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.

RoundsRx

Dashboard

Overview

Recent

Rotations

Quick Reference

Antibiotic Guide Analgesia Guide Sedation Guide Bowel Regimen Electrolyte Replacement Pain Management & Conversions Drug Interactions Anticoag Reversal IV Fluid Guide Inotropes Guide Vasopressors Insulin Guide Code Blue & Rapid Response Procedures Guide ECG Interpretation Lab Interpretation Radiology Quick Ref GCS Pocket Card Admission Orders & I-PASS Landmark Trials

Tools

💎 Clinical Pearls 🧠 Pimp Me Quiz 🧮 Clinical Calculators 📰 What's New 🎓 Intern Survival Guide ✅ Rounding Checklists 🩺 Procedure Guides ⚡ Electrolyte Replacement 💧 IV Fluids Guide 🩸 Transfusion Guide 💓 ECG Pattern Guide 🧪 Lab Interpretation Guide 📱 QR Poster 🔗 Resources 🎙️ Channels & Podcasts 🎮 Medical Games 🏛️ Famous Cases 🎬 Media Library

ℹ️ About

Available offline

QualityWards

Falls & Delirium Prevention

Inpatient falls are a "never event" -they cause hip fractures, subdural hematomas, and prolonged hospitalization. Delirium prevention is the same bundle. Most of this is medication review + non-pharmacologic interventions.

🛡️ Prevention Bundle

High-Risk Medications -Review and Stop

Drug Class	Examples to Stop/Minimize	Safer Alternative
Benzodiazepines	Lorazepam, midazolam, diazepam	Melatonin 3–5 mg for sleep. Trazodone 25–50 mg. Non-pharmacologic sleep hygiene.
Anticholinergics	Diphenhydramine (Benadryl) -#1 offender on inpatient med lists. Also: hydroxyzine, oxybutynin, promethazine, cyclobenzaprine.	Cetirizine (non-sedating antihistamine). Acetaminophen for pain. Remove diphenhydramine from every PRN order set.
Opioids (excess)	High-dose PRN without scheduled non-opioid adjuncts	Scheduled acetaminophen 1g q6h. Add gabapentin for neuropathic. Use opioids for breakthrough only.
Antihypertensives (excess)	Home doses continued despite lower inpatient BP → orthostatic hypotension	Hold/reduce home antihypertensives if SBP < 120 or symptomatic orthostasis. Reassess at discharge.
Sedating antipsychotics	Quetiapine, chlorpromazine at high doses	Use lowest effective dose. Time-limit orders.

Non-Pharmacologic Prevention (HELP Protocol)

Reorientation -whiteboard with date, day, nurse name. Clock in room. Familiar objects. Family at bedside.
Sleep hygiene -lights off by 10 PM, minimize nighttime vitals, cluster care, earplugs + eye mask, avoid nighttime medication administration if possible
Early mobility -PT/OT consult on admission for at-risk patients. Ambulate TID minimum. Chair for meals (not bed).
Sensory aids -glasses and hearing aids AT BEDSIDE (not in a drawer). Dentures in for meals.
Remove tethers -Foley (remove by day 2 unless specific indication), unnecessary IV lines, telemetry if not needed, restraints (worsen agitation)
Nutrition + hydration -avoid NPO status if possible. Offer fluids. Malnutrition worsens delirium.
Avoid physical restraints -restraints increase agitation, prolong delirium, increase falls (patients climb over them), and increase mortality

The HELP (Hospital Elder Life Program) protocol reduces delirium incidence by 30-40%. It's entirely non-pharmacologic and costs nothing. It works better than any drug.

Key Evidence: The HELP program reduced delirium incidence by 40% using non-pharmacologic interventions Inouye (HELP), 1999. Antipsychotics do NOT prevent delirium in hospitalized patients Neufeld, 2016 AID-ICU, 2018. Melatonin shows promise for sleep-wake cycle regulation but evidence is mixed Al-Aama, 2011.

Post-Fall Assessment

🧪 Workup

Post-Fall Assessment

Assessment	What to Check	Action
Injury survey	Head (laceration, hematoma), hip/pelvis (pain on log-roll), spine (tenderness), extremities	CT head if head strike (mandatory if on anticoagulation). Hip X-ray if hip/groin pain. C-spine if neck pain.
Neuro exam	GCS, pupil symmetry, focal deficits, gait (if ambulatory)	Document GCS and neuro status. If on anticoag + head strike → CT head STAT + repeat at 24h if on warfarin.
Vitals	Orthostatic BP/HR (lying → sitting → standing)	Drop ≥ 20/10 or HR rise ≥ 30 = orthostatic hypotension → volume depletion, meds, autonomic dysfunction
ECG	Arrhythmia, heart block, QTc prolongation	New arrhythmia → telemetry. Syncope-related fall → full syncope workup.
Labs	BMP (Na, glucose, Ca), CBC (anemia), INR if on warfarin	Correct metabolic causes. Check drug levels if applicable (digoxin, AEDs).
Medication review	Benzos, opioids, antihypertensives, anticholinergics, antipsychotics, diuretics	Deprescribe fall-risk meds. Use Beers Criteria AGS, 2023. Taper, don't abruptly stop.

