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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EmergentGI

Lower GI Bleed

Bleeding distal to the ligament of Treitz. Usually presents with hematochezia (bright red blood per rectum). 80–85% stop spontaneously. The key question: is this really a lower bleed, or is it a brisk upper GI bleed presenting with hematochezia?

🔍 Overview

Common Causes

Rule out upper GI source first. Up to 15% of patients presenting with hematochezia have a brisk UPPER GI bleed. If hemodynamically unstable with hematochezia, place NGT or perform upper endoscopy (EGD) BEFORE colonoscopy to rule out upper source.

Is It Really Lower?

~10-15% of patients presenting with hematochezia have an upper GI source. A brisk upper GI bleed can transit fast enough to present as bright red blood per rectum. If the patient is hemodynamically unstable with hematochezia, consider upper GI source and place an NG tube or perform urgent EGD first.

Clues to upper source: hemodynamic instability, BUN/Cr ratio > 30, melanotic stool mixed with red blood, history of liver disease/varices/NSAID use
BUN/Cr ratio > 30 suggests upper GI bleed (absorbed blood products increase BUN)

🚨 Management

Initial Approach

Resuscitate

ABCs. Two large-bore IVs. Crystalloid resuscitation. Type and crossmatch. Transfuse pRBCs if Hgb < 7 (or < 9 if active ongoing hemorrhage or CAD). Correct coagulopathy -reverse anticoagulation if life-threatening bleed (4F-PCC for warfarin, idarucizumab for dabigatran, andexanet alfa for Xa inhibitors).

Risk stratify

Oakland score (age, sex, prior LGIB, DRE findings, HR, SBP, Hgb) -score ≤ 8 = safe for outpatient management. Higher scores → admit. Hemodynamic instability → ICU.

Rule out upper source

If hemodynamically unstable or high suspicion → NG lavage (if returns bile = upper source less likely, if returns blood = upper confirmed) or urgent EGD. BUN/Cr ratio > 30 → think upper.

Colonoscopy

Colonoscopy within 24h after adequate bowel prep ACG Guidelines, 2023. Diagnostic AND therapeutic (clipping, cauterization, epinephrine injection).

Key Evidence: Early colonoscopy (within 24h) did NOT reduce mortality or rebleeding in acute LGIB compared to elective timing COOLNG-2 (Strate), 2020. Restrictive transfusion (Hgb threshold 7 g/dL) is recommended over liberal (9 g/dL) for most GI bleeds Villanueva, 2013. CTA (CT angiography) can localize active bleeding for IR embolization when colonoscopy fails ACG Guidelines (Strate), 2023.

If Colonoscopy Fails to Localize

Cause	% of LGIB	Key Features
Diverticular bleed	~30-40%	Most common cause in adults > 60. Painless, large-volume, bright red blood. Usually self-limited (80% stop spontaneously). Right-sided diverticula bleed more often than left. Recurrence ~20-35% at 1 year Niikura, 2015.
Hemorrhoids	~20%	Bright red blood on toilet paper or coating stool. Most common cause of LGIB overall when including outpatient. Usually minor.
Angiodysplasia / AVM	~10%	Vascular ectasias, usually right colon. Chronic, intermittent bleeding. Associated with aortic stenosis (Heyde syndrome) and CKD.
Colitis (ischemic, IBD, infectious)	~10–15%	Bloody diarrhea + abdominal pain. Ischemic colitis: elderly + hypotension → "watershed" (splenic flexure). IBD: younger, chronic.
Colorectal cancer/polyps	~5–10%	Occult or slow chronic bleeding → iron deficiency anemia. Mass on colonoscopy.
Post-polypectomy bleed	Variable	1–7 days after colonoscopy with polypectomy. Usually self-limited.

