Pain and dyspnea
Opioids are the mainstay of treatment
Choice of opioid based on provider preference, no trials to support one over another
Opioid naïve patients:
Consider starting doses of 1-2mg IV morphine or 0.2 to 0.4mg IV hydromorphone
May safely redose in 10 minutes
Opioid tolerant patients:
Consider starting with 10% of total daily opioid dose
Airway secretions
The “death rattle” tend to be more distressing to family members than to the patients themselves
Discontinue non-essential IV fluids or enteral feedings
Position the patient on his or her side
Glycopyrrolate (0.2 mg SC q4-6hrs, or 0.2 to 0.4 mg PO q8hrs
Generally preferred over atropine and scopolamine because of less central effects
Delirium
Haloperidol 0.5 to 1 mg haloperidol (PO, IV, IM, or SC),  repeat dose every 45 to 60 minutes titrated against symptoms
For patients with persistent agitated delirium, a single dose of lorazepam may be beneficial as an adjunct to haloperidol.
Opioids are the mainstay of treatment
Choice of opioid based on provider preference, no trials to support one over another
Opioid naïve patients:
Consider starting doses of 1-2mg IV morphine or 0.2 to 0.4mg IV hydromorphone
May safely redose in 10 minutes
Opioid tolerant patients:
Consider starting with 10% of total daily opioid dose
Consider starting doses of 1-2mg IV morphine or 0.2 to 0.4mg IV hydromorphone
May safely redose in 10 minutes
Consider starting with 10% of total daily opioid dose
The “death rattle” tend to be more distressing to family members than to the patients themselves
Discontinue non-essential IV fluids or enteral feedings
Position the patient on his or her side
Glycopyrrolate (0.2 mg SC q4-6hrs, or 0.2 to 0.4 mg PO q8hrs
Generally preferred over atropine and scopolamine because of less central effects
Generally preferred over atropine and scopolamine because of less central effects
Haloperidol 0.5 to 1 mg haloperidol (PO, IV, IM, or SC),  repeat dose every 45 to 60 minutes titrated against symptoms
For patients with persistent agitated delirium, a single dose of lorazepam may be beneficial as an adjunct to haloperidol.
End of life care
Goals of care
Palliative medicine
Poison control
Post cardiac arrest care
Tactical combat casualty care
Tactical field care
Involuntary psychiatric hold