⚡ Management

Fall Prevention -Inpatient

Intervention	Details
Bed alarm	For high-risk patients (delirium, impaired mobility, prior fall). NOT physical restraints -restraints increase falls and agitation.
Non-slip socks + clear pathway	Remove clutter, ensure call bell within reach, bed in lowest position, nightlight on.
Medication reconciliation	Reduce/eliminate: benzodiazepines (#1 contributor), opioids, sedating antihistamines (diphenhydramine), antihypertensives causing orthostasis, anticholinergics.
Delirium prevention (HELP protocol)	Orientation aids (clock, calendar), minimize nighttime disruptions, early mobilization, hearing aids/glasses at bedside, avoid unnecessary catheters.
PT/OT consult	Gait assessment, strength training, assistive device evaluation. Early mobilization reduces deconditioning.
Treat underlying cause	Orthostatic hypotension → IVF, adjust meds. Syncope → cardiac workup. Delirium → find precipitant. Neuropathy → B12, glucose control.

Physical restraints do NOT prevent falls -they increase agitation, delirium, pressure injuries, aspiration, and functional decline. They are a last resort only for imminent self-harm, never routine fall prevention.

Non-pharmacologic delirium prevention bundle (HELP): Reorient frequently (clock, calendar, family photos). Mobilize early (PT by day 1-2). Remove unnecessary tethers (Foley, telemetry, restraints). Ensure glasses and hearing aids are at bedside. Promote sleep hygiene (lights off, minimize nighttime vitals). Avoid deliriogenic medications (Beers Criteria) AGS Beers Criteria, 2023.

💊 Medications

High-Risk Medications for Falls -Beers Criteria

Drug Class	Examples	Mechanism of Fall Risk	Action
Benzodiazepines	Lorazepam, diazepam, alprazolam	Sedation, impaired balance, cognitive slowing	Taper and discontinue. Use melatonin or trazodone for insomnia.
Anticholinergics	Diphenhydramine, oxybutynin, cyclobenzaprine	Delirium, sedation, blurred vision, urinary retention	Substitute: cetirizine for allergy, mirabegron for OAB.
Opioids	Oxycodone, morphine, tramadol	Sedation, dizziness, impaired coordination	Multimodal pain: acetaminophen, topical NSAIDs, nerve blocks.
Antihypertensives	Alpha-blockers (doxazosin), loop diuretics	Orthostatic hypotension, volume depletion	Liberalize BP target in frail elderly (SBP 150 may be acceptable).
Antipsychotics	Haloperidol, quetiapine	Sedation, orthostasis, EPS	Avoid for delirium if possible. If needed, use lowest dose × shortest duration.
Hypoglycemics	Sulfonylureas (glipizide), insulin	Hypoglycemia → syncope → fall	Liberalize glucose targets in elderly (A1c 7.5–8.5% acceptable).

Avoid benzodiazepines for delirium (except alcohol/benzo withdrawal). Benzodiazepines worsen confusion and increase fall risk. If pharmacologic management is needed for agitated delirium, use low-dose haloperidol 0.5-1 mg IV/PO or quetiapine 12.5-25 mg PO Devlin, 2010. Dexmedetomidine is preferred in ICU for delirious mechanically ventilated patients MENDS2, 2021.

Diphenhydramine is the #1 culprit. It appears on almost every inpatient PRN list as "sleep aid" or "allergy." It is strongly anticholinergic, causes delirium in elderly, and increases fall risk. Remove it from every order set. Alternatives: melatonin 3-5 mg for sleep, cetirizine for allergy Gray, 2015.

📋 On Rounds

Pimp Questions

Why is diphenhydramine (Benadryl) the worst PRN sleep medication for hospitalized elderly patients?

Diphenhydramine is a first-generation antihistamine with strong anticholinergic properties. In elderly patients, anticholinergics cause: (1) delirium (crosses BBB, blocks muscarinic receptors in CNS), (2) urinary retention (→ UTI, agitation from discomfort), (3) falls (sedation + orthostatic hypotension + impaired coordination), (4) constipation (→ more agitation).

