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.

LV Filling Pressure (E/e') Mini-Calculator (reduced EF logic included)

LV Filling Pressure (E/e') — Minimal Inputs

LVEF (%) Mitral E (cm/s) Septal e' (cm/s) — optional Lateral e' (cm/s) — optional

Copied.

Computed ratios: —

Interpretation: Enter values and click Calculate.

Conclusion: —

How it works / reminders

• Uses E/e' septal and/or E/e' lateral from your inputs.
• Lateral: normal < 8; elevated > 12; 8-12 indeterminate.
• Septal: normal < 8; elevated > 15; 8-15 indeterminate.
• Normal EF (>= 50%): low E/e' can support normal filling; elevated E/e' supports elevated filling.
• Reduced EF (< 50%): elevated E/e' supports elevated filling; low/normal E/e' does not exclude elevated filling.
• Formal grading needs LA volume index and TR velocity.

Diastolic Dysfunction Classifier for Normal LVEF and detemination Filling Pressures for Myocardial Disease or Low LVEF

ASE 2016 – Diastolic Function (Normal EF) Classifier

Fill in what you have. Missing items are not counted in the denominator. Thresholds reflect ASE 2016.

Average E/e' ratio

Abnormal if > 14

TR peak velocity (m/s)

Abnormal if > 2.8 m/s

LA volume index (mL/m²)

Abnormal if > 34 mL/m²

Mitral annular e' velocity (cm/s)

Abnormal if < 7

Abnormal if < 10

This counts as one variable. If either septal or lateral meets the abnormal cutoff, this variable is positive.

How it works (ASE 2016 logic)

Applies only to patients with normal LVEF. Four variables are evaluated and only the ones you filled in are counted:

• Average E/e' ratio > 14
• Mitral annular e' velocity reduced: septal e' < 7 cm/s or lateral e' < 10 cm/s (counts as one variable)
• TR peak velocity > 2.8 m/s
• LA volume index > 34 mL/m²

Decision rule (use only the available variables):

• > 50% of available variables are positive → Diastolic dysfunction present
• = 50% positive → Indeterminate
• < 50% positive → Normal diastolic function

ASE 2016 – Diastolic Function Grading (Reduced EF / Myocardial Disease)

Start with mitral inflow (E and A). Use supportive criteria only when needed. Missing items are not counted; PV S/D can substitute when one main item is unavailable.

Mitral E velocity (cm/s)

Used with E/A and the 50 cm/s threshold

Mitral A velocity (cm/s)

E/A is computed from E ÷ A

Average E/e' ratio

Abnormal if > 14

TR peak velocity (m/s)

Abnormal if > 2.8 m/s

LA volume index (mL/m²)

Abnormal if > 34 mL/m²

Pulmonary vein S/D ratio (optional)

Abnormal if < 1; used only when one main item is missing

How it works (ASE 2016 logic)

For reduced EF or myocardial disease & sinus rhythm:

• E/A ≤ 0.8 and E ≤ 50 cm/s → Grade I
• E/A ≥ 2 → Grade III
• Else (E/A ≤ 0.8 with E > 50, or 0.8 < E/A < 2): evaluate 3 supportive criteria: Avg E/e' > 14, TR Vmax > 2.8 m/s, LAVI > 34 mL/m².

Supportive decision (use only available items; PV S/D < 1 may substitute when one main item is unavailable):

• 2 or 3 positive → Grade II (pseudonormal)
• 0 or 1 positive → Grade I
• If only one supportive item available → Indeterminate

Use of of Antiarrhytmics in the ICU for Atrial Fibrillation : Sepsis and Septic Shock

Preferred Caution / Consider Avoid (or avoid in shock)

