1. Oxygen — FIO2 0.6-1 should be given, either by face mask if the patient is spontaneously breathing, or via mechanical ventilation. Comatose patients should be intubated. Early CPAP or PEEP may be useful.

2. Bronchospasm is often present and may require nebulised p2 agonists, and either nebulised or SC epinephrine.

3. Fluid replacement should be directed by appropriate monitoring. Inotrope therapy may be necessary if hypoperfusion persists after adequate fluid resuscitation. Intravascular fluid overload is uncommon and the role of early diuretic therapy with a view to lowering intracranial pressure is controversial. Haemolysis may occur and require blood transfusion.

4. Arrhythmias may arise secondary to myocardial hypoxia, hypothermia and electrolyte abnormalities. These should be treated conventionally.

5. Metabolic acidosis may be profound, but sodium bicarbonate therapy is rarely indicated as the acidosis will usually correct on restoration of adequate tissue perfusion.

6. Electrolyte abnormalities are usually minor and should be managed conventionally.

7. Rewarming follows conventional practice; cardiopulmonary bypass may be considered if core temperature is <30°C. Cardiopulmonary resuscitation including cardiac massage should be continued until normothermia is achieved.

8. Cerebral protection usually follows raised intracranial pressure protocols though, as mentioned above, the role of diuretic therapy and fluid restriction is controversial. Signs of brain damage such as seizures may become apparent and should be treated as they arise.

9. Antibiotic therapy (e.g. clindamycin, or cefuroxime plus metronidazole) should be given if strong evidence of aspiration exists. Otherwise, take specimens and treat as indicated.

10. Decompress the stomach using a nasogastric tube to lessen any risk of aspiration. Enteral feeding can be initiated afterwards.


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