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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Pain Management & Conversions

WHO pain ladder, PCA dosing, multimodal analgesia, equianalgesic opioid conversions, and steroid equivalency. The complete analgesic guide.

📶 WHO Pain Ladder & Analgesic Guide

WHO Analgesic Ladder (Modified)

Start at the step that matches the patient's pain severity. You do NOT have to climb from Step 1 → 2 → 3 sequentially. A patient with severe post-op pain can start at Step 3 immediately. Add adjuvants at EVERY step.

Step 1 -Mild Pain (1–3/10)

Non-opioid analgesics:
• Acetaminophen (Tylenol) 650–1000 mg PO q6h (max 3g/day if liver disease, 4g if healthy)
• Ibuprofen (Advil) 400–600 mg PO q6h with food
• Ketorolac (Toradol) 15–30 mg IV q6h (max 5 days -renal/GI risk)
• Celecoxib (Celebrex) 200 mg PO BID (lower GI bleed risk)

⚠️ NSAIDs: avoid in CKD (GFR < 30), active GI bleed, HF, post-CABG, concurrent anticoagulation, platelets < 50K

Step 2 -Moderate Pain (4–6/10)

Weak opioids ± non-opioids:
• Tramadol (Ultram) 50–100 mg PO q6h (max 400 mg/day)
• Hydrocodone/APAP (Norco) 5/325 -1-2 tabs q4-6h
• Oxycodone IR (OxyContin) 5 mg PO q4-6h PRN
• Continue scheduled acetaminophen + NSAIDs if safe

⚠️ Tramadol: seizure risk, serotonin syndrome with SSRIs/SNRIs, avoid in epilepsy

Step 3 -Severe Pain (7–10/10)

Strong opioids ± non-opioids:
• Morphine (MS Contin) 2–4 mg IV q3-4h PRN
• Hydromorphone (Dilaudid) 0.5–1 mg IV q3-4h PRN
• Fentanyl (Sublimaze) 25–50 mcg IV q1-2h (short duration)
• Oxycodone 5–10 mg PO q4h
• Continue non-opioid adjuncts (multimodal)

⚠️ Always start bowel regimen with opioids (PEG 3350 + senna). No ceiling for opioid dose in cancer/palliative pain.

Adjuvant Analgesics -Add at ANY Step

Drug	MOA	Dose	Best For	⚠️ Side Effects
Gabapentin (Neurontin)	Calcium channel α2δ ligand -reduces excitatory neurotransmitter release	100–300 mg PO TID, titrate to 900–3600 mg/day	Neuropathic pain (diabetic neuropathy, post-herpetic neuralgia, radiculopathy)	⚠️ Sedation, dizziness, peripheral edema. Renally cleared -reduce dose in CKD.
Pregabalin (Lyrica)	Same as gabapentin, higher affinity, more predictable (linear) absorption. ~6× more potent than gabapentin (300 mg gabapentin ≈ 50 mg pregabalin), so dose numbers are smaller.	75 mg PO BID → max 300 mg BID	Neuropathic pain, fibromyalgia	⚠️ Same as gabapentin. Schedule V controlled substance (abuse potential).
Duloxetine (Cymbalta)	SNRI -inhibits serotonin + norepinephrine reuptake in descending pain pathways	30 mg PO daily × 1 week → 60 mg daily	Diabetic neuropathy, musculoskeletal pain, fibromyalgia	⚠️ Nausea (take with food), serotonin syndrome risk with tramadol/other serotonergics. Do NOT stop abruptly.
Dexamethasone (Decadron)	Glucocorticoid -reduces peritumoral edema and inflammation	4–8 mg IV/PO daily	Bone metastases, spinal cord compression, bowel obstruction, cerebral edema	⚠️ Hyperglycemia, insomnia, GI upset, immunosuppression. Short-term use preferred.
Lidocaine patch (5%)	Sodium channel blockade -local anesthetic	1–3 patches to painful area, 12h on / 12h off	Localized neuropathic pain, post-herpetic neuralgia, musculoskeletal	⚠️ Minimal systemic absorption. Skin irritation at site.
Ketamine (low-dose)	NMDA receptor antagonist -blocks central sensitization	0.1–0.3 mg/kg/hr IV infusion	Opioid-refractory pain, chronic pain crises, sickle cell VOC	⚠️ Dissociation, hallucinations, nausea, ↑ secretions. Avoid in psychosis, elevated ICP.
Muscle relaxants	Various -central acting (tizanidine, cyclobenzaprine, baclofen)	Tizanidine 2–4 mg TID, Cyclobenzaprine 5–10 mg TID, Baclofen 5–10 mg TID	Musculoskeletal spasm, back pain	⚠️ Sedation (all), hepatotoxicity (tizanidine), anticholinergic (cyclobenzaprine). Baclofen withdrawal can cause seizures.

