Question 1

When to intubate in GCS?

Accepted Answer

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.

Question 2

What is the best initial fluid for sepsis resuscitation?

Accepted Answer

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.

Question 3

When to start vasopressors in septic shock?

Accepted Answer

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.

Question 4

Why can serum uric acid be normal during acute gout?

Accepted Answer

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.

Question 5

How do you distinguish lupus flare from infection in SLE?

Accepted Answer

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.

Question 6

What is the difference between DKA and HHS?

Accepted Answer

DKA features acidosis (pH < 7.3), elevated anion gap, and ketones -typically in Type 1 DM. HHS features severe hyperglycemia (often > 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

Question 7

When to give tPA in acute ischemic stroke?

Accepted Answer

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.

Question 8

What antibiotics for community-acquired pneumonia?

Accepted Answer

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.

Question 9

How to interpret iron studies?

Accepted Answer

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.

Question 10

What is the correction rate for hyponatremia?

Accepted Answer

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.

Question 11

When to start antibiotics in meningitis?

Accepted Answer

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.

Question 12

DOACs vs warfarin in antiphospholipid syndrome?

Accepted Answer

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.

Question 13

How to manage scleroderma renal crisis?

Accepted Answer

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.

Question 14

What are the 4 pillars of heart failure treatment?

Accepted Answer

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.

Agent	Dose	Receptor	Role	Avoid / Caution
Norepinephrine (Levophed) 1ST LINE	0.01–3 mcg/kg/min	α₁>>β₁	First-line in septic shock (conditional recommendation per SSC 2026). ↑ SVR + mild inotropy. SSC, 2026	-
Vasopressin (Vasostrict) ADD-ON	0.03 units/min (fixed, no titration)	V1/V2	Add-on to NE (NE-sparing). May reduce AKI. Add when NE ≥ 0.25–0.5 mcg/kg/min. VASST, 2008	Coronary vasospasm, mesenteric ischemia at higher doses
Epinephrine (Adrenalin) 2ND LINE	0.01–0.5 mcg/kg/min	α₁, β₁, β₂	Refractory shock. Strong inotropy + vasoconstriction. Also cardiac arrest.	Falsely elevates lactate (β₂-mediated aerobic glycolysis) -can't use lactate to guide resuscitation
Phenylephrine (Neo-Synephrine) 3RD LINE	0.5–6 mcg/kg/min	α₁ pure	Use if tachyarrhythmia limits NE use. Pure vasoconstriction.	Low CO states (no inotropy -worsens cardiac output)
Dobutamine (Dobutrex) INOTROPE	2–20 mcg/kg/min	β₁>β₂	Low CO despite adequate MAP (cardiogenic component). Not a vasopressor -an inotrope.	Never use alone if MAP < 65 (drops SVR via β₂). Always pair with NE.
Milrinone (Primacor) INOTROPE	0.125–0.75 mcg/kg/min	PDE3 inhibitor	Inodilator. RV failure, pulmonary HTN, post-cardiac surgery. Inotropy + ↓ PVR.	Hypotension (vasodilation). Renally cleared -dose-adjust in AKI.
Angiotensin II (Giapreza) LAST RESORT	20–200 ng/kg/min	AT1 receptor	Catecholamine-refractory vasodilatory shock. ATHOS-3, 2017	Thrombosis risk. Very expensive. Last-line agent.
Dopamine (Intropin) AVOID	2–20 mcg/kg/min	D1, β₁, α₁ (dose-dependent)	AVOID in sepsis. More arrhythmias, higher mortality vs NE. SOAP II, 2010	Avoid. Only remaining role: symptomatic bradycardia if no pacing available.

Drug	Indication	Dose	Evidence
Hydrocortisone (Solu-Cortef)	Refractory septic shock with ongoing vasopressor requirement	200 mg/day IV (50 mg q6h or continuous infusion)	ADRENAL, 2018: faster shock reversal, no mortality benefit. APROCCHSS, 2018: mortality benefit in most severe subgroup.
Methylene blue (ProvayBlue)	Vasoplegia (post-cardiac surgery, refractory distributive shock)	1–2 mg/kg IV bolus, may repeat or infuse 0.5 mg/kg/hr	Case series. Inhibits NO synthase → restores SVR. Rescue agent.
Thiamine (Vitamin B1)	Suspected deficiency (alcoholism, malnutrition, refeeding)	200–500 mg IV q8h × 3 days	Prevents Wernicke's. May help refractory lactic acidosis.

Trial	Year	Finding
SOAP II	2010	NE vs dopamine in shock: NE had lower mortality + fewer arrhythmias
VASST	2008	Vasopressin + NE vs NE alone: no overall mortality difference, but possible benefit in less severe shock
VANISH	2016	Vasopressin vs NE as first-line: no difference. Vasopressin may reduce need for RRT.
ADRENAL	2018	Hydrocortisone in septic shock: faster shock reversal, no 90-day mortality benefit
APROCCHSS	2018	Hydrocortisone + fludrocortisone: 90-day mortality benefit in severe septic shock
ATHOS-3	2017	Angiotensin II in vasodilatory shock: improved MAP response vs placebo

Vasopressor Guide