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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EMERGENTHeme/Onc

Neutropenic Fever

Fever (≥ 38.3°C single or ≥ 38.0°C sustained ≥ 1h) + ANC < 500 (or expected to drop < 500). This is a medical emergency -antibiotics within 60 minutes. These patients can go from febrile to septic shock in hours because they have no immune defense.

🔍 Overview

Definition

Neutropenia: ANC < 500 cells/μL, or ANC < 1000 and expected to decline to < 500 within 48h
Fever: single temperature ≥ 38.3°C (101°F) OR sustained ≥ 38.0°C (100.4°F) for ≥ 1 hour
Profound neutropenia: ANC < 100 → highest risk of bacteremia and death

Neutropenic patients cannot mount a normal inflammatory response. They may have no localizing signs -no pus, no infiltrate on CXR (no neutrophils to create one), minimal erythema at infection site. Fever may be the ONLY sign of life-threatening infection.

Risk Stratification -MASCC Score -low- vs high-risk febrile neutropenia (≥21 = low risk, may be eligible for outpatient oral antibiotics)

MASCC (Multinational Association for Supportive Care in Cancer) score predicts low-risk vs high-risk for serious complications.

Criterion	Points
Burden of illness: mild or no symptoms	+5
Burden of illness: moderate symptoms	+3
No hypotension (SBP ≥ 90)	+5
No COPD	+4
Solid tumor or no prior fungal infection	+4
No dehydration requiring IV fluids	+3
Outpatient at onset of fever	+3
Age < 60	+2

Score ≥ 21: low risk (~5% serious complication rate) → may consider outpatient oral antibiotics if reliable follow-up. Score < 21: high risk → admit for IV antibiotics.

Workup

Blood cultures × 2 sets (one from each lumen if central line + one peripheral). Draw BEFORE antibiotics but do NOT delay antibiotics for culture results.
CBC with differential, BMP, LFTs, lactate
UA + urine culture
CXR (may be falsely negative -no neutrophils to create infiltrate)
Sputum culture if productive cough
Stool for C. diff if diarrhea
Consider CT chest if pulmonary symptoms (CXR insensitive in neutropenia)
Consider fungal markers (galactomannan, β-D-glucan) if prolonged neutropenia (> 7 days)

🚨 Management

Empiric Antibiotics -Within 60 Minutes

Time to antibiotics matters. Start within 60 minutes of presentation. Mortality increases with every hour of delay.

Setting	Regimen	Notes
Standard empiric	Cefepime (Maxipime) 2g IV q8h 1ST LINE	Or piperacillin-tazobactam 4.5g IV q6h or meropenem 1g IV q8h. Anti-pseudomonal coverage is essential. Monotherapy is sufficient for uncomplicated cases IDSA, 2010.
Add vancomycin if:	Vancomycin (Vancocin) 15–20 mg/kg IV q8–12h	Hemodynamic instability, skin/soft tissue infection, catheter-site infection, known MRSA colonization, severe mucositis, PNA on imaging. Do NOT add vanc routinely -only for specific indications.
Add antifungal if:	Micafungin (Mycamine) 100 mg IV daily or voriconazole or liposomal amphotericin B	Persistent fever after 4–7 days of antibiotics with no identified source. Prolonged neutropenia (> 7 days). Consider CT chest for invasive aspergillosis (halo sign). Galactomannan, β-D-glucan.
Low-risk outpatient	Ciprofloxacin (Cipro) 750 mg PO BID + amoxicillin-clavulanate (Augmentin) 875 mg PO BID	Only if MASCC ≥ 21, reliable patient, close follow-up within 24h, no IV line infection. Must observe 4–6h first.

G-CSF (Filgrastim/Neupogen)

NOT routine in all neutropenic fever -per ASCO/IDSA, G-CSF is considered for: pneumonia, sepsis/septic shock, fungal infection, expected prolonged neutropenia (> 10 days), ANC < 100
Dose: filgrastim 5 mcg/kg SC daily until ANC recovery

