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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EMERGENTQuick Reference

Code Blue & Rapid Response

Your pocket card for running or assisting in a code. ACLS algorithms, drug doses, H's & T's, and the rapid response assessment framework. Launch Code Clock for real-time code documentation.

⏱️ Code Clock App

Real-time code documentation -track interventions, drug times, rhythm checks, and generate a code summary.

🚀 Launch Code Clock →

⚡ Cardiac Arrest -ACLS

Shockable Rhythms: VFib / Pulseless VTach

CPR

High-quality CPR immediately. Rate 100–120/min, depth 2–2.4 inches, full chest recoil. Minimize interruptions (< 10 sec for rhythm checks). Rotate compressors q2 min.

Shock

Defibrillate as soon as possible. Biphasic: 200J first shock, escalate if needed. Resume CPR immediately after shock × 2 min before rhythm check.

Epinephrine

Epinephrine 1 mg IV q3–5 min (give after 2nd shock if VFib/pVT). Do NOT delay shocks for epi.

Antiarrhythmic

Amiodarone 300 mg IV bolus (after 3rd shock if refractory VFib/pVT). 2nd dose: 150 mg. Alternative: lidocaine 1–1.5 mg/kg then 0.5–0.75 mg/kg.

H's & T's

Find and treat the cause. See below.

Non-Shockable: PEA / Asystole

CPR + Epinephrine 1 mg IV q3–5 min. No shock. No antiarrhythmic.
Focus on finding and treating the cause -PEA/asystole rarely responds to CPR alone without correcting the underlying etiology.
Asystole: confirm in ≥ 2 leads (rule out fine VFib). No atropine (removed from algorithm). No defibrillation.

H's and T's -Reversible Causes

PEA and asystole will NOT respond to CPR alone -you MUST find and fix the underlying cause. Run through H's and T's every 2-minute cycle.

Cause	Clues (History & Exam)	Intervention
H's
Hypovolemia	Trauma, GI bleed (hematemesis, melena), ruptured AAA, ruptured ectopic. Flat neck veins, pale, bloody NG aspirate.	Aggressive IVF boluses. Activate massive transfusion protocol. Blood products 1:1:1. Surgical consult if hemorrhagic.
Hypoxia	Pre-arrest desaturation, cyanosis, COPD/asthma history, mucus plug, aspiration event, known difficult airway.	Confirm ETT placement (ETCO₂). Auscultate both lungs. If no breath sounds unilateral → mainstem intubation or PTX. Suction. Increase FiO₂ to 100%.
Hydrogen ion (acidosis)	Known DKA, renal failure, severe sepsis, toxic ingestion (methanol, ethylene glycol, ASA). Pre-arrest ABG with pH < 7.1.	Sodium bicarbonate 1 mEq/kg IV push. Ventilate aggressively (blow off CO₂). Treat underlying cause (insulin for DKA, dialysis for renal failure, fomepizole for toxic alcohols).
Hyper/Hypokalemia	Renal failure (hyperK), dialysis patient who missed session, recent K⁺ lab, ECG changes (peaked T waves, wide QRS). HypoK: diuretic use, GI losses, prolonged QT.	HyperK: Calcium chloride 1–2g IV push (stabilize membrane) → insulin 10 units + D50 → bicarb → albuterol. HypoK: KCl 40 mEq IV + MgSO₄ 2g IV.
Hypothermia	Found down outdoors, drowning, exposure, elderly. Core temp < 30°C. "Not dead until warm and dead."	Active rewarming: warm IVF (40°C), warm humidified O₂, forced-air warming blankets. If < 30°C: defib may not work until rewarmed → limit to 1 shock attempt, hold meds until temp > 30°C. Continue CPR. Consider ECMO rewarming if available.
Hypoglycemia	Diabetic on insulin/sulfonylureas, altered mental status pre-arrest, missed meals, liver failure, adrenal crisis.	D50 (dextrose 50%) 1 amp (25g) IV push. Recheck in 15 min. If no IV access: glucagon 1 mg IM.
T's
Tension pneumothorax	Absent breath sounds unilaterally, JVD, tracheal deviation (late sign), recent central line or thoracentesis, trauma, patient on positive pressure ventilation.	Needle decompression: 14–16G needle, 2nd intercostal space midclavicular line (or 5th ICS anterior axillary). Do NOT wait for CXR. Follow with chest tube (28–32 Fr).
Tamponade (cardiac)	Beck's triad: JVD + hypotension + muffled heart sounds. Recent cardiac surgery, pericardial effusion on prior imaging, dialysis patient (uremic pericarditis), trauma, malignancy, post-MI (free wall rupture).	Pericardiocentesis: subxiphoid approach, US-guided. Remove even 20–30 mL → dramatic improvement. In post-surgical: emergent sternotomy (re-open).
Toxins	Pill bottles at scene, history of depression/suicidal ideation, drug paraphernalia. Wide QRS (TCAs, Na-channel blockers). Opioid presentation (pinpoint pupils). Bradycardia (beta-blocker, CCB, digoxin). Seizure history (local anesthetic toxicity).	Specific antidotes: Naloxone (opioid), sodium bicarb (TCA -QRS > 100), intralipid 20% (local anesthetic toxicity, lipophilic drug OD), glucagon (beta-blocker), calcium + high-dose insulin (CCB), DigiFab (digoxin). See Toxicology.
Thrombosis -coronary (MI)	Pre-arrest chest pain, STEMI on last ECG, known CAD, cardiac risk factors. PEA with organized narrow-complex rhythm on monitor.	Consider emergent PCI (cath lab activation during CPR -some centers do this). If no PCI available: fibrinolytics (tPA 50 mg IV during CPR) -consider if high suspicion and no other cause found. Continue CPR for 60–90 min after lytics.
Thrombosis -pulmonary (massive PE)	Pre-arrest dyspnea + pleuritic pain + tachycardia, recent surgery/immobilization/cancer, known DVT, RV strain on prior echo, dilated RV on bedside echo during CPR.	Systemic thrombolytics: tPA 50 mg IV bolus (can give during CPR). Continue CPR for 60–90 min after lytics to allow time to work. If available: consider surgical embolectomy or catheter-directed therapy. Bedside echo during CPR showing RV dilation supports PE diagnosis.

💊 Code Drug Doses

Drug	Dose	Indication
Epinephrine (Adrenalin)	1 mg IV q3–5 min	All cardiac arrest rhythms. First-line vasopressor.
Amiodarone (Cordarone)	300 mg IV push (1st dose), 150 mg (2nd dose)	Refractory VFib/pVT after 3+ shocks.
Lidocaine	1–1.5 mg/kg IV, then 0.5–0.75 mg/kg	Alternative to amiodarone for VFib/pVT.
Atropine	1 mg IV q3–5 min (max 3 mg)	Symptomatic bradycardia (NOT for asystole or PEA).
Adenosine (Adenocard)	6 mg rapid IV push → if no effect → 12 mg → 12 mg	Stable SVT. Must use rapid push + flush at proximal IV site.
Calcium chloride	1–2 g IV (10–20 mL of 10%)	Hyperkalemia with ECG changes, calcium channel blocker OD, hypocalcemia.
Calcium gluconate	3 g IV (30 mL of 10%)	Same indications. 3× less elemental calcium than CaCl₂. Safer peripherally.
Sodium bicarbonate	1 mEq/kg IV	Severe metabolic acidosis, TCA overdose, hyperkalemia (adjunct).
Magnesium	2 g IV over 15 min	Torsades de pointes. Also hypomagnesemia-related arrhythmias.
Vasopressin (Pitressin)	40 units IV × 1	Can replace first or second epi dose in cardiac arrest (AHA 2020 removed specific recommendation but still acceptable).

🏥 Rapid Response Assessment

When You Get the Call -ABCDE

A -Airway

Speaking? Stridor? Secretions? Can they protect their airway? If not → jaw thrust, suction, consider intubation. Call anesthesia early if airway is threatened.

B -Breathing

RR, SpO₂, work of breathing, auscultate. Wheezing → bronchodilator. Crackles → fluid overload vs pneumonia. Absent breath sounds → PTX? Stridor → upper airway obstruction → call ENT/anesthesia. Apply O₂ while assessing.

C -Circulation

HR, BP, rhythm, mental status, cap refill, urine output. If hypotensive → IVF bolus (unless cardiogenic). If no pulse → call code, start CPR. Get 12-lead ECG. Access: 2 large-bore IVs.

D -Disability

GCS, pupils, glucose (stat fingerstick -ALWAYS check). New focal deficit → stroke alert. Seizure → benzos (lorazepam 4 mg IV). AMS → consider naloxone 0.4 mg IV (opioid reversal).

E -Exposure/Environment

Expose the patient -look for rashes (anaphylaxis, meningococcemia), surgical sites, lines, drains, skin findings. Check temperature. Review meds + recent changes. What changed?

Common Rapid Response Triggers

Trigger	First Steps	Think
Acute desaturation	O₂, check SpO₂ probe, auscultate, CXR, ABG	PE, mucus plug, PTX, flash pulm edema, pneumonia, aspiration
Acute hypotension	Passive leg raise (NOT Trendelenburg -no evidence), IVF bolus, HR check, 12-lead ECG	Sepsis, hemorrhage, PE, cardiogenic, anaphylaxis, adrenal crisis
Tachycardia	12-lead ECG, BP, fluid status, pain assessment	SVT, Afib/RVR, PE, sepsis, hypovolemia, pain, anxiety, withdrawal
Acute AMS	Glucose, O₂, vitals, pupils, review meds	Hypoglycemia, opioids, stroke, seizure (postictal), sepsis, hypercarbia
Acute chest pain	12-lead ECG within 10 min, troponin, vitals, O₂	ACS, PE, dissection, PTX, pericarditis