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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EssentialWards

VTE Prophylaxis

Every inpatient needs VTE risk assessment. Padua score for medical patients. Caprini score for surgical. Pharmacologic (LMWH preferred) unless contraindicated. Mechanical (SCDs) if bleeding risk. "Did you order the DVT ppx?" -yes, always.

🔍 Overview

Risk Assessment

Tool	Population	Threshold
Padua Score	Medical inpatients	≥ 4 = high risk → pharmacologic prophylaxis
Caprini Score	Surgical patients	Score-based: 0 = early ambulation, 1–2 = SCDs, 3–4 = pharmacologic, ≥ 5 = extended prophylaxis
IMPROVE Bleed Score	Medical inpatients	Assesses bleeding risk -high score → mechanical prophylaxis instead

Padua Score Components

Active cancer (+3)
Previous VTE (+3)
Reduced mobility (+3)
Known thrombophilia (+3)
Recent trauma/surgery (+2)
Age ≥ 70 (+1)
Heart or respiratory failure (+1)
AMI or stroke (+1)
Acute infection or rheumatic disorder (+1)
Obesity BMI ≥ 30 (+1)
Hormonal therapy (+1)

VTE prophylaxis is one of the most impactful things you order every day. Hospital-acquired VTE is preventable. Not ordering prophylaxis is a patient safety event.

Key Evidence: Enoxaparin 40 mg daily reduced VTE by 63% in acutely ill medical patients MEDENOX, 1999. Dalteparin reduced VTE in medical patients PREVENT, 2004. Fondaparinux reduced VTE in medical patients ARTEMIS, 2006. Extended post-discharge prophylaxis with rivaroxaban did not significantly reduce symptomatic VTE MARINER, 2018.

Special Populations

Population	Recommendation	Notes
Pregnancy	Enoxaparin preferred; avoid warfarin	Increased VTE risk in pregnancy + postpartum. Warfarin is teratogenic (crosses placenta).
Cancer patients	LMWH superior to UFH	Consider extended prophylaxis post-discharge (COMPASS-CAT score for risk stratification). CASSINI/AVERT, 2019
Orthopedic surgery (hip/knee)	Extended prophylaxis × 35 days post-op	LMWH, rivaroxaban, or apixaban all acceptable ADVANCE-3, 2010. Standard 10-14 days is insufficient.
Morbid obesity (BMI >40)	Standard enoxaparin 40 mg may be subtherapeutic	Consider enoxaparin 40 mg q12h or UFH 7,500 units q8h for adequate prophylaxis.
CKD (CrCl <30)	Use UFH instead of LMWH	LMWH is renally cleared and accumulates → increased bleeding risk.
HIT history	Mechanical only or fondaparinux	NO heparin products (UFH or LMWH). Fondaparinux does not cross-react with HIT antibodies.
ICU patients	Pharmacologic + mechanical	Highest risk population, combination prophylaxis recommended.

Mnemonic for VTE Risk Factors, "THROMBOSIS":
Travel / Thrombophilia · Hypercoagulable / HRT · Recent surgery · Obesity / Oral contraceptives · Malignancy · Bed rest / immobility · Obstetric (pregnancy) · Smoking · Injury / Inflammation · Sickle cell / SLE

Clinical Examples

📋 Case 1, Medical Patient VTE Prophylaxis

Patient: 72M admitted for pneumonia, BMI 25, no active bleeding.

Risk assessment (Padua Score):

Acute infection (+1)
Age ≥ 70 (+1)
Reduced mobility (+3)
Total = 5 → High risk

IMPROVE Bleed Score: Low → pharmacologic prophylaxis appropriate.

Order: Enoxaparin 40 mg SC daily + SCDs.

Key lesson: Most medical inpatients with acute illness + reduced mobility will score ≥ 4 on Padua. Always calculate, always prophylax.

📋 Case 2, Extended Prophylaxis Post-Hip Replacement

Patient: 55F post-hip replacement, no active bleeding risk.

Risk assessment: Caprini ≥ 5 (major orthopedic surgery).

