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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EMERGENTICU/EM

Intubation / RSI

Rapid Sequence Intubation. Pre-oxygenate, push induction + paralytic, confirm with ETCO2 waveform. Know your agents, contraindications, and difficult airway algorithm.

Overview

Indications

Failure to protect airway (GCS ≤8), respiratory failure despite NIV, expected deterioration

The 7 P's of RSI

#	Step	Details
1	Preparation	Equipment check (ETT, laryngoscope, bougie, LMA, suction, BVM), IV access, monitors, difficult airway plan
2	Pre-oxygenation	3–5 min 100% O2 via NRB or HFNC. Goal: denitrogenation of FRC. Creates O2 reserve for apnea.
3	Pre-treatment	Optional. Fentanyl 1–2 mcg/kg for ICP concerns, lidocaine 1.5 mg/kg for reactive airways (controversial)
4	Paralysis with Induction	Push induction agent + paralytic simultaneously. Wait 45–60s for fasciculations to stop.
5	Protection & Positioning	Sniffing position (ear-to-sternal-notch alignment). Avoid cricoid pressure (Sellick) unless vomiting.
6	Placement	Direct or video laryngoscopy. Pass ETT through cords. Inflate cuff. Confirm with waveform ETCO2.
7	Post-intubation Management	Sedation + analgesia, initial vent settings, CXR, ABG at 30 min. Secure tube.

RSI Sequence

Pre-oxygenate 3–5min 100% O2, HFNC apneic oxygenation, HOB 20–30°
Push induction + paralytic simultaneously → wait 45–60s → laryngoscopy
Confirm with continuous waveform ETCO2

ETCO2 waveform is the GOLD STANDARD. Auscultation alone is NOT sufficient. No waveform = esophageal until proven otherwise.

Induction Agents

Agent	Dose	Pros	Cons
Etomidate	0.3mg/kg	Hemodynamically neutral	Adrenal suppression
Ketamine	1–2mg/kg	Bronchodilator, maintains BP. Best for asthma/sepsis	Emergence reactions
Propofol	1–2mg/kg	Fast onset	Drops BP, avoid in hypotension

Paralytics

Agent	Dose	Onset	Contraindications
Succinylcholine	1–1.5mg/kg	45s (fastest)	HyperK, burns >48h, crush, NMD, malignant hyperthermia
Rocuronium	1.2mg/kg	60s	Reversible with sugammadex

🔄 Updated Practice: Old teaching: succinylcholine is the default paralytic for RSI due to fastest onset. Current practice: rocuronium (Zemuron) 1.2 mg/kg has equivalent onset (~60 seconds at this dose), is reversible with sugammadex (Bridion), and has fewer contraindications (no hyperkalemia risk in burns/crush/renal failure/neuromuscular disease). Many centers now use rocuronium as the default paralytic for RSI.

Difficult Airway

Bougie (first adjunct), video laryngoscopy, LMA rescue, cricothyrotomy last resort

Failed Airway Algorithm

Step	Intervention	Details
1st attempt fails	Reposition + Bougie	Optimize head position (ear-to-sternal-notch), use bougie as first-line adjunct through direct or video laryngoscopy
2nd attempt fails	Video laryngoscopy	Switch to video if using direct. Different blade (hyperangulated). Limit to 3 total attempts.
Can oxygenate, can't intubate	Supraglottic airway (LMA/iGel)	Place LMA as rescue device. Can ventilate through it and even intubate through certain LMAs.
Can't intubate, can't oxygenate (CICO)	Surgical airway (cricothyrotomy)	Do NOT delay. Scalpel-bougie-tube technique. Vertical skin incision, horizontal through cricothyroid membrane.

The most dangerous decision is the next attempt. After 3 failed laryngoscopy attempts, the probability of success drops and the risk of cannot-intubate-cannot-oxygenate (CICO) rises sharply. Call for help early. Declare a failed airway and move to surgical airway without delay if you cannot oxygenate.

