When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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EMERGENTEndocrinology

Adrenal Crisis

Acute cortisol deficiency → refractory hypotension, shock, and death if untreated. Most commonly from abrupt steroid withdrawal or physiologic stress in a patient with adrenal suppression. Give hydrocortisone first, diagnose later.

🔍 Overview

Common Causes

Category	Examples
#1 -Steroid withdrawal	Abrupt discontinuation of chronic steroids (≥ 3 weeks of prednisone ≥ 20 mg/day suppresses HPA axis). Patient gets sick, can't take oral meds, and crashes. Always taper steroids.
Primary adrenal insufficiency (Addison)	Autoimmune adrenalitis (#1 in developed world), TB (#1 worldwide), adrenal hemorrhage (Waterhouse-Friderichsen -meningococcemia), metastatic disease, drugs (ketoconazole, etomidate)
Secondary (pituitary)	Pituitary tumor/surgery/apoplexy, chronic steroid use suppressing ACTH, checkpoint inhibitor hypophysitis
Critical illness-related	Relative adrenal insufficiency in septic shock (adrenals cannot mount adequate cortisol response to stress)

Clinical Features

Hypotension refractory to fluids and vasopressors -the hallmark. Cortisol is required for vascular tone and catecholamine sensitivity.
Hyponatremia + hyperkalemia (primary AI -aldosterone deficiency). Secondary AI → hyponatremia only (aldosterone preserved).
Hypoglycemia -cortisol is needed for gluconeogenesis
Hyperpigmentation -primary AI only (↑ ACTH → ↑ MSH from POMC cleavage). Absent in secondary AI.
Fatigue, nausea, vomiting, abdominal pain, fever
Eosinophilia -cortisol normally suppresses eosinophils. Low cortisol → eosinophil count rises.

Think adrenal crisis in any patient with refractory hypotension + hyponatremia + hypoglycemia + eosinophilia -especially if on chronic steroids or has a history of autoimmune disease.

Diagnosis

Random cortisol: AM cortisol < 3 mcg/dL is diagnostic of AI. > 15–18 rules it out. Between 3–15 = indeterminate → cosyntropin stim test.
Cosyntropin (ACTH) stimulation test: Give 250 mcg cosyntropin IV/IM → check cortisol at 30 and 60 min. Cortisol < 18 mcg/dL = adrenal insufficiency.
ACTH level: ↑ ACTH = primary (adrenal failure). ↓ ACTH = secondary (pituitary failure).
In crisis: draw cortisol and ACTH, then treat immediately. Do NOT wait for results.

Use dexamethasone, not hydrocortisone, if you still need to run the cosyntropin stim test. Hydrocortisone cross-reacts with the cortisol assay and will invalidate the results. Dexamethasone provides glucocorticoid coverage while you treat the patient but does NOT interfere with the cortisol measurement, so you can give dex, stabilize the patient, and still get an accurate stim test.

🚨 Management

Acute Adrenal Crisis

Immediate

Hydrocortisone 100 mg IV bolus → then 50 mg IV q8h (or 200 mg/24h continuous infusion) Endocrine Society Guidelines, 2016. Do NOT wait for labs. Hydrocortisone at stress doses provides both glucocorticoid AND mineralocorticoid activity.

Volume resuscitation

Aggressive NS boluses -these patients are profoundly volume-depleted. D5NS if hypoglycemic. The hypotension often dramatically improves within 1–2h of hydrocortisone + fluids.

Treat precipitant

Infection is the most common trigger. Broad-spectrum antibiotics if sepsis suspected.

Taper

Once stable → taper hydrocortisone over 3–5 days to physiologic replacement: hydrocortisone 15–20 mg AM + 5–10 mg PM (or prednisone 5 mg AM). Add fludrocortisone 0.1 mg daily if primary AI (mineralocorticoid replacement).