Order:

Inpatient: Enoxaparin 40 mg SC daily starting 12h post-op.
Extended prophylaxis: Continue × 35 days post-op (not just until discharge).
At discharge: May switch to rivaroxaban 10 mg PO daily for convenience.

Key lesson: Hip and knee replacement require extended prophylaxis × 35 days. VTE risk persists well beyond hospitalization. Standard 10–14 days is insufficient.

📋 Case 3, CKD Patient (LMWH Contraindicated)

Patient: 68M with CKD stage 4 (CrCl 22 mL/min), admitted for CHF exacerbation.

Why LMWH is contraindicated: Enoxaparin is renally cleared. CrCl < 30 → drug accumulates → bleeding risk.

Order:

Heparin 5,000 units SC q8h (hepatic metabolism, not renally cleared)
SCDs (combination prophylaxis for added protection)

Key lesson: Always check CrCl before ordering enoxaparin. CrCl < 30 = use UFH. This is one of the most common prophylaxis errors on wards.

🚨 Management

Prophylaxis Options

Method	Option	Dose
Pharmacologic (preferred)	Enoxaparin (Lovenox)	40 mg SC daily (or 30 mg SC q12h if BMI > 40 or CrCl < 30 → use UFH)
	Heparin (unfractionated)	5,000 units SC q8h (preferred if CrCl < 30 or high bleed risk -shorter half-life)
Mechanical	SCDs (sequential compression devices)	Both legs, worn whenever in bed
Extended prophylaxis	Rivaroxaban (Xarelto) or Enoxaparin (Lovenox)	Post-discharge for high-risk medical (MARINER) or post-surgical (hip/knee)

🔄 Updated Practice: Old teaching: sequential compression devices (SCDs) are equivalent to pharmacologic VTE prophylaxis. Current practice: pharmacologic prophylaxis (enoxaparin 40 mg SQ daily or heparin 5000 units SQ q8-12h) is superior to mechanical prophylaxis alone. SCDs should be used only when pharmacologic prophylaxis is contraindicated (active bleeding, severe thrombocytopenia). The combination of both is used in highest-risk patients (trauma, major orthopedic surgery).

Extended Prophylaxis Evidence: Hip/knee replacement: Extended prophylaxis x 35 days reduces VTE by ~60% RECORD, 2008. Cancer surgery: Extended LMWH x 4 weeks post-op reduces VTE ENOXACAN II, 2002. Medical patients: Extended prophylaxis NOT routinely recommended APEX, 2016 EXCLAIM, 2010.

Contraindications to Pharmacologic Prophylaxis

Active bleeding
Severe thrombocytopenia (platelets < 50K)
Recent intracranial hemorrhage
Epidural/spinal anesthesia (hold LMWH around procedure)
HIT (heparin-induced thrombocytopenia) -use mechanical only or argatroban if treatment-dose needed

🧪 Workup

Padua Score (medical) or Caprini Score (surgical) -on admission
IMPROVE Bleed Score -if considering pharmacologic
Platelet count -< 50K → mechanical only
Creatinine/CrCl -CrCl < 30 → use UFH instead of LMWH
Review medications -anticoagulants already on board?

💊 Medications

Drug	Dose	Key Notes
Enoxaparin (Lovenox)	40 mg SC daily	Preferred LMWH. Predictable pharmacokinetics. No monitoring needed.
Heparin (UFH)	5,000 units SC q8h	Use if CrCl < 30, high bleed risk (shorter half-life), or obese patients.
Fondaparinux (Arixtra)	2.5 mg SC daily	Alternative if HIT. Factor Xa inhibitor. Renally cleared.

📋 On Rounds

Pimp Questions

Why is q8h UFH preferred over q12h for VTE prophylaxis?

Multiple meta-analyses show that 5,000 units SC q8h (TID) is superior to q12h (BID) for preventing VTE in medical patients. The difference is particularly significant for DVT prevention. Q8h maintains more consistent anti-Xa levels. The trade-off is slightly higher minor bleeding risk, but the VTE prevention benefit outweighs this.

When should you use UFH instead of LMWH for prophylaxis?

