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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CoreNight Float

Cross-Cover Algorithms

The 6 calls you'll get at 3 AM and the 60-second decision tree for each. Assess, intervene, decide if you need to call your senior.

🌡️ Fever (T ≥ 38.3°C / 101°F)

Assess

Vitals (HR, BP, SpO₂). Is the patient septic? (Tachycardic, hypotensive, altered?) Look at the patient -line sites, surgical wounds, skin, lungs, abdomen, Foley.

Workup

Blood cultures × 2 (before abx). UA + urine culture. CXR. CBC, BMP, lactate. C. diff stool if diarrhea. Line cultures if central line > 48h. Wound culture if surgical site erythema.

Intervene

Acetaminophen 1g PO/IV. If septic → IVF bolus + start empiric antibiotics per source. If neutropenic → cefepime 2g IV within 60 min (oncologic emergency).

Call senior if

Sepsis (HR > 110, SBP < 90, lactate > 2, altered). Neutropenic fever (ANC < 500). New fever on immunosuppression. Unclear source with clinical deterioration.

Common pitfalls: Post-op day 1–2 fever is often atelectasis (encourage incentive spirometry) -but still work it up. Drug fever (eosinophilia, timing with new med). DVT (check legs). C. diff (new diarrhea + recent abx).

📉 Hypotension (SBP < 90 or MAP < 65)

Assess

Go see the patient immediately. Vitals + mental status. Check lines/drains for blood. Recent meds (antihypertensives, opioids, sedatives). Abdomen (GI bleed?). JVD (PE, tamponade, tension PTX)?

Intervene

IVF bolus 500 mL–1L NS or LR. Passive leg raise to assess fluid responsiveness. Hold antihypertensives. If on pressors → uptitrate and notify ICU. If bleeding → type and screen, activate MTP if massive.

Workup

CBC (drop in Hgb?), BMP, lactate, 12-lead ECG. Blood cultures if febrile. Consider: bedside echo (tamponade? RV strain? empty LV?), CXR (PTX? widened mediastinum?).

Call senior if

Not responding to 2L IVF. Active hemorrhage. New arrhythmia. Concern for PE, tamponade, or tension PTX. Need for pressors.

Think SHOCK: Septic (warm, febrile), Hypovolemic (dry, bleeding), Obstructive (PE, tamponade, PTX), Cardiogenic (JVD, crackles, cold), Anaphylactic (rash, wheezing, new med/food).

📉 Desaturation (SpO₂ < 92%)

Assess

Apply O₂ first, assess second. Check probe placement (cold fingers, nail polish give false readings). Confirm with ABG if uncertain. Look at patient: work of breathing, tracheal position, breath sounds, JVD.

Intervene

Nasal cannula 2–6 L → face mask 10–15 L → non-rebreather → high-flow nasal cannula → BiPAP → intubation. If wheezing → albuterol nebulizer. If crackles + JVD → furosemide IV (flash pulm edema). If absent breath sounds unilateral → PTX? (needle decompress if tension).

Workup

CXR (stat portable), ABG, 12-lead ECG. Consider: CTPA if PE suspected (tachycardia + pleuritic pain + risk factors). BNP if heart failure. Troponin if ACS.

Call senior if

Not improving with supplemental O₂. Need for BiPAP or intubation. Concern for PE, PTX, or flash pulm edema. New infiltrate on CXR in the right clinical context.

Top 5 overnight causes: mucus plug (suction + turn), flash pulmonary edema (Lasix), PE, aspiration, pneumothorax (post-procedure or on vent). Also: opioid-induced hypoventilation → check RR, give naloxone if < 8.

🧠 Altered Mental Status

Assess

Stat fingerstick glucose (hypoglycemia is the fastest fixable cause). Vitals. Pupils. GCS. Focal neuro exam (asymmetry → stroke alert). Review med list (opioids, benzos, anticholinergics).

Intervene

Glucose < 70 → D50 1 amp IV. Suspected opioid OD (pinpoint pupils, RR < 8) → naloxone 0.4 mg IV. Benzodiazepine OD → supportive (flumazenil rarely indicated). Seizure → lorazepam 4 mg IV.

Workup

BMP (Na⁺, Ca²⁺, glucose), CBC, ammonia (if liver disease), UA (UTI in elderly?), ABG, lactate. CT head if focal deficit, fall, anticoagulated, or not improving. Consider LP if meningitis suspected (fever + nuchal rigidity).

Call senior if

Focal neuro deficit (stroke alert). Seizure. Meningeal signs. Not correcting with glucose/naloxone. GCS ≤ 8 (airway at risk).

Most common overnight AMS cause: delirium from medications. Review med list first -Benadryl, benzos, opioids, anticholinergics, steroids. Reorient, minimize stimulation, avoid restraints. Haldol 0.5–1 mg IV only if danger to self/others.

💔 Chest Pain

Assess

12-lead ECG within 10 min. Vitals. Character of pain (substernal pressure vs pleuritic vs positional vs reproducible). Cardiac history. Risk factors.

Intervene

ASA 325 mg chew (if ACS suspected and not already on). NTG 0.4 mg SL q5 min × 3 (hold if SBP < 90 or suspected RV infarct). Morphine only if refractory (not routine). O₂ if SpO₂ < 94%.

Workup

ECG (compare to prior). Troponin (serial 0 and 3h if hs-troponin). CXR. BMP. If ECG shows STEMI → activate cath lab immediately. If PE suspected → D-dimer or CTPA based on Wells score.

Call senior if

STEMI or new ST changes. Hemodynamic instability. Concern for dissection (tearing pain + BP differential). Positive troponin. Chest pain not resolving with NTG.

💧 Low Urine Output (< 0.5 mL/kg/hr × 6h)

Assess

Is the Foley kinked, clogged, or draining? Flush 30 mL NS. If no Foley → bladder scan (> 300 mL = retention → straight cath). Check vitals, volume status (dry vs overloaded), recent meds (NSAIDs, ACEi, diuretics).

Intervene

If hypovolemic → IVF 500 mL NS bolus. If retention → straight cath or Foley. Stop nephrotoxins (NSAIDs, aminoglycosides, contrast). Hold ACEi/ARB if Cr rising. If overloaded (JVD, crackles, edema) → do NOT give more fluid -consider diuresis.

Workup

BMP (Cr trend -compare to baseline), UA with sediment, bladder scan. FENa or FEUrea to differentiate pre-renal vs intrinsic (see Calculators). Consider renal US if obstruction suspected.

Call senior if

Cr doubled from baseline. Anuria (< 50 mL/12h). Hyperkalemia (K⁺ > 6 + ECG changes). Volume overloaded + oliguric (may need emergent dialysis).