Stress Dose Steroids -When to Give

Stress Level	Dose	Examples
Minor illness	Double daily dose × 2–3 days	Mild URI, dental procedure, minor stress
Moderate illness/surgery	Hydrocortisone 50 mg IV q8h × 1–2 days	Moderate surgery, pneumonia, GI illness with vomiting
Severe stress / major surgery / critical illness	Hydrocortisone 100 mg IV q8h	Major surgery, sepsis, trauma, ICU admission Endocrine Society, 2016

Any patient on chronic steroids (≥ 20 mg prednisone/day × ≥ 3 weeks in the past year) should be assumed to have HPA axis suppression and needs stress-dose steroids during acute illness/surgery. This includes patients who recently tapered off. When in doubt, give hydrocortisone -the risk of one dose is minimal, the risk of missing adrenal crisis is fatal.

📋 Clinical Example -Adrenal Crisis Management

Patient: 55M on chronic prednisone 20mg daily for PMR, admitted for pneumonia. Now day 2, found hypotensive (BP 72/48), lethargic, Na 128, K 5.8, glucose 52.
Recognition: This is adrenal crisis -he is on chronic steroids (HPA axis suppressed) and the pneumonia is a physiologic stress. His daily prednisone dose is insufficient for acute illness.
Immediate treatment (do NOT wait for cortisol levels):
- Hydrocortisone (Solu-Cortef) 100mg IV STAT → then 50mg IV q8h. This is life-saving.
- NS bolus 1-2L (correct hypotension and hyponatremia). Dextrose for hypoglycemia.
- If a cortisol level / cosyntropin stim test is still pending: give dexamethasone (4 mg IV) instead of hydrocortisone for the initial coverage. Dexamethasone does NOT cross-react with the cortisol assay, so it provides glucocorticoid coverage while preserving the diagnostic measurement. Hydrocortisone DOES cross-react and will invalidate the cortisol level. Switch to hydrocortisone after the stim test is drawn.
Stress dose steroid equivalents:
- Mild stress (minor procedure): hydrocortisone 50mg IV × 1
- Moderate stress (pneumonia, surgery): hydrocortisone 50mg IV q8h × 24-48h
- Severe stress (septic shock, major surgery): hydrocortisone 100mg IV q8h
Who needs stress dose steroids? Any patient on ≥ prednisone 5mg/day for ≥3 weeks (or equivalent) in the past year. When in doubt, give stress dose -the risk of NOT giving it (death) far outweighs the risk of giving it (mild hyperglycemia).
Taper: Once stress resolves, taper back to home dose over 1-3 days. Do NOT abruptly stop.

📋 On Rounds

How do you distinguish primary from secondary adrenal insufficiency?

Key differences: (1) ACTH level: ↑ in primary (adrenal glands failing → pituitary cranks up ACTH), ↓ in secondary (pituitary failing → no ACTH signal). (2) Hyperkalemia: present in primary (aldosterone deficiency from destroyed adrenal cortex), absent in secondary (aldosterone is regulated by RAAS, not ACTH, so it's preserved). (3) Hyperpigmentation: present in primary only (high ACTH → cleavage of POMC → MSH)

A surgical patient on chronic prednisone 10 mg daily is going to the OR. What stress dose do you give?

The adrenal gland normally produces ~5–10 mg cortisol/day at baseline and up to 75–100 mg/day during major physiological stress (surgery, sepsis, trauma). A patient on chronic prednisone ≥ 5 mg/day for > 3 weeks has HPA axis suppression and cannot mount this stress response. Stress dosing by surgical severity: Minor (local/dental): take usual dose morning of surgery.

How do you differentiate primary from secondary adrenal insufficiency?

Primary (Addison's): adrenal gland destruction → low cortisol + HIGH ACTH (pituitary trying to stimulate failed adrenals). Hyperpigmentation (ACTH shares a precursor with MSH → melanin production). Mineralocorticoid deficiency → hyperkalemia + hyponatremia. Causes: autoimmune (#1 in developed world), TB (#1 worldwide), bilateral adrenal hemorrhage (Waterhouse-Friderichsen in meningococcemia), metastases.

What is the cosyntropin stimulation test and how do you interpret it?

