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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UrgentCardiology

Pericarditis & Pericardial Disease

Inflammation of the pericardium. Usually viral and self-limited. The danger: missing tamponade and confusing it with STEMI. Colchicine reduces recurrence by 50%.

🔍 Overview

Diagnosis (≥ 2 of 4 criteria)

Pleuritic chest pain -sharp, worse with inspiration and supine, improved leaning forward
Pericardial friction rub -scratchy, 3-component (best heard with diaphragm, patient leaning forward)
Diffuse ST elevation with PR depression (concave-up, diffuse -NOT territorial like STEMI)
New or worsening pericardial effusion on echo

Pericarditis vs STEMI on ECG

Feature	Pericarditis	STEMI
ST elevation	Diffuse, concave-up ("smiley face")	Territorial (matches coronary distribution), convex-up
PR segment	PR depression (except aVR -PR elevation)	Usually normal
Reciprocal changes	None (except aVR)	Present (ST depression in opposite leads)
Q waves	Absent	May develop
T-wave evolution	ST normalizes BEFORE T inversions	T inversions occur WITH persistent ST elevation

Cardiac Tamponade

Tamponade is a clinical diagnosis, not an echocardiographic one. A large effusion can be well-tolerated (chronic); a small rapidly accumulating effusion can cause tamponade.

Beck's triad: hypotension, JVD, muffled heart sounds (only ~30% have all three)
Pulsus paradoxus > 10 mmHg (SBP drop > 10 with inspiration) -most sensitive clinical sign
Echo: RA collapse in systole (earliest), RV diastolic collapse, IVC plethora (no collapse with inspiration)
Electrical alternans on ECG (swinging heart) -classic but uncommon
Treatment: emergent pericardiocentesis -subxiphoid approach, echo-guided. Drain as much as possible. Send fluid for cell count, protein, LDH, glucose, gram stain, culture, cytology, ADA.

🚨 Management

Acute Pericarditis -Treatment

Drug	Dose	Duration	Notes
NSAIDs 1ST LINE	Ibuprofen 600 mg PO TID or ASA 750–1000 mg PO TID	1–2 weeks, taper over 2–4 weeks	First-line anti-inflammatory. ASA preferred post-MI (NSAIDs impair scar formation). Add PPI for gastric protection.
Colchicine (Colcrys) ADD TO ALL	0.5 mg BID (if > 70 kg) or 0.5 mg daily (if ≤ 70 kg)	3 months	COPE, 2005 + ICAP, 2013: colchicine reduced recurrence by ~50%. Should be added to ALL pericarditis treatment. GI side effects (diarrhea). Renal dose if CrCl < 30.
Corticosteroids LAST RESORT	Prednisone 0.25–0.5 mg/kg/day	Taper over weeks–months	Avoid if possible -steroids increase recurrence rate. Use only if NSAIDs + colchicine contraindicated or failed, or autoimmune etiology confirmed. Taper VERY slowly.

Exercise restriction: Non-athletes → restrict until symptoms resolve + CRP normalizes. Athletes → minimum 3 months of no competitive sports ESC 2015 guidelines.

📋 On Rounds

Pimp Questions

Why do steroids increase recurrence in pericarditis?

Steroids suppress the immune response so effectively that the underlying viral/inflammatory process doesn't fully resolve -it smolders. When you taper the steroids, the inflammation rebounds. This is why COPE, 2005 and subsequent studies showed steroids as an independent predictor of recurrence. Colchicine, by contrast, modulates the inflammatory response without suppressing it entirely, leading to more durable resolution.

How do you differentiate pericardial effusion from tamponade?

Effusion is an anatomic finding. Tamponade is a hemodynamic diagnosis. A patient can have a massive chronic effusion with no hemodynamic compromise (the pericardium stretches slowly). Conversely, 200 mL accumulating rapidly (e.g., post-procedure, trauma, aortic dissection) can cause tamponade. The diagnosis is clinical: hypotension + JVD + pulsus paradoxus + echo showing diastolic chamber collapse.

When should you suspect cardiac tamponade in a patient with pericarditis?

Beck's triad: hypotension + JVD + muffled heart sounds (only 10-40% have all three). More reliable: pulsus paradoxus > 10 mmHg (SBP drops > 10 during inspiration). Best bedside test: echo showing diastolic RV collapse (most specific), RA collapse, IVC plethora (dilated, no respiratory variation), respiratory variation in mitral/tricuspid inflow velocities.

Why do you add colchicine to NSAIDs for pericarditis?

COPE, 2005 and ICAP, 2011: adding colchicine to NSAIDs halved the recurrence rate from ~30% to ~15%. Colchicine inhibits tubulin polymerization → blocks neutrophil chemotaxis and inflammasome activation. Dose: 0.5 mg BID (or 0.5 mg daily if < 70 kg) × 3 months for first episode, × 6 months for recurrence. Start colchicine on day 1 -not just for recurrence prevention.

Clinical Examples

📋 Case 1, Acute Viral Pericarditis with Myopericarditis

Patient: 26M, previously healthy, presents with 2 days of sharp pleuritic chest pain worse lying flat and improved leaning forward. Recent URI 10 days ago.

