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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EssentialPalliative

Non-Opioid Symptom Management

Multimodal non-opioid strategies for pain, nausea, dyspnea, constipation, insomnia, pruritus, and hiccups in hospitalized patients. Layer therapies by mechanism. Assess with validated tools. Anticipate symptoms before they escalate. Comfort is always achievable without defaulting to opioids.

🔎 Overview

Why Non-Opioid First?

Opioids carry risks of respiratory depression, delirium, constipation, dependence, and falls, especially in elderly and hospitalized patients. A multimodal non-opioid approach targets multiple pain and symptom pathways, reduces opioid requirements by 30–50%, and improves functional recovery.

Multimodal analgesia, combine agents with different mechanisms (peripheral, central, anti-inflammatory) to achieve synergistic relief at lower individual doses
Anticipatory prescribing, order PRN symptom medications on admission before symptoms escalate
Non-pharmacologic adjuncts, positioning, fan therapy, sleep hygiene, music therapy, ice/heat, and spiritual care are evidence-based and underutilized
Goals-of-care alignment, symptom management intensity should match patient and family goals

Symptom-by-Symptom Overview

Symptom	First-Line Non-Opioid	Second-Line	Key Principle
Pain	Acetaminophen (Tylenol) 1g q6h scheduled, Ibuprofen (Advil) 400–600mg q6h	Gabapentin (Neurontin), Lidocaine 5% patch, Ketorolac (Toradol) IV, Cyclobenzaprine (Flexeril)	Scheduled acetaminophen reduces opioid use by 30%. WHO ladder modified for non-opioid focus.
Nausea/Vomiting	Ondansetron (Zofran) 4mg IV/PO q6h	Metoclopramide (Reglan) 10mg, Prochlorperazine (Compazine) 10mg, Scopolamine patch	Match antiemetic to mechanism: 5-HT3 for chemo/post-op, dopamine antagonist for gastroparesis, anticholinergic for vestibular.
Dyspnea	Fan to face, upright positioning, oxygen only if SpO2 < 90%	Low-dose morphine 2mg IV q2h (exception, treats air hunger centrally), Lorazepam (Ativan) 0.5mg for anxiety component	Fan across trigeminal V2 distribution suppresses breathlessness centrally. More effective than O2 in non-hypoxic patients.
Constipation	Senna (Senokot) 2 tabs BID + PEG 3350 (MiraLAX) 17g daily	Bisacodyl (Dulcolax) 10mg PR, Methylnaltrexone (Relistor), Naloxegol (Movantik) 25mg PO daily	Stimulant laxative (senna) + osmotic (PEG) is the evidence-based regimen. Docusate is no better than placebo AGA-ACG, 2023, do not use. Start bowel regimen with every opioid order.
Insomnia	Sleep hygiene protocol, Melatonin 3–5mg QHS	Trazodone (Desyrel) 25–50mg QHS	Avoid benzodiazepines and zolpidem in hospitalized patients, delirium, falls, respiratory depression risk. Fix the environment first.
Pruritus	Hydroxyzine (Vistaril) 25mg PO q6h, moisturizers	Diphenhydramine (Benadryl) 25mg (use cautiously, anticholinergic), Cholestyramine (Questran) for cholestatic pruritus	Identify cause: uremic → gabapentin; cholestatic → cholestyramine/naltrexone; histamine-mediated → antihistamines.
Hiccups	Chlorpromazine (Thorazine) 25–50mg PO/IV	Baclofen (Lioresal) 5–10mg TID, Gabapentin (Neurontin) 300mg TID	Chlorpromazine is the only FDA-approved drug for hiccups. Baclofen and gabapentin are evidence-based alternatives.

Non-Pharmacologic Interventions

Non-pharmacologic therapies are evidence-based, low-risk, and should be offered to every hospitalized patient alongside medications. They are not "alternative" medicine, they are standard of care.

