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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Quick ReferenceICUWards

Bowel Regimen

Constipation affects > 80% of ICU patients. Diarrhea is the #1 overnight cross-cover call. Prevent constipation from day 1, and always rule out C. diff before treating diarrhea.

💊 Constipation

Don't wait for the patient to complain. Start a bowel regimen on day 1 for ALL patients on opioids, immobilized, post-surgical, or on constipating medications (anticholinergics, calcium channel blockers, iron). A constipated inpatient becomes a distended, painful, ileus-complicated patient.

▶ Inpatient Bowel Escalation Protocol

DAY 1

Step 1, Prevention (ALL at-risk inpatients)

PEG 3350 (MiraLAX) 17g in 8 oz water PO daily
Start on admission for: opioid use, immobility, post-surgical, anticholinergic meds, iron, CCBs. PEG = osmotic laxative, first-line per AGA-ACG 2023 (strong recommendation, moderate evidence). Safe in CKD. Do NOT use docusate (Colace), no better than placebo.
Alternative: Lactulose (Kristalose) 15–30 mL PO daily if PEG unavailable or in hepatic encephalopathy patients (serves dual purpose). More bloating/gas than PEG.

↓ No BM × 48h ↓

DAY 2–3

Step 2, Add Stimulant

Senna (Senokot) 8.6–17.2 mg PO BID
Add to PEG. Senna = stimulant laxative (activates colonic myenteric plexus). For opioid-induced constipation, start PEG + senna together from day 1. Can increase PEG to BID.

↓ No BM × 72h ↓

📋 CONSIDER KUB X-RAY AT THIS POINT

Order KUB when:
• No BM × 72h despite Steps 1–2
• Abdominal distension or new tympany on percussion
• Nausea/vomiting with absent bowel sounds
• Concern for ileus vs obstruction vs fecal impaction
• Post-operative patient with increasing abdominal girth
What to look for: Stool burden (fecal loading pattern), air-fluid levels (obstruction), dilated loops (> 6 cm small bowel, > 9 cm cecum = concerning), free air (perforation). If obstruction suspected → CT abdomen/pelvis with contrast.

↓

DAY 3–4

Step 3, Add Second Stimulant / Increase Osmotic

Bisacodyl (Dulcolax) 10 mg PO daily or 10 mg PR
Add to Steps 1–2. PR suppository works faster (15–60 min vs 6–12h PO). Avoid in bowel obstruction. Can also increase PEG to BID–TID.
Or add Lactulose 15–30 mL PO q6–8h as additional osmotic agent alongside PEG. Particularly useful in patients with concomitant hepatic encephalopathy.

↓ Still no BM despite 72h escalation ↓

DAY 4–5

Step 4, Opioid-Specific Reversal

Methylnaltrexone (Relistor) 8–12 mg SC q48h
OR Naloxegol (Movantik) 25 mg PO daily
Peripheral μ-opioid antagonist, reverses opioid-induced constipation WITHOUT crossing BBB. No reversal of analgesia. Use when standard regimen fails.

↓ Impaction / acute obstipation ↓

RESCUE

Step 5, Acute Impaction / Last Resort

Soap suds enema (SSE) 1500 mL PR, first-line rectal intervention. Gentle, safe in CKD.
Tap water enema, alternative if SSE unavailable. Safe in renal patients.
Fleet enema (sodium phosphate) PR, faster acting but ⚠️ avoid in CKD (fatal hyperphosphatemia).
Manual disimpaction if palpable fecal mass on DRE, last resort, requires analgesia/sedation.
Order of preference: SSE → tap water → Fleet (if no CKD) → manual disimpaction.

▶ Bowel Agents -Full Table

Drug (Brand)	Class	Dose	Onset	Key Notes
Docusate (Colace) NOT RECOMMENDED	Stool softener	,	,	No better than placebo. Omitted from all AGA-ACG 2023 recommendations. Removed from hospital formularies (UAB 2024). No FDA-approved indication. Do not prescribe.
PEG 3350 (MiraLAX) 1ST LINE	Osmotic laxative	17g in 8 oz water PO daily–BID	24–48h	First-line per AGA-ACG 2023 (strong recommendation, moderate evidence). Non-absorbed. Less bloating than lactulose. Safe in CKD. Can increase to TID if refractory.
Senna (Senokot) 2ND LINE	Stimulant laxative	8.6–17.2 mg PO BID (1–2 tabs)	6–12h	Add to PEG. Stimulates colonic motility via myenteric plexus. In OIC, start PEG + senna together from day 1. Conditional recommendation per AGA-ACG 2023.
Bisacodyl (Dulcolax) ESCALATION	Stimulant laxative	10 mg PO daily or 10 mg PR	PO: 6–12h PR: 15–60 min	Add when PEG + senna insufficient. PR suppository much faster. Strong recommendation per AGA-ACG 2023. Avoid in acute abdomen or bowel obstruction.
Lactulose (Kristalose) ALTERNATIVE	Osmotic laxative	15–30 mL PO q6–8h	24–48h	Also used for hepatic encephalopathy (different dose: 30–45 mL q1–2h until BM). More bloating/gas than MiraLAX.
Methylnaltrexone (Relistor) OIC-SPECIFIC	Peripheral μ-opioid antagonist	8 mg SC (< 62 kg) or 12 mg SC (≥ 62 kg) q48h	30 min–4h	Targets opioid-induced constipation (OIC) specifically. Does NOT cross BBB -no reversal of analgesia or withdrawal. Expensive. Use after standard regimen fails.
Naloxegol (Movantik) OIC-SPECIFIC	Peripheral μ-opioid antagonist (PO)	25 mg PO daily (12.5 mg if CrCl < 60 or moderate CYP3A4 inhibitor)	6–12h	Oral alternative to methylnaltrexone. Avoid with strong CYP3A4 inhibitors. Renal dose needed.
Magnesium citrate ADJUNCT	Osmotic / saline laxative	150–300 mL PO × 1	30 min–3h	Fast-acting. Avoid in renal failure (hypermagnesemia). Single-use, not for maintenance.
Soap suds enema (SSE) RESCUE	Rectal enema	1500 mL warm water + castile soap PR	5–30 min	First-line rectal intervention. Safe in CKD. Stimulates peristalsis via distension + mild irritation. Preferred over Fleet in renal patients.
Tap water enema RESCUE	Rectal enema	500–1000 mL warm tap water PR	5–30 min	Alternative to SSE. Safe in CKD. Less effective than SSE but gentler. Can repeat.
Fleet enema (sodium phosphate) ACUTE ONLY	Rectal enema	1 bottle (133 mL) PR × 1	2–15 min	⚠️ Avoid in CKD, can cause fatal hyperphosphatemia. Avoid in elderly, dehydrated, or bowel obstruction. Use SSE or tap water enema instead.

▶ Special Situations

Scenario	Approach
Opioid-induced (most ICU patients)	PEG 3350 + senna from day 1 → escalate per protocol. Methylnaltrexone if refractory. Consider opioid rotation or reduction.
Post-operative ileus	Ambulation is the best treatment. Gum chewing stimulates gut motility. Alvimopan (Entereg) 12 mg PO BID × 7 days for post-surgical ileus (hospital use only). Avoid NG tube for uncomplicated ileus.
Hepatic encephalopathy	Lactulose 30–45 mL q1–2h titrated to 3–4 BMs/day. Goal is ammonia clearance, not just bowel movement. Rifaximin 550 mg PO BID for maintenance. See HE topic.
Hyperkalemia (kayexalate alternative)	Patiromer (Veltassa) or sodium zirconium (Lokelma) preferred over sodium polystyrene sulfonate (Kayexalate) -Kayexalate has risk of bowel necrosis and questionable efficacy.
CKD / dialysis patients	Avoid Fleet enemas (hyperphosphatemia), magnesium-containing laxatives (hypermagnesemia), and mineral oil (aspiration risk). Use PEG 3350 + senna (MiraLAX), lactulose, or bisacodyl. Lactulose is safe in CKD and can be used as PEG alternative.
C. difficile concern	If new diarrhea after bowel regimen → check C. diff toxin. Hold laxatives. If C. diff positive: fidaxomicin 200 mg PO BID × 10d (preferred) or vancomycin 125 mg PO QID × 10d. Avoid loperamide.

🚿 Diarrhea

Rule out C. difficile before giving antidiarrheals. Loperamide in active C. diff infection can precipitate toxic megacolon. Always send C. diff toxin PCR if new diarrhea in a patient on antibiotics, recent hospitalization, or age > 65.

▶ Inpatient Diarrhea -Workup & Management

STEP 1

Assess & Rule Out Dangerous Causes

Check immediately:
• C. diff toxin PCR, if on antibiotics, recent hospitalization, age > 65, immunosuppressed
• Stool studies, culture, ova & parasites if travel history or immunocompromised
• Rectal exam, rule out overflow diarrhea from fecal impaction (liquid stool around impacted mass, commonly missed!)
• KUB, if distension or concern for obstruction/toxic megacolon
• Electrolytes, check K, Mg, Na (diarrhea causes rapid depletion)

↓

STEP 2

Review Medications

Common offenders:
• Antibiotics, most common cause of inpatient diarrhea. Consider narrowing spectrum
• Lactulose / PEG overdose, check if bowel regimen needs dose reduction
• Magnesium-containing meds, antacids, supplements
• Metformin, colchicine, SSRIs, dose-dependent
• Enteral feeds, rate, osmolality, formula type (see tube feed section below)
• Sorbitol-containing elixirs, liquid acetaminophen, liquid potassium often contain sorbitol

↓

STEP 3

Treat by Cause

• C. diff positive: Fidaxomicin 200 mg PO BID × 10d (preferred) or vancomycin 125 mg PO QID × 10d. Stop offending antibiotic if possible. No loperamide.
• Antibiotic-associated (C. diff negative): Loperamide 4 mg × 1, then 2 mg after each loose stool (max 16 mg/day). Consider probiotics (Saccharomyces boulardii)
• Tube feed diarrhea: Reduce rate by 25%, switch to peptide-based or fiber-enriched formula, check for sorbitol in meds, add banana flakes or fiber supplement
• Overflow (impaction): Disimpact first, then restart bowel regimen. Do NOT give loperamide
• Medication-related: Dose-reduce or substitute the offending agent
• Secretory / high-output: Octreotide 50–100 mcg SC q8h for refractory secretory diarrhea (carcinoid, VIPoma, short gut, chemo-related)

▶ Antidiarrheal Agents -Full Table

Drug (Brand)	Class	Dose	Onset	Key Notes
Loperamide (Imodium) 1ST LINE	Peripheral μ-opioid agonist	4 mg × 1, then 2 mg after each loose stool	1–3h	Max 16 mg/day. ⚠️ CONTRAINDICATED in C. diff, bloody diarrhea, toxic megacolon, ileus. Does not cross BBB at standard doses. Safe in CKD. OTC.
Bismuth subsalicylate (Pepto-Bismol) ADJUNCT	Antisecretory / antimicrobial	524 mg (2 tabs) PO q30min–1h PRN	30–60 min	Max 8 doses/day. Avoid with aspirin allergy or anticoagulants (salicylate content). Turns stool/tongue black (harmless). Helpful for traveler's diarrhea.
Diphenoxylate-atropine (Lomotil) 2ND LINE	Opioid agonist + anticholinergic	5 mg/0.05 mg: 2 tabs QID, then taper	45–60 min	Schedule V controlled. Atropine added to discourage abuse. Same contraindications as loperamide. May cause anticholinergic effects at high doses.
Cholestyramine (Questran) BILE ACID	Bile acid sequestrant	4 g PO BID–TID (mix in water)	24–48h	First-line for bile acid diarrhea (post-cholecystectomy, ileal resection, Crohn's). Binds bile acids in gut. Must take 1h before or 4h after other meds (impairs absorption).
Octreotide (Sandostatin) REFRACTORY	Somatostatin analog	50–100 mcg SC q8h (can ↑ to 500 mcg)	30 min	For secretory / high-output diarrhea: carcinoid, VIPoma, short gut syndrome, chemo-induced, refractory to other agents. Also used for GI fistula output reduction. Expensive.
Psyllium (Metamucil) BULK FORMER	Soluble fiber	1 rounded tsp (3.4 g) in 8 oz water PO TID	12–72h	Absorbs water → bulks stool. Helpful for tube feed diarrhea and mild functional diarrhea. Must take with adequate water (risk of obstruction if dehydrated). Also used for IBS-D.
Probiotics (Saccharomyces boulardii) ADJUNCT	Live yeast probiotic	250–500 mg PO BID	Days	Best evidence for antibiotic-associated diarrhea prevention. Goldenberg, Cochrane 2017. Avoid in immunocompromised (risk of fungemia). Not effective for acute C. diff treatment.
Kaolin-pectin (Kaopectate) ADJUNCT	Adsorbent	60–120 mL PO after each loose stool	Variable	Mild effect. Adsorbs toxins and bacteria. Safe but less effective than loperamide. Can impair absorption of other medications.

▶ Tube Feed Diarrhea -ICU Specific

Cause	Intervention
Rate too high	Reduce rate by 25%. Advance slowly (10–20 mL/h q4–6h). Continuous feeds cause less diarrhea than bolus feeds.
Hyperosmolar formula	Switch to isotonic, peptide-based formula (e.g., Peptamen, Vital AF). Elemental formulas for severe malabsorption.
Sorbitol in medications	Switch liquid meds to tablet/crush form. Common culprits: liquid acetaminophen, KCl elixir, liquid theophylline. Each 5 mL of sorbitol-containing elixir adds osmotic load.
Fiber deficiency	Add soluble fiber supplement (banana flakes 2 tbsp q8h via tube, or switch to fiber-enriched formula like Jevity 1.2 or Promote with Fiber).
Contamination	Replace tubing q24h. Use closed-system ready-to-hang bags. Hang time ≤ 8h for open systems. Check for improper storage.
C. diff	Always rule out even in tube-fed patients. Do NOT stop feeds for C. diff, trophic feeding maintains gut mucosal integrity.

💎 Key Pearls

Constipation Pearls

Fleet enema + CKD = hyperphosphatemia. Can be fatal. Use tap water enema instead in any patient with renal impairment.

Docusate (Colace) is no better than placebo. The 2023 AGA-ACG Joint Guideline omitted docusate from all recommendations. McRorie 2021 reviewed 7 RCTs, none showed benefit over placebo. Multiple hospitals have removed it from formulary. Use PEG 3350 + senna instead.

Methylnaltrexone (Relistor) does NOT reverse analgesia. It's peripherally restricted -blocks opioid receptors in the gut only. No crossing the BBB. Safe to give without worrying about pain control.

"Nothing by mouth" doesn't mean nothing for the gut. Bisacodyl suppositories and enemas work even if the patient is NPO. Don't forget rectal options.

Diarrhea Pearls

Never give loperamide in C. diff or bloody diarrhea. Slowing gut motility traps toxins → toxic megacolon, perforation, death. Always rule out C. diff first.

Overflow diarrhea ≠ real diarrhea. Liquid stool leaking around a fecal impaction is the #1 missed diagnosis. Always do a rectal exam before treating "diarrhea" with antidiarrheals, you may need to disimpact instead.

Tube feed diarrhea is rarely infectious. Check for sorbitol in meds, reduce rate, add fiber, and switch to peptide-based formula before ordering stool studies.

Cholestyramine is the answer for post-cholecystectomy diarrhea. Bile acid malabsorption is the #1 cause. Must separate from other medications by 1h before or 4h after (it binds everything).