(1) CrCl < 30 mL/min -LMWH is renally cleared and accumulates → bleeding risk. UFH is metabolized by the reticuloendothelial system. (2) High bleeding risk -UFH has a shorter half-life (1–2h vs 4–5h for LMWH), so effects wear off faster if bleeding occurs. (3) Planned procedures -easier to manage perioperatively. (4) Morbid obesity -some guidelines recommend UFH q8h or adjusted LMWH dosing (enoxaparin 40 mg q12h for BMI > 40).

Why is LMWH preferred over UFH for VTE prophylaxis?

LMWH has more predictable pharmacokinetics, longer half-life allowing once daily dosing (vs q8h for UFH), lower risk of HIT, and no need for aPTT monitoring. RCTs have shown LMWH is at least as effective as UFH for VTE prevention. UFH is preferred only when LMWH is contraindicated: CrCl < 30 (LMWH accumulates), high bleed risk (shorter half-life advantage), or perioperative setting (easier to hold and reverse).

Should you hold DVT prophylaxis for a procedure?

Depends on the procedure and bleeding risk. LMWH: hold 12h before and resume 12h after low-bleed-risk procedures. For high-bleed-risk procedures: hold 24h before. UFH: hold 4–6h (shorter half-life is an advantage here). Neuraxial procedures (epidural/spinal): hold LMWH ≥12h before placement and ≥4h after catheter removal, risk of epidural hematoma is devastating.

What is the IMPROVE VTE score?

A validated risk assessment tool specifically for acutely ill medical patients that predicts 3-month VTE risk. Components: Previous VTE (+3), known thrombophilia (+2), lower limb paralysis (+2), active cancer (+2), ICU/CCU stay (+1), complete immobilization ≥1 day (+1), age ≥60 (+1). Score ≥ 4 = high risk → pharmacologic prophylaxis indicated.

What did the MEDENOX trial show?

MEDENOX, 1999: Enoxaparin 40 mg daily reduced VTE in acutely ill medical patients by 63% vs placebo. Established the standard prophylactic dose of enoxaparin 40 mg SC daily. The 20 mg dose was NOT effective - only 40 mg showed benefit. Landmark trial that changed practice for medical inpatient prophylaxis.

What is the evidence for extended VTE prophylaxis after hospital discharge?

MARINER, 2018: Rivaroxaban 10 mg x 45 days post-discharge did NOT significantly reduce symptomatic VTE in acutely ill medical patients. APEX, 2016: Betrixaban showed modest benefit. Extended prophylaxis is supported for orthopedic surgery (hip/knee x 35 days) but NOT routinely for medical patients.

What is the Caprini score and how does it differ from Padua?

Caprini is for SURGICAL patients. Assigns weighted points for risk factors (prior VTE, cancer, age, surgery type, immobility). Score determines prophylaxis intensity: 0 = ambulation only, 1-2 = SCDs, 3-4 = pharmacologic, ≥ 5 = pharmacologic + extended. Padua is for MEDICAL patients with threshold ≥ 4 for pharmacologic prophylaxis.

Why is fondaparinux safe in HIT?

Fondaparinux (Arixtra) is a synthetic pentasaccharide that inhibits factor Xa. Unlike UFH and LMWH, it does NOT bind to platelet factor 4 (PF4), so it does not trigger the HIT antibody response. Can be used for prophylaxis (2.5 mg SC daily) or treatment-dose anticoagulation in confirmed HIT as an alternative to argatroban or bivalirudin.

⚡ Summary

Every Patient

VTE risk assessment on admission. Padua ≥ 4 (medical) or Caprini-based (surgical) → prophylax.

First-Line

Enoxaparin 40mg SC daily. Use UFH 5000 SC q8h if CrCl < 30 or high bleed risk.

Mechanical

SCDs if pharmacologic contraindicated (active bleed, plt < 50K, HIT, recent ICH).

Contraindications

Active bleeding, plt < 50K, recent ICH, epidural, HIT.

Obese Patients

Standard enox 40mg may be insufficient. Consider 40mg q12h or UFH q8h for BMI > 40.

Discharge

Assess need for extended prophylaxis (post-hip/knee surgery, high-risk medical → rivaroxaban).