Pain: ice/heat application, positioning, physical therapy, TENS unit, guided imagery, music therapy
Nausea: ginger ale, small frequent meals, acupressure wristbands (P6 point), aromatherapy (peppermint oil)
Dyspnea: fan to face, upright/tripod positioning, pursed lip breathing, cool room temperature, reduce anxiety
Insomnia: minimize nighttime vitals/labs, earplugs/eye mask, limit caffeine after noon, consistent wake time, reduce ambient light
Constipation: ambulation, adequate hydration, fiber supplementation (if not obstructed), abdominal massage
Pruritus: cool compresses, moisturizers, oatmeal baths, keep nails short, loose-fitting clothing

🧪 Workup

Symptom Assessment Tools

Tool	Application	Details
Numeric Rating Scale (NRS)	Pain (alert patients)	0–10 scale. Most widely used. Document at rest AND with movement.
Wong-Baker FACES	Pain (non-verbal, pediatric, cognitive impairment)	Visual faces scale. Useful when patients cannot verbalize a number.
BPS (Behavioral Pain Scale)	Pain (intubated/sedated patients)	Scores facial expression, upper limb movement, ventilator compliance (3–12). > 5 = significant pain.
CPOT (Critical-Care Pain Observation Tool)	Pain (non-verbal ICU patients)	4 domains: facial expression, body movements, muscle tension, ventilator compliance or vocalization. Score 0–8.
ESAS (Edmonton Symptom Assessment Scale)	Global symptom burden	9 symptoms rated 0–10: pain, fatigue, nausea, depression, anxiety, drowsiness, appetite, dyspnea, wellbeing. Quick, validated, tracks trends over time.
CAM (Confusion Assessment Method)	Delirium screening	4 features: acute onset + fluctuating course, inattention, disorganized thinking, altered consciousness. Need features 1+2 plus 3 or 4.

Pre-Prescribing Checklist

Before prescribing any symptom medication, always check renal function, hepatic function, and perform medication reconciliation. Many common non-opioid agents require dose adjustment or are contraindicated in organ dysfunction.

Renal function (eGFR): NSAIDs contraindicated if eGFR < 30. Gabapentin requires dose reduction. PEG 3350 safe in CKD. Avoid magnesium-based laxatives in renal failure.
Hepatic function: Acetaminophen max 2g/day in cirrhosis (not contraindicated, just dose-reduce). Avoid NSAIDs in cirrhosis (GI bleed + hepatorenal syndrome risk). Ondansetron max 8mg/day in severe hepatic impairment.
Medication reconciliation: Identify drug-induced symptoms, PPIs cause hypomagnesemia, statins cause myalgias, antibiotics cause nausea/diarrhea, diuretics cause constipation. Treat the cause, not just the symptom.
Polypharmacy screening: Anticholinergic burden score, hydroxyzine + diphenhydramine + promethazine stacked = delirium risk. Use Beers Criteria in elderly.
Allergies/intolerances: NSAID allergy → acetaminophen safe. True aspirin allergy (angioedema/anaphylaxis) → avoid all NSAIDs. Ondansetron → try prochlorperazine.

Reversible Causes to Rule Out

Nausea: bowel obstruction (KUB/CT), medication side effect (review med list), hypercalcemia (check calcium), increased ICP (neuro exam + imaging), gastroparesis (DM history)
Constipation: opioid-induced (most common inpatient cause), bowel obstruction (imaging), hypothyroidism (TSH), hypercalcemia, hypokalemia, medications (anticholinergics, calcium channel blockers)
Dyspnea: pleural effusion (CXR → thoracentesis), PE (CT-PA), pneumonia, heart failure exacerbation, anxiety/panic, metabolic acidosis (compensatory hyperventilation)
Pruritus: cholestatic liver disease (LFTs, bilirubin), uremia (BUN/Cr), drug reaction (timeline with new medications), contact dermatitis (exam)
Insomnia: uncontrolled pain, delirium (CAM), medication effect (steroids, beta-agonists), sleep apnea, hospital environment

🚨 Management

Pain, Modified WHO Ladder (Non-Opioid Focus)

Step 1 (Mild, NRS 1–3): Scheduled Acetaminophen 1g PO q6h + non-pharm (ice, heat, positioning). Step 2 (Moderate, NRS 4–6): Add NSAID (Ibuprofen 400mg q6h or Ketorolac 15–30mg IV q6h x 5 days max) + adjuvant (Gabapentin for neuropathic, Cyclobenzaprine for muscle spasm, Lidocaine 5% patch for localized). Step 3 (Severe, NRS 7–10): All of above + consult pain service. Low-dose opioid may be needed as rescue only, not as default.