Drug	Typical ICU Dose	Onset	Hemodynamically Unstable Role	Hemodynamically Stable Role	Contraindications (major)	Sepsis / ICU Notes
Propafenone (Class IC)	IV: 2 mg/kg over 10–20 min (max ~150 mg) (IV availability varies) PO (pill-in-the-pocket): 600 mg once (only for truly stable, preserved LV function)	Minutes–hours (IV); hours (PO)	Caution Consider only if EF normal, no structural heart disease, ischemia excluded, and BP supported; avoid otherwise.	Preferred (select) Rapid rhythm conversion if no structural heart disease, EF normal, and sepsis physiology allows.	Structural heart disease, LV dysfunction, recent MI, significant conduction disease w/o pacer	In septic shock with preserved LV, shown to convert faster and with fewer recurrences than amiodarone; niche use only.
Ibutilide (Class III)	>60 kg: 1 mg IV over 10 min ≤60 kg: 0.01 mg/kg IV over 10 min May repeat once after 10 min if no conversion	~20–30 min	Caution Cardioversion first; consider if CV fails/unavailable and QTc acceptable.	Preferred Very effective for recent-onset AF/AFL; continuous ECG monitoring required.	Baseline QTc > 440–450 ms, history of torsades, severe LV dysfunction, recent MI	High torsades risk in sepsis; correct K > 4.0 and Mg > 2.0 before dosing; monitor ≥ 4 h post-dose.
Amiodarone (Class III)	Load: 150 mg IV over 10 min (may repeat) Infusion: 1 mg/min x 6 h → 0.5 mg/min x 18 h Oral: 200–400 mg daily	~1–2 h for rate; slower for conversion	Preferred Useful when hypotensive or after failed cardioversion; watch for bradycardia/hypotension.	Caution Versatile when others fail/contraindicated; slower conversion than ibutilide.	Severe bradycardia, high-grade AV block w/o pacer, true iodine allergy	Common in ICU; observational data suggest β-blockers may have mortality benefit for rate control when BP tolerates.
Esmolol (β1-blocker)	500–1000 mcg/kg IV bolus → 50–200 mcg/kg/min infusion (titrate)	Minutes	Avoid in shock May worsen hypotension; consider only if BP supported and need tight rate control.	Preferred Rate control with outcome benefits in sepsis if BP tolerates; rapid titration.	Bradycardia, hypotension, severe bronchospasm, acute decomp HF	Very short half-life allows fine control; reassess frequently as sepsis evolves.
Landiolol (β1-blocker)	Start 1 mcg/kg/min → titrate to HR goal (often up to ~10 mcg/kg/min)	Minutes	Caution Less hypotension than esmolol, but still use carefully in unstable shock.	Preferred Rapid HR control with minimal BP drop; availability varies by region.	Similar to esmolol (bradycardia, hypotension, bronchospasm, acute decomp HF)	Good option in septic AF with borderline BP when available.
Digoxin (cardiac glycoside)	IV load total 8–12 mcg/kg: give 50% initially, then 25% q6h x 2 doses Adjust for renal function; monitor levels and conduction.	Hours	Caution / Adjunct Useful for rate control in LV dysfunction with hypotension; not a converter.	Adjunct Slower rate control; combine with other agents as needed.	2nd/3rd-degree AV block w/o pacer, WPW with AF, digoxin toxicity	Less effective in high sympathetic tone early in sepsis; minimal BP effect makes it attractive in hypotension.
Diltiazem (Cardizem, non-DHP CCB)	IV bolus: 0.25 mg/kg over 2 min → may repeat in 15 min at 0.35 mg/kg Maintenance: 5–15 mg/h infusion	Minutes	Avoid in shock Can worsen hypotension; avoid in severe LV dysfunction.	Preferred Effective rate control in stable patients with preserved BP.	Severe LV dysfunction (EF < 40%), hypotension, WPW with AF, bradycardia, AV block	Rapid rate control in stable AF; hypotension frequently limits use in septic ICU patients.
Verapamil (non-DHP CCB)	IV bolus: 2.5–5 mg over 2 min; may repeat 5–10 mg after 15–30 min Maintenance: 5–10 mg/h infusion	Minutes	Avoid in shock Negative inotropy/vasodilation may worsen hemodynamics.	Caution Can control rate in stable AF, but more hypotension risk than diltiazem.	Severe LV dysfunction, hypotension, WPW with AF, bradycardia, AV block	Less favored in septic AF due to hypotension risk; avoid in severe LV dysfunction.

Practical pearls: Treat sepsis source, correct hypoxia/acidosis, and replete electrolytes (target K > 4.0, Mg > 2.0) before pharmacologic conversion. In true hemodynamic instability, electrical cardioversion remains first-line; drugs here are adjuncts or alternatives when CV fails or is not feasible.

