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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ℹ️ About

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Palliative Care

Hospice Eligibility Criteria

Hospice = comfort-focused care for patients with prognosis ≤ 6 months. It's a Medicare benefit, not giving up. Patients and families consistently say they wish hospice was offered earlier. Know the disease-specific criteria.

🕊️ Hospice Eligibility

General Criteria (All Diseases)

Prognosis ≤ 6 months if disease runs its expected course (physician certification)
Patient (or surrogate) elects comfort-focused care -no curative intent treatments
General decline indicators: Karnofsky < 50% or PPS ≤ 50%, recurrent hospitalizations, progressive weight loss (> 10% in 6 months), declining functional status (increasing dependence in ADLs), albumin < 2.5
"Surprise question": "Would you be surprised if this patient died in the next 6 months?" If no → hospice referral appropriate. SUPPORT Study, 1995

Disease-Specific Criteria

Disease	Hospice-Eligible When
Heart Failure	NYHA Class IV at rest despite optimal therapy. EF ≤ 20%. Recurrent hospitalizations (≥ 3 in 6 months). Refractory to diuretics. Not a candidate for transplant/LVAD. Symptomatic hypotension limiting meds.
COPD / Pulmonary	FEV₁ < 30% predicted. Resting dyspnea on max therapy. O₂-dependent. Cor pulmonale / RHF. Recurrent exacerbations requiring hospitalization. pCO₂ > 50 or O₂ sat ≤ 88% on room air.
Dementia	FAST scale ≥ 7 (unable to ambulate, dress, bathe without assistance; < 6 intelligible words). Plus ≥ 1 complication in past 12 months: aspiration pneumonia, pyelonephritis, sepsis, decubitus ulcer stage III+, recurrent fever despite abx.
Cancer	Metastatic disease declining despite treatment or patient declines further disease-directed therapy. Poor performance status (ECOG 3–4). Progressive despite ≥ 2 lines of therapy. Hypercalcemia, malignant effusions, cachexia.
Liver disease	MELD ≥ 30 (not transplant candidate). Refractory ascites. SBP recurrence. HRS. Hepatic encephalopathy despite lactulose/rifaximin. Progressive jaundice.
Renal disease	CKD stage 5 (GFR < 15) and patient declines or discontinues dialysis. Creatinine clearance < 10 mL/min (CrCl < 15 for diabetics). Uremic symptoms not being treated with RRT.
Stroke / Neurologic	Coma or persistent vegetative state. Dysphagia with aspiration + declining to PEG. Progressive decline despite rehab. Recurrent aspiration pneumonia.

What Hospice Provides

Covered by Medicare Part A -no out-of-pocket cost to patient for hospice services
Includes: RN visits (typically 1–3×/week), aide visits, social worker, chaplain, medications related to terminal diagnosis, DME (hospital bed, O₂, wheelchair), continuous care during crises, respite care (5 days), bereavement support for 13 months after death
Does NOT mean stopping all meds. Comfort medications continue (pain, nausea, dyspnea, anxiety). Disease-modifying meds may continue if they provide symptom benefit. Temel et al., 2010
Can be revoked at any time -patient can re-elect curative care if they change their mind

📋 On Rounds

Pimp Questions

A family asks: 'Does hospice mean you're giving up on my father?' How do you respond?

This is one of the most important conversations in medicine. The key reframe: 'Hospice isn't giving up -it's refocusing.' We're shifting from treatments that aren't working to treatments that improve quality of life. Hospice provides more care, not less: a nurse visits regularly, medications for comfort are covered, a chaplain and social worker support the family, and there's 24/7 phone access for crises.

What is the difference between hospice and palliative care?

Palliative care can be provided at any stage of serious illness, alongside curative treatment. It focuses on symptom management, goals of care, and quality of life. There is no prognosis requirement. Hospice is a specific Medicare benefit for patients with prognosis ≤ 6 months who elect comfort-focused care (no curative-intent treatments). Think of it this way: all hospice is palliative care, but not all palliative care is hospice.

What are the general hospice eligibility criteria beyond disease-specific ones?

General LCD (Local Coverage Determination) criteria: (1) Prognosis ≤ 6 months if disease runs its usual course (certified by 2 physicians), (2) Patient has elected comfort-focused care (no curative-intent treatments), (3) Functional decline: PPS (Palliative Performance Scale) ≤ 50% or declining, increasing dependence in ADLs, spending > 50% of day in bed

What symptoms can hospice patients still receive treatment for?

Hospice is NOT withdrawal of all treatment -it's refocusing on comfort. Hospice covers: (1) Pain: opioids, adjuvants (gabapentin, duloxetine, dexamethasone), nerve blocks, radiation for bone mets pain. (2) Dyspnea: morphine (first-line, low-dose), supplemental O₂ for comfort (not to chase SpO₂), fan directed at face, benzodiazepines if anxiety-related. (3) Nausea: ondansetron, haloperidol, metoclopramide, dexamethasone

📣 Sample Presentation

One-Liner

"Mrs. Martinez is a 78-year-old with metastatic pancreatic cancer, declining PPS (30%), unable to eat or ambulate, with increasing pain and dyspnea. Oncology confirms no further disease-directed therapy. Family meeting held -patient and family electing hospice."