Key findings: T 100.4°F, HR 88, BP 122/74. Pericardial friction rub on auscultation. ECG: diffuse concave ST elevation + PR depression. Troponin 0.18 (mildly elevated). CRP 8.4. Echo: small circumferential effusion, no tamponade.

Management:

Ibuprofen 600 mg PO TID x 1-2 weeks, then taper by 200-400 mg/week. PPI for GI protection.
Colchicine 0.5 mg BID x 3 months (reduces recurrence by ~50%)
Activity restriction until symptoms resolved AND CRP normalized (critical with troponin elevation)
Repeat echo in 1 week; CRP weekly until normalized
Avoid steroids, increase recurrence risk

Teaching point: The mildly elevated troponin indicates myopericarditis (myocardial involvement). This does not change treatment but mandates strict exercise restriction, return to sport only after 3-6 months symptom-free with normal CRP, ECG, and echo. ICAP, 2013

📋 Case 2, Recurrent Pericarditis on Steroid Taper

Patient: 41F, 3rd episode of pericarditis in 18 months. Initially treated with NSAIDs alone (no colchicine). Second episode treated with prednisone 40 mg with rapid taper. Now recurs 2 weeks after completing steroid taper.

Key findings: Pleuritic chest pain, CRP 12.8, small effusion on echo. No tamponade physiology. ECG with recurrent ST changes.

Management:

Restart ibuprofen 600 mg TID + colchicine 0.5 mg BID x 6 months (longer duration for recurrence)
If steroid-dependent: very slow taper (decrease by 2.5 mg every 2-4 weeks only if asymptomatic + CRP normal)
If refractory to colchicine + NSAIDs + slow steroid taper: consider anakinra (IL-1 receptor antagonist)
Avoid exercise until CRP normalizes

Teaching point: Steroids are an independent risk factor for recurrent pericarditis. COPE, 2005 demonstrated colchicine should be first-line for all pericarditis. In steroid-dependent recurrent pericarditis, AIRTRIP, 2016 showed anakinra achieved complete response in 80%+ of patients.

📋 Case 3, Post-MI Pericarditis (Dressler Syndrome)

Patient: 63M, admitted 3 weeks ago for anterior STEMI with PCI to LAD. Now re-presents with pleuritic chest pain, low-grade fever, and new pericardial friction rub.

Key findings: ECG: diffuse ST elevation (different from prior focal anterior changes). Troponin re-elevated to 0.42. CRP 15.2. Echo: moderate pericardial effusion, no tamponade. On aspirin 81 mg + ticagrelor (DAPT).

Management:

Aspirin 750-1000 mg TID (preferred NSAID post-MI)
Colchicine 0.5 mg BID x 3 months
Avoid ibuprofen post-MI, interferes with aspirin's antiplatelet effect
Continue DAPT (do not stop ticagrelor for pericarditis)
Monitor for tamponade, anticoagulated patients at higher risk of hemorrhagic effusion

Teaching point: Dressler syndrome is autoimmune pericarditis occurring 2-10 weeks post-MI. Use aspirin (not ibuprofen) as the anti-inflammatory because ibuprofen competitively inhibits aspirin's irreversible COX-1 platelet binding. Avoid anticoagulation if large effusion due to hemorrhagic tamponade risk.

📣 Sample Presentation

One-Liner

"Mr. Okafor is a 24-year-old presenting with sharp pleuritic chest pain worse lying flat, improved leaning forward, following a URI 10 days ago. ECG shows diffuse ST elevation with PR depression. Troponin mildly elevated at 0.15 suggesting myopericarditis."

Key Points to Cover on Rounds

Etiology: likely viral (post-URI). Troponin 0.15 (mild, myopericarditis). Echo: small pericardial effusion, no tamponade physiology. CRP 8.4 (elevated, will trend). Treatment: ibuprofen 600 mg TID × 2 weeks + colchicine 0.5 mg BID × 3 months. Pain improving. Avoiding exercise until CRP normalizes and symptoms resolve. Plan: repeat echo in 1 week, CRP weekly.

Monitoring -Pericarditis & Pericardial Disease

Parameter	Frequency	Target / Action
CRP	Weekly until normal	Guides duration of therapy. Do NOT taper NSAIDs until CRP normalizes. Premature taper = recurrence.
ECG	At diagnosis, then at follow-up	Monitor ST/PR normalization through 4 stages. Persistent changes may suggest constrictive physiology.
TTE (Echo)	Repeat in 1-2 weeks	Confirm effusion resolution. Repeat sooner if hemodynamic compromise or clinical worsening.
Symptoms	Each visit	Pleuritic chest pain, dyspnea, positional symptoms. Worsening = consider effusion enlargement or recurrence.
Renal function (Cr)	1-2 weeks after starting NSAIDs	NSAID nephrotoxicity. Check BMP especially in elderly, CKD, heart failure, or concurrent ACEi/ARB.
Activity restriction	Until CRP normal + asymptomatic	Non-athletes: restrict until symptom resolution. Athletes: no competitive sports for minimum 3 months (6 months if myopericarditis).

