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.

Procedure Guides -Step-by-Step Technique, Landmarks & Complications -RoundsRx

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🔴

Central Venous Catheter (Central Line)

IJ, Subclavian, Femoral -Seldinger technique under ultrasound guidance

Indications

• Vasopressor administration (norepinephrine, vasopressin)
• Inadequate peripheral access
• CVP monitoring
• TPN / hyperosmolar infusions (> 900 mOsm)
• Hemodialysis access
• Rapid volume resuscitation (large-bore catheter)

Contraindications

• Infection at insertion site
• Thrombus in target vessel
• Subclavian: avoid if coagulopathic (non-compressible)
• IJ: caution with ↑ ICP (Trendelenburg worsens ICP)
• Femoral: higher infection rate -use only if IJ/subclavian not feasible

Technique (IJ -Most Common)

1. Consent, time-out, full barrier precautions (cap, mask, sterile gown, gloves, full drape)
2. Position: Trendelenburg, head turned away
3. Ultrasound: Identify IJ (compressible) lateral to carotid (pulsatile, non-compressible)
4. Prep & drape -chlorhexidine, wide sterile field
5. Lidocaine -local anesthesia at insertion site
6. Access: 18G needle under US guidance, confirm venous blood (dark, non-pulsatile)
7. Guidewire -advance through needle, watch on US, confirm no arrhythmia on monitor
8. Nick skin with scalpel, dilator over wire
9. Thread catheter over wire -never let go of the wire!
10. Remove wire, flush all ports, suture, dressing
11. CXR -confirm tip at cavoatrial junction, rule out pneumothorax

⚠️ Complications

Pneumothorax (subclavian > IJ), arterial puncture, air embolism, arrhythmia (wire in heart), infection (CLABSI), thrombosis. Never advance against resistance.

🟠

Arterial Line

Radial (preferred), femoral, brachial -continuous BP monitoring and frequent ABGs

Indications

• Continuous BP monitoring (hemodynamic instability, vasopressors)
• Frequent ABG sampling
• Intra-operative monitoring (cardiac surgery, major procedures)
• BP cuff unreliable (morbid obesity, arrhythmia)

Pre-Procedure

• Modified Allen test -confirm dual blood supply (radial + ulnar) before radial art line
• Compress both radial and ulnar arteries → release ulnar → hand should pink up in < 7 seconds
• If Allen test negative (no collateral flow) → use other wrist or femoral

Technique (Radial)

1. Position: Wrist dorsiflexed 20–30° over towel roll, tape hand to arm board
2. Prep: Chlorhexidine, sterile drape
3. Lidocaine: Small wheal over radial pulse
4. US-guided (recommended) or palpation
5. 20G catheter-over-needle at 15–30° angle, advance until flash of arterial blood (pulsatile, bright red)
6. Advance catheter off needle into artery, remove needle
7. Connect to transducer, level at phlebostatic axis (4th ICS, mid-axillary)
8. Confirm waveform -arterial waveform with dicrotic notch

⚠️ Complications

Hematoma, thrombosis, distal ischemia (rare with good Allen test), infection, pseudoaneurysm. Never flush forcefully -risk of retrograde embolism to brain.

🟡

Lumbar Puncture (LP)

Diagnostic and therapeutic -meningitis, SAH, idiopathic intracranial hypertension

Indications

• Suspected meningitis/encephalitis
• Rule out SAH (CT-negative thunderclap headache)
• Diagnosis: MS, GBS, carcinomatous meningitis, normal pressure hydrocephalus
• Therapeutic: idiopathic intracranial hypertension (IIH), intrathecal medications

Contraindications

• ↑ ICP with mass lesion -get CT head BEFORE LP if: papilledema, focal neuro deficits, altered consciousness, immunocompromised, age > 60, seizure within 1 week
• Skin infection at puncture site
• Severe coagulopathy (INR > 1.5, platelets < 50K)
• Spinal epidural abscess