Bites & Envenomation Quick Guide

Clinical reference for domestic and wild exposures (USA / North Carolina focus). Tap any blue bar to expand details. No JavaScript required.

Section A — Quick Reference

Category	Common Example	Scientific Name	Key Risks	Details
Domestic (Mammal)	Cat	Felis catus	Deep punctures; Pasteurella multocida	View Treatment Copious irrigation; gentle debridement. Prophylaxis: amoxicillin–clavulanate 875/125 mg PO BID × 5–7 days. Beta-lactam allergy: see “Antibiotic Alternatives” below. Tetanus booster if >5 years; rabies PEP if cat unavailable for observation/testing.
Domestic (Mammal)	Dog	Canis lupus familiaris	Crush/tear injuries; mixed flora	View Treatment Irrigation; debride devitalized tissue; explore for tendon/joint violation. Amoxicillin–clavulanate first-line; consider broader coverage for hand wounds, deep punctures, or immunocompromise. Tetanus update; rabies risk assessment. Primary closure often acceptable except high-risk locations (e.g., hand).
Human	Closed-fist injury (“fight bite”)	Homo sapiens	Eikenella corrodens; joint inoculation risk	View Treatment Avoid primary closure on the hand; evaluate for tendon, joint, bone involvement; consider imaging. Oral: amoxicillin–clavulanate. IV: ampicillin–sulbactam if needed. Beta-lactam allergy: see “Antibiotic Alternatives.” Tetanus update; assess blood-borne pathogen exposure as indicated.
Arthropod (Tick)	Blacklegged tick	Ixodes scapularis	Lyme, babesiosis, anaplasmosis	View Treatment Remove with fine-tipped tweezers at skin line; steady upward traction. Lyme prophylaxis: doxycycline 200 mg PO once within 72 h if high-risk criteria met (engorged Ixodes, attachment ~≥36 h, local risk supports PEP). Observe for rash/systemic symptoms for 30 days.
Arthropod (Spider)	Black widow	Latrodectus mactans	Neurotoxin; pain, spasm	View Treatment Supportive care; opioids for pain; benzodiazepines for spasm. Antivenom for severe/refractory cases after risk-benefit discussion.
Arthropod (Spider)	Brown recluse	Loxosceles reclusa	Local necrosis; systemic loxoscelism uncommon	View Treatment Local care, analgesia; avoid early wide excision. Delayed debridement if needed; evaluate for hemolysis if systemic signs.
Reptile (Snake)	Copperhead	Agkistrodon contortrix	Common NC envenomation; local pain/swelling	View Treatment Immobilize limb; remove constrictive items; keep at heart level. Hospital eval; antivenom if progressive swelling, systemic toxicity, or coagulopathy. Avoid incision, suction, ice, tourniquets.

Section B — Expanded Species List (USA / North Carolina Focus)

Common Name	Scientific Name	Risk Notes	Details
Raccoon	Procyon lotor	Rabies reservoir in NC	View Treatment Immediate soap/water wash; irrigate thoroughly. Rabies PEP unless the animal tests negative via public health. Tetanus booster as indicated.
Bat (various)	Chiroptera	Rabies risk; wounds may be occult	View Treatment Rabies PEP if bat not available for testing or exposure cannot be ruled out (asleep in room with bat, child, intoxicated, cognitively impaired). Tetanus update.
Cottonmouth (Water Moccasin)	Agkistrodon piscivorus	Hemotoxic venom; tissue injury	View Treatment Immobilize; prompt hospital care; serial limb measurements. Antivenom if progression/systemic effects. Labs: CBC, BMP, PT/INR, fibrinogen, CK.
Eastern Diamondback Rattlesnake	Crotalus adamanteus	Severe envenomation; coagulopathy risk	View Treatment Immobilize limb; rapid transport; avoid harmful field techniques. Antivenom per protocol; monitor for recurrent coagulopathy.
Timber Rattlesnake	Crotalus horridus	Hemotoxic ± neurotoxic effects	View Treatment Hospital observation; antivenom guided by progression. Continuous cardiopulmonary and coagulation monitoring.
Eastern Coral Snake (regional)	Micrurus fulvius	Neurotoxic; cranial nerve/respiratory risk	View Treatment Rapid evaluation; observe for delayed neurotoxicity. Antivenom if available/indicated; airway support as needed.
American Dog Tick	Dermacentor variabilis	RMSF vector in NC	View Treatment Prompt tick removal; do not crush body. Empiric doxycycline for suspected RMSF regardless of age when clinically indicated.
Black Widow	Latrodectus mactans	Pain, spasm, autonomic symptoms	View Treatment Analgesia and benzodiazepines; consider antivenom for severe cases with shared decision making.
Brown Recluse	Loxosceles reclusa	Necrotic ulcers possible; true bites uncommon in NC	View Treatment Local care, tetanus as indicated, delayed debridement if necessary. Assess for hemolysis/systemic symptoms if suspected.

