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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EmergentNeurology

Intracerebral Hemorrhage

Spontaneous bleeding into brain parenchyma. Hypertension is #1 cause. Rapid BP lowering to SBP < 140. Reverse anticoagulation STAT. Hematoma expansion in first 6h drives mortality. Neurosurgery consult for all ICH.

🔍 Overview

Etiology by Location

Location	Most Likely Cause
Basal ganglia / putamen	Hypertension (#1 cause, #1 location)
Thalamus	Hypertension
Pons	Hypertension
Cerebellum	Hypertension (surgical emergency if > 3 cm)
Lobar (cortical)	Cerebral amyloid angiopathy (elderly), AVM (young), tumor

Hematoma expansion occurs in ~30% of ICH patients within the first 6 hours. This is the main driver of early deterioration. Aggressive BP control and anticoagulation reversal are TIME-CRITICAL.

ICH Score (Hemphill, 2001)

Component	Criteria	Points
GCS 3–4	Comatose	2
GCS 5–12	Obtunded / moderate impairment	1
GCS 13–15	Alert / mild impairment	0
ICH volume ≥ 30 mL	Use ABC/2 formula on CT	1
ICH volume < 30 mL		0
IVH present	Intraventricular extension of hemorrhage	1
Infratentorial origin	Cerebellum or brainstem	1
Age ≥ 80		1

ICH Score → 30-day mortality: 0 = 0%, 1 = 13%, 2 = 26%, 3 = 72%, 4 = 97%, 5 = 100%. Caution: Do NOT use as sole basis for withdrawal of care, prognostic nihilism contributes to self-fulfilling prophecies. Early aggressive care is warranted for all patients.

ICH Volume Estimation, ABC/2 Method

On CT, measure: A = largest diameter of hemorrhage (cm), B = diameter perpendicular to A on same slice (cm), C = number of CT slices with hemorrhage × slice thickness (cm). Volume ≈ (A × B × C) / 2 mL.

🚨 Management

Acute Management

BP control: Target SBP < 140 within 1 hour (INTERACT2, 2013). Use Nicardipine (Cardene) or Clevidipine (Cleviprex) drip.
Reverse anticoagulation STAT:
- Warfarin → 4-factor PCC (KCentra) + Vitamin K 10 mg IV
- Dabigatran → Idarucizumab (Praxbind) 5g IV
- Rivaroxaban/Apixaban → Andexanet Alfa (Andexxa) or 4F-PCC
Neurosurgery consult -all ICH. Cerebellar ICH > 3 cm or with hydrocephalus → surgical evacuation
ICP management: HOB 30°, osmotic therapy (mannitol or hypertonic saline), EVD if hydrocephalus
Seizure prophylaxis: NOT routine -treat only clinical seizures. Continuous EEG if altered.
Tranexamic acid (TXA): Consider within 3 hours of injury, especially in mild-to-moderate TBI. CRASH-3, 2019 showed reduced head-injury related death when given early.

BP Management, Key Trials

Trial	Target	Key Finding
INTERACT2, 2013	SBP < 140 mmHg within 1h	Improved functional outcomes (mRS). Safe. Current standard of care.
ATACH-2, 2016	SBP 110–139 vs 140–179	No additional benefit from more aggressive lowering. Increased renal AKI.

Bottom line: Target SBP < 140 within 1 hour (INTERACT2). Do NOT push below 110–120 (ATACH-2 showed harm). Use nicardipine or clevidipine drip with arterial line monitoring.

Anticoagulant Reversal, Emergency Protocol

Anticoagulant	Reversal Agent	Dose	Key Notes
Warfarin	4-factor PCC (KCentra) + Vitamin K	PCC 25–50 units/kg IV + Vit K 10 mg IV	PCC reverses in minutes. Vit K sustains reversal (takes 6–24h). Do NOT use FFP alone (slow, volume overload).
Dabigatran (Pradaxa)	Idarucizumab (Praxbind)	5 g IV (two 2.5g vials)	Monoclonal antibody fragment. Immediate, complete reversal. RE-VERSE AD, 2017
Rivaroxaban / Apixaban (Xa inhibitors)	Andexanet alfa (Andexxa)	Low dose: 400mg bolus + 4mg/min x 2h; High dose: 800mg bolus + 8mg/min x 2h	Recombinant Xa decoy. ANNEXA-4, 2019. If unavailable, use 4F-PCC 50 units/kg.
Heparin (UFH)	Protamine sulfate	1 mg per 100 units heparin (last 2–3h of infusion)	Max 50 mg. Only partially reverses LMWH (~60%).

Do NOT wait for coagulation studies. If patient is on anticoagulation and has ICH on CT, reverse EMPIRICALLY and immediately. Time to reversal correlates with hematoma expansion and mortality.

Surgical Indications

Cerebellar ICH > 3 cm or with brainstem compression → Surgical evacuation (life-saving, often good outcomes)
Obstructive hydrocephalus → EVD (external ventricular drain) placement, regardless of ICH location
Supratentorial ICH with deterioration: Consider surgery for lobar hemorrhages within 1 cm of cortical surface. STICH II, 2013 showed no broad benefit for early surgery, but consider in deteriorating patients.
Minimally invasive surgery: MISTIE III, 2019, catheter-based clot evacuation showed trend toward benefit if residual clot < 15 mL.