Test	When	Notes
CT angiography	Active bleeding (requires > 0.3-0.5 mL/min)	Fast, widely available. Localizes active extravasation Defined, 2019. Can guide IR embolization. Get BEFORE colonoscopy if hemodynamically unstable.
Tagged RBC scan (nuclear medicine)	Intermittent or slow bleeding (> 0.1 mL/min)	More sensitive than CTA for slow bleeds. Localizes to a region (not exact vessel). Takes hours. Less useful in acute management.
Angiography + embolization (IR)	Active hemorrhage not controlled by endoscopy	Requires active bleeding (> 0.5 mL/min). Can embolize the bleeding vessel. Risk: bowel ischemia (~5%).
Surgery	Massive, life-threatening, refractory bleed	Last resort. Segmental colectomy if source localized. Subtotal colectomy if source unknown (high morbidity). Always try to localize before surgery.

Anticoagulation in LGIB

Hold anticoagulation during active bleed + resuscitation
Restart early -within 7 days for most patients (if indication is strong: Afib, mechanical valve, recent VTE). Longer delay → increased thromboembolic events without mortality benefit from reduced rebleeding.
Aspirin for secondary cardiovascular prevention: do NOT stop (increased cardiac events outweigh GI bleed risk). Hold only if life-threatening hemorrhage.

Anticoagulant Management in LGIB: Hold anticoagulants during active bleed. For warfarin: give vitamin K if INR > 2.5 with significant bleeding. For DOACs: consider reversal only if life-threatening (idarucizumab (Praxbind) for dabigatran, andexanet alfa (Andexxa) for factor Xa inhibitors). Resume anticoagulation within 7 days if possible - delayed resumption increases thrombotic events Witt, 2017.

🧪 Workup

Initial Labs & Studies

CBC -Hgb/Hct (may lag in acute hemorrhage), platelets
BMP -BUN/Cr ratio > 20:1 suggests upper GI source (digested blood raises BUN)
Coags -PT/INR, PTT (especially if on anticoagulants or liver disease)
Type & Screen -always. Type & Cross if actively bleeding or Hgb dropping
Lactate -marker of hypoperfusion from hemorrhagic shock
LFTs -if upper source suspected (cirrhosis, varices)

Diagnostic Approach

Digital rectal exam -stool color (bright red, maroon, melena), hemorrhoids, masses
Colonoscopy within 24h -diagnostic AND therapeutic. Requires bowel prep (GoLYTELY 4L over 3–4h). Identifies source in 70–80%.
CT angiography -if hemodynamically unstable or too unstable for prep. Detects active bleeding > 0.3 mL/min.
EGD first -if BUN/Cr > 20, hemodynamic instability with hematochezia, or high suspicion for upper source (~15% of hematochezia is upper GI)
Tagged RBC scan -for intermittent or slow bleeds (> 0.1 mL/min). More sensitive but less specific than CTA. Takes hours.
Capsule endoscopy -for obscure GI bleeding when EGD and colonoscopy are negative

Oakland Score: Validated risk stratification tool for LGIB. Score ≤ 8 predicts safe discharge from ED without inpatient admission (99% sensitivity for no adverse outcomes). Components: age, sex, prior LGIB admission, HR, SBP, DRE findings, hemoglobin Oakland, 2017.

💊 Medications

Key Medications

Drug	Dose	Route	Notes
pRBCs	Transfuse if Hgb < 7 (or < 9 if CAD/active hemorrhage)	IV	Restrictive strategy preferred. 1 unit raises Hgb ~1 g/dL.
Pantoprazole (Protonix)	40 mg IV BID	IV	If upper source not yet excluded. Switch to PO once upper ruled out.
4F-PCC (KCentra)	25–50 units/kg IV	IV	Warfarin reversal for life-threatening bleed. Effect within 15 min.
Idarucizumab (Praxbind)	5 g IV	IV	Reversal of dabigatran. Complete reversal within minutes.
Andexanet alfa (Andexxa)	Weight-based IV	IV	Reversal of rivaroxaban/apixaban. Use for life-threatening bleed only (expensive).
GoLYTELY (PEG)	4L over 3–4h	PO/NGT	Bowel prep before colonoscopy. Can give via NGT if patient unable to drink.

📋 On Rounds

A patient presents with massive hematochezia and hemodynamic instability. What do you do first?