Pre-Assessment

Checklist

LEMON airway assessment, equipment ready (ETT, laryngoscope, bougie, LMA, suction)
Hemodynamics: optimize BEFORE intubation, push-dose vasopressors ready
Pre-oxygenation: 3–5min NRB or HFNC, HOB elevated

LEMON Difficult Airway Assessment

Letter	Assessment	Concerning Findings
L	Look externally	Facial trauma, large tongue, short neck, obesity, beard, cervical collar
E	Evaluate 3-3-2 rule	< 3 fingers mouth opening, < 3 fingers mentum to hyoid, < 2 fingers hyoid to thyroid notch
M	Mallampati	Class III (soft palate only) or IV (hard palate only) = difficult view
O	Obstruction / Obesity	Epiglottitis, peritonsillar abscess, angioedema, neck mass, BMI > 30
N	Neck mobility	C-spine immobilization, ankylosing spondylitis, rheumatoid arthritis (C1-2 instability)

If LEMON assessment is concerning: Have a backup plan BEFORE you push drugs. Consider awake intubation with flexible bronchoscopy, call anesthesia/ENT for support, and always have a surgical airway setup at bedside.

Post-Intubation

Initial Vent Settings

Parameter	Setting
TV	6–8 mL/kg IBW (6 if ARDS)
RR	14–16 (higher if met acidosis)
FiO2	100% → wean to SpO2 92–96%
PEEP	5 cmH2O (higher if ARDS)

CXR for tube position (3–5cm above carina)
Sedation: propofol or midazolam + fentanyl, target RASS -2 to 0
HOB 30–45°, oral care q4h, DVT ppx, stress ulcer ppx

Post-Intubation Sedation & Analgesia

Agent	Dose	Pros	Cons	Best For
Propofol	5–50 mcg/kg/min	Fast on/off, daily awakening trials easy, anti-epileptic	Hypotension, propofol infusion syndrome (PRIS) if > 48h at high doses	Short-term sedation, neuro patients (exam needed)
Dexmedetomidine (Precedex)	0.2–1.5 mcg/kg/h	No respiratory depression, patients are arousable, less delirium	Bradycardia, hypotension, expensive. Not deep enough for some patients.	Awake-sedation, extubation readiness, delirium-prone
Midazolam (Versed)	1–5 mg/h	Anxiolysis, anti-epileptic	Accumulation in renal/hepatic failure, worst delirium profile, prolonged sedation	Refractory agitation, seizures. Avoid as first-line.
Fentanyl	25–200 mcg/h	Potent analgesia, hemodynamically neutral	Chest wall rigidity at high doses, accumulation	Analgesia-first strategy, combine with sedative

Analgesia-first approach: Start with fentanyl for pain control, then add sedation as needed to target RASS -2 to 0. Daily sedation awakening trials (SATs) paired with spontaneous breathing trials (SBTs) reduce ventilator days and mortality (ABC Trial, 2008).

Medications

RSI Meds

Drug	Class	Dose	Pearl
Etomidate	Induction	0.3mg/kg	Hemodynamically neutral
Ketamine	Induction	1–2mg/kg	Best for asthma/sepsis
Propofol	Induction	1–2mg/kg	Drops BP. Avoid in shock
Succinylcholine	Depolarizing NMB	1–1.5mg/kg	Fastest (45s). CI in hyperK/burns/NMD
Rocuronium	Non-depolarizing NMB	1.2mg/kg	Reversible with sugammadex 16mg/kg