Antibiotic Alternatives for Penicillin Allergy

Show Allergy-Safe Regimens for Mammalian Bites

Goal coverage: Pasteurella spp., streptococci, staphylococci (consider community MRSA), and oral anaerobes. Tailor to severity, site, comorbidities, and local stewardship.

• Adults (oral):
  • Doxycycline + metronidazole
  • Clindamycin + ciprofloxacin or clindamycin + levofloxacin
  • Moxifloxacin monotherapy (adults only; check QT/pregnancy)
  • Trimethoprim–sulfamethoxazole + metronidazole
• Adults (IV):
  • Clindamycin + a fluoroquinolone for severe beta-lactam allergy
  • Doxycycline + metronidazole if appropriate/available IV
  • Non-anaphylactic PCN reactions: consider ceftriaxone + metronidazole per allergy history/stewardship
• Pediatrics: discuss with pediatrics/ID for age-specific dosing; options may include TMP-SMX + clindamycin or TMP-SMX + metronidazole tailored to Pasteurella, streptococci, and anaerobes.
• Human bites (hand/closed-fist): adult options include clindamycin + ciprofloxacin, clindamycin + levofloxacin, or doxycycline + metronidazole; ensure early surgical eval for suspected joint/tendon sheath violation.
• Duration: typically 3–5 days for prophylaxis of high-risk wounds; 5–7+ days for infection, extended per clinical course.

Notes: Avoid fluoroquinolones in pregnancy when possible; moxifloxacin not for children. Doxycycline generally avoided in pregnancy (short courses for certain tick-borne illnesses are exceptions). Adjust for renal function/drug interactions.

North Carolina Rabies PEP Quick Flow

Show PEP Decision Steps & Dosing

1. Immediate wound care: Wash with soap/water; irrigate copiously.
2. Animal type & availability:
   • Dog/cat/ferret healthy & available: 10-day observation; PEP only if animal becomes ill or cannot be observed.
   • Wild carnivores (raccoon, fox, skunk) or bats: if exposure possible and animal not promptly testable, begin PEP; coordinate with public health.
   • Others (livestock, small rodents, lagomorphs): consult public health.
3. Exposure scenarios: Bite or saliva to mucosa/broken skin = exposure. Bat encounters where a bite can’t be ruled out = treat as exposure.
4. PEP (not previously vaccinated):
   • Vaccine IM on days 0, 3, 7, 14 (deltoid adults; anterolateral thigh young children).
   • HRIG 20 IU/kg once on day 0: infiltrate into/around wounds; remainder IM at a site distant from vaccine.
   • Immunocompromised: add day-28 vaccine dose; verify response per public health.
5. PEP (previously vaccinated or pre-exposed): vaccine IM on days 0 and 3; no HRIG.
6. Coordination: contact your local NC health department for testing/exposure classification and schedule support.

Administration tips: Separate syringes/sites for vaccine and HRIG; don’t mix; avoid gluteal vaccine administration.

Abbreviation Key

Show Medical Abbreviation Key

• PEP: Post-exposure prophylaxis
• PO: By mouth
• IV: Intravenous
• IM: Intramuscular
• BID: Twice daily
• TID: Three times daily
• q (e.g., q8h): Every (every 8 hours)
• RMSF: Rocky Mountain spotted fever
• CK: Creatine kinase
• NC: North Carolina

Always follow local public health guidance. Adjust choices for renal function, pregnancy, pediatrics, allergies, and antimicrobial stewardship.