RVSP/Pulmonary Hypertension Workup – Quick Reference

RVSP / PH Workup – Quick Reference

Enter what you have (TR Vmax and RAP, or RVSP and RAP). The tool will solve the missing value, classify PH likelihood, and suggest next steps.

Inputs

TR Vmax

m/s

RAP

mmHg

RVSP

mmHg

Assume no RVOT/PR obstruction (PASP ≈ RVSP)

Formula: RVSP = 4 × (TR Vmax)² + RAP

Supportive Echo Signs (check what’s present)

Category A – RV/RA

RV basal diameter > 41 mm
RA area > 18 cm²
TAPSE < 17 mm
S′ (TDI) < 9.5 cm/s
RV FAC < 35%

Category B – Septum/LV

Septal flattening (D-shaped LV)
LV eccentricity index > 1.1

Category C – PA/IVC

PA diameter > 25 mm
IVC > 21 mm with poor collapse
PAAT < 105 ms (if available)

Symptoms / Context (optional)

Unexplained dyspnea
Syncope/presyncope
Signs of right-sided congestion

Risk for CTEPH (prior PE/DVT)
Connective tissue disease, portal HTN, HIV, drugs/toxins
Chronic lung/OSA/ILD

Results

Enter values and click Calculate.

Suggested Next Step

Action — will populate after calculation —

Reference cutoffs & logic (tap to view)

• TR Vmax ≤ 2.8 m/s (RVSP ≲ 36 mmHg with RAP 3–5): PH unlikely.
• TR Vmax 2.9–3.4 m/s (RVSP ~ 37–50 mmHg): PH possible.
• TR Vmax > 3.4 m/s (RVSP > 50 mmHg): PH likely.
• Upgrade suspicion if ≥2 supportive signs across ≥2 categories (A/B/C).
• Assume PASP ≈ RVSP only if no RVOT obstruction or significant PR.

Ketamine

Ketamine in the ICU – quick reference

Adult dosing; light background for readability. Use with your fentanyl ± dexmedetomidine plan; avoid large rapid boluses if hypertension is a concern.

Indications (ICU and ED)

• Analgesia Sub-dissociative opioid-sparing pain control in trauma, burns, post-op abdominal pain, opioid tolerance/hyperalgesia, neuropathic pain.
• Sickle crisis Vaso-occlusive crisis pain when opioid-sparing is needed or allodynia limits opioid escalation.
• Procedural sedation Short painful procedures, dressing changes, reductions.
• RSI/induction Especially in hypotensive trauma or with bronchospasm.
• ICU sedation Analgosedation adjunct or alternative to propofol/benzodiazepines.
• Status asthmaticus Bronchodilation and improved ventilation.
• Refractory status epilepticus NMDA antagonism for seizure control.
• Severe agitation Excited delirium rescue with airway-ready monitoring.
• Status migrainosus Rescue in selected protocols.
• Alcohol withdrawal Refractory cases as adjunct to standard care.
• Psychiatry Treatment-resistant depression (protocolized settings).

Dosing cheat sheet

• Analgesia (sub-dissociative): bolus 0.1–0.3 mg/kg IV given slowly; infusion 0.1–0.3 mg/kg/hr (≈1.7–5 mcg/kg/min). Titrate by 0.05–0.1 mg/kg/hr q15–30 min.
• Sickle cell VOC pain: same sub-dissociative dosing; avoid large/rapid boluses if BP/HR sensitive.
• Procedural sedation: 0.5–1 mg/kg IV over 1–2 min, then 0.25–0.5 mg/kg IV q5–10 min PRN. IM 3–5 mg/kg if no IV.
• RSI/induction: 1–2 mg/kg IV once (lower end if shocked/on pressors).
• ICU maintenance sedation: 0.3–1 mg/kg/hr; short-term up to 2 mg/kg/hr with close monitoring.
• Status asthmaticus: 0.5–1 mg/kg IV once, then 0.5–1 mg/kg/hr.
• Refractory status epilepticus: load 1–2 mg/kg IV, then 1–5 mg/kg/hr (protocols up to 10 mg/kg/hr to EEG target).
• Severe agitation/excited delirium: 4–5 mg/kg IM or 1–2 mg/kg IV with airway-ready monitoring.
• Status migrainosus: 0.2–0.3 mg/kg IV once or infusion 0.1–0.3 mg/kg/hr for 3–6 hr.
• Refractory alcohol withdrawal: 0.3 mg/kg IV then 0.3–0.5 mg/kg/hr as adjunct to standard therapy.