🧪 Workup

Workup -Pericarditis & Pericardial Disease

Test	Findings	Clinical Significance
12-lead ECG	Diffuse ST elevation (concave up), PR depression, Spodick sign (downsloping TP segment)	Stage I changes present in ~80%. Diffuse = not in a coronary territory (distinguishes from STEMI).
TTE (Echocardiogram)	Pericardial effusion size, tamponade physiology (RA/RV collapse, IVC plethora, respiratory variation)	Assess effusion size and hemodynamic impact. Repeat in 1-2 weeks to monitor resolution.
Troponin	Elevated if myopericarditis	Mild elevation suggests myocardial involvement. Does NOT change treatment but restricts activity longer.
CRP / ESR	Elevated (CRP often markedly)	CRP guides treatment duration -continue colchicine + NSAIDs until CRP normalizes.
CBC	Leukocytosis (if infectious/inflammatory)	WBC differential helps distinguish viral (lymphocytic) vs bacterial (neutrophilic).
BMP	Cr (baseline), electrolytes	Baseline renal function before NSAID therapy. Monitor during treatment.
Blood cultures	If infectious etiology suspected	Obtain if febrile, immunocompromised, or subacute presentation suggesting bacterial/TB pericarditis.

Diagnosis requires 2 of 4: (1) pleuritic chest pain, (2) pericardial friction rub, (3) diffuse ST elevation + PR depression, (4) new/worsening pericardial effusion.

💊 Medications

Medications -Pericarditis & Pericardial Disease

Drug	Dose	Duration	Notes
Ibuprofen (Advil) 1ST LINE	600 mg PO TID	1-2 weeks, then taper over 2-3 weeks	First-line NSAID. Take with PPI for GI protection. Taper by 200-400 mg/week.
Colchicine (Colcrys) 1ST LINE	0.5 mg BID (0.5 mg daily if <70 kg)	3 months (first episode), 6 months (recurrent)	Halves recurrence rate. COPE, 2005 + ICAP, 2013. GI side effects (diarrhea) -dose-reduce if needed.
Aspirin	750-1000 mg PO TID	1-2 weeks, then taper	Preferred over ibuprofen if recent MI (post-infarction pericarditis / Dressler syndrome).
Prednisone 2ND LINE ONLY	0.25-0.5 mg/kg/day	Slow taper over weeks-months	Only if contraindication to NSAIDs (renal failure, GI bleeding). Increases recurrence risk. Always use with colchicine.

Avoid anticoagulants if moderate-large effusion -risk of hemorrhagic pericardial effusion and tamponade. If on anticoagulation for other indication, discuss risk-benefit with cardiology.

⚡ Summary

Summary

Diagnosis

Need 2 of 4: pleuritic chest pain, pericardial rub, diffuse ST elevation + PR depression, new pericardial effusion.

Treatment

Ibuprofen 600 TID × 2 weeks + colchicine 0.5 BID × 3 months. Colchicine halves recurrence [COPE, 2005, ICAP, 2013].

Tamponade

Beck's triad (hypotension + JVD + muffled sounds). Pulsus paradoxus > 10. RV collapse on echo. → Pericardiocentesis.

Avoid

Anticoagulation (risk of hemorrhagic pericardial effusion). Steroids first-line (high recurrence rate).

Myopericarditis

Pericarditis + troponin elevation. Avoid exercise until CRP normalizes and symptoms resolve × 3 months.

Recurrence

Restart colchicine × 6 months. Consider IVIG or anakinra (IL-1 blocker) for refractory cases.

📄 One Pager

Cardiology · One Pager

Acute Pericarditis

Pleuritic chest pain + diffuse ST elevation + PR depression. NSAIDs + colchicine. Always rule out tamponade. Avoid anticoagulation.

🧪 Diagnosis -Need 2 of 4

Pleuritic chest pain (sharp, worse lying flat, better leaning forward)
Pericardial friction rub
Diffuse ST elevation + PR depression on ECG
New or worsening pericardial effusion on echo

🚨 Management

Ibuprofen 600 mg TID × 2 weeks (taper over weeks)
Colchicine 0.5 mg BID × 3 months (halves recurrence) [COPE, 2005, ICAP, 2013]
Activity restriction until CRP normalizes + symptoms resolve
Myopericarditis (troponin ↑): no exercise × 3-6 months

⚠️ Tamponade -Recognize Early

Beck's triad: hypotension + JVD + muffled heart sounds
Pulsus paradoxus > 10 mmHg
Echo: RV diastolic collapse (most specific), IVC plethora
Treatment: emergent pericardiocentesis (echo-guided)

💊 Key Drugs

Ibuprofen600 mg TID × 2wk

Colchicine0.5 mg BID × 3mo

AcetaminophenPRN adjunct

AvoidAnticoagulation, steroids first-line

⚠️ Pitfalls

Missing tamponade
Using steroids first-line (high recurrence)
Anticoagulation → hemorrhagic effusion
Not adding colchicine from day 1
Confusing with STEMI on ECG