Key Points to Cover on Rounds

Goals of care discussion completed using REMAP framework. Patient priorities: comfort, being at home, no more ER visits. Prognosis: weeks to low months (PPS 30%, declining trajectory). Code status: DNR/DNI documented and in chart. Hospice eligibility: metastatic cancer with declining functional status despite treatment -meets LCD criteria. Hospice agency contacted -admission tomorrow. Comfort medications ordered: morphine 5 mg PO q4h PRN pain, lorazepam 0.5 mg SL q4h PRN anxiety, ondansetron 4 mg q6h PRN nausea, glycopyrrolate 0.2 mg SL q4h PRN secretions. Unnecessary meds stopped: statin, metformin, lisinopril. Hospital bed and O₂ arranged for home.

Monitoring in Hospice

Parameter	Approach	Notes
Symptom assessment	Each visit (RN 1-3x/week)	Pain, dyspnea, nausea, anxiety, delirium -use validated scales
Functional status	Weekly	PPS trending. Declining PPS confirms trajectory. Document for recertification
Medication review	Each visit	Are comfort meds working? Side effects? Need dose adjustment? Route change needed?
Caregiver assessment	Each visit	Burnout, coping, need for respite care, bereavement risk assessment
Labs	Generally NOT indicated	Labs rarely change management in hospice. Only draw if result will change comfort plan
Recertification	90 days, 90 days, then 60-day periods	Two physicians must certify continued eligibility. Document ongoing decline

Less is more in hospice monitoring. Stop checking labs that won't change management. Focus on symptoms, comfort, and family support -not numbers.

Monitoring Parameters -Opioid Rotation

Parameter	Frequency	Target / Action
Pain scores	q4h + 1h after each PRN dose	Target ≤ 4/10 or functional goals (e.g., able to ambulate, sleep). Track breakthrough use -if > 3 PRN doses/day, increase scheduled dose.
Sedation (Pasero Opioid-Induced Sedation Scale)	q4h with vitals (q1–2h first 24h post-rotation)	S = sleep, easy to arouse; 1 = awake, alert (acceptable); 2 = slightly drowsy (acceptable); 3 = frequently drowsy (hold dose, reduce); 4 = somnolent (hold, consider naloxone). Naloxone (Narcan) must be at bedside.
Respiratory rate	q4h (q1h first 24h of new opioid)	RR < 10 → hold opioid. RR < 8 or unresponsive → naloxone 0.04–0.4 mg IV (titrate to respirations, not consciousness). Monitor closely × 48–72h after rotation.
Bowel regimen	Daily assessment (BM frequency)	Start bowel regimen with ALL opioids, PEG 3350 (MiraLAX) 17g daily + senna 8.6 mg BID. No BM × 3 days → add bisacodyl or methylnaltrexone (Relistor) 12 mg SC if refractory. Tolerance does NOT develop to constipation. Do not use docusate (no better than placebo, AGA-ACG 2023).
Pruritus	Each assessment	Common opioid side effect (histamine release). Rotation may resolve it. Treat with low-dose nalbuphine 2.5 mg IV or hydroxyzine 25 mg PO. Avoid diphenhydramine (additive sedation).
Nausea	Each assessment	Often resolves with rotation. Ondansetron 4 mg IV/PO q8h PRN. Haloperidol 0.5–1 mg PO/IV for refractory opioid-induced nausea.
Functional status	Daily	Can the patient ambulate, participate in PT, perform ADLs? Pain management goal is function, not a number. Reassess total opioid requirements and consider multimodal adjuncts.

Monitor closely × 48–72h after any opioid rotation. Incomplete cross-tolerance means the new opioid may be unexpectedly potent. Have naloxone (Narcan) at bedside for all patients on opioid drips or after recent rotation. Adjust based on pain scores, breakthrough use, and side effect profile.

🧪 Workup

Hospice Evaluation

Functional assessment: PPS (Palliative Performance Scale) or Karnofsky score. PPS ≤ 50% supports hospice eligibility
Prognostic tools: "Surprise question" -would you be surprised if this patient died in 6 months? Disease-specific criteria (see Criteria tab)
Goals of care discussion: Use REMAP framework -Reframe, Expect emotion, Map values, Align, Plan. Document in chart
Review active medications: Identify meds to continue (comfort) vs discontinue (no longer beneficial). Stop statins, metformin, vitamins, screening meds
Assess symptom burden: Pain (numeric scale), dyspnea (at rest vs exertion), nausea, anxiety, delirium, constipation
Code status: Confirm and document DNR/DNI. Ensure POLST/MOLST form completed
Caregiver assessment: Evaluate family support, caregiver burnout risk, need for respite care