Resuscitate and consider an upper source. Massive hematochezia with hemodynamic instability has a ~15% chance of being from a brisk upper GI bleed (variceal, ulcer). Steps: (1) Large-bore IVs, crystalloid, activate massive transfusion if needed. (2) Urgent EGD or NG lavage to rule out upper source -this changes management completely (octreotide for varices, PPI for ulcer)

What is Heyde syndrome?

Aortic stenosis + GI bleeding from angiodysplasia. The mechanism: blood flowing through the stenotic aortic valve experiences high shear stress → destruction of von Willebrand factor (vWF) high-molecular-weight multimers → acquired von Willebrand disease type 2A → impaired hemostasis → bleeding from pre-existing angiodysplasia in the GI tract.

15% of patients presenting with hematochezia actually have an upper GI source. How do you catch this?

Bright red blood per rectum doesn't always mean lower GI bleed. A brisk upper GI bleed can transit fast enough to appear as hematochezia. Clues it's actually upper: (1) Hemodynamic instability disproportionate to rectal bleeding, (2) Elevated BUN/Cr ratio > 20 (blood protein digestion in upper GI → urea absorption), (3) NG tube with bloody aspirate (but a clear aspirate does NOT rule out upper -pyloric spasm can prevent reflux)

What is the role of CTA in acute lower GI bleed?

CT angiography can detect active bleeding if the rate is ≥ 0.3-0.5 mL/min (extravasation of contrast = active bleed). Best for: (1) hemodynamically unstable patient too sick for colonoscopy, (2) massive ongoing bleed where endoscopy can't visualize the source, (3) localizing the bleed for IR angiographic embolization. Limitation: if the bleeding is intermittent or has stopped, CTA will be negative.

What is the Oakland Score and when can you safely discharge an LGIB patient from the ED?

Oakland Score: validated risk stratification tool using age, sex, prior LGIB admission, HR, SBP, DRE findings, and hemoglobin. Score ≤ 8 identifies very low-risk patients safe for outpatient management (99% sensitivity for no adverse outcomes). Avoids unnecessary admissions for self-limited bleeding like hemorrhoids. Oakland, BMJ 2017.

Case 1: Diverticular Bleed

Presentation: 72M with PMH of HTN, diverticulosis presents with 3 episodes of painless maroon stools over 6 hours. Denies abdominal pain, NSAID use, or anticoagulation.

Vitals: HR 92, BP 128/74, afebrile. Abdomen soft, non-tender. Rectal: maroon stool, no hemorrhoids.

Labs: Hgb 8.0 (baseline 12.0), BUN/Cr ratio 14, INR 1.0, platelets 210K.

Management: Two large-bore IVs, resuscitate with lactated Ringer's (LR). Type & screen, crossmatch 2 units pRBC. Transfuse for Hgb < 7 (restrictive strategy). Hold aspirin if on it. GI consult → colonoscopy within 24 hours after bowel prep. If active diverticulum found → endoscopic hemostasis with clip placement or epinephrine injection. Hgb q6h during active monitoring.

Case 2: Severe Hematochezia with Hemodynamic Instability

Presentation: 65F on apixaban (Eliquis) for AFib presents with massive bright red blood per rectum, lightheadedness, and near-syncope.

Vitals: HR 120, BP 85/50, RR 22, pale and diaphoretic. Abdomen soft. Rectal: large-volume bright red blood.

Labs: Hgb 6.2, lactate 3.8, BUN/Cr ratio 22 (consider upper source).

Management: Activate massive transfusion protocol (MTP). Two large-bore IVs, lactated Ringer's (LR) wide open. Reverse anticoagulation with andexanet alfa (Andexxa) or 4-factor PCC (Kcentra) if unavailable. CTA abdomen/pelvis to localize active extravasation. If source identified → IR angiographic embolization. If no source on CTA or ongoing instability → surgery consult for possible subtotal colectomy. Elevated BUN/Cr → consider EGD to rule out upper source first.

Case 3: Ischemic Colitis

Presentation: 80F POD#3 from CABG presents with acute LLQ cramping pain and bloody diarrhea (6 episodes). History of PVD and CHF.