🧪 Workup

Workup

Blood cultures × 2 sets -1 peripheral + 1 from each lumen of central line. Draw BEFORE antibiotics. If no central line, 2 peripheral sets from different sites.
CBC with differential -confirm ANC < 500/μL (or < 1000 and expected to decline). Trend for nadir timing.
BMP + LFTs -baseline renal/hepatic function for antibiotic dosing
Lactate -if any concern for sepsis (tachycardia, hypotension)
CXR -may be NORMAL even with pneumonia (neutropenic patients cannot mount an inflammatory infiltrate). A normal CXR does NOT exclude pulmonary infection.
UA + urine culture -but note: pyuria may be absent (no WBCs to form pus)
Skin exam -inspect ALL skin including perianal area, line sites, oral mucosa. Cellulitis without pus/erythema is common in neutropenia.
Stool studies -C. diff PCR if diarrhea (mucositis + antibiotics = high risk)
CT chest -if persistent fever day 4-5 despite antibiotics. Look for halo sign (invasive aspergillosis).
Galactomannan + β-D-glucan -at day 4-5 if fevers persist (fungal biomarkers). Galactomannan specific for Aspergillus. β-D-glucan broad (not Mucor/Crypto).
MASCC score -risk stratification for outpatient vs inpatient management (≥ 21 = low risk → may consider oral FQ + amoxicillin-clav)

💊 Medications

Medications

Drug	Dose	Route	Notes
Cefepime	2g IV q8h	IV	First-line anti-pseudomonal β-lactam. Start within 1 hour of presentation. IDSA, 2010
Meropenem	1g IV q8h	IV	Alternative if prior ESBL, cefepime allergy, or hemodynamic instability. Also covers anaerobes.
Pip-tazo	4.5g IV q6h	IV	Alternative first-line. Covers Pseudomonas + anaerobes. Avoid if concern for seizures (piperacillin lowers threshold).
Vancomycin	15-20 mg/kg IV	IV	NOT routine. Add ONLY if: hemodynamic instability, skin/soft tissue infection, suspected line infection, known MRSA colonization, severe mucositis, or blood culture growing GP cocci.
Micafungin	100 mg IV daily	IV	Empiric antifungal at day 4-5 if fever persists despite antibiotics. Echinocandin covers Candida + Aspergillus.
Voriconazole	6 mg/kg q12h × 2 → 4 mg/kg q12h	IV/PO	If invasive aspergillosis suspected (halo sign on CT, positive galactomannan). Voriconazole Aspergillosis Trial, 2002
G-CSF (filgrastim)	5 mcg/kg SQ daily	SQ	Consider if ANC expected to be < 100 for > 10 days, pneumonia, sepsis, or invasive fungal infection. Not routine for uncomplicated neutropenic fever.
Levofloxacin + Amox-clav	750 mg daily + 875 mg BID	PO	Outpatient option for LOW-RISK patients only (MASCC ≥ 21, expected short neutropenia, no comorbidities).

📋 On Rounds

Why can the CXR be falsely normal in neutropenic pneumonia?

Infiltrates on CXR are caused by neutrophilic inflammation -exudate, pus, and cellular debris filling the alveoli. Without neutrophils (ANC < 500), the patient cannot mount this inflammatory response, so the infection exists but there's nothing to create a visible infiltrate. As the ANC recovers, the infiltrate may suddenly "appear" -this doesn't mean the infection is getting worse, it means the immune system is now responding.

When do you add vancomycin to neutropenic fever empiric coverage?

NOT routinely. IDSA guidelines recommend adding vancomycin only for specific indications: (1) hemodynamic instability/septic shock, (2) suspected catheter-related infection (tunnel infection, port-site cellulitis), (3) known MRSA colonization, (4) skin/soft tissue infection, (5) severe mucositis with fluoroquinolone prophylaxis (risk of viridans strep bacteremia).

When do you add vancomycin to cefepime in neutropenic fever?

Vancomycin is NOT routine first-line -add only for specific indications: (1) Hemodynamic instability / septic shock, (2) Suspected catheter-related infection (line erythema, tunnel infection, positive line cultures), (3) Skin/soft tissue infection (cellulitis, wound), (4) Blood culture growing gram-positive cocci (pending identification), (5) Mucositis (severe -increases risk of viridans strep bacteremia, which can cause septic shock).

What is the MASCC score and how does it guide management?

MASCC (Multinational Association for Supportive Care in Cancer) score stratifies neutropenic fever risk. Points for: burden of illness (5 or 3), no hypotension (5), no COPD (4), solid tumor or no prior fungal infection (4), no dehydration (3), outpatient onset (3), age < 60 (2). Score ≥ 21: low risk (~5% serious complications) → candidate for outpatient oral antibiotics (ciprofloxacin + amox-clav)

❓ What is the MASCC score and when do you use it?

The MASCC score risk-stratifies neutropenic fever patients. Score ≥ 21 = low risk (may consider outpatient oral antibiotics: levofloxacin + amoxicillin-clavulanate). Criteria include: burden of illness, no hypotension, no COPD, solid tumor (vs hematologic), no dehydration, outpatient at onset, and age < 60.

❓ When do you add vancomycin to empiric therapy in neutropenic fever?