Scheduled acetaminophen,1g PO/IV q6h (max 4g/day; 2g/day in hepatic impairment). Reduces opioid consumption by ~30%. Schedule it, PRN acetaminophen is rarely requested by patients. Sinatra, 2005
NSAIDs, excellent for inflammatory, musculoskeletal, and renal colic pain. Ketorolac (Toradol) 15–30mg IV q6h (max 5 days, GI/renal toxicity). Ibuprofen 400–600mg PO q6h with food. Avoid in CKD (eGFR < 30), GI bleed history, heart failure, cirrhosis PRECISION, 2016
Gabapentinoids, first-line for neuropathic pain. Gabapentin 100–300mg TID (titrate up). Pregabalin 75mg BID. Reduce dose in renal impairment. Side effects: sedation, dizziness, peripheral edema.
Lidocaine 5% patch, apply to area of maximal pain (not on broken skin). Up to 3 patches simultaneously, 12h on / 12h off. Excellent for post-herpetic neuralgia, localized musculoskeletal pain.
Muscle relaxants,Cyclobenzaprine (Flexeril) 5–10mg TID for acute musculoskeletal spasm. Avoid in elderly (anticholinergic, sedation). Short-term only (2–3 weeks).
Ketamine (sub-anesthetic),0.1–0.3 mg/kg/hr IV infusion for refractory pain. Pain service consult. Evidence in sickle cell crisis, burns, opioid-tolerant patients.

Nausea / Vomiting, Mechanism-Based Approach

Mechanism	Common Causes	Preferred Antiemetic
Serotonin (5-HT3)	Chemotherapy, post-operative, radiation	Ondansetron (Zofran) 4mg IV/PO q6h
Dopamine (D2)	Gastroparesis, medications, uremia	Metoclopramide (Reglan) 10mg IV/PO q6h (prokinetic), Prochlorperazine (Compazine) 10mg IV/PO q6h
Vestibular / Motion	Vertigo, inner ear, opioid-induced	Scopolamine patch 1.5mg q72h (transdermal), Meclizine 25mg q6h
Increased ICP / Obstruction	Brain metastases, bowel obstruction	Dexamethasone 4–8mg IV daily (reduces edema + direct antiemetic)
Anticipatory / Anxiety	Pre-chemo, anxiety-related	Lorazepam (Ativan) 0.5–1mg, behavioral therapy

Metoclopramide warning: avoid in complete bowel obstruction (risk of perforation). Limit duration to < 12 weeks, risk of tardive dyskinesia with prolonged use (FDA black box). Promethazine (Phenergan): causes significant sedation and tissue necrosis if given IV (give deep IM only). Avoid in elderly, strong anticholinergic.

Dyspnea, Non-Opioid Strategies

Fan therapy, direct airflow to face. Stimulates trigeminal V2 mechanoreceptors, suppresses central breathlessness perception. Multiple RCTs demonstrate efficacy. Free, safe, first-line for all causes of dyspnea.
Positioning, upright or tripod position improves diaphragm mechanics and reduces venous return (reduces pulmonary congestion)
Supplemental O2, only if SpO2 < 90%. In non-hypoxic dyspnea, supplemental O2 is no better than room air via fan Abernethy, 2010
Anxiolytics,Lorazepam (Ativan) 0.5mg SL/PO for anxiety-driven dyspnea component. Use cautiously, sedation risk
Low-dose opioids (exception), morphine 2mg IV q2h treats air hunger centrally by reducing ventilatory drive to hypoxia/hypercapnia. This is the one scenario where low-dose opioids are appropriate even in a non-opioid strategy.
Treat the cause, diuresis for CHF, thoracentesis for large effusion, antibiotics for pneumonia, bronchodilators for COPD/asthma

Constipation, Stepwise Approach

Step 1: PEG 3350 (MiraLAX) 17g PO daily (osmotic, first-line) + Senna (Senokot) 2 tabs PO BID (stimulant). Start with every opioid order. Do NOT use docusate (Colace), no better than placebo per AGA-ACG, 2023.
Step 2: Add PEG 3350 (MiraLAX) 17g in 8oz water daily (osmotic). Safe in renal failure. Takes 1–3 days for effect.
Step 3: Bisacodyl (Dulcolax) 10mg PO or PR for acute relief. Suppository works within 15–60 min.
Step 4 (opioid-induced): Methylnaltrexone (Relistor) 8–12mg SC q48h. Peripheral mu-opioid antagonist, reverses GI opioid effects WITHOUT reversing analgesia. Also: Naloxegol (Movantik) 25mg PO daily.
Avoid: magnesium-based laxatives in CKD (hypermagnesemia risk), lactulose if concern for bowel obstruction

Rule out obstruction first: If no BM for > 3 days with nausea/vomiting/distension, get a KUB or CT abdomen before aggressive laxative therapy. Stimulant laxatives in mechanical obstruction can cause perforation.