Induction Agent Comparison, Detailed

Agent	Dose	Onset	Duration	Best Used For	Pros	Cons	Contraindications
Etomidate	0.3 mg/kg IV	15–45s	3–12 min	Default for hemodynamically stable patients. Specifically: head injury / elevated ICP (cerebroprotective), cardiac patients (BP-neutral), borderline hypotension where propofol would crash them. Most commonly used RSI agent in US EDs.	Hemodynamically neutral, cerebro-protective (lowers ICP, maintains CPP)	Adrenal suppression (single dose clinically insignificant per Jabre, 2009), myoclonus, no analgesic properties	Relative: sepsis/adrenal insufficiency (some avoid, data equivocal)
Ketamine	1–2 mg/kg IV	45–60s	10–20 min	Asthma / status asthmaticus (bronchodilator). Septic shock or any hypotensive patient (sympathomimetic, maintains BP). Trauma / hemorrhagic shock. Awake / delayed-sequence intubation (preserves respiratory drive). Pediatric airway. Increasingly the default ED induction agent for unstable patients.	Bronchodilator, sympathomimetic (maintains BP), analgesic, does not suppress respirations	Emergence reactions (give midazolam), hypersalivation (give glycopyrrolate), increases HR	Relative: severe uncontrolled HTN. Old concern about raising ICP is largely debunked.
Propofol	1–2 mg/kg IV	15–30s	5–10 min	Status epilepticus (anti-epileptic) requiring intubation. Stable elective intubation (OR setting). Neurosurgical patients with stable BP (lowers ICP, smooth induction). Patients on chronic opioids / sedatives who tolerate higher doses. Avoid in any hemodynamically unstable patient.	Fastest onset, anti-epileptic, lowers ICP, smooth induction	Significant hypotension (drops MAP 20–30%), myocardial depression, apnea, pain on injection	Avoid in hemodynamic instability, shock, hypovolemia, egg/soy allergy (controversial)
Midazolam (Versed) ALTERNATIVE	0.1–0.3 mg/kg IV	2–5 min	30–80 min	When etomidate, ketamine, and propofol are unavailable. Useful in seizing patient requiring intubation (also treats the seizure). Sometimes added in low dose to reduce ketamine emergence reactions.	Anxiolytic, anti-epileptic, amnestic, reversible with flumazenil	Slow onset (2–5 min, too slow for true RSI), variable hypotension, prolonged duration in elderly / liver disease	Avoid in airway compromise from sedative buildup; reverse cautiously in chronic benzo users (precipitates withdrawal seizures).

Paralytic Comparison, Detailed

Feature	Succinylcholine	Rocuronium
Class	Depolarizing NMB	Non-depolarizing NMB
RSI dose	1–1.5 mg/kg IV	1.2 mg/kg IV (RSI dose)
Onset	45 seconds (fastest)	60 seconds at RSI dose
Duration	6–10 minutes (ultra-short)	45–70 minutes
Reversal	None (metabolized by pseudocholinesterase)	Sugammadex (Bridion) 16 mg/kg for immediate reversal
Contraindications	Hyperkalemia, burns > 48h, crush injuries, denervation injuries, NMD, malignant hyperthermia (personal or family hx), prolonged immobility	Very few. True allergy only.
Side effects	Fasciculations, hyperkalemia (+0.5 mEq/L), bradycardia (especially repeat doses or pediatrics), masseter spasm, malignant hyperthermia	Minimal. No hyperkalemia. No fasciculations.
Advantage	Ultra-short duration (returns spontaneous breathing faster if you cannot intubate)	Reversible with sugammadex, safer profile, fewer contraindications
Best Used For	Brief / anticipated easy airway when you want fast spontaneous breathing recovery if intubation fails. Useful when sugammadex unavailable. Historically the default but losing ground to rocuronium.	Default in modern practice. Hyperkalemia risk patients (CKD, ESRD, dialysis), burns > 48h, crush / denervation injuries, NMD (Guillain-Barré, ALS, MS, MD), prolonged immobility, MH personal/family history, prolonged paralysis needed (e.g., transport, OR), unknown patient history. Sugammadex availability makes it nearly universal first choice.