What workup is mandatory after an inpatient fall in a patient on anticoagulation?

CT head without contrast -even if asymptomatic. Patients on anticoagulation (warfarin, DOACs, heparin) are at high risk for delayed intracranial hemorrhage, particularly subdural hematoma (SDH). SDH can present hours to days after a seemingly minor fall, and the patient may initially appear fine. If on warfarin, repeat CT head in 24 hours even if the initial CT is negative -delayed bleeds occur as INR fluctuates.

What is the Beers Criteria and why does every intern need to know it?

AGS Beers Criteria is a list of potentially inappropriate medications (PIMs) in adults ≥ 65 that increase fall risk, delirium, bleeding, and other harms. Key categories: (1) Anticholinergics: diphenhydramine, hydroxyzine, oxybutynin, cyclobenzaprine → delirium + falls. (2) Benzodiazepines: all of them → oversedation, falls, hip fractures. (3) Non-benzo hypnotics: zolpidem → falls, complex sleep behaviors

What medications most commonly contribute to falls in hospitalized patients?

The 'fall-risk' medication classes (overlaps heavily with Beers Criteria): (1) Benzodiazepines -sedation, impaired balance, cognitive slowing. Even short-acting (lorazepam) increases fall risk. (2) Opioids -sedation, orthostatic hypotension, cognitive impairment. (3) Antihypertensives -orthostatic hypotension (especially alpha-blockers, diuretics at night). (4) Anticholinergics -confusion, blurred vision, urinary retention → agitation

What is the HELP program and what did it show for delirium prevention?

Hospital Elder Life Program (HELP): multicomponent non-pharmacologic intervention targeting 6 delirium risk factors (cognitive impairment, sleep deprivation, immobility, visual/hearing impairment, dehydration). Inouye, 1999 (NEJM): Reduced delirium incidence by 40% in hospitalized elderly. Now the gold standard for delirium prevention. Costs less than pharmacologic approaches.

Clinical Examples

📋 Case 1, Inpatient Fall on Anticoagulation

Patient: 84F on apixaban for Afib, found on floor next to bed at 3 AM. Unwitnessed. Denies head strike but cannot recall details. Oriented, no focal deficits. Small forehead hematoma.

Key findings: High-risk fall: elderly + anticoagulation + possible head strike + unreliable history. Intracranial hemorrhage can present delayed in anticoagulated patients, symptoms may appear hours later.

Management:

CT head without contrast STAT (low threshold for imaging in anticoagulated patients with any head trauma)
Neuro checks q1h × 4h, then q2h × 8h (delayed ICH risk)
Fall risk assessment: Morse Fall Scale, bed alarm, non-skid socks, call light within reach, low bed position
Medication review: identify fall-risk medications (benzos, opioids, anticholinergics, alpha-blockers, sleep aids)
PT/OT evaluation for mobility assessment, assistive device needs, home safety evaluation before discharge

Teaching point: In anticoagulated patients, CT head should be obtained for any fall with possible head strike, even if the patient looks fine. Subdural hematomas in elderly anticoagulated patients can be insidious, expanding slowly over hours to days before symptoms appear.

📋 Case 2, Recurrent Falls with Orthostatic Hypotension

Patient: 78M with HTN, BPH, T2DM. Third fall in 2 months. Home meds: amlodipine 10, doxazosin 4 mg, metoprolol 50 BID, trazodone 50 mg QHS. Orthostatic vitals: supine 148/82 → standing 108/58 with dizziness.

Key findings: Orthostatic hypotension (≥ 20 mmHg SBP drop or ≥ 10 mmHg DBP drop within 3 min of standing). Multiple contributing medications: doxazosin (alpha-blocker, worst offender), amlodipine, trazodone. Polypharmacy in elderly = falls.

Management:

Deprescribe doxazosin (alpha-blocker, highest fall risk of all antihypertensives, minimal CV benefit in elderly)
Switch BPH agent to tamsulosin 0.4 mg QHS (more uroselective, less orthostasis) or finasteride
Reduce amlodipine if BP allows (contributor to vasodilation)
Trazodone: assess if still needed for sleep, consider melatonin as safer alternative
Non-pharmacologic: rise slowly, sit at bedside 1 min before standing, compression stockings, adequate hydration

Teaching point: The #1 intervention for falls is medication review. Deprescribing fall-risk medications prevents more falls than any exercise program or environmental modification. Doxazosin is the classic "stop this drug" answer on falls assessment.