Insomnia, Hospital Sleep Protocol

Sleep hygiene first, minimize nighttime vitals/labs (cluster care), earplugs + eye mask, reduce ambient light, limit caffeine after noon, consistent wake time, turn off unnecessary alarms and monitors
First-line: Melatonin 3–5mg PO QHS (30 min before desired sleep). Safe, minimal interactions, no delirium risk. Evidence supports use in ICU to restore circadian rhythm.
Second-line: Trazodone (Desyrel) 25–50mg PO QHS. Serotonin antagonist/reuptake inhibitor. Causes drowsiness without anticholinergic burden. Low delirium risk vs alternatives.
Avoid in hospitalized patients: benzodiazepines (delirium, falls, respiratory depression), zolpidem/Ambien (parasomnias, falls, delirium, Beers Criteria), diphenhydramine for sleep (anticholinergic, delirium, especially in elderly)

Pruritus, Cause-Directed Therapy

Etiology	Treatment	Notes
Histamine-mediated (allergic, drug reaction, urticaria)	Hydroxyzine (Vistaril) 25mg PO q6h or Diphenhydramine (Benadryl) 25mg PO/IV q6h	Hydroxyzine preferred, less anticholinergic than diphenhydramine. Avoid diphenhydramine in elderly (Beers Criteria).
Cholestatic (obstructive jaundice, PBC, drug-induced)	Cholestyramine (Questran) 4g PO BID–TID, Rifampin 150mg PO BID, Naltrexone 25–50mg PO daily	Cholestyramine binds bile salts. Separate from other meds by 2h (reduces absorption). Rifampin induces bile salt metabolism.
Uremic (CKD/ESRD)	Gabapentin (Neurontin) 100mg PO after each dialysis session, UVB phototherapy	Gabapentin is first-line for uremic pruritus, dose-adjust for renal function. Antihistamines less effective here.
Opioid-induced	Rotate opioid, Nalbuphine 2.5–5mg IV, Ondansetron 4mg IV	Mu-receptor mediated. Ondansetron can help. Nalbuphine (mixed agonist-antagonist) reverses pruritus without reversing analgesia.

Hiccups, Persistent (> 48h) Management

Non-pharmacologic first: vagal maneuvers (Valsalva, cold water gargle, biting a lemon), nasopharyngeal stimulation (catheter tip in posterior pharynx), rebreathing into paper bag
First-line: Chlorpromazine (Thorazine) 25–50mg PO TID or 25mg IV (only FDA-approved drug for hiccups). Monitor for hypotension, QTc prolongation.
Second-line: Baclofen (Lioresal) 5–10mg PO TID. GABA-B agonist. Particularly effective for hiccups of central origin.
Third-line: Gabapentin (Neurontin) 300mg PO TID. Also useful when hiccups coexist with neuropathic pain or pruritus.
Refractory: consider phrenic nerve block (IR guided), acupuncture (evidence growing), or metoclopramide 10mg if GI-related trigger.

IV vs PO Considerations

Use PO whenever possible, equivalent efficacy for most agents, lower cost, fewer line-related complications
IV preferred when: NPO status, active vomiting, severe acute pain requiring rapid onset, bowel obstruction/ileus, unreliable GI absorption (post-surgical, critical illness)
IV acetaminophen, onset 5–10 min (vs 30–60 min PO). Cost is ~100x higher. Reserve for NPO patients or immediate post-operative period. Switch to PO as soon as tolerating.
IV ketorolac, onset 10 min. Max 5 days (GI and renal toxicity). Convert to PO ibuprofen as soon as tolerating oral.

De-Escalation Strategies

Pain improving: Scheduled → PRN → discontinue. Remove ketorolac by day 5. Taper gabapentin (do not stop abruptly, seizure risk). Remove lidocaine patches last (benign).
Nausea resolved: Switch ondansetron from scheduled to PRN → discontinue after 24h symptom-free. Taper dexamethasone (do not stop abruptly if > 7 days).
At discharge: Reconcile all symptom medications. Provide written de-escalation plan. Avoid discharging patients on ketorolac, IV medications, or hospital-only agents.