Vitals: HR 98, BP 108/62, T 37.8°C. Abdomen tender in LLQ, no peritoneal signs. Rectal: bloody stool.

Labs: Hgb 10.2, WBC 14K, lactate 2.1. CT abdomen shows colonic wall thickening at splenic flexure (watershed area) with pericolonic fat stranding, no pneumatosis or free air.

Management: Supportive care - bowel rest (NPO), IV lactated Ringer's (LR) for hydration, optimize cardiac output. Avoid vasopressors if possible (worsen ischemia). Broad-spectrum antibiotics (piperacillin-tazobactam (Zosyn)) if concern for transmural ischemia or sepsis. Serial abdominal exams q4-6h. Repeat imaging if worsening pain, rising lactate, or peritoneal signs. Surgery consult for perforation, gangrene, or clinical deterioration. Most cases resolve in 48-72h with supportive care.

📣 Sample Presentation

One-Liner

"Mr. Peters is a 74-year-old on apixaban presenting with 3 episodes of painless bright red blood per rectum. Hemodynamically stable, Hgb 9.8 from baseline 13.2."

Key Points to Cover on Rounds

Lower GI bleed, likely diverticular (painless, large-volume, elderly). Hemodynamically stable (HR 82, BP 134/78). Apixaban held. Hgb 9.8 -transfused 1 unit pRBC. Upper source ruled out (no melena, no hematemesis, BUN/Cr ratio normal). GI consulted -colonoscopy planned within 24h after bowel prep. If active bleeding identified → endoscopic hemostasis. If massive/unstable → CTA abdomen/pelvis. Bleeding has stopped spontaneously. Plan: colonoscopy tomorrow, resume apixaban after hemostasis confirmed.

Monitoring

Hgb q6-8h during active bleed
Hemodynamics
Stool output
Repeat Hgb after transfusion

⚡ Summary

Summary

Most Common

Diverticular bleeding (#1 in elderly, painless), hemorrhoids (#1 overall), angiodysplasia, ischemic colitis, malignancy.

15% Are Upper

Brisk upper GI bleed → hematochezia. Clues: hemodynamic instability, elevated BUN/Cr ratio > 20. EGD before colonoscopy if suspected.

Stable

Colonoscopy within 24h (after prep). Hold anticoag. Transfuse if Hgb < 7.

Unstable

CTA abdomen/pelvis → if active extravasation → IR embolization. If unlocalized → tagged RBC scan or surgical consult.

Ischemic Colitis

Elderly + hypotension + bloody diarrhea + left colon. CT: thumbprinting. Colonoscopy for diagnosis. Supportive care; surgery if gangrenous.

Most Stop

80-85% of LGIB stops spontaneously. Diverticular bleeds recur in ~25%. Definitive treatment if identified: endoscopic, IR, or surgical.

📄 One Pager

GI · One Pager

Lower GI Bleed

15% are actually upper source. Stable → colonoscopy within 24h. Unstable → CTA → IR embolization. Most stop spontaneously. Restrictive transfusion.

🧪 DDx

Diverticular (#1 in elderly, painless, large-volume), hemorrhoids (#1 overall), angiodysplasia, ischemic colitis, malignancy, IBD, post-polypectomy.

🚨 Management

Stable: resuscitate → colonoscopy within 24h (after prep). Unstable: CTA abdomen/pelvis → if active bleed → IR embolization. EGD first if upper source suspected.

⚠️ 15% Rule

15% of hematochezia is from upper GI source. Clues: hemodynamic instability disproportionate to rectal bleeding, BUN/Cr ratio > 20. If in doubt → EGD before colonoscopy.

💊 Key Drugs

TransfusepRBC if Hgb < 7

IVFLR resuscitation

Hold anticoagResume after hemostasis

PPIOnly if upper source suspected

⚠️ Pitfalls

Assuming hematochezia = lower source (15% are upper)
Not holding anticoagulation
Over-transfusion (Hgb > 7 threshold for most)
Not doing colonoscopy within 24h