📋 Case 3, Fall with Hip Fracture

Patient: 82F with osteoporosis (T-score -3.4), fell from standing. Unable to bear weight on left leg. Left leg shortened and externally rotated. XR: left intertrochanteric hip fracture.

Key findings: Hip fracture from low-energy fall, pathologic fracture through osteoporotic bone. Hip fractures in elderly carry 20-30% 1-year mortality. Time to surgery is critical, OR within 24-48h reduces complications and mortality.

Management:

Orthopedic surgery consult for surgical fixation (intertrochanteric → intramedullary nail or sliding hip screw)
Surgery within 24-48h of admission (delay > 48h increases mortality, pneumonia, DVT, delirium)
Pain management: fascia iliaca block (regional anesthesia, superior to systemic opioids, reduces delirium risk)
DVT prophylaxis, delirium prevention (avoid benzos/anticholinergics, reorient, early mobility post-op)
Start osteoporosis treatment post-op: IV zoledronic acid after surgical healing + calcium/vitamin D (prevent next fracture)

Teaching point: A hip fracture is an orthopedic emergency, not an elective case. Every hour of surgical delay increases morbidity. The fascia iliaca block is a game-changer, it provides excellent pain control without the delirium risk of systemic opioids in elderly patients.

📣 Sample Presentation

One-Liner

"Mrs. Chen is an 85-year-old on apixaban who had an unwitnessed fall on the ward. She reports tripping on the IV tubing. No head strike per patient. Oriented, no focal deficits."

Key Points to Cover on Rounds

Unwitnessed fall on anticoagulation. No reported head strike but unwitnessed → CT head obtained (negative for acute intracranial hemorrhage). Neuro exam intact. Orthostatic vitals: positive (sitting→standing: 138/82→110/64). Medication review: amlodipine 10 mg (contributor to orthostatic hypotension) → reduced to 5 mg. Lorazepam 0.5 PRN sleep → discontinued. Foley removed (mobility barrier). PT evaluation: gait instability with walker. Plan: fall prevention bundle initiated, 24h repeat CT head (on apixaban), notify family, incident report filed.

Post-Fall Monitoring

Parameter	Frequency	Action
Neuro checks	q4h × 24h if head strike + anticoag	GCS, pupil reactivity, focal deficits. Decline → repeat CT head STAT.
Repeat CT head	24h post-fall if on warfarin + head strike	Delayed SDH can develop. Even if initial CT negative.
Vitals + orthostatics	Daily until resolved	Orthostatic hypotension → adjust meds, IVF.
Morse Fall Scale	Each shift	Reassess fall risk. Update care plan.
Incident report	Immediately	Document fall circumstances, injuries, interventions. Notify family.

Monitoring Parameters -VTE / DVT

Parameter	Frequency	Target / Action
aPTT (heparin drip)	q6h until stable, then q12h	Target aPTT 60–80 sec (or per institutional protocol). Adjust infusion rate per nomogram.
INR (warfarin)	Daily while inpatient, then weekly → monthly when stable	Target INR 2.0–3.0. Bridge with heparin x 5 days AND until INR ≥ 2 for 24h before stopping heparin.
Platelets (HIT surveillance)	q2–3 days on heparin (days 4–14)	HIT: > 50% drop from baseline or platelets < 150K on heparin → check HIT antibody (PF4/heparin). 4T score to assess probability. If HIT → stop all heparin, start argatroban or bivalirudin.
Creatinine (DOAC dosing)	Baseline and periodically	CrCl determines DOAC eligibility. For VTE: apixaban approved down to CrCl 15 (AMPLIFY excluded < 25, so data weakest 15–25); rivaroxaban avoid < 30; dabigatran avoid < 30; edoxaban avoid < 15. For A-fib (different cutoffs): apixaban dose-reduce to 2.5 mg BID if ≥ 2 of (age ≥ 80, wt ≤ 60, Cr ≥ 1.5); rivaroxaban 15 mg daily if CrCl 15–50. Declining renal function may require switch to warfarin.
Bleeding symptoms	Each assessment	GI bleeding (melena, hematochezia), hematuria, gum bleeding, easy bruising, menorrhagia. Any major bleed → hold anticoagulation, assess need for reversal.
Recurrent VTE symptoms	Each assessment + patient education	New leg swelling/pain → repeat ultrasound. New dyspnea/chest pain → CTPA. Recurrence on anticoagulation → consider non-compliance, cancer workup, APS testing.

HIT surveillance is critical on heparin. Check platelets baseline, then q2–3 days from days 4–14. A > 50% drop is the trigger -not an absolute threshold. Use the 4T score before sending the expensive PF4 antibody.