💊 Medications

Non-Opioid Drug Reference

Drug	Class	Dose	Route	Max Daily	Key Considerations
Acetaminophen (Tylenol)	Analgesic/Antipyretic	1g q6h	PO/IV	4g (2g if hepatic impairment)	Schedule it, PRN is underused. Safe in CKD. IV onset 5 min but ~100x cost of PO.
Ibuprofen (Advil/Motrin)	NSAID	400–600mg q6h	PO	2400mg	Take with food. Avoid if eGFR < 30, GI bleed hx, CHF, cirrhosis. PRECISION, 2016
Ketorolac (Toradol)	NSAID (parenteral)	15–30mg q6h	IV/IM	120mg (day 1), 60mg (day 2+)	Max 5 days. Same contraindications as all NSAIDs. Excellent for renal colic, post-surgical, MSK pain.
Gabapentin (Neurontin)	Gabapentinoid	100–300mg TID	PO	3600mg (titrate slowly)	First-line neuropathic pain. Dose-adjust in renal impairment. Sedation, dizziness. Also treats uremic pruritus and hiccups.
Pregabalin (Lyrica)	Gabapentinoid	75mg BID	PO	600mg	~6× more potent than gabapentin (300 mg gabapentin ≈ 50 mg pregabalin). More predictable (linear) absorption. Schedule V controlled substance. Dose-adjust in CKD.
Lidocaine 5% patch (Lidoderm)	Topical anesthetic	1–3 patches to painful area	Topical	3 patches/12h (12h on/12h off)	No systemic absorption at standard doses. Safe in CKD/hepatic disease. Do not apply to broken skin.
Cyclobenzaprine (Flexeril)	Muscle relaxant	5–10mg TID	PO	30mg	Short-term use only (2–3 weeks). Avoid in elderly (anticholinergic, sedation). Contraindicated with MAOIs.
Ondansetron (Zofran)	5-HT3 antagonist	4mg q6h	IV/PO/ODT	16mg (8mg if hepatic impairment)	First-line antiemetic. Causes constipation, add senna. QTc prolongation at higher doses. ODT tab dissolves on tongue.
Metoclopramide (Reglan)	Dopamine antagonist / Prokinetic	10mg q6h	IV/PO	40mg	Prokinetic for gastroparesis. Avoid in complete bowel obstruction. Black box: tardive dyskinesia with > 12 weeks use.
Prochlorperazine (Compazine)	Dopamine antagonist / Phenothiazine	10mg q6h	IV/PO/PR	40mg	Excellent for migraine-associated nausea. Akathisia and EPS possible. Give with diphenhydramine 25mg to prevent dystonia.
Promethazine (Phenergan)	Phenothiazine / Antihistamine	12.5–25mg q4–6h	IM/PO/PR	75mg	Strongly anticholinergic, avoid in elderly. Never give IV push (tissue necrosis, gangrene). Give deep IM only.
Scopolamine (Transderm Scop)	Anticholinergic	1.5mg patch q72h	Transdermal	1 patch	Best for vestibular/motion-related nausea. Apply behind ear. Onset 4–8h. Crosses BBB, delirium risk in elderly.
Senna (Senokot)	Stimulant laxative	2 tabs (17.2mg) BID	PO	4 tabs (34.4mg)	Essential component of bowel regimen. Stimulates colonic motility. Takes 6–12h for effect.
Docusate (Colace) NOT RECOMMENDED	Stool softener	,	PO	,	No better than placebo per AGA-ACG, 2023. Removed from hospital formularies (UAB 2024). No FDA-approved indication. Do not prescribe. Use PEG 3350 + senna instead.
PEG 3350 (MiraLAX)	Osmotic laxative	17g in 8oz water daily	PO	34g	Safe in CKD. Tasteless, mixes into any liquid. Takes 1–3 days. Can increase to BID for refractory constipation.
Lactulose (Kristalose)	Osmotic laxative	15–30 mL daily–BID	PO	60 mL/day	Alternative to PEG. Also used for hepatic encephalopathy (30–45 mL q1–2h titrated to 3–4 BMs/day). More bloating than PEG. Safe in CKD.
Bisacodyl (Dulcolax)	Stimulant laxative	10mg PO or PR	PO/PR	30mg	Suppository works within 15–60 min (useful for acute relief). PO takes 6–12h. Do not crush enteric-coated tablets.
Melatonin	Hormone / Sleep aid	3–5mg QHS	PO	10mg	Safe, no delirium risk. Give 30 min before desired sleep. Evidence in ICU circadian rhythm restoration.
Trazodone (Desyrel)	SARI antidepressant	25–50mg QHS	PO	100mg (for insomnia)	Low delirium risk. Minimal anticholinergic burden. Rare: priapism. Safe in CKD.
Hydroxyzine (Vistaril)	Antihistamine (H1)	25mg q6h	PO/IM	100mg	First-line for histamine-mediated pruritus. Moderate anticholinergic, use cautiously in elderly. Also has anxiolytic properties.