PCA (Patient-Controlled Analgesia) Dosing

PCA is for patients who can self-dose -must be alert, understand the button, and have no cognitive impairment. Family members should NEVER press the PCA button (risk of oversedation/respiratory arrest).

Opioid	Demand Dose	Lockout	Basal Rate (if needed)	1-hour Limit	Notes
Morphine PCA	1–2 mg	6–10 min	0–1 mg/hr (avoid in opioid-naive)	10 mg	Standard first-line PCA. Avoid in renal failure (M6G accumulation).
Hydromorphone PCA	0.2–0.4 mg	6–10 min	0–0.2 mg/hr	2 mg	Preferred in renal impairment. ~5–7× more potent than morphine IV.
Fentanyl PCA	10–25 mcg	6–10 min	0–25 mcg/hr	150 mcg	Short acting. Good for procedure-related pain. Lipophilic -accumulates with prolonged use.

⚠️ Basal rate + PCA in opioid-naive patients = dangerous. A continuous basal rate removes the safety net of the PCA system (patient stops pressing button when sedated). Use demand-only dosing for opioid-naive patients. Basal rate only for opioid-tolerant patients with established requirements.

IV → PO Opioid Conversion -When to Switch

Switch IV → PO when: patient tolerating PO intake, pain controlled ≥ 24h on stable IV dose, no nausea/vomiting
How: Calculate total 24h IV morphine equivalents → convert to PO using equianalgesic table → reduce by 25% for cross-tolerance → split into scheduled + PRN
Example: Patient on morphine PCA using 30 mg IV/24h → PO equivalent = 30 × 3 = 90 mg PO morphine/day → reduce 25% = ~68 mg → split: oxycodone ER 30 mg PO BID (60 mg/day) + oxycodone IR 5–10 mg q4h PRN for breakthrough
PRN breakthrough dose: 10–15% of total daily dose given q3-4h PRN

Multimodal Analgesia -The Modern Approach

Multimodal = combine drugs from different classes to target different pain pathways. This reduces opioid requirements by 30–50%, lowers side effects, and improves pain control. Every patient should get scheduled acetaminophen + NSAID (if safe) BEFORE reaching for opioids.

Pain Type	Recommended Multimodal Regimen
Post-surgical	Scheduled APAP 1g q6h + ketorolac 15 mg IV q6h (≤ 5 days) + gabapentin 300 mg preop + opioid PRN. Consider regional/nerve block.
Neuropathic	Gabapentin/pregabalin + duloxetine + lidocaine patch. Opioids are second-line (less effective for neuropathic pain).
Cancer / bone mets	Scheduled long-acting opioid + APAP + dexamethasone 4–8 mg + radiation therapy referral. Bisphosphonates for widespread bone mets.
Sickle cell VOC	IV morphine/hydromorphone PCA + scheduled APAP + ketorolac (≤ 5 days) + low-dose ketamine if refractory. NSAIDs safe short-term if GFR ok.
Chronic non-cancer	Maximize non-opioid: APAP, NSAIDs, duloxetine, gabapentin, PT/CBT. Opioids are last resort -risks of dependence, hyperalgesia.
Palliative / end-of-life	Scheduled opioid (no ceiling) + PRN breakthrough + adjuvants. Titrate to comfort. Address total pain (physical, emotional, spiritual).

