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.

Anticoagulant	Reversal Agent	Dose	Onset	Key Notes
Warfarin	4-Factor PCC (Kcentra) LIFE-THREATENING	INR 2–4: 25 units/kg INR 4–6: 35 units/kg INR > 6: 50 units/kg	Minutes	First-line for life-threatening bleed. Always give with vitamin K 10 mg IV (slow push over 10 min -anaphylaxis risk if fast). PCC effect is temporary (6–8h); vitamin K provides sustained reversal (6–24h). FFP is second-line (large volume, slow, infection risk).
Warfarin	Vitamin K (phytonadione) NON-EMERGENT	INR > 10, no bleed: 2.5–5 mg PO Minor bleed: 5–10 mg IV slow	6–24h	PO preferred for non-emergent. IV onset faster but anaphylaxis risk. SubQ absorption is erratic -avoid. Recheck INR in 6–12h.
Dabigatran (Pradaxa)	Idarucizumab (Praxbind)	5g IV (given as 2 × 2.5g boluses)	Minutes	Specific monoclonal antibody fragment. Complete reversal within minutes. Single use. If unavailable: 4F-PCC 50 units/kg (partial effect). Hemodialysis removes ~60% of dabigatran (it's dialyzable -unique among DOACs).
Rivaroxaban (Xarelto) Apixaban (Eliquis) Edoxaban: andexanet NOT approved, use 4F-PCC 50 units/kg	Andexanet alfa (Andexxa)	Low dose: 400 mg bolus → 4 mg/min × 2h (total 480 mg) High dose: 800 mg bolus → 8 mg/min × 2h (total 960 mg)	Minutes	Recombinant modified Factor Xa decoy. Approved for apixaban and rivaroxaban only (not edoxaban, not LMWH, not fondaparinux). Very expensive (~$50,000/dose). Dose selection: high dose only if the last dose was apixaban > 5 mg or rivaroxaban > 10 mg AND taken within 8h (or timing unknown). Everything else gets the low dose, including any dose taken ≥ 8h ago. Increased thromboembolism after reversal ANNEXA-I, 2024. If unavailable: 4F-PCC 50 units/kg (reasonable alternative, much cheaper).
Unfractionated heparin	Protamine sulfate	1 mg per 100 units heparin given in last 2–3h. Max 50 mg.	5 min	Full reversal. Risk: hypotension, bradycardia, anaphylaxis (especially in patients with fish allergy, prior protamine, or NPH insulin use -NPH contains protamine).
Enoxaparin (LMWH)	Protamine sulfate	1 mg per 1 mg enoxaparin (if within 8h of dose). 0.5 mg per 1 mg if 8–12h.	5 min	Only ~60% reversal (protamine neutralizes anti-IIa but not anti-Xa activity of LMWH). If still bleeding → consider 4F-PCC.
tPA / fibrinolytics	Cryoprecipitate + TXA	Cryo 10 units (fibrinogen > 200). TXA 1g IV over 10 min.	Minutes	Replenish fibrinogen (consumed by tPA). TXA is antifibrinolytic. Also give platelets if < 100K. Aminocaproic acid is alternative to TXA.

Drug	Hold Before Procedure	Resume After	Bridging Needed?
Warfarin (Coumadin)	5 days (INR < 1.5 for most procedures)	12–24h post (once hemostasis confirmed)	Only if high thrombotic risk: mechanical mitral valve, recent VTE (< 3 mo), CHA₂DS₂-VASc ≥ 7. Use enoxaparin 1 mg/kg BID. Most patients do NOT need bridging BRIDGE, 2015: bridging increased bleeding without reducing thromboembolism.
Apixaban (Eliquis)	48h (72h if high bleed risk or CrCl < 30)	24–48h post	No bridging needed (short half-life, rapid onset on resumption).
Rivaroxaban (Xarelto)	48h (72h if CrCl < 30)	24–48h post	No bridging.
Dabigatran (Pradaxa)	48–72h (CrCl 50–80). 96h+ if CrCl < 50.	24–48h post	No bridging. Longer hold in renal impairment (renally cleared).
Enoxaparin (therapeutic)	24h	24–48h post	N/A
Heparin drip	4–6h (check aPTT)	When safe per surgeon	N/A
Aspirin (primary prevention)	7 days	24h post	N/A
Aspirin (cardiac stent)	DO NOT STOP	N/A	Continue through procedure unless life-threatening bleed risk. Stopping ASA within 6 months of DES → stent thrombosis → MI.
Clopidogrel (Plavix)	5 days	24h post	Consult cardiology before holding if recent stent.

Anticoagulation Reversal