Cosyntropin (synthetic ACTH) 250 mcg IV or IM → check cortisol at 0, 30, and 60 minutes. Normal response: cortisol rises to ≥ 18 mcg/dL (some labs use ≥ 20) at 30 or 60 min. If cortisol fails to rise to ≥ 18 → adrenal insufficiency confirmed. Interpretation: Low baseline + fails stim = AI. Low baseline + passes stim = may still have secondary AI (pituitary failure) if the adrenals haven't atrophied yet (early secondary AI).

A critically ill patient with refractory hypotension has a random cortisol of 8. Do you treat?

Yes -empirically. In critical illness, cortisol should be > 18-25. A level of 8 in a stressed patient = relative adrenal insufficiency. Give hydrocortisone 100 mg IV and don't wait for ACTH stim test.

Why must you treat cortisol deficiency BEFORE starting levothyroxine?

Levothyroxine increases metabolic rate and cortisol clearance. In a patient with unrecognized adrenal insufficiency, starting thyroid hormone can precipitate adrenal crisis. Always replace cortisol first.

What are the sick-day rules for adrenal insufficiency?

Double oral dose for minor illness, triple for major illness, IV stress-dose (100 mg hydrocortisone) for surgery/trauma/vomiting. All AI patients must carry an emergency injection kit and wear a medical alert bracelet.

Clinical Examples

📋 Case 1, Adrenal Crisis from Steroid Withdrawal

Patient: 62M, COPD on chronic prednisone 15 mg daily x 2 years, ran out of medication 5 days ago. Presents with nausea, vomiting, abdominal pain, and near-syncope.

Key findings: T 99.8°F, HR 112, BP 74/48 (refractory to 3L NS). Na 128, K 5.6, glucose 58, Cr 1.9 (baseline 1.1). Random cortisol 2.1. ACTH pending.

Management:

Hydrocortisone 100 mg IV bolus IMMEDIATELY, do not wait for confirmatory tests
D5NS for volume resuscitation + hypoglycemia correction
Hydrocortisone 50 mg IV q8h after initial bolus
BP improved to 98/62 within 2 hours of steroid administration
Taper to oral prednisone over 3-5 days; endocrine consult for slow taper plan

Teaching point: This is tertiary adrenal insufficiency (chronic exogenous steroids suppressed the HPA axis). Abrupt withdrawal after ≥ 3 weeks of prednisone ≥ 5 mg/day can precipitate crisis. BP improved rapidly because cortisol restores vascular catecholamine sensitivity. Endocrine Society, 2016

📋 Case 2, Perioperative Stress Dosing Failure

Patient: 45F, SLE on prednisone 10 mg daily, undergoes elective total knee replacement. Took her usual morning prednisone but no stress-dose steroids were given. 6 hours post-op: hypotension (BP 72/40), tachycardia (HR 130), unresponsive to 4L crystalloid and norepinephrine.

Key findings: Glucose 52, Na 131, K 5.4. Lactate 4.2. Surgical site hemostasis adequate. Intra-op blood loss 400 mL (EBL). Random cortisol 3.8.

Management:

Hydrocortisone 100 mg IV stat, vasopressor-refractory hypotension in chronic steroid user = adrenal crisis until proven otherwise
Continue hydrocortisone 50 mg IV q8h x 48-72h
Rapid hemodynamic improvement (weaned norepi within 4h)
Taper to home prednisone dose over 3 days as clinical status improves

Teaching point: Major surgery requires stress-dose steroids in any patient on chronic steroids (≥ 5 mg prednisone daily for > 3 weeks). The adrenals normally produce up to 75-100 mg cortisol/day under surgical stress. The usual 10 mg prednisone is equivalent to only ~12.5 mg hydrocortisone, far below perioperative needs.

📋 Case 3, Primary Adrenal Insufficiency (Addison's) with Sepsis

Patient: 38F, known Addison disease on hydrocortisone 20 mg AM / 10 mg PM + fludrocortisone 0.1 mg daily, presents with 2 days of fever, cough, and inability to keep medications down due to vomiting.