High-Risk Drug Interactions

NSAIDs + anticoagulants,3–6x increased GI bleeding risk. If must use, add PPI and limit to 3–5 days.
Ondansetron + QTc-prolonging drugs (haloperidol, fluoroquinolones, methadone), check baseline ECG. Avoid if QTc > 500ms.
Metoclopramide + antipsychotics, both are dopamine antagonists. Additive EPS/tardive dyskinesia risk.
Gabapentin + opioids, synergistic respiratory depression. FDA warning. Start gabapentin low and titrate slowly if on opioids.
Stacking anticholinergics (hydroxyzine + diphenhydramine + promethazine + scopolamine), delirium, urinary retention, ileus. Calculate anticholinergic burden score.
NSAIDs + ACEi/ARB + diuretic,"triple whammy" for AKI. Avoid this combination entirely.

Oral Herpes (HSV-1), Treatment & Pain Management

Oral HSV-1 is extremely common (seroprevalence ~50–80% of adults). Most inpatient encounters involve reactivation (herpes labialis / cold sores) or primary herpetic gingivostomatitis in immunocompromised patients. The key inpatient concern is oral pain preventing hydration and PO intake.

Scenario	Drug	Dose	Duration	Notes
Herpes Labialis (Cold Sores), Recurrent
First-line (episodic)	Valacyclovir (Valtrex)	2g PO BID × 1 day (2 doses, 12h apart)	1 day	Start at earliest prodrome (tingling, burning). Most convenient regimen. Adjust for CrCl < 50.
Alternative (episodic)	Acyclovir (Zovirax)	400 mg PO 5×/day × 5 days	5 days	Less convenient dosing. Cheaper. Adequate hydration to prevent crystalluria.
Alternative (episodic)	Famciclovir (Famvir)	1500 mg PO × 1 dose	1 dose	Single-dose option. Prodrug of penciclovir.
Suppressive therapy	Valacyclovir	500 mg–1g PO daily	Ongoing	For frequent recurrences (≥6/year). Reduces outbreaks by 70–80%. CDC STI Guidelines, 2021
Primary Herpetic Gingivostomatitis
Immunocompetent	Valacyclovir	1g PO BID × 7–10 days	7–10 days	Start within 72h of symptom onset. Acyclovir 400 mg PO 5×/day is alternative. Primary episode is more severe and prolonged.
Immunocompromised (mild–moderate)	Valacyclovir	1g PO BID × 7–14 days	7–14 days	Longer course. Step up to IV if not improving or unable to take PO. NIH OI Guidelines
Immunocompromised (severe) or NPO	Acyclovir IV	5 mg/kg IV q8h	7–14 days	For severe mucocutaneous HSV, disseminated disease, or patients unable to take PO. Transition to PO when lesions regressing. Hydrate aggressively, crystalluria/AKI risk.
Orolabial HSV in Immunocompromised (HIV, Transplant, Chemo)
Treatment	Valacyclovir	1g PO BID × 5–10 days	5–10 days	Or acyclovir 400 mg PO 5×/day. Famciclovir 500 mg PO BID is alternative.
Chronic suppression	Valacyclovir	500 mg PO BID	Ongoing	For CD4 < 200 or frequent recurrences. Acyclovir 400 mg PO BID is alternative.

Lidocaine Viscous 2%, When & How to Use

Lidocaine viscous is for oral mucosal pain relief, NOT a treatment for HSV. Use it as an adjunct for pain control when oral lesions prevent eating/drinking. The #1 goal in oral HSV management is maintaining hydration and PO intake.