CSF Interpretation

Bacterial: ↑ WBC (>1000, PMN predominant), ↑ protein, ↓ glucose, + Gram stain
Viral: ↑ WBC (10-500, lymphocyte predominant), normal/↑ protein, normal glucose
TB/fungal: ↑ WBC (lymphocytes), ↑ protein, ↓↓ glucose
SAH: RBCs that do NOT clear (tube 1 vs tube 4), xanthochromia
Normal: OP 6-20 cmH₂O, WBC < 5, protein 15-45, glucose 40-70

Technique

1. Position: Lateral decubitus (fetal position) or seated, spine flexed. Lateral decubitus preferred for opening pressure measurement.
2. Landmark: L3-L4 or L4-L5 interspace (iliac crest line = L4 spinous process). Always below L2 (conus medullaris ends at L1-L2).
3. Prep: Chlorhexidine, sterile drape
4. Lidocaine: Local anesthesia (subcutaneous + deeper tissues along planned needle path)
5. Spinal needle (20-22G, atraumatic tip preferred -reduces post-LP headache): advance midline with bevel parallel to longitudinal fibers of dura, angled slightly cephalad
6. Feel the "pop" through ligamentum flavum and dura
7. Remove stylet -CSF should flow
8. Opening pressure -measured with manometer in lateral decubitus. Normal: 6-20 cmH₂O
9. Collect tubes: Tube 1 (cell count), Tube 2 (glucose, protein), Tube 3 (Gram stain, culture, extras), Tube 4 (cell count -compare to tube 1 for traumatic tap)
10. Replace stylet before removing needle (reduces post-LP headache risk)

⚠️ Post-LP Headache

Positional headache (worse upright, better supine) in ~10-30%. Reduce risk: atraumatic needle, smaller gauge, replace stylet before removal. Treatment: caffeine, analgesics, and if severe → epidural blood patch (definitive).

🟢

Paracentesis

Diagnostic and therapeutic -ascites evaluation, large-volume removal

Indications

• Diagnostic: New-onset ascites, rule out SBP (all cirrhotics admitted with ascites should get diagnostic para)
• Therapeutic: Tense ascites causing respiratory compromise, abdominal discomfort

Key Studies to Send

• Cell count with differential -PMN ≥ 250 = SBP (treat empirically with ceftriaxone)
• Albumin -calculate SAAG (serum albumin - ascites albumin). SAAG ≥ 1.1 = portal hypertension
• Total protein
• Culture -inoculate blood culture bottles at bedside (higher yield)
• Glucose, LDH, amylase, cytology -if secondary peritonitis or malignancy suspected

Technique

1. Position: Supine, slightly tilted to side of puncture
2. Site: LLQ (preferred) -2 fingerbreadths medial and cephalad to ASIS. Avoid surgical scars, visible vessels, rectus sheath
3. US guidance -confirm fluid pocket ≥ 2 cm, mark site
4. Prep: Chlorhexidine, sterile drape
5. Lidocaine: All layers including peritoneum
6. Z-track technique -pull skin 2 cm caudally before inserting needle (reduces post-procedure leak)
7. Insert needle/catheter while aspirating, advance until fluid returns
8. Collect samples or connect to vacuum bottles for large-volume
9. Large-volume (> 5L): Give albumin 6-8g per liter removed (prevents post-paracentesis circulatory dysfunction)

⚠️ Key Points

Do NOT correct coagulopathy before paracentesis in cirrhosis. INR/platelets do not predict bleeding risk in liver disease (rebalanced hemostasis). Routine transfusion of FFP/platelets is NOT indicated. SBP: PMN ≥ 250 → start ceftriaxone (Rocephin) 2g IV daily empirically, don't wait for culture.

🔵

Thoracentesis

Diagnostic and therapeutic -pleural effusion evaluation and drainage

Indications

• Diagnostic: Any new or unexplained pleural effusion
• Therapeutic: Symptomatic (dyspnea) effusion
• Exception: bilateral small effusions in known CHF responding to diuretics -can observe without tapping

Light's Criteria (Exudate if ANY met)

• Pleural protein / serum protein > 0.5
• Pleural LDH / serum LDH > 0.6
• Pleural LDH > 2/3 upper limit of normal serum LDH

Transudate: CHF, cirrhosis, nephrotic syndrome
Exudate: Infection (parapneumonic/empyema), malignancy, PE, TB, rheumatologic

Technique

1. Position: Seated, leaning forward on bedside table
2. US guidance mandatory -mark fluid pocket, ensure ≥ 1 cm depth
3. Site: 1-2 interspaces below fluid level, posterior axillary or midscapular line. Always go ABOVE the rib (neurovascular bundle runs under each rib)
4. Prep: Chlorhexidine, sterile drape
5. Lidocaine: Subcutaneous → intercostal muscles → OVER the rib → parietal pleura (aspirate as you go -fluid confirms pleural space)
6. Insert catheter-over-needle -advance while aspirating, then thread catheter
7. Collect samples: Cell count, protein, LDH, glucose, pH, culture, cytology
8. Max removal: 1-1.5L per session (prevents re-expansion pulmonary edema). Stop if chest tightness or cough.
9. Post-procedure CXR -only if air aspirated, symptoms, or multiple needle passes

⚠️ Complications

Pneumothorax (US guidance reduces risk dramatically), bleeding, re-expansion pulmonary edema (remove ≤ 1.5L), vasovagal, infection. Empyema (pH < 7.2, glucose < 40, pus) → chest tube, NOT repeat thoracentesis.

🟣

Rapid Sequence Intubation (RSI)

Emergent airway management -preparation, pre-oxygenation, induction, paralysis, placement

Indications for Intubation

• Failure to protect airway (GCS ≤ 8)
• Failure to oxygenate (refractory hypoxemia despite NRB/NIPPV)
• Failure to ventilate (rising PaCO₂, respiratory fatigue)
• Anticipated clinical course (burns, angioedema, massive hematemesis)

The 7 P's of RSI

1. Preparation: Equipment check (ETT sizes 7.0-8.0, laryngoscope, suction, BVM, bougie, backup airway -LMA), monitors on, IV access
2. Pre-oxygenation: 100% FiO₂ × 3-5 min (NRB at 15L/min or flush rate). Apneic oxygenation via nasal cannula at 15L during attempt
3. Pre-treatment: Consider fentanyl (Sublimaze) 1-3 mcg/kg for sympathetic response
4. Paralysis with induction: Induction agent + paralytic simultaneously
5. Protection/Positioning: Sniffing position (ear to sternal notch alignment). Cricoid pressure (Sellick) -controversial
6. Placement: Direct/video laryngoscopy. Visualize cords, pass ETT, confirm with ETCO₂
7. Post-intubation: CXR, vent settings, sedation, secure tube

RSI Medications

Induction agents:
• Ketamine (Ketalar) 1-2 mg/kg IV -hemodynamically stable, bronchodilator. First choice in asthma/sepsis
• Etomidate (Amidate) 0.3 mg/kg IV -hemodynamically neutral. Adrenal suppression (single dose is safe)
• Propofol (Diprivan) 1-2 mg/kg IV -↓ BP, ↓ ICP. Avoid in hypotension

Paralytics:
• Succinylcholine (Anectine) 1.5 mg/kg IV -fastest onset (45-60 sec), shortest duration (6-10 min). Avoid in hyperkalemia, burns > 48h, crush injury, neuromuscular disease
• Rocuronium (Zemuron) 1.2 mg/kg IV -onset 60-90 sec, duration 45-60 min. Reversible with sugammadex (Bridion). Preferred if succinylcholine contraindicated

⚠️ Confirmation

End-tidal CO₂ (ETCO₂) is the ONLY reliable confirmation of ETT placement. Auscultation alone is NOT sufficient. No ETCO₂ = esophageal intubation until proven otherwise → remove tube and re-attempt. CXR confirms position but NOT placement (takes too long).