Units crosswalk: 0.1 mg/kg/hr ≈ 1.7 mcg/kg/min. Use kg weight and round to practical infusion rates.

Practical pearls and safety

• Hemodynamics: mild–moderate ↑BP/↑HR, most after bolus; prefer slow small boluses or start a low infusion if hypertension is a concern.
• Catecholamine depletion: late sepsis/critical illness can unmask myocardial depression → BP may fall; start low and be ready to support.
• Airway/secretions: hypersalivation common → suction first; consider glycopyrrolate 0.2 mg IV PRN.
• CNS: dysphoria/emergence reactions are dose/rate-related; avoid rapid pushes; tiny GABAergic rescue if needed.
• Gut: generally motility-neutral—useful when ileus risk makes anticholinergics undesirable.
• Combinations: plays well with opioids; dexmedetomidine offsets tachy/HTN and improves sleep continuity.
• Titration: adjust q15–30 min to pain/RASS/BP/HR; continuous ECG/SpO₂; capnography preferred with opioids.
• Renal/hepatic: no renal adjustment; go slow in hepatic impairment/cirrhosis.

Contraindications and cautions

• Absolute: known ketamine or formulation allergy.
• Strong cautions: uncontrolled HTN; acute aortic dissection; active ischemia/severe CAD; tachyarrhythmias; severe pulmonary HTN; ICH/SAH where BP surges are hazardous.
• Neuropsychiatric: severe psychosis/mania—use only if benefits outweigh risks with close monitoring.
• Endocrine: pheochromocytoma or untreated thyrotoxicosis → exaggerated sympathetic response.
• Pregnancy: use only when benefits outweigh risks and after OB consult.
• Peri-MI/HOCM: avoid large boluses; prefer slow titration.

If severe hypertension, chest pain, ischemic ECG changes, or distressing dysphoria occurs, pause and treat; resume at a lower rate or consider an alternative.

Monitoring and hold parameters

• Continuous ECG and pulse oximetry; use capnography when combined with opioids.
• Check BP/HR every 5 min during bolus and every 15 min during titration.
• Hold or reduce for: new chest pain/ischemic ECG, severe uncontrolled HTN, sustained HR above target, intolerable dysphoria, or SpO₂ < 92% despite support.

Indications and Dosing Ketamine

Ketamine in the ICU – quick reference

Adult dosing, scoped for your blog’s dark theme. Aim for analgesia first, sleep with dexmedetomidine if desired, and avoid large rapid boluses when hypertension is a concern.

Indications (ICU and ED)

• Analgesia Sub-dissociative opioid-sparing pain control in trauma, burns, post-op abdominal pain, opioid tolerance or hyperalgesia, neuropathic pain.
• Sickle crisis Vaso-occlusive crisis pain when opioid-sparing is needed or allodynia limits opioid escalation.
• Procedural sedation Short painful procedures, dressing changes, reductions.
• RSI/induction Especially in hypotensive trauma or when bronchospasm is present.
• ICU sedation Analgosedation adjunct or alternative to propofol/benzodiazepines.
• Status asthmaticus Bronchodilation and improved ventilation.
• Refractory status epilepticus NMDA antagonism for seizure control.
• Severe agitation Excited delirium rescue with airway-ready monitoring.
• Status migrainosus Rescue in selected protocols.
• Alcohol withdrawal Refractory cases as adjunct to standard care.
• Psychiatry Treatment-resistant depression (protocolized settings).

Dosing cheat sheet

• Analgesia (sub-dissociative): bolus 0.1 to 0.3 mg/kg IV given slowly; infusion 0.1 to 0.3 mg/kg/hr (about 1.7 to 5 mcg/kg/min). Titrate by 0.05 to 0.1 mg/kg/hr every 15 to 30 min.
• Sickle cell VOC pain: same sub-dissociative dosing as above; consider avoiding large boluses to limit blood pressure and heart rate rise.
• Procedural sedation: 0.5 to 1 mg/kg IV over 1 to 2 min, then 0.25 to 0.5 mg/kg IV every 5 to 10 min as needed. IM 3 to 5 mg/kg when no IV.
• RSI/induction: 1 to 2 mg/kg IV once (use lower end if in shock or on vasopressors).
• ICU maintenance sedation: 0.3 to 1 mg/kg/hr; short-term up to 2 mg/kg/hr with EEG or close monitoring when needed.
• Status asthmaticus: 0.5 to 1 mg/kg IV once, then 0.5 to 1 mg/kg/hr.
• Refractory status epilepticus: load 1 to 2 mg/kg IV, then 1 to 5 mg/kg/hr (some protocols allow up to 10 mg/kg/hr) to EEG target.
• Severe agitation/excited delirium: 4 to 5 mg/kg IM or 1 to 2 mg/kg IV with airway-ready monitoring.
• Status migrainosus: 0.2 to 0.3 mg/kg IV once or infusion 0.1 to 0.3 mg/kg/hr for 3 to 6 hr.
• Refractory alcohol withdrawal: 0.3 mg/kg IV then 0.3 to 0.5 mg/kg/hr as adjunct to standard therapy.

Units crosswalk: 0.1 mg/kg/hr equals about 1.7 mcg/kg/min. Use weight in kilograms and round to practical infusion rates.

Practical pearls and safety

• Hemodynamics: expect mild to moderate rise in blood pressure and heart rate, most noticeable after bolus. Prefer slow small boluses or start a low infusion if hypertension is a concern.
• Catecholamine depletion: in late sepsis or prolonged critical illness, direct myocardial depression can dominate and blood pressure may fall. Start low and be ready to support.
• Airway and secretions: hypersalivation is common. Glycopyrrolate 0.2 mg IV can be used if needed. Laryngospasm is rare and usually linked to large rapid pushes.
• CNS effects: dysphoria or emergence reactions are dose and rate related. Reduce risk by avoiding rapid pushes; a small dose of a GABAergic agent can help if required.
• Gut: generally neutral for motility and a useful adjunct when ileus risk makes anticholinergic sedatives undesirable.
• Combinations: pairs well with opioids for analgesia. Dexmedetomidine can offset tachycardia and hypertension and improve sleep continuity.
• Titration: adjust every 15 to 30 min based on pain scores, RASS, blood pressure, and heart rate. Use continuous cardiac and pulse oximetry monitoring. Capnography is preferred when also using opioids.
• Renal and hepatic: no renal adjustment; in hepatic impairment or cirrhosis use lower doses and slower titration.

Contraindications and cautions

• Absolute: known ketamine or formulation allergy.
• Strong cautions: uncontrolled hypertension; acute aortic dissection; severe coronary disease with active ischemia; tachyarrhythmias; severe pulmonary hypertension; intracranial hemorrhage or subarachnoid hemorrhage where blood pressure surges are hazardous.
• Neuropsychiatric: history of severe psychosis or mania may worsen; use only if benefits outweigh risks with close monitoring.
• Endocrine: pheochromocytoma or untreated thyrotoxicosis can have exaggerated sympathetic responses.
• Pregnancy: use only when benefits outweigh risks and after obstetric consultation.
• Peri-MI and HOCM: avoid large boluses; prefer slow titration to limit demand ischemia or dynamic obstruction.

If severe hypertension, chest pain, ischemic ECG changes, or distressing dysphoria occurs, pause titration and treat the cause. Resume at a lower rate or consider an alternative.

Monitoring and hold parameters

• Continuous ECG and pulse oximetry. Use capnography when combined with opioids.
• Blood pressure and heart rate at least every 5 min during bolus and every 15 min during titration.
• Hold or reduce for: new chest pain or ischemic ECG changes; severe uncontrolled hypertension; sustained heart rate above target; intolerable dysphoria; oxygen saturation under 92 percent despite support.

AE drugs ICU ( Phenobarbital missing)

Antiepileptic Drugs in ICU: IV vs Non-IV

Drug (Generic)	Brand	IV?	Primary ICU Role	Key Contraindications / Cautions
Levetiracetam	Keppra	Yes	First-line adjunct; broad spectrum; safe hemodynamics	Renal impairment (dose adjust); behavioral effects
Valproate	Depacon	Yes	Broad spectrum; myoclonus	Severe liver disease, pregnancy, hyperammonemia
Phenytoin / Fosphenytoin	Dilantin / Cerebyx	Yes	Convulsive status epilepticus; focal	Bradycardia, AV block, hypotension; arrhythmia risk
Lacosamide	Vimpat	Yes	Focal; easy IV loading	PR prolongation/AV block; cardiac monitoring
Phenobarbital	Luminal	Yes	Refractory status; sedation	Respiratory depression; hypotension; porphyria
Benzodiazepines	Lorazepam/Diazepam/Midazolam	Yes	First-line emergent seizure control	Resp depression; hypotension; oversedation
Topiramate	Topamax	No	Maintenance/adjunct	Metabolic acidosis; nephrolithiasis; glaucoma
Oxcarbazepine	Trileptal	No	Focal maintenance	Hyponatremia; cross-reactivity with carbamazepine
Carbamazepine	Tegretol	No	Chronic focal control	Hyponatremia; marrow suppression; drug interactions
Lamotrigine	Lamictal	No	Long-term adjunct; mood benefit	SJS/TEN risk; must titrate slowly
Zonisamide	Zonegran	No	Adjunct broad spectrum	Sulfa allergy; metabolic acidosis; renal stones
Gabapentin / Pregabalin	Neurontin / Lyrica	No	Neuropathic pain; adjunct	Renal dose adjust; sedation
Perampanel	Fycompa	No	Adjunct; GTC	Psych/behavioral adverse effects

Click to expand dosing/contraindications/ICU notes

Levetiracetam (Keppra)

Dosing (IV/PO): load 1–3 g IV once (commonly 1.5–2 g); maintenance 500–1500 mg q12h; max ~4.5 g/day; renal adjust.
Contraindications/Cautions: renal impairment (lower dose); behavioral effects (agitation/psychosis).
Primary benefits: broad spectrum, minimal interactions, stable hemodynamics.
ICU notes: excellent first add-on; safe with pressors/TTM.

Valproate (Depacon)

Dosing (IV/PO): load 20–40 mg/kg IV; maintenance 15–60 mg/kg/day divided q8–12h; target level 50–100 (up to 125 in ICU if needed).
Contraindications/Cautions: severe hepatic disease, pregnancy, mitochondrial disorders; risk hyperammonemia/pancreatitis; check LFTs, ammonia, platelets.
Primary benefits: generalized/myoclonic control; mood benefit; non-hypotensive.
ICU notes: avoid if hepatic failure or unexplained hyperammonemia; consider L-carnitine if ammonia rises.

Phenytoin / Fosphenytoin

Dosing: phenytoin load 15–20 mg/kg IV (rate <= 50 mg/min); fosphenytoin load 15–20 mg PE/kg IV (rate <= 150 mg PE/min). Maintenance 4–6 mg/kg/day divided; target total level 10–20 mcg/mL.
Contraindications/Cautions: bradycardia, AV block; hypotension/arrhythmias with rapid infusion; purple-glove risk (phenytoin).
Primary benefits: convulsive status epilepticus (after benzo); focal seizures.
ICU notes: prefer fosphenytoin IV for safer infusion; monitor ECG/BP; many drug interactions (enzyme induction).

Lacosamide (Vimpat)

Dosing (IV/PO): load 200–400 mg IV; maintenance 100–200 mg q12h (max 400 mg/day).
Contraindications/Cautions: PR prolongation/AV block, baseline conduction disease, concurrent PR-prolonging drugs.
Primary benefits: clean interaction profile; useful add-on in focal status.
ICU notes: place on telemetry during load and titration.

Phenobarbital (Luminal)

Dosing: load 15–20 mg/kg IV (can give additional 5–10 mg/kg); maintenance 1–5 mg/kg/day (or level-guided).
Contraindications/Cautions: respiratory depression, hypotension, porphyria; accumulation with hepatic failure.
Primary benefits: refractory status epilepticus; synergy with benzos.
ICU notes: may require airway control/vasopressors; enzyme inducer with many interactions.

Benzodiazepines (Lorazepam, Diazepam, Midazolam)

Emergency dosing: Lorazepam 4 mg IV (2 mg/min), repeat once in 10–15 min; Diazepam 5–10 mg IV q10–15 min (max 30 mg); Midazolam 10 mg IM if no IV.
Refractory infusion: Midazolam infusion per ICU protocol.
Cautions: respiratory depression, hypotension, delirium with prolonged use.
ICU notes: always first step in convulsive status epilepticus.

Topiramate (Topamax) — Oral only

Dosing (PO): 25–400 mg/day divided; go slow to avoid cognitive effects.
Cautions: metabolic acidosis, renal stones, angle-closure glaucoma, weight loss.
ICU notes: not for acute control; can be crushed/NG if needed.

Oxcarbazepine (Trileptal) — Oral only

Dosing (PO): 300 mg BID, titrate to 1200–2400 mg/day.
Cautions: hyponatremia (check Na), rash; cross-reactivity with carbamazepine.
ICU notes: no IV; not for status epilepticus.

Carbamazepine (Tegretol) — Oral only

Dosing (PO): often 200 mg BID, titrate to 800–1200 mg/day; monitor levels.
Cautions: hyponatremia, marrow suppression, strong enzyme inducer, HLA-B*1502 risk (SJS/TEN in certain ancestries).
ICU notes: avoid in acute setting; many drug interactions.

Lamotrigine (Lamictal) — Oral only

Dosing (PO): must titrate slowly (e.g., 25 mg/day and up) to avoid rash; adjust with valproate/enzyme inducers.
Cautions: SJS/TEN; interactions with valproate (increase levels).
ICU notes: not suitable for acute control; continuation med.

Zonisamide (Zonegran) — Oral only

Dosing (PO): 100–600 mg/day divided; slow uptitration.
Cautions: sulfonamide allergy, metabolic acidosis, stones, weight loss.
ICU notes: adjunct maintenance; not acute control.

Gabapentin / Pregabalin — Oral only

Dosing (PO): Gabapentin 300–3600 mg/day; Pregabalin 150–600 mg/day, both divided; renal adjust.
Cautions: sedation, ataxia; adjust for CrCl.
ICU notes: not for acute seizures; helpful for neuropathic pain.

Perampanel (Fycompa) — Oral only

Dosing (PO): 2–12 mg HS; adjust with enzyme inducers.
Cautions: irritability, aggression, dizziness; fall risk.
ICU notes: not acute; monitor behavior.

Hyperammonemia/ Refractory -Encepalopathy

Refractory Hyperammonemia / Hepatic Encephalopathy (ICU Algorithm)

Use when ammonia stays high or mental status isn’t improving (treat clinically; ammonia levels are supportive, not targets).

1) Immediate Actions & Goals

• Airway/O₂/CO₂ Optimize oxygenation/ventilation; check ABG/VBG.
• Stool goal Titrate therapy to 2–3 soft stools/day.
• Pain Adequate analgesia; avoid sedatives/anticholinergics.
• Electrolytes Correct hypokalemia & alkalosis.

2) Optimize Lactulose

• PO/NG: 20–30 g q1–2h until BM, then 10–20 g q6–8h (2–3 soft stools/day).
• PR (enema): 300 mL lactulose + 700 mL water/NS, retain 30–60 min, repeat q4–6h.
• Ensure no bowel obstruction; PEG-ELS if stool burden large.

3) Add Rifaximin

• Rifaximin 550 mg PO BID (start now if lactulose alone insufficient).
• If unavailable: short course neomycin or metronidazole (toxicity risk).

4) If Still High

• PEG-ELS 4 L over ~4h (rapid catharsis).
• L-ornithine L-aspartate (if available).
• Zinc if deficient.
• TIPS? Consider revision if recalcitrant HE.

5) Precipitant Checklist

• GI bleed / constipation / infection
• Electrolytes: ↓K⁺, alkalosis
• Renal failure / dehydration
• New meds: benzos, opioids, anticholinergics

6) Dialysis/CRRT

• Acute liver failure with cerebral edema or ammonia >150–200.
• Refractory HE with renal failure or volume overload.
• Urea cycle disorders, valproate toxicity.

Second Generation Anti-Psychotics for ICU Use

Note No SGA has an IV formulation. Short-acting IM options: olanzapine (Zyprexa), ziprasidone (Geodon), aripiprazole (Abilify). All antipsychotics carry a boxed warning for ↑ mortality in elderly patients with dementia-related psychosis.

Dosing & Frequency

• Start 12.5–25 mg PO q8–12h; ↑ by 12.5–50 mg/day to effect.
• Typical ICU total: 50–300 mg/day (divide). Often 50–100 mg HS plus small daytime doses.
• Usual max (delirium): 400–600 mg/day; titrate to sedation/orthostasis tolerance.

Onset & PK

• Onset of sedation ~1–2 h; t½ (IR) ~6 h.
• Hepatic metabolism (CYP3A4).

Contraindications/Cautions

• Orthostatic hypotension, somnolence; start low in frail or hepatic impairment.
• Boxed warning in dementia psychosis.

Interactions

• ↑ levels: strong CYP3A4 inhibitors (azoles, clarithromycin, ritonavir).
• ↓ levels: CYP3A4 inducers (carbamazepine, phenytoin, rifampin).

Monitoring

• RASS/oversedation, vitals, falls risk.
• ECG if QT risk/polypharmacy.
• Metabolic panel if >1–2 weeks (glucose, lipids); LFTs if prolonged use.

Tip Helpful for hyperactive/mixed delirium and sleep reversal; relatively low EPS.

Dosing & Frequency

• PO/ODT: 2.5–5 mg q12–24h; ↑ by 2.5–5 mg to 5–20 mg/day.
• IM (short-acting): 5–10 mg once; may repeat ≥2 h; max 30 mg/day.

Onset & PK

• IM onset ~15–45 min; PO ~1–2 h; t½ ~30 h.
• Lower QT effect vs ziprasidone/haloperidol.

Contraindications/Cautions

• Avoid IM within ~1 hour of parenteral benzodiazepines (respiratory/CNS depression).
• Anticholinergic burden; metabolic effects.

Interactions

• Smoking (CYP1A2 induction) ↓ levels; CNS depressants ↑ sedation.

Monitoring

• RASS/oversedation, airway after IM if combined sedatives.
• ECG if risk; metabolic labs if extended use.

Dosing & Frequency

• 0.5–1 mg PO q12h; ↑ by 0.5–1 mg every 12–24 h to 2–4 mg/day.
• Frail/renal/hepatic: consider 0.25–0.5 mg q12h start.

Onset & PK

• Onset 1–2 h; active metabolite t½ ~21 h.
• Renal/hepatic considerations for dose.

Contraindications/Cautions

• Orthostasis; ↑ prolactin/EPS risk; dementia boxed warning.

Interactions

• CYP2D6 inhibitors (fluoxetine, paroxetine) ↑ levels; additive QT agents.

Monitoring

• ECG if QT risk; EPS/AIMS; prolactin symptoms; renal/hepatic function.

Dosing & Frequency

• IM: 10 mg q2h or 20 mg q4h PRN; max 40 mg/day.
• PO: 20–40 mg BID with ≥500 kcal (not ideal in NPO/poor intake).

Contraindications/Cautions

• Contraindicated in known QT prolongation, recent MI, uncompensated HF, or significant arrhythmias. Correct K/Mg first.

Interactions

• Avoid other QT-prolongers (amiodarone, methadone, azithro/fluoroquinolones, ondansetron); caution with diuretics.

Monitoring

• ECG baseline/post-dose if risk; K/Mg; vitals; EPS/NMS surveillance.

Onset & PK

• IM onset ~15–30 min; notable QT liability.

Dosing & Frequency

• IM: 9.75 mg once (range 5.25–15 mg); may repeat q2h; max 30 mg/day.
• PO (delirium off-label): 2–5 mg daily → 5–10 mg/day.

Onset & PK

• IM onset ~1–3 h; very long t½ (~75–95 h including metabolite).
• Lower QT liability; risk of akathisia/activation.

Interactions

• CYP2D6/3A4 inhibitors ↑ levels (fluoxetine, paroxetine, azoles, macrolides); inducers ↓ levels (carbamazepine, rifampin).
• Consider dose adjustments per interaction strength.

Monitoring

• RASS; EPS/akathisia; ECG if risk; sedation vs activation balance.

Dosing & Frequency

• 3–6 mg PO daily (ER).
• Renal adjust: CrCl 50–80 → 3 mg daily (max 6); CrCl 10–50 → 1.5 mg daily (max 3).
• Depot forms are not for acute agitation.

Contraindications/Cautions

• Orthostasis; ↑ prolactin; dose per renal function.

Interactions & Monitoring

• Fewer CYP issues (active metabolite of risperidone); additive QT agents.
• ECG if risk; renal function; EPS/AIMS; prolactin symptoms.

Dosing & Frequency

• 5–10 mg SL q12h. No food/drink for 10 min after dose.

Cautions & Interactions

• Avoid severe hepatic impairment; oral hypoesthesia common.
• CYP1A2/2D6 interactions possible (smoking induction).

Monitoring

• RASS; EPS; ECG if QT risk; hepatic function if concern.

Dosing & Frequency

• 20–40 mg nightly with ≥350 kcal; may ↑ to 80 mg/day.
• Not ideal for rapid ICU control (slower onset).

Interactions & Monitoring

• Strong CYP3A4 inhibitors/inducers significantly alter levels (azoles/clarithro vs rifampin/carbamazepine).
• RASS; EPS; ECG if risk; basic metabolic monitoring if >1–2 weeks.

Cautions

• Akathisia; generally low metabolic/QT profile.

Dosing & Role

• Start 12.5 mg once–BID; ↑ by 25–50 mg/day. Not for acute ICU agitation initiation.

Major Safety

• REMS/ANC required; agranulocytosis, myocarditis, seizures, ileus, sialorrhea, orthostasis.

Interactions & Monitoring

• Multiple CYPs (1A2, 3A4, 2D6); smoking ↓ levels.
• ANC per program; ECG if risk; troponin/CRP early; bowel regimen/watch ileus.

Use case Continue home therapy if already established; avoid de-novo starts for agitation in ICU.

Dosing & Frequency

• Titration needed due to orthostasis: Day 1 1 mg BID → over several days to 6–12 mg BID.
• Not suited for rapid agitation control.

Cautions & Monitoring

• Orthostatic hypotension; moderate QT risk → ECG if risk.
• EPS checks.

Interactions

• CYP2D6/3A4 inhibitors ↑ levels; avoid additive QT agents.

Dosing & Frequency

• 0.5–1 mg daily; titrate to 2–3 mg/day; slower onset (maintenance role).

Interactions & Monitoring

• CYP2D6/3A4 inhibitors ↑ levels; inducers ↓ levels.
• RASS; EPS/akathisia; ECG if risk.

Notes

• Long t½ (~91 h); not ideal for fast titration.

Dosing & Frequency

• 1.5 mg daily → may ↑ to 3 mg; very long effective t½ (active metabolite up to weeks).

Cautions & Interactions

• Akathisia/insomnia; avoid for rapid control needs.
• Strong CYP3A4 inhibitors/inducers significantly alter levels.

Monitoring

• RASS; EPS; ECG if risk; watch for activation.

Dosing & Frequency

• 42 mg PO daily; not for acute agitation (slower onset).

Cautions & Interactions

• Somnolence; relatively low metabolic/QT profile; limited ICU data.
• Strong CYP3A4 inhibitors/inducers—avoid/adjust per label.

Monitoring

• RASS; EPS; ECG if risk; consider metabolic labs if extended use.

Safety Reconcile sedatives, opioids, and QT-prolonging drugs; correct K/Mg/Ca before agents with QT liability. No IV SGAs exist; short-acting IMs shown above are options for rapid control when appropriate.

Alcohol Withdrawel Treatment

CIWA-Ar Protocol (0–67 points)
First-line guide

0–9 (mild): supportive care; consider PRN benzodiazepine if symptoms evolve.
10–19 (moderate): medication indicated — symptom-triggered benzodiazepines preferred.
≥20 (severe): high seizure/DT risk — aggressive therapy, consider ICU, phenobarbital ± adjuncts.
Reassess CIWA every 1–2 hours. CIWA is unreliable in delirious/non-verbal ICU patients — use a sedation target (e.g., RASS) with a fixed/weight-based regimen.

Clinical context	First-line	Escalate / Add-on	Monitoring notes
Mild (CIWA 0–9), stable, outpatient or floor	Oral benzodiazepine PRN (chlordiazepoxide or lorazepam)	Short oral taper if symptoms persist or trend upward	Re-score q2–4h; thiamine, fluids, electrolytes
Moderate (CIWA 10–19), ED/floor	Symptom-triggered benzodiazepines (PO/IV)	If high needs/poor response: phenobarbital adjunct; clonidine for autonomic symptoms	Frequent CIWA; watch oversedation/hypoxia; correct Mg/K/PO4
Severe (CIWA ≥20), seizures, DTs, or rapid escalation	High-dose benzodiazepine strategy or phenobarbital-based regimen; ICU consult	Adjuncts: dexmedetomidine for agitation; haloperidol for psychosis (with benzo/barb); propofol if intubated	ICU-level monitoring pulse-ox ± capnography; use RASS-based titration

Benzodiazepines (first-line)

General: Symptom-triggered dosing guided by CIWA-Ar preferred when feasible.

Diazepam (PO/IV): 10–20 mg q1–2h PRN until calm/lightly drowsy (typical early cumulative 20–60 mg). In monitored settings for severe agitation: 5–10 mg IV q5–10 min to effect.
Lorazepam (PO/IV/IM): 2–4 mg q1–2h PRN; slower onset, safer in liver disease/elderly; typical early cumulative 8–16 mg.
Chlordiazepoxide (Librium) (PO): 25–50 mg q1–2h PRN; or fixed taper e.g., Day 1 total 50–100 mg, then 25–50 mg q6h; taper over 3–5 days.