Drug	Dose	How to Use	Max	Key Safety Points
Lidocaine Viscous 2%	15 mL (1 tbsp) swish & spit	Swish in mouth for 1–2 min, then spit out. Do not swallow unless pharyngeal pain (then gargle & swallow).	8 doses/24h. Minimum 3h between doses. Max 300 mg (4.5 mg/kg)	⚠️ Aspiration risk, numbs throat/swallow reflex. NPO × 60 min after use. ⚠️ Seizures/cardiac toxicity if absorbed excessively (traumatized mucosa). ⚠️ FDA Black Box in children < 3 yo (deaths reported). ⚠️ Methemoglobinemia risk.
Magic Mouthwash (compound)	15 mL swish & spit q4–6h	Typical formulation: lidocaine 2% + diphenhydramine + antacid (Maalox) ± nystatin. Swish 1–2 min, spit.	4–6 doses/24h	Compounded, no standardized formula. Minimal evidence vs individual components. Commonly ordered but not superior to single-agent lidocaine viscous in most studies.

When to Use Lidocaine Viscous

Herpetic gingivostomatitis, severe oral pain preventing PO intake. Apply 15–30 min before meals to facilitate eating.
Chemotherapy-induced mucositis, common with 5-FU, methotrexate, melphalan (post-ASCT). WHO grade 3–4 mucositis.
Aphthous ulcers (canker sores), for symptomatic relief of large/multiple ulcers.
Esophageal candidiasis pain, as bridge while awaiting fluconazole effect (2–3 days).
Radiation mucositis, head/neck radiation patients with severe oral pain.

Do NOT use lidocaine viscous for: teething pain in infants/toddlers (FDA Black Box, deaths reported from accidental overdose). Do not apply to large areas of traumatized mucosa, rapid systemic absorption → seizures, cardiac arrest. Always NPO × 60 min after use to prevent aspiration.

📋 On Rounds

Pimp Questions

Why is a fan to the face effective for dyspnea, and when is it superior to supplemental oxygen?

Cool air flow across the trigeminal nerve (V2 distribution) stimulates mechanoreceptors that suppress the central perception of breathlessness. Multiple RCTs show it reduces dyspnea independent of SpO2. In non-hypoxic patients, supplemental O2 is no better than room air, a bedside fan is more effective, free, and has no side effects Abernethy, 2010.

Why should acetaminophen be scheduled rather than PRN in hospitalized patients?

Scheduled acetaminophen maintains steady-state plasma levels, providing consistent baseline analgesia. Studies show it reduces opioid consumption by ~30% compared to PRN dosing. Patients rarely request PRN acetaminophen because the pain must first worsen before they ask, defeating the purpose of multimodal analgesia. Max 4g/day (2g in hepatic impairment). Safe in CKD. Cost-effective and the foundation of the non-opioid pain ladder Sinatra, 2005.

Why should you NOT use docusate (Colace) for constipation, and what is the evidence-based bowel regimen?

Docusate is no better than placebo. The AGA-ACG 2023 guideline omitted docusate from all recommendations. McRorie 2021 reviewed 7 RCTs, none showed benefit over placebo. The Tarumi hospice RCT showed senna + docusate = senna + placebo. Docusate has no FDA-approved indication and has been removed from hospital formularies (UAB 2024). The evidence-based regimen is senna 2 tabs BID (stimulant) + PEG 3350 17g daily (osmotic). For opioid-induced constipation, add methylnaltrexone or naloxegol.

What is the maximum duration for ketorolac (Toradol) and why?

Maximum 5 days for any route (IV, IM, or PO). Beyond 5 days, the risk of GI bleeding increases 5-fold and risk of AKI rises significantly. Ketorolac inhibits COX-1 (protective gastric prostaglandins) and COX-2 (renal afferent vasodilation). It also inhibits platelet aggregation. Same contraindications as all NSAIDs: avoid in CKD, GI bleed history, CHF, cirrhosis, and patients on anticoagulants. Convert to PO ibuprofen as soon as patient tolerates oral.

Why should you avoid benzodiazepines and zolpidem for insomnia in hospitalized patients?

Both cause delirium, falls, and respiratory depression, the top 3 causes of hospital-acquired harm. Zolpidem (Ambien) causes parasomnias (sleep-walking, sleep-eating) and is on the Beers Criteria for inappropriate use in elderly. Benzodiazepines impair consolidation of memory and worsen sleep architecture long-term. First-line is melatonin 3–5mg QHS (no delirium risk) followed by trazodone 25–50mg (low anticholinergic burden). Fix the hospital environment first: earplugs, eye mask, cluster nighttime care.

How do you manage cholestatic pruritus differently from histamine-mediated pruritus?