Vancomycin is NOT routine. Add only for: (1) hemodynamic instability/sepsis, (2) skin/soft tissue infection or suspected line infection, (3) blood cultures growing gram-positive cocci pending speciation, (4) known MRSA colonization, (5) severe mucositis (fluoroquinolone prophylaxis setting). IDSA, 2010

❓ At what point do you add empiric antifungal therapy?

At day 4-5 if fever persists despite broad-spectrum antibiotics. Start echinocandin (micafungin 100 mg daily). Send galactomannan + β-D-glucan. CT chest looking for halo sign (invasive aspergillosis). If CT or galactomannan positive → switch to voriconazole (better CNS penetration for Aspergillus). Voriconazole Aspergillosis Trial, 2002

❓ Name three organisms neutropenic patients are particularly susceptible to.

Pseudomonas aeruginosa (gram-negative, most feared -drives anti-pseudomonal empiric therapy), Aspergillus (invasive pulmonary aspergillosis in prolonged neutropenia > 10 days), and Candida (especially with mucositis, central lines, broad-spectrum antibiotics). Also viridans group streptococci in severe mucositis.

❓ Why can a CXR be normal in a neutropenic patient with pneumonia?

Neutropenic patients cannot mount an adequate inflammatory response. Pulmonary infiltrates require neutrophil recruitment to the infection site. With ANC < 500, there are insufficient neutrophils to form the inflammatory exudate that creates the radiographic infiltrate. The infiltrate may "appear" on CXR as neutrophils recover -this is why some patients develop new infiltrates during count recovery.

❓ What is the role of G-CSF (filgrastim) in neutropenic fever?

G-CSF is NOT routine for uncomplicated neutropenic fever. Consider in: (1) ANC expected < 100 for > 10 days, (2) pneumonia, (3) sepsis/septic shock, (4) invasive fungal infection, (5) age > 65. Prophylactic G-CSF is indicated for chemo regimens with ≥ 20% risk of febrile neutropenia. [ASCO/NCCN Guidelines]

Clinical Examples

📋 Case 1, Straightforward Neutropenic Fever

Patient: 62M with AML on induction chemotherapy (7+3), day 12 post-chemo. Presents with fever 39.1C, no localizing symptoms. ANC 40.

Key findings: HR 102, BP 128/74, SpO2 97%. No oral mucositis, no line erythema, no skin lesions. CXR clear. UA bland. MASCC score 18 (high risk).

Management:

Blood cultures x2 (1 peripheral + 1 from central line) BEFORE antibiotics
Cefepime 2g IV q8h started within 60 minutes of fever onset
No vancomycin (no hemodynamic instability, no line infection, no skin findings)
Daily reassessment: add vancomycin if clinical deterioration, antifungal at day 4-5 if persistent fever
Continue cefepime until ANC > 500 and afebrile ≥ 48h

Teaching point: Cefepime monotherapy is sufficient for uncomplicated neutropenic fever. Adding vancomycin empirically increases VRE selection and nephrotoxicity without improving outcomes. IDSA Guidelines, 2010

📋 Case 2, Neutropenic Fever with Line Infection

Patient: 45F with NHL on R-CHOP cycle 3, ANC 120. Fever 38.5C with rigors after PICC line flush. Erythema and tenderness at PICC insertion site.

Key findings: HR 115, BP 98/58. Tunnel erythema along PICC tract. Blood cultures drawn: differential time to positivity pending.

Management:

Cefepime 2g IV q8h (anti-pseudomonal coverage)
ADD vancomycin 25-30 mg/kg loading dose (suspected catheter-related infection)
Blood cultures from PICC AND peripheral, differential time to positivity > 2h = line infection
Consult ID for line removal vs salvage (tunnel infection usually requires removal)
NS bolus 30 mL/kg for hypotension

Teaching point: Vancomycin is added to neutropenic fever ONLY for specific indications: line infection, hemodynamic instability, skin/soft tissue infection, gram-positive bacteremia, or severe mucositis. De-escalate at 48-72h if cultures negative for gram-positives.

📋 Case 3, Persistent Fever Requiring Antifungal Escalation

Patient: 58M with AML, ANC 0, day 5 of cefepime for neutropenic fever. Still febrile (38.8C daily). Blood cultures negative. No source identified.

Key findings: CT chest: new 1.5 cm nodule with surrounding ground-glass halo ("halo sign"). Galactomannan index 1.8 (positive). Beta-D-glucan 245 (elevated).