ICP Management

Head of bed 30°, promotes venous drainage, reduces ICP
Osmotic therapy: Mannitol 0.5–1 g/kg IV bolus OR hypertonic saline (23.4% 30 mL via central line, or 3% NaCl 250 mL bolus peripherally)
EVD, both diagnostic (measure ICP) and therapeutic (drain CSF). Target ICP < 20 mmHg, CPP > 60 mmHg
Avoid: hyperthermia (active cooling to normothermia), hyperglycemia (target glucose 140–180), hyponatremia
Herniation protocol: If acute pupil dilation or posturing → hyperventilate briefly (target pCO2 30–35), give osmotic bolus, emergent CT and neurosurgery

Seizure Prophylaxis, The Debate

AHA/ASA Guidelines: Routine seizure prophylaxis is NOT recommended. Clinical seizures occur in 8–16% of ICH patients. Subclinical seizures (on EEG) occur in up to 30%. Levetiracetam is preferred if prophylaxis is used; phenytoin is associated with worse outcomes in ICH (Naidech, 2009). Continuous EEG monitoring recommended for patients with GCS decline out of proportion to hemorrhage size.

🧪 Workup

Non-contrast CT head -STAT. Shows hyperdense (white) acute blood. First-line.
CTA head -spot sign (contrast extravasation = active bleeding, predicts expansion)
CBC, PT/INR, PTT, fibrinogen -coagulation status
BMP, glucose
Type and screen
MRI -can evaluate underlying cause (tumor, AVM, cavernoma) once stable
CTA/MRA -evaluate for vascular malformation if non-hypertensive location

💊 Medications

Drug	Dose	Purpose
Nicardipine (Cardene)	5–15 mg/h IV drip	BP control -titratable, no ICP effects
Clevidipine (Cleviprex)	1–21 mg/h IV drip	Ultra-short acting alternative
4-factor PCC (KCentra)	25–50 units/kg IV	Warfarin reversal. Faster than FFP.
Idarucizumab (Praxbind)	5 g IV	Dabigatran reversal. Immediate effect.
Mannitol (Osmitrol)	0.5–1 g/kg IV bolus	ICP reduction -osmotic diuresis
Hypertonic Saline (23.4%)	30 mL IV via central line	ICP crisis -can use via peripheral at lower concentration (3%)

📋 On Rounds

Pimp Questions

What is the ICH Score and what does it predict?

Prognostic score for 30-day mortality: GCS 3-4 (+2), GCS 5-12 (+1), ICH volume ≥ 30 mL (+1), IVH present (+1), Infratentorial (+1), Age ≥ 80 (+1). Score 0 = 0% mortality, Score 5 = 100% mortality. Do NOT use as sole basis for withdrawal of care -prognostic models are imperfect and self-fulfilling prophecies contribute to poor outcomes.

Why is cerebellar hemorrhage a neurosurgical emergency?

The posterior fossa is a tight space. Cerebellar hemorrhage > 3 cm can cause: (1) Brainstem compression → rapid decline, (2) 4th ventricle obstruction → obstructive hydrocephalus, (3) Tonsillar herniation → death. Surgical evacuation is life-saving. EVD for hydrocephalus. These patients can have excellent outcomes with timely intervention -unlike supratentorial ICH.

How do you reverse DOACs in acute ICH?

Dabigatran: Idarucizumab (Praxbind) 5g IV -monoclonal antibody fragment, immediate full reversal. Rivaroxaban/Apixaban (factor Xa inhibitors): Andexanet alfa (Andexxa) -recombinant modified factor Xa decoy. If unavailable, use 4-factor PCC 50 units/kg IV. Key: Do NOT wait for drug levels. Time is brain -reverse empirically if recent DOAC use and ICH confirmed on CT.

What is the BP target in acute ICH and what trials support it?

Target SBP < 140 mmHg within 1 hour, supported by INTERACT2 (2013), which showed improved functional outcomes with intensive lowering. ATACH-2 (2016) tested even more aggressive targets (SBP 110–139) but showed no additional benefit and increased renal injury. Bottom line: aim for SBP < 140, but do not push below 110–120. Use nicardipine or clevidipine drip with an arterial line.

What is the "spot sign" on CTA and why does it matter?

The spot sign is a focus of contrast extravasation within the hematoma seen on CTA. It indicates active, ongoing bleeding and strongly predicts hematoma expansion (positive predictive value ~60–70%). Patients with a spot sign are at higher risk for clinical deterioration and may warrant more aggressive BP management and closer monitoring with repeat imaging.

Why is phenytoin avoided in ICH, and what is the preferred antiepileptic?

Phenytoin use in ICH is associated with worse functional outcomes, more fever, and longer ICU stays (Naidech, 2009). Levetiracetam (Keppra) is preferred if seizure prophylaxis or treatment is needed, it has a better side-effect profile, no drug-drug interactions, and does not require monitoring of drug levels.