Key findings: T 102.4°F, HR 128, BP 68/38. Hyperpigmented skin creases and buccal mucosa. Na 126, K 6.2, glucose 48. CXR: RLL consolidation. Lactate 5.8.

Management:

Hydrocortisone 100 mg IV bolus, then 50 mg IV q6h (crisis-dose)
D5NS aggressive resuscitation; dextrose for hypoglycemia
No additional fludrocortisone needed at stress doses (hydrocortisone > 50 mg/day has adequate mineralocorticoid activity)
Ceftriaxone + azithromycin for CAP (the trigger)
Emergent K management: calcium gluconate, insulin + D50, kayexalate

Teaching point: All patients with known adrenal insufficiency must have sick-day rules: double oral dose for minor illness, triple for major illness, IM/IV stress dose if vomiting. This patient could not absorb oral meds. The hyperkalemia is from mineralocorticoid deficiency (primary AI destroys the entire adrenal cortex including zona glomerulosa).

📣 Sample Presentation

One-Liner

"Mr. Owens is a 58-year-old on chronic prednisone 15 mg daily for COPD who ran out of medication 5 days ago and presents with hypotension (BP 74/48 refractory to 3L IVF), nausea, and confusion. Na⁺ 128, K⁺ 5.6. Adrenal crisis."

Key Points to Cover on Rounds

Adrenal crisis -tertiary adrenal insufficiency (chronic exogenous steroid → HPA axis suppression → abrupt withdrawal). Treatment: hydrocortisone 100 mg IV bolus immediately, then 50 mg IV q8h. IVF resuscitation with D5NS (hypoglycemia risk). Na 128 will correct with cortisol replacement (cortisol is needed for free water excretion). K⁺ 5.6 will correct with cortisol (mineralocorticoid effect). Cortisol and ACTH were drawn before hydrocortisone (but didn't delay treatment). BP improved to 98/62 within 2 hours. Plan: taper to oral prednisone over 3-5 days, endocrine to develop slow steroid taper schedule, medic alert bracelet.

🧪 Workup

Workup

AM cortisol -draw before giving steroids if possible. < 3 mcg/dL = adrenal insufficiency confirmed. > 18 = AI excluded. 3-18 = need ACTH stim test.
ACTH stimulation test (cosyntropin) -250 mcg IV → cortisol at 0 and 60 min. Normal = cortisol ≥ 18 at 60 min. Do NOT delay steroids for this test -give dexamethasone (does not interfere with cortisol assay) while awaiting results.
ACTH level -high ACTH + low cortisol = primary (Addison's). Low ACTH + low cortisol = secondary (pituitary/hypothalamic) or chronic steroid use.
BMP -classic: hyponatremia + hyperkalemia (primary AI only -mineralocorticoid deficiency). Also hypoglycemia, mild hypercalcemia.
CBC -eosinophilia (cortisol normally suppresses eosinophils)
TSH -hypothyroidism common in autoimmune polyglandular syndrome. Treat cortisol BEFORE thyroid hormone (levothyroxine can precipitate crisis).
CT adrenals -hemorrhage (anticoagulation, Waterhouse-Friderichsen), metastases, infiltration (TB, histoplasmosis, sarcoid)
21-hydroxylase antibodies -autoimmune adrenalitis (most common cause in developed countries)

💊 Medications

Medications

Drug	Dose	Route	Notes
Hydrocortisone	Endocrine Society, 2016 100 mg IV bolus → 50 mg IV q8h	IV	First-line for adrenal crisis. Has both glucocorticoid AND mineralocorticoid activity. Taper as patient improves.
Dexamethasone	Endocrine Society, 2016 4 mg IV q12h	IV	Alternative if ACTH stim test pending -does not interfere with cortisol assay. No mineralocorticoid activity -add fludrocortisone.
NS (normal saline)	1-2L bolus, then maintenance	IV	Aggressive volume resuscitation. These patients are volume-depleted from mineralocorticoid deficiency. Add D5 if hypoglycemic.
Fludrocortisone (Florinef)	Endocrine Society, 2016 0.05-0.2 mg daily	PO	Mineralocorticoid replacement for primary AI (Addison's). Not needed in secondary AI (ACTH deficiency preserves aldosterone). Start once PO tolerating.
Hydrocortisone (maintenance)	15-25 mg daily (10 AM + 5 PM)	PO	Chronic replacement. Mimic diurnal pattern. Sick-day rules: double or triple dose during illness/surgery.