Tiered PRN Pain Order Set -What to Write on Admission

Write pain orders in 3 tiers so the nurse can choose based on the patient's assessed pain level -without paging you for every dose. The nurse uses NRS (0–10) for alert patients or CPOT (0–8) for intubated/non-verbal patients to select the right tier.

Alert Patients -Numeric Rating Scale (NRS 0–10)

Pain Level	NRS Score	Medication	Dose	Route	Frequency
Mild	1–3	Acetaminophen (Tylenol)	650–1000 mg	PO	q6h PRN
Moderate	4–6	Oxycodone IR (OxyContin)	5 mg	PO	q4h PRN
Moderate	4–6	Alternative: Tramadol (Ultram)	50 mg	PO	q6h PRN
Severe	7–10	Hydromorphone (Dilaudid)	0.5–1 mg	IV	q3h PRN
Severe	7–10	Alternative: Morphine (MS Contin)	2–4 mg	IV	q3-4h PRN

⚠️ Adjust for special populations:
• Elderly / CKD / hepatic: Start at lower end of each tier (oxycodone 2.5 mg, hydromorphone 0.25 mg)
• Opioid-tolerant: May need higher doses at each tier
• Post-surgical: Add scheduled APAP 1g q6h + ketorolac 15 mg IV q6h (multimodal reduces opioid need by 30–50%)

Intubated / Non-Verbal Patients -CPOT Score (0–8)

Domain	0 Points	1 Point	2 Points
Facial expression	Relaxed, neutral	Tense (brow furrowed, orbit tightened)	Grimacing (teeth clenching, deep furrows)
Body movements	Absent, normal position	Protection (slow, cautious, touching pain site)	Restlessness (pulling at tubes, attempting to sit up, thrashing)
Compliance with ventilator (intubated) or Vocalization (extubated)	Tolerating vent / talking normally	Coughing but tolerating / sighing, moaning	Fighting vent, triggering alarms / crying out, sobbing
Muscle tension (passive flexion/extension of upper extremity)	Relaxed, no resistance	Resistance to passive movements	Strong resistance, unable to complete movement

Pain Level	CPOT Score	Medication	Dose	Route	Frequency
Minimal	0–2	Acetaminophen (Tylenol)	1000 mg	IV	q6h PRN
Moderate	3–4	Fentanyl (Sublimaze)	25 mcg	IV	q2h PRN
Significant	5–8	Fentanyl (Sublimaze)	50–100 mcg	IV	q1-2h PRN
Significant	5–8	Alternative: Hydromorphone (Dilaudid)	0.5 mg	IV	q3h PRN

⚠️ CPOT ≥ 3 = significant pain -treat it. Intubated patients cannot tell you they hurt. Studies show ICU patients experience moderate-to-severe pain during routine care (turning, suctioning, wound care). Undertreated pain increases delirium, prolongs ventilation, and causes PTSD.

⚠️ Always reassess within 30 minutes of giving PRN pain medication. If CPOT or NRS unchanged → escalate to next tier or consider continuous infusion. Document pre- and post-intervention pain scores.

💊 Opioid Equianalgesic Table

When converting between opioids, reduce the calculated equianalgesic dose by 25–50% to account for incomplete cross-tolerance. Conversion ratios are approximate -always titrate to effect.