Notes: Prefer long-acting agents (diazepam/chlordiazepoxide) for smoother course; choose lorazepam if significant hepatic dysfunction. Monitor respiration and mental status closely.

Phenobarbital (alternative/adjunct; refractory AWS)

Loading (IV): 10–15 mg/kg total, divided as 130–260 mg IV boluses q20–30 min to effect (stop with adequate sedation/adverse effects).
Maintenance: ~1–3 mg/kg/day (e.g., 60–120 mg IV/PO q12h) with clinical reassessment.
Use when: Severe AWS, benzodiazepine-resistant cases, or contraindication to benzos. Can be monotherapy protocols or combined with lower benzo doses.
Caution: Synergistic respiratory depression with benzos — use in monitored settings; avoid if significant respiratory compromise without airway support.

Dexmedetomidine (Precedex) — adjunct for agitation/autonomic surge

Infusion: Start 0.2–0.3 mcg/kg/hr; titrate ~0.7–1.2 mcg/kg/hr by agitation/hemodynamics. Avoid bolus.
Role: Reduces sympathetic hyperactivity and benzo needs in ICU. Does not prevent seizures — always pair with benzo and/or phenobarbital.
Watch: Bradycardia, hypotension; continuous monitoring required.

Propofol (ICU; intubated or impending airway)

Infusion: 5–10 mcg/kg/min, titrate as needed (often 10–50 mcg/kg/min).
Role: Rapid control of severe agitation/DTs in intubated patients; anticonvulsant properties.
Notes: Requires airway/ICU monitoring; monitor BP and triglycerides with prolonged use.

Antipsychotics (adjunct only; NOT monotherapy)

Haloperidol 2.5–5 mg IV/IM q4–6h PRN for severe hallucinations/psychosis; consider lower doses in elderly. Always with benzo/barb coverage (do not treat AWS pathophysiology alone; may lower seizure threshold).
Monitor: QTc/EPS; correct K/Mg first.

Autonomic symptom control: Clonidine

Clonidine 0.1–0.2 mg PO q6–8h (typical total 0.2–0.8 mg/day) or transdermal 0.1–0.3 mg/24h weekly.
Role: Controls tachycardia, hypertension, diaphoresis as adjunct. Not antiepileptic; not monotherapy for AWS.
Hold for: Hypotension, bradycardia.

Outpatient/mild adjuncts: Gabapentin, Carbamazepine, Valproate

Gabapentin 300 mg PO TID, titrate to 600 mg TID (renal dosing). Helps mild–moderate symptoms; may reduce benzo needs.
Carbamazepine 200 mg PO QID (day 1), then TID (days 2–3), then BID (days 4–5) — for selected mild–moderate cases; not for severe/DTs.
Valproate 250–500 mg PO/IV TID as adjunct in selected patients; avoid in liver disease, pregnancy, thrombocytopenia.

Supportive therapy (give thiamine before glucose when possible)

Thiamine:
• Prophylaxis (no strong Wernicke’s suspicion): 100 mg IV/IM once daily for 3–5 days, then 100 mg PO daily.
• Suspected/confirmed Wernicke’s: 200–500 mg IV every 8 hours for 2–3 days, then 250 mg IV/IM daily for 3–5 days, then 100 mg PO daily.
• Timing: Give thiamine before glucose when feasible. If hypoglycemic, give glucose immediately and administer thiamine as soon as possible thereafter.

Electrolytes/Fluids: Replete Mg (e.g., 1–2 g IV to keep > 2 mg/dL), K (target ~4–5 mEq/L), phosphate (target normal range), maintain euvolemia; add folate and multivitamins.

Specialist-guided adjunct: Ketamine (selected refractory cases)

Ketamine: infusion ~0.1–0.3 mg/kg/hr (± small bolus) to reduce benzo needs in refractory agitation; ICU monitoring required.
Note: Always combine with GABAergic therapy (benzodiazepine/phenobarbital). Monitor BP/HR and emergence phenomena.

Implementation tip: If CIWA cannot be obtained reliably (e.g., intubated/delirious), switch to a fixed-dose benzodiazepine or phenobarbital protocol with a sedation target (RASS), plus supportive care and seizure prophylaxis.