Sick-day rules: All AI patients must carry an emergency injection kit (100 mg hydrocortisone IM) and wear a medical alert bracelet. Double oral dose for minor illness, triple for major illness, IV stress-dose for surgery/trauma.

⚡ Summary

Summary

Crisis Treatment

Hydrocortisone 100 mg IV bolus immediately → 50 mg IV q8h. Don't wait for lab results. IVF with D5NS (hypoglycemia risk).

Primary vs Secondary

Primary (Addison): high ACTH, hyperpigmentation, hyperkalemia. Secondary: low ACTH, no hyperpigmentation, no hyperkalemia.

Most Common Cause

Chronic exogenous steroids → HPA suppression → abrupt withdrawal → crisis. Also: autoimmune (#1 primary), TB (#1 worldwide).

Cosyntropin Test

250 mcg IV → cortisol at 0, 30, 60 min. Normal: cortisol ≥ 18. Fails to stimulate → AI confirmed.

Stress Dosing

Minor illness: double home dose × 3 days. Major surgery: hydrocortisone 100 mg IV → 50 q8h × 24h → taper. Always carry emergency injection.

Medic Alert

All patients with adrenal insufficiency need medic alert bracelet + emergency injection kit + sick day rules written down.

📄 One Pager

Adrenal Insufficiency & Crisis -Quick Reference Card

Print this page (Ctrl/Cmd + P) for a condensed reference card. All tabs will print on the same page for a complete topic summary.

ADRENAL INSUFFICIENCY & CRISIS -AT A GLANCE

📋 Diagnose: See Overview tab for criteria
🧪 Workup: Focused labs + imaging → see Workup tab
⚡ Treat: Evidence-based algorithm → see Management tab
💊 Drugs: Key medications with dosing → see Medications tab
📣 Present: One-liner + key points → see Rounds tab

📄 One Pager

Endocrine · One Pager

Adrenal Insufficiency & Crisis

Hydrocortisone 100 mg IV immediately for crisis. Don't wait for labs. Primary = high ACTH + hyperpigmentation + hyperK. Secondary = low ACTH. Stress dosing rules for all patients.

🧪 Classification

Primary (Addison): adrenal destruction → low cortisol + HIGH ACTH + hyperpigmentation + hyperkalemia. Secondary/tertiary: pituitary/hypothalamic failure or chronic steroids → low cortisol + LOW ACTH. No hyperpigmentation, no hyperK.

🚨 Crisis Treatment

Hydrocortisone 100 mg IV bolus immediately → 50 mg q8h. IVF with D5NS (hypoglycemia risk). Don't wait for cosyntropin test results. Draw cortisol + ACTH before treatment if possible (don't delay).

💊 Chronic Management

Hydrocortisone 15-25 mg/day (divided: 2/3 AM + 1/3 PM). Fludrocortisone 0.05-0.1 mg daily (primary only -mineralocorticoid). Stress dosing: double dose for illness, 100 mg IV for surgery. Medic alert bracelet.

💊 Key Drugs

Hydrocortisone (Solu-Cortef)100 mg IV bolus (crisis)

Hydrocortisone (Solu-Cortef)15-25 mg/day PO (chronic)

Fludrocortisone0.05-0.1 mg daily (primary)

DexamethasoneIf testing needed (doesn't interfere with assay)

⚠️ Pitfalls

Waiting for cosyntropin results to treat crisis (treat immediately)
Forgetting fludrocortisone in primary AI (needed for mineralocorticoid)
Abrupt steroid withdrawal → crisis
Not teaching stress dosing rules and emergency injection