How do you calculate ICH volume and why does it matter?

Use the ABC/2 method: A = largest hemorrhage diameter (cm), B = perpendicular diameter on same slice (cm), C = number of slices with hemorrhage x slice thickness (cm). Volume = (A x B x C) / 2 mL. Volume matters because: (1) ICH volume ≥ 30 mL is a component of the ICH Score predicting mortality, (2) volume > 60 mL in supratentorial ICH has ~90% mortality, (3) serial volume assessment detects hematoma expansion (≥33% or ≥6 mL increase).

When would you choose mannitol vs hypertonic saline for ICP management in ICH?

Both are osmotic agents that reduce ICP. Mannitol (0.5–1 g/kg IV): causes osmotic diuresis, avoid in hypotension as it depletes volume. Requires a Foley catheter. Monitor serum osmolality (hold if > 320). Hypertonic saline (HTS): 23.4% (30 mL) via central line or 3% NaCl (250 mL bolus) peripherally, preferred in hypotensive patients as it expands intravascular volume. Target Na 145–155. HTS may be more effective for refractory ICP elevation.

Clinical Examples

📋 Case 1, Hypertensive ICH with BP Management

Patient: 62-year-old male with HTN (non-adherent to meds), presents with sudden severe headache, left hemiparesis, and slurred speech. BP 218/112 on arrival. GCS 12.

CT Head: 25 mL right basal ganglia hemorrhage, no IVH, no hydrocephalus.

Management:

Start nicardipine drip 5 mg/h, titrate to SBP < 140 within 1 hour (INTERACT2 target)
Place arterial line for continuous BP monitoring
Confirm no anticoagulant use → no reversal needed
Neurosurgery consult, supratentorial, non-surgical candidate at this size
Neuro checks q1h, repeat CT at 6 hours
ICH Score = 1 (GCS 12 = +1) → 13% predicted 30-day mortality

Teaching point: Hypertensive basal ganglia hemorrhage is the classic ICH. Rapid BP control to SBP < 140 is the cornerstone of management. Do NOT overshoot below 110 (ATACH-2).

📋 Case 2, Warfarin-Associated ICH with Reversal

Patient: 78-year-old female on warfarin (INR 3.8) for atrial fibrillation. Found by family with confusion and right-sided weakness. BP 176/94. GCS 10.

CT Head: 40 mL left frontoparietal lobar hemorrhage with intraventricular extension.

Management:

4-factor PCC (KCentra) 25–50 units/kg IV STAT, do NOT wait for pharmacy to mix FFP
Vitamin K 10 mg IV, sustains reversal after PCC wears off
Nicardipine drip → target SBP < 140
ICH Score = 4 (GCS 10 = +1, volume ≥ 30 = +1, IVH = +1, age ≥ 80 = +1) → 97% predicted mortality
Repeat INR 30 min after PCC, goal < 1.5
Goals of care discussion with family, but do NOT withdraw care based solely on ICH score

Teaching point: Warfarin-associated ICH has the worst outcomes. Time to INR reversal directly impacts hematoma expansion. PCC reverses in minutes vs hours for FFP. Always give vitamin K concurrently for sustained reversal.

📋 Case 3, Cerebellar Hemorrhage Needing Surgery

Patient: 55-year-old male with HTN, presents with sudden occipital headache, vomiting, severe ataxia, unable to stand. BP 198/108. GCS 13 initially, drops to 9 over 30 minutes.

CT Head: 3.5 cm cerebellar hemorrhage with compression of 4th ventricle and early obstructive hydrocephalus.

Management:

EMERGENT neurosurgery consult, this is a surgical emergency
Suboccipital craniectomy and clot evacuation, life-saving for cerebellar ICH > 3 cm with mass effect
EVD placement for obstructive hydrocephalus (caution: draining supratentorial CSF alone can worsen upward herniation)
Nicardipine drip → SBP < 140
HOB 30°, osmotic therapy as bridge to OR
These patients can have excellent functional recovery with timely surgery, unlike supratentorial ICH

Teaching point: Cerebellar ICH is the one ICH where surgery is clearly beneficial. The posterior fossa is a confined space, a 3 cm hemorrhage can cause brainstem compression, obstructive hydrocephalus, and tonsillar herniation within hours. Rapid clinical deterioration (as in this case) demands emergent intervention.

⚡ Summary

Diagnosis

Non-contrast CT head STAT. Hyperdense acute blood. CTA for spot sign (active bleeding).

BP Target

SBP < 140 within 1h (INTERACT2). Nicardipine or clevidipine drip. A-line for monitoring.

Anticoag Reversal

Warfarin → 4F-PCC + Vit K. Dabigatran → idarucizumab. Xa-inhibitors → andexanet or PCC.

Surgery

Cerebellar ICH > 3cm or with hydrocephalus → surgical evacuation. Neurosurgery consult for all.

ICP Management

HOB 30°, mannitol/HTS, EVD if hydrocephalus. Target ICP < 20, CPP > 60.

Prognosis

ICH Score predicts 30-day mortality. Do NOT use as sole basis for withdrawal of care.