Cholestatic pruritus is caused by bile salt deposition in skin, not histamine release, so antihistamines are largely ineffective. First-line: cholestyramine (Questran) 4g BID–TID, a bile acid sequestrant (separate from other meds by 2h). Second-line: rifampin 150mg BID (induces bile salt metabolism, monitor LFTs). Third-line: naltrexone 25–50mg daily (endogenous opioid tone contributes to cholestatic itch). Histamine-mediated pruritus responds to H1 blockers (hydroxyzine, diphenhydramine).

Clinical Examples

📋 Case 1, Multimodal Pain Management Post-Hip Fracture

Patient: 82 y/o F with osteoporosis and CKD3 (eGFR 38), admitted with left hip fracture awaiting surgical repair. NRS pain score 7/10 at rest, 9/10 with movement.

Key considerations: Elderly + CKD → NSAIDs contraindicated. Opioids risky → delirium, respiratory depression, falls. Need multimodal non-opioid approach.

Management:

Scheduled Acetaminophen 1g PO q6h (safe in CKD, max 4g/day)
Gabapentin 100mg PO BID (dose-reduced for CKD, titrate to 100mg TID)
Lidocaine 5% patch to anterior thigh/hip region (12h on/12h off)
Ice packs to hip q2h for 20 min, positioning with pillows between knees
Fascia iliaca nerve block by anesthesia (single-shot or continuous catheter, gold standard for hip fracture)
Reserve low-dose morphine 2mg IV q4h PRN for breakthrough only

Teaching point: In elderly patients with CKD, the non-opioid toolbox becomes critical because both NSAIDs and opioids carry high risk. Regional anesthesia (nerve block) + scheduled acetaminophen + gabapentin + topical agents can achieve excellent pain control with minimal systemic side effects.

📋 Case 2, Refractory Nausea in Bowel Obstruction

Patient: 65 y/o M with metastatic colon cancer, admitted with partial small bowel obstruction. Persistent nausea/vomiting despite ondansetron 4mg IV q6h. NG tube in place.

Key considerations: Ondansetron targets 5-HT3 pathway. Bowel obstruction nausea is multifactorial, need mechanism-based approach. Metoclopramide contraindicated in complete obstruction.

Management:

Continue Ondansetron 4mg IV q6h (partial benefit)
Add Dexamethasone 8mg IV daily (reduces bowel wall edema + direct antiemetic via central mechanisms)
Add Haloperidol 0.5mg IV q8h (dopamine antagonist, different pathway than ondansetron)
Scopolamine patch 1.5mg behind ear (anticholinergic, reduces GI secretions and vestibular input)
Avoid metoclopramide (prokinetic in obstruction = perforation risk)
Surgical and palliative care co-management for goals of care

Teaching point: When first-line antiemetic fails, layer agents from different receptor classes rather than increasing the dose. Ondansetron (5-HT3) + haloperidol (D2) + scopolamine (muscarinic) + dexamethasone (central) provides quadruple-pathway coverage.

📋 Case 3, Hospital-Acquired Insomnia and Delirium Prevention

Patient: 75 y/o M, POD 2 after colectomy. Reports sleeping < 2 hours per night since admission. CAM negative but appearing increasingly confused during daytime. Night nurse requesting "something for sleep."

Key considerations: Post-surgical elderly patient at extreme delirium risk. Sleep deprivation is a major delirium trigger. Benzodiazepines and zolpidem will precipitate delirium.

Management:

Environmental: Cluster nighttime vitals/labs, earplugs + eye mask, lights off by 10 PM, curtains open by 7 AM, minimize nighttime alarms
Melatonin 5mg PO QHS (restore circadian rhythm, no delirium risk)
Trazodone 25mg PO QHS if melatonin insufficient (low anticholinergic burden)
Ensure pain is controlled (uncontrolled pain → poor sleep → delirium)
Review medication list, discontinue any unnecessary anticholinergics, steroids at bedtime
Do NOT order zolpidem, lorazepam, or diphenhydramine for sleep

Teaching point: Sleep deprivation is a modifiable delirium risk factor. The hospital environment is inherently sleep-disruptive. Fix the environment first, then use melatonin (safe) or trazodone (safe), never benzodiazepines or zolpidem in post-surgical elderly patients.

Sample Presentation

One-Liner

"Mrs. Chen is an 82-year-old with CKD3 and osteoