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.

Feature	Fentanyl (Sublimaze)	Remifentanil (Ultiva)	Hydromorphone (Dilaudid)	Morphine (MS Contin)
ICU Role	1st LINE	Specialized	2nd Line	AVOID
Dose	Analgesia: 25–100 mcg/hr Analgo-sedation: 100–200+ mcg/hr PRN: 25–100 mcg q1h	0.05–0.2 mcg/kg/min	0.2–0.5 mg/hr or 0.2–1 mg IV q3–4h PRN	2–4 mg IV q2–4h PRN
Potency (vs morphine)	80–100×	100–200×	5–7×	1× (reference)
Onset	1–2 min	< 1 min	5 min	5–10 min
Duration (single dose)	30–60 min	3–5 min	3–4 hrs	3–5 hrs
Hemodynamic effect	Minimal -safest	Minimal	Mild hypotension	Hypotension (histamine release)
Renal failure	Safe (hepatic metabolism)	Safe (plasma esterases)	Caution (H3G at high doses)	AVOID -M6G accumulates → prolonged sedation, resp depression
Hepatic failure	Accumulates	Safe	Accumulates	Accumulates
Best for	Everything. Low dose = analgesia. High dose = analgo-sedation. Often sufficient alone.	Frequent neuro checks. Ultra-rapid offset. Procedural.	Alt to fentanyl. Better renal profile than morphine.	Palliative care only. Floor patients, opioid-naive.
Watch out	Chest wall rigidity (rapid bolus). Accumulates > 72h (lipophilic).	Expensive. Rapid tolerance. No analgesic effect after stopping.	Neuroexcitation (myoclonus) at very high doses in renal failure.	Histamine → bronchospasm. M6G. Hypotension. Avoid in asthma, CKD, ICU.

Drug (Brand)	Dose	Role	Key Notes
Acetaminophen (Ofirmev IV / Tylenol PO)	650–1000 mg q6h (max 4g/day; 2g if liver disease)	Non-opioid baseline -schedule for ALL ICU patients	Reduces opioid need 20–30%. Very safe. Should be scheduled, not PRN.
Ketamine (Ketalar) -sub-dissociative	0.1–0.3 mg/kg/hr IV	Opioid-sparing. Neuropathic pain. Bronchospasm. Hemodynamically unstable.	NMDA antagonist -synergistic with opioids. Reduces opioid use 30–50%. Bronchodilator.
Ketorolac (Toradol)	15–30 mg IV q6h (max 5 days)	Short-term non-opioid. Post-op. Renal colic.	Avoid: renal failure, GI bleed, platelet dysfunction, elderly. Max 5 days.
Gabapentin (Neurontin)	100–300 mg PO TID (renal dose!)	Neuropathic pain adjunct	Renally cleared -#1 cause of iatrogenic AMS in CKD patients. Always renal dose.
Lidocaine patch (Lidoderm 5%)	1–3 patches, 12h on / 12h off	Localized pain (rib fractures, post-herpetic, incision site)	No systemic side effects. Underutilized opioid-sparing option.
Pregabalin (Lyrica)	25–150 mg PO BID (renal dose!)	Neuropathic pain. Alternative to gabapentin.	Also renally cleared. Dose-adjust in CKD. Fewer drug interactions than gabapentin.

Analgesia Guide