Quick "which agent" decision rules

Asthmatic / wheezing patient → ketamine (bronchodilator, sympathomimetic) + rocuronium (no histamine release, unlike succinylcholine).
Septic shock / hypotension → ketamine (sympathomimetic, maintains BP) + rocuronium (no risk of hyperK in coexisting AKI / renal failure).
Head injury / elevated ICP → etomidate (cerebroprotective, lowers ICP, BP-neutral) + rocuronium (avoids succinylcholine fasciculations that transiently raise ICP).
Status epilepticus → propofol (anti-epileptic, lowers ICP) or midazolam (anti-epileptic, amnestic, reversible with flumazenil) + rocuronium (doesn't mask ongoing seizure activity needing EEG; succinylcholine can trigger MH-like rigidity in some seizure patients).
Hyperkalemia (CKD/ESRD, crush, burns > 48h) → any induction + rocuronium (no K⁺ shift). NEVER succinylcholine (raises K⁺ ~0.5 mEq/L; can be much higher in upregulated extrajunctional receptor states → fatal hyperK arrest).
Stable elective intubation → propofol (smooth induction, fast recovery, anti-emetic) + rocuronium (sugammadex-reversible) or succinylcholine (ultra-short duration if you anticipate quick extubation).
Anticipated difficult airway / awake intubation → ketamine alone (dissociative anesthesia, preserves respiratory drive and airway reflexes). Avoid paralytic until the tube is in and confirmed.

On Rounds

Why is succinylcholine contraindicated in burns/crush injuries?

Extrajunctional ACh receptor upregulation after denervation/injury → massive K+ efflux → fatal hyperkalemia. Risk starts ~48h post-injury. Use rocuronium instead.

When choose ketamine over etomidate?

Ketamine for: asthma (bronchodilator), sepsis/hypotension (sympathomimetic, maintains BP). Increasingly the default ED induction agent.

What are the 7 P's of RSI?

P reparation (equipment, IV, monitors) · P re-oxygenation (3–5 min 100% O2) · P re-treatment (optional: fentanyl, lidocaine) · P aralysis with Induction (push both simultaneously) · P rotection & Positioning (sniffing position, avoid cricoid pressure) · P lacement (laryngoscopy, ETT through cords) · P ost-intubation Management (sedation, vent settings, CXR, ABG)

What does LEMON stand for in difficult airway assessment?

L ook externally (facial trauma, obesity, short neck) · E valuate 3-3-2 rule (3 fingers mouth opening, 3 fingers mentum-hyoid, 2 fingers hyoid-thyroid notch) · M allampati score (III/IV = difficult) · O bstruction/Obesity (angioedema, epiglottitis, BMI > 30) · N eck mobility (C-spine collar, ankylosing spondylitis). If concerning, have backup plan before pushing drugs.

Why is propofol dangerous in a septic shock patient requiring intubation?

Propofol causes vasodilation and myocardial depression, dropping MAP by 20–30% in hemodynamically stable patients. In a septic patient who is already vasodilated with impaired cardiac function, propofol can cause cardiovascular collapse and PEA arrest. Use ketamine instead, it is sympathomimetic, maintains BP, and is increasingly the default induction agent for hemodynamically unstable patients.

What is sugammadex and when do you use it?

Sugammadex (Bridion) is a modified gamma-cyclodextrin that encapsulates and inactivates rocuronium (and vecuronium). Dose for immediate reversal during RSI: 16 mg/kg IV. For routine reversal: 2–4 mg/kg. It provides complete neuromuscular reversal within 2–3 minutes. This is the main advantage of rocuronium over succinylcholine, if you cannot intubate, you can fully reverse paralysis and the patient can resume spontaneous breathing.

What is peri-intubation cardiac arrest and how do you prevent it?

Peri-intubation cardiac arrest occurs in 2–4% of emergency intubations, typically from: (1) Hypoxemia, inadequate pre-oxygenation, (2) Hypotension, induction agents causing vasodilation in already compromised patients, (3) Vagal response, laryngoscopy-induced bradycardia.

Clinical Examples

📋 Case 1, Status Epilepticus Requiring Intubation

Patient: 34-year-old male with epilepsy, brought in with ongoing seizures for 25 minutes. Failed IV lorazepam 4 mg x 2 and levetiracetam loading dose. Still seizing. SpO2 88%, GCS 3.

Decision to intubate: Refractory status epilepticus, failure to protect airway, hypoxemia despite supplemental O2.

