
Have a “what matters” conversation
Advance Directives
Living will
POA
POLST/MOST
EMS DNR
Advanced care planning–ICD code, must spend 16 minutes to bill
MOST form
A physician’s order
Must be honored by all KY healthcare providers in all KY settings
State of KY Hierarchy of Decision making authority if no advance directives
Court appointed guardian
Healthcare surrogate
Spouse
Adult children
Parents
Adult siblings
Closest living relative
ECMO (Ritchie)
Components
Motor/pump
Filter/oxygenator
Blender
Ventilation–to increase, go up on gas flow aka sweep
Oxygenation–to increase, go up on blood flow aka flow