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.

Sedation -ICU Sedation & Analgesia -RoundsRx

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Have you treated pain first? Before reaching for a sedative, ensure fentanyl (or equivalent) is optimized. If CPOT ≥ 3 → the patient needs more analgesia, not sedation. Go to Analgesia Guide.

Sedation Agent Comparison

Agent	Dose	Onset	Best For	Avoid When	Key Side Effects
Propofol (Diprivan) (Diprivan) 1ST LINE	5–50 mcg/kg/min IV	30–60 sec	Most ventilated ICU patients. Rapid on/off -ideal for daily SAT, neuro checks.	Egg/soy allergy, hypertriglyceridemia, propofol infusion syndrome risk	Hypotension (vasodilatory). Check TGs q48h. Propofol infusion syndrome if > 4 mg/kg/hr × > 48h.
Dexmedetomidine (Precedex)	0.2–1.5 mcg/kg/hr IV (no load in ICU)	15–30 min	Light sedation. Delirium prevention. Vent weaning. Only sedative without respiratory depression -can use in non-intubated patients.	Bradycardia, heart block, hemodynamic instability	Bradycardia (most common), hypotension, rebound HTN on discontinuation. Less delirium than benzos MENDS, 2007.
Ketamine (Ketalar) (Ketalar)	0.5–2 mg/kg/hr IV (dissociative) 1–2 mg/kg bolus (procedural)	1 min	Hemodynamically unstable (supports BP). Status asthmaticus. Refractory status epilepticus. Procedural.	Elevated ICP (relative), uncontrolled HTN, psychosis	Emergence phenomena, hypersalivation, tachycardia. Bronchodilator.
Midazolam (Versed) (Versed) 2ND/3RD LINE	0.02–0.1 mg/kg/hr IV	2–5 min	Benzo/alcohol withdrawal, status epilepticus, when propofol/dex contraindicated.	Prolonged ICU use, renal/hepatic failure, elderly	Accumulates → prolonged wake-up. ↑ delirium + mortality SEDCOM, 2009. Tolerance, withdrawal.
Lorazepam (Ativan) LAST RESORT	0.01–0.1 mg/kg/hr IV or 0.5–4 mg PRN	5 min	Alcohol/benzo withdrawal only (CIWA). Status epilepticus. Last resort.	Routine ICU sedation, renal failure (propylene glycol)	Propylene glycol toxicity (high-dose infusion). Worst delirium profile of all ICU sedatives. Do NOT use as first-line.

RASS Scale -Sedation Targets

RASS	Description	When to Target
+4	Combative	- (never a target)
+3	Very agitated	- (evaluate for pain, delirium, hypoxia)
+2	Agitated	- (treat cause before escalating sedation)
+1	Restless	May be acceptable if comfortable
0	Alert and calm	Ideal target for most patients
−1	Drowsy -opens eyes to voice	Most common ICU target (RASS −1 to 0)
−2	Light sedation -brief awakening to voice	Post-op, mild agitation
−3	Moderate sedation -movement to voice only	NMB use, severe ARDS
−4	Deep sedation -no response to voice	NMB, status epilepticus, elevated ICP
−5	Unarousable	NMB only -reassess if unintentional

Quick Selection Flowchart

Step 1: Pain controlled? (CPOT < 3, NRS ≤ 3) → If no, optimize analgesia first. Do not add sedation.

Step 2: Standard ventilated patient → Propofol. Target RASS −1 to 0. Daily SAT + SBT.

Step 3: Delirium, agitation, or vent weaning → Dexmedetomidine. Preserves respiratory drive.

Hypotensive patient needing sedation → Ketamine (supports BP). Or low-dose propofol with vasopressor support.

Alcohol/benzo withdrawal → Benzodiazepines (CIWA-guided). Phenobarbital for severe/refractory. Add dex as adjunct.

Severe ARDS + NMB → Deep sedation (RASS −3 to −4). Propofol or midazolam + fentanyl. Ensure adequate analgesia -paralyzed patients cannot communicate pain.

Procedural sedation → Propofol 0.5–1 mg/kg bolus ± fentanyl. Etomidate for cardioversion. Ketamine for hemodynamically unstable procedures.