Management:

Start voriconazole 6 mg/kg IV q12h x2 doses (loading), then 4 mg/kg IV q12h
Check voriconazole trough at day 5 (target 1-5.5 mcg/mL)
Continue cefepime for bacterial coverage
Consider G-CSF (ANC 0 for > 10 days with invasive fungal infection)
Repeat CT chest in 1-2 weeks to assess response

Teaching point: Persistent fever at day 4-5 on broad-spectrum antibiotics triggers empiric antifungal therapy. The halo sign on CT suggests invasive aspergillosis. Voriconazole is preferred over amphotericin B. Herbrecht et al., 2002

📣 Sample Presentation

One-Liner

"Mr. Wilson is a 58-year-old with AML on induction chemotherapy, day 10 post-chemo, ANC 80, presenting with fever 38.8°C. Hemodynamically stable. MASCC score 21 (high risk)."

Key Points to Cover on Rounds

Neutropenic fever -ANC 80 (profound neutropenia). Blood cultures × 2 drawn (1 peripheral + 1 from PICC). Cefepime 2g IV q8h started within 45 min of fever. No vancomycin yet (no hemodynamic instability, no line erythema, no skin infection). Chest CT: no infiltrate. UA: no pyuria. No oral mucositis. Source: occult bacteremia until proven otherwise. Plan: daily assessment -add vancomycin if clinical deterioration or positive cultures with GP. Add antifungal (micafungin) if fever persists at day 4-5. Continue cefepime until ANC >500 + afebrile ≥48h.

Monitoring

Temperature curve -defervescence expected within 3-5 days on appropriate antibiotics. Persistent fever at day 4-5 = expand workup (CT chest, fungal markers, line cultures)
ANC daily -recovery above 500/μL is the key milestone. Antibiotics generally continued until ANC > 500 AND afebrile × 48h.
Blood cultures at 48h -if initial cultures positive, repeat to document clearance. If persistent bacteremia → evaluate for endovascular source, line removal.
Daily clinical assessment -new symptoms (cough, diarrhea, skin changes, abdominal pain), line sites (erythema, drainage), perianal exam, oral mucositis grade
Galactomannan + β-D-glucan at day 4-5 if fever persists -repeat twice weekly if high suspicion for invasive fungal infection
CRP trending -useful adjunct for tracking infection response (if rising on day 3-4, consider broadening coverage)
Cr + LFTs -drug toxicity monitoring (vancomycin nephrotoxicity, voriconazole hepatotoxicity)
Trough levels -vancomycin AUC/MIC targeting, voriconazole trough 1-5.5 mcg/mL

⚡ Summary

Summary

Definition

ANC < 500 (or expected to fall to < 500) + single temp ≥ 38.3°C or sustained ≥ 38.0°C over 1 hour.

First-Line

Cefepime 2g IV q8h. Monotherapy. Start within 1 hour of fever. Don't add vancomycin unless specific indication.

Add Vancomycin

Hemodynamic instability, catheter infection, skin/soft tissue infection, gram-positive bacteremia, mucositis.

Add Antifungal

Persistent fever at day 4-5 on antibiotics → micafungin or caspofungin. Galactomannan and β-D-glucan to guide.

MASCC Score

≥ 21 = low risk → outpatient oral abx (ciprofloxacin + amox-clav) if reliable patient, no organ dysfunction, close follow-up.

Stop Abx When

ANC > 500 rising + afebrile ≥ 48h + cultures negative + clinically stable. Don't continue indefinitely.

📄 One Pager

Oncology / ID · One Pager

Neutropenic Fever

ANC < 500 + fever → cefepime within 1 hour. No vancomycin unless specific indication. Add antifungal at day 4-5 if persistent fever. MASCC ≥ 21 may go home.

🧪 Definition

ANC < 500 (or expected to fall to < 500) + single temp ≥ 38.3°C or sustained ≥ 38.0°C over 1 hour. Medical emergency -clock starts at fever.

🚨 Treatment

Cefepime 2g IV q8h started within 1 hour. Blood cultures × 2 (peripheral + from line). CXR. UA. No vancomycin unless: shock, skin/line infection, GP bacteremia, mucositis.

💊 Escalation

Add vancomycin if specific indication at any time. Add antifungal (micafungin/caspofungin) at day 4-5 if persistent fever. MASCC ≥ 21: low-risk → outpatient oral abx (cipro + amox-clav) if reliable.

💊 Key Drugs

Cefepime2g IV q8h

Meropenem1g q8h (if prior resistant GNR)

Vancomycin15-20 mg/kg (only if indicated)

Micafungin100 mg daily (persistent fever)

⚠️ Pitfalls

Delaying cefepime (start within 1 hour)
Routine vancomycin (not needed unless specific indication)
Missing perianal abscess (physical exam including perirectal)
Not considering antifungal at day 4-5