Opioid	IV/IM Dose	PO Dose	IV:PO Ratio	Duration	Notes
Morphine (MS Contin)	10 mg	30 mg	1:3	3–4h	Reference standard. Active metabolite (M6G) accumulates in renal failure → ↑ sedation/respiratory depression.
Hydromorphone (Dilaudid)	1.5 mg	7.5 mg	1:5	3–4h	~7× more potent than morphine IV. Preferred in renal failure (no active metabolite). Most commonly used IV opioid on wards.
Oxycodone (OxyContin)	N/A (PO only)	20 mg	PO only	3–4h	~1.5× morphine PO. Available as IR and ER (OxyContin).
Hydrocodone	N/A (PO only)	30 mg	PO only	4–6h	Equivalent to PO morphine mg-for-mg. Often combined with acetaminophen (Norco).
Fentanyl IV	100 mcg	N/A	IV only*	0.5–1h	~100× morphine potency. Rapid onset (1–2 min IV). Short acting -good for procedures. Lipophilic → accumulates with repeated dosing.
Fentanyl patch	25 mcg/hr ≈ 60–90 mg PO morphine/day		-	72h	Only for opioid-tolerant patients. Takes 12–24h to reach steady state. Fever increases absorption → overdose risk.
Tramadol (Ultram)	N/A	~100–150 mg ≈ morphine 10 mg PO	-	4–6h	Weak opioid + SNRI. Seizure risk. Serotonin syndrome risk. Max 400 mg/day.
Methadone	DO NOT use standard equianalgesic ratios. Conversion is non-linear -becomes dramatically more potent at higher morphine equivalents. Always consult pharmacy or pain service for methadone conversions. Long QTc risk.

Quick Conversion Math

Morphine IV to PO: multiply by 3 (10 mg IV = 30 mg PO)
Hydromorphone IV to PO: multiply by 5 (1 mg IV = 5 mg PO)
Morphine PO to oxycodone PO: multiply by 0.67 (30 mg morphine = 20 mg oxycodone)
Morphine PO to hydromorphone PO: divide by 4 (30 mg morphine = 7.5 mg hydromorphone)

💊 Steroid Equivalency Table

Steroid	Equivalent Dose	Relative Anti-inflammatory Potency	Relative Mineralocorticoid	Duration	Notes
Hydrocortisone (Solu-Cortef)	20 mg	1×	1×	Short (8–12h)	Physiologic replacement: 15–20 mg AM + 5–10 mg PM. Stress dose: 100 mg IV q8h. Has mineralocorticoid activity → fluid retention at high doses. Endocrine Society, 2016
Prednisone (Deltasone) / Prednisolone (Orapred)	5 mg	4×	0.6×	Intermediate (12–36h)	Most commonly prescribed oral steroid. Prednisone is a prodrug (converted to prednisolone in liver, use prednisolone in liver failure). COPD exacerbation: 40 mg PO × 5 days. REDUCE, 2013
Methylprednisolone (Solu-Medrol)	4 mg	5×	0.5×	Intermediate (12–36h)	Preferred IV steroid for most indications. Pulse dose: 1g IV daily × 3 days (lupus, vasculitis, MS flare). EULAR, 2020
Dexamethasone (Decadron)	0.75 mg	25–30×	0 (none)	Long (36–72h)	Most potent. No mineralocorticoid → no fluid retention. Best for cerebral edema, croup, meningitis. Does NOT cross-react with cortisol assay (use when cosyntropin stim test needed). de Gans, 2002
Fludrocortisone (Florinef)	N/A	10×	125×	Intermediate (18–36h)	Mineralocorticoid replacement only (primary AI, 0.05–0.2 mg daily). NOT used as anti-inflammatory. Not needed in secondary AI (aldosterone preserved). Endocrine Society, 2016

Quick Conversions

Prednisone 40 mg PO = methylprednisolone 32 mg IV = dexamethasone 6 mg = hydrocortisone 160 mg
Prednisone 5 mg = the classic "physiologic" equivalent dose
≥ 20 mg prednisone/day × ≥ 3 weeks = HPA axis suppression → needs taper

See full Corticosteroids topic → Complete guide with glucocorticoid vs mineralocorticoid potency, when to use which steroid, side effects, tapering protocols, and pimp questions.