Key Pearls

Light sedation saves lives. RASS −1 to 0 reduces ICU mortality, ventilator days, and long-term cognitive impairment vs deep sedation. There is almost never a reason for RASS −4/−5 without NMB.

Benzos cause delirium. Midazolam and lorazepam are independently associated with ↑ delirium and ↑ mortality compared to propofol or dexmedetomidine MENDS, 2007 SEDCOM, 2009. Never use as first-line ICU sedation.

Propofol infusion syndrome: > 4 mg/kg/hr × > 48h → new metabolic acidosis, ↑ lactate, rhabdomyolysis, Brugada-like ECG, cardiac failure. Stop propofol immediately, switch agent, supportive care.

Dexmedetomidine is the only sedative without respiratory depression. Can sedate non-intubated patients (post-extubation agitation, NIV patients, procedural sedation).

Daily SAT + SBT. Every day ask: can we turn off sedation? Can we do a breathing trial? The ABCDEF bundle reduces mortality and delirium. Do it every single day.

Special Clinical Scenarios

Alcohol / Benzodiazepine Withdrawal

Benzodiazepines are the treatment -NOT propofol or dexmedetomidine alone.

CIWA-Ar score q4–8h -score > 8 → treat
Lorazepam 1–4 mg IV q1h PRN (symptom-triggered) OR diazepam 5–20 mg PO/IV PRN
Severe/refractory (CIWA > 20): phenobarbital 130–260 mg IV q15–30 min until controlled
Add dexmedetomidine as adjunct for autonomic symptoms (tachycardia, HTN)
Thiamine 100 mg IV before any glucose (prevents Wernicke's)

Delirium Management

Non-pharmacologic first: reorientation, day/night cycle, early mobility, hearing aids/glasses
Dexmedetomidine -reduces delirium duration vs benzos MENDS, 2007
Haloperidol 1–5 mg IV/IM q6–12h PRN -QTc monitoring required. MIND-USA, 2018
Quetiapine 25–50 mg PO BID-TID -alternative in non-intubated patients
Avoid: benzos (worsen delirium unless withdrawal), anticholinergics, polypharmacy

Neuromuscular Blockade (NMB)

Indications: severe ARDS (P/F < 150), refractory dyssynchrony, elevated ICP, status epilepticus
Cisatracurium preferred (Hofmann elimination -no renal/hepatic clearance)
Always ensure adequate sedation AND analgesia before NMB -aware paralysis is catastrophic
Train-of-four (TOF) monitoring -target 1–2 twitches out of 4

Procedural Sedation

Procedure	Regimen
Bronchoscopy	Propofol 0.5–1 mg/kg bolus + fentanyl 25–50 mcg + topical lidocaine
Central / arterial line	Midazolam 1–2 mg IV + fentanyl 25–50 mcg (or local only)
Cardioversion	Propofol 0.5–1 mg/kg IV or etomidate 0.2 mg/kg IV
Paracentesis / thoracentesis	Topical lidocaine only; add midazolam if anxious

Pimp Questions

What is propofol infusion syndrome and how do you recognize it?

Rare but fatal complication of high-dose (> 4 mg/kg/hr) or prolonged propofol. Caused by impaired mitochondrial fatty acid oxidation. Features: new metabolic acidosis + elevated lactate, rhabdomyolysis, hyperkalemia, lipemic plasma, Brugada-like ECG, cardiac failure. Treatment: stop propofol immediately, switch agent, supportive care.

Why are benzodiazepines associated with worse ICU outcomes?

MENDS, 2007 SEDCOM, 2009: more delirium, longer ventilator time, increased ICU stay vs propofol or dexmedetomidine. Accumulate in renal/hepatic failure. Paradoxical agitation in elderly. Reserve for withdrawal and status epilepticus only.

What makes dexmedetomidine unique compared to other sedatives?

Only ICU sedative without respiratory depression. Mechanism: α₂ agonism (locus coeruleus) → sleep-like state, patients arouse easily. Can sedate non-intubated patients, continue during vent weaning, and doesn't interfere with respiratory drive during SBT.