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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EmergentNeuro · ICU

Glasgow Coma Scale -Pocket Card

Print this and tape it to your badge. GCS ≤ 8 = intubate. Motor is the most prognostically important component.

Component	Response	Score
Eye Opening (E)	Spontaneous	4
	To voice / command	3
	To pressure / pain	2
	None	1
Verbal Response (V)	Oriented (person, place, time, event)	5
	Confused (converses but disoriented)	4
	Inappropriate words (random words, no conversation)	3
	Incomprehensible sounds (moaning, no words)	2
	None	1
Motor Response (M) Most prognostically important	Obeys commands	6
	Localizes pain (reaches toward stimulus)	5
	Normal flexion / withdrawal (pulls away)	4
	Abnormal flexion / decorticate (arms flex, legs extend)	3
	Extension / decerebrate (arms and legs extend)	2
	None	1

Severity Classification

GCS Score	Severity	Action
13 – 15	Mild	Observation, serial neuro exams q1–2h. CT head if: anticoagulation, focal deficit, LOC, persistent vomiting, age > 65, coagulopathy.
9 – 12	Moderate	CT head. Frequent neuro checks (q1h). ICU admission. Neurosurgery consult if structural lesion.
3 – 8	Severe	INTUBATE for airway protection. CT head STAT. ICU. Neurosurgery consult. Consider ICP monitoring if TBI (bolt if GCS ≤ 8 + abnormal CT).
3	Minimum (coma)	Worst possible score. No eye opening, no verbal, no motor. Evaluate for brain death criteria if persistent.

Clinical Pearls

GCS ≤ 8 = intubate. The patient cannot protect their own airway. This is the single most important GCS threshold.
Motor score is the most prognostically important component. A patient with E1V1M5 (GCS 7) has a much better prognosis than E2V2M3 (GCS 7) -same total, very different meaning.
Always report components, not just the total: "GCS 8 (E2V2M4)" -not just "GCS 8." The components tell you where the deficit is.
Intubated patients: Verbal = 1T (denotes tube). Report as "GCS 7T (E2V1TM4)." Cannot assess verbal in intubated patients.
Confounders: sedation, paralysis, alcohol, metabolic encephalopathy, aphasia, orbital swelling (can't assess eye opening). Always document confounders.
GCS was validated for TBI -it is less reliable in metabolic coma, drug overdose, or non-traumatic causes. Use alongside pupil reactivity for better prognostication (GCS-Pupils score).
Pupil reactivity: GCS-P = GCS − pupil reactivity score (both reactive = 0, one reactive = −1, neither reactive = −2). GCS-P adds prognostic value to GCS alone GCS-Pupils Study, 2018.

How to Present GCS on Rounds

Scenario	What to Say
Normal / alert patient	"GCS is 15 -eyes open spontaneously, oriented and conversing, following commands."
Confused patient	"GCS is 13, that's E4 V4 M5 -eyes open spontaneously, conversing but confused to date and place, localizes to pain."
Obtunded patient	"GCS is 9, E2 V3 M4 -eyes open to pain only, inappropriate words, withdraws from pain. This is down from 12 yesterday -we need a stat CT head."
Intubated patient	"GCS is 7T -that's E2 V1T M4. Eyes open to pain, intubated so verbal is untestable, withdraws to pain. Sedation is off for over 2 hours."
Comatose patient	"GCS is 3, E1 V1 M1 -no eye opening, no verbal, no motor response to central pain. Pupils are 4 mm and fixed bilaterally. We need to discuss brain death evaluation."
Improving patient	"GCS improved from 8 to 11 overnight -now E3 V3 M5. Eyes opening to voice, still using inappropriate words, but now localizing to pain. Motor improvement is the most important prognostic sign here."

The formula for presenting GCS: "GCS is [total], that's E[_] V[_] M[_] -[describe what each means in plain English]." Always state the trend compared to prior ("up from…" / "down from…" / "unchanged from…"). If intubated, say "V1T" and note how long sedation has been off. If there are confounders (sedation, paralysis, orbital swelling), state them: "GCS is limited by ongoing propofol -motor is the only reliable component."

How to Test

Component	How to Assess
Eye	Observe → if no spontaneous opening, call patient's name loudly → if no response, apply central pain (trapezius squeeze or sternal rub). Do NOT use peripheral pain for eye opening (may cause withdrawal without eye opening).
Verbal	Ask: "What is your name? Where are you? What month/year is it? What happened?" Oriented = all 4 correct. Confused = conversing but wrong answers. Inappropriate = single words, no conversation. Incomprehensible = moans/groans only.
Motor	Ask patient to "show me two fingers" or "lift your arms." If no response → apply central pain (trapezius squeeze preferred over sternal rub -less tissue damage). Observe best response in any limb. Localizes = hand crosses midline and reaches above clavicle toward stimulus. Flexion = arm bends at elbow. Extension = arm straightens and internally rotates.

Decorticate (flexion, GCS M3) vs Decerebrate (extension, GCS M2): Decorticate = cortical damage above red nucleus → arms flex, legs extend. Decerebrate = brainstem damage below red nucleus → all limbs extend. Decerebrate carries a worse prognosis. Mnemonic: de-COR-ticate = CORtex = arms toward CORE (flex). de-CERE-brate = CEREbellum level = arms extend.