💊 Medications

Comfort Medications in Hospice

Symptom	First-Line	Dose	Notes
Pain	Morphine	5-10 mg PO q4h PRN; 2-4 mg IV/SC q2h PRN	Gold standard. Also treats dyspnea. Reduce dose in renal failure
Pain (renal failure)	Hydromorphone	0.5-1 mg PO q4h PRN	Safer than morphine in CKD/ESRD -no active metabolites
Pain (neuropathic)	Gabapentin	100-300 mg TID, titrate	Adjuvant for neuropathic pain. Also helps anxiety/insomnia
Dyspnea	Morphine	2.5-5 mg PO q4h PRN	Low-dose morphine is first-line. Fan to face also effective
Nausea	Ondansetron	4 mg PO/IV q6h PRN	First-line. Haloperidol 0.5-1 mg PO/IV q6h is excellent alternative
Secretions (death rattle)	Glycopyrrolate	0.2 mg SL/SC q4h PRN	Does not cross BBB (less delirium). Atropine 1% drops SL also works
Agitation/delirium	Haloperidol	0.5-2 mg PO/IV/SC q4-6h	First-line for terminal delirium. Add lorazepam if refractory
Anxiety	Lorazepam	0.5-1 mg PO/SL q4-6h PRN	Short-acting. Can be given sublingual if unable to swallow
Constipation	PEG 3350 + senna	Senna 2 tabs BID + MiraLAX 17g daily	Start with opioids. Methylnaltrexone SC if refractory. Docusate ineffective (AGA-ACG 2023)

Key principle: Route matters at end of life. When patients can no longer swallow, switch to SL (sublingual), SC (subcutaneous), or rectal routes. IV access is rarely needed in hospice.

⚡ Summary

Summary

Eligibility

Prognosis ≤ 6 months if disease runs its usual course. Patient elects comfort. Certified by 2 physicians. Can be revoked if patient improves.

Comfort Meds

Pain: morphine. Dyspnea: morphine + fan. Nausea: ondansetron, haloperidol. Secretions: glycopyrrolate/atropine. Agitation: lorazepam, haloperidol.

Stop Unnecessary

Statins, metformin, vitamins, screening tests, antihypertensives (if comfort-focused). Each med removed = reduced pill burden + side effects.

Hospice ≠ Giving Up

Hospice provides active symptom management, emotional/spiritual support, family bereavement, aide services, equipment, medications.

Prognostic Tools

PPS (Palliative Performance Scale): ≤ 50% supports hospice eligibility. Disease-specific criteria: CHF NYHA IV, COPD FEV₁ < 30%, dementia FAST ≥ 7.

Family Support

Caregiver burnout is real. Hospice provides: respite care (5 days), bereavement counseling × 13 months post-death, 24/7 nurse phone access.

⚡ Management

Hospice Management Priorities

Symptom management is the primary goal. Pain, dyspnea, nausea, agitation -treat aggressively. There is no ceiling dose for opioids in hospice if symptoms persist
Medication reconciliation: Stop all non-comfort medications. Statins, antihypertensives (unless symptomatic), diabetes meds (unless symptomatic hyperglycemia), vitamins, screening labs
Anticipatory prescribing: Write PRN orders for common end-of-life symptoms BEFORE they occur -pain, dyspnea, secretions, agitation, nausea, fever
Crisis plan: Document what to do for symptom emergencies. Continuous care (24h nursing) available for crises. Avoid unnecessary 911 calls/ER visits
Family education: Prepare family for signs of active dying -Cheyne-Stokes breathing, mottling, decreased urine output, terminal restlessness, changes in consciousness
Spiritual/psychosocial care: Chaplain, social worker, life review, legacy work. Address existential distress

📄 One Pager

Palliative Care · One Pager

Hospice

Prognosis ≤ 6 months. Comfort-focused. Active symptom management + family support. Can be revoked if patient improves. Hospice ≠ giving up.

🧪 Eligibility

Prognosis ≤ 6 months (certified by 2 physicians). Patient elects comfort care. PPS ≤ 50%. Declining functional status, nutritional decline, recurrent hospitalizations. Disease-specific criteria exist.

🚨 Comfort Medications

Pain: morphine (first-line). Dyspnea: morphine + fan at face. Nausea: ondansetron, haloperidol. Secretions: glycopyrrolate/atropine drops. Agitation: haloperidol, lorazepam.

💊 What to Stop

Statins, metformin, vitamins, screening tests, antihypertensives (unless symptomatic). Each med removed = reduced pill burden + side effects. Focus on comfort and quality of life.

💊 Key Drugs

Morphine2-5 mg PO/SL q2-4h PRN

Lorazepam0.5-1 mg SL q4h PRN

Ondansetron4 mg q6h PRN

Glycopyrrolate0.2 mg SL q4h PRN

⚠️ Pitfalls

Hospice = giving up (it's active symptom management + support)
Continuing aggressive meds that add no comfort benefit
Not offering hospice early enough (many patients referred too late)
Not supporting caregivers (burnout is real -hospice provides respite care)