RSI approach:

Pre-oxygenate with BVM (patient cannot cooperate due to seizures)
Induction: Propofol 1.5 mg/kg, serves dual purpose as both induction agent AND anti-epileptic. Hemodynamics acceptable (BP 142/88)
Paralytic: Rocuronium 1.2 mg/kg, preferred over succinylcholine because (1) already hyperkalemic risk from prolonged seizures, (2) longer duration is acceptable since patient will need ongoing sedation
Post-intubation: Continue propofol drip for both sedation and seizure suppression. Continuous EEG monitoring.

Teaching point: Propofol is ideal when seizure control is needed alongside intubation. Avoid succinylcholine in status epilepticus due to rhabdomyolysis-induced hyperkalemia risk.

📋 Case 2, Septic Shock with Hemodynamic Caution

Patient: 68-year-old female with pneumonia, septic shock on norepinephrine 15 mcg/min. BP 84/52 despite 3L crystalloid. SpO2 91% on 15L NRB. RR 34, using accessory muscles. GCS 14.

Decision to intubate: Respiratory failure with impending arrest, failing despite maximal oxygen.

RSI approach:

Pre-oxygenate with HFNC at 60L/min (continue during apneic period via nasal cannula at 15L)
Push-dose phenylephrine 100 mcg IV ready at bedside BEFORE induction
Give 500 mL NS bolus during pre-oxygenation
Induction: Ketamine 1.5 mg/kg, sympathomimetic, maintains BP. Do NOT use propofol (will cause cardiovascular collapse)
Paralytic: Rocuronium 1.2 mg/kg
Post-intubation: Immediately increase norepinephrine to compensate for loss of sympathetic drive from sedation. Start fentanyl + propofol at LOW dose for sedation.

Teaching point: The most dangerous part of intubating a septic patient is the hemodynamic collapse that follows induction. Have vasopressors drawn up, fluids running, and choose ketamine. Anticipate BP drop and treat preemptively.

📋 Case 3, Hyperkalemia Patient Avoiding Succinylcholine

Patient: 56-year-old male with ESRD (missed last 2 dialysis sessions), presents with severe dyspnea, bilateral crackles, SpO2 82% on NRB. K+ 7.2. ECG shows peaked T-waves and widened QRS. GCS 15 but tiring rapidly.

Decision to intubate: Severe pulmonary edema with respiratory failure, cannot tolerate BiPAP due to volume overload.

RSI approach:

Pre-intubation: Give calcium gluconate 3g IV for cardiac membrane stabilization, insulin 10 units + D50 for K+ shifting
Pre-oxygenate with BiPAP or HFNC if tolerated
Induction: Etomidate 0.3 mg/kg, hemodynamically neutral (patient is volume overloaded but may drop BP with positive pressure ventilation)
Paralytic: Rocuronium 1.2 mg/kg, NEVER succinylcholine in hyperkalemia (raises K+ by 0.5–1.0 mEq/L → can cause fatal cardiac arrest at K+ 7.2)
Post-intubation: Emergent nephrology consult for dialysis. Low tidal volumes, high PEEP for pulmonary edema.

Teaching point: Succinylcholine is absolutely contraindicated in hyperkalemia. At K+ 7.2 with ECG changes, even a 0.5 mEq/L rise can trigger VFib. Rocuronium is the only paralytic choice. Treat the hyperkalemia before and during intubation.

Monitoring

Parameter	Target
ETCO2	Continuous. 35–45 mmHg. Loss = dislodged tube
SpO2	92–96% (88–92% COPD)
Plateau pressure	<30 cmH2O
ABG	30min post-intubation
CXR	Immediately post-intubation

Summary

Gold Standard

Waveform ETCO2. No waveform = esophageal.

Induction

Etomidate (neutral), Ketamine (asthma/sepsis), Propofol (avoid in hypotension).

Paralytic

Sux 1.5mg/kg (45s, fastest) or Roc 1.2mg/kg (sugammadex reversible).

Post-Intubation

TV 6–8mL/kg IBW, RR 14–16, FiO2 wean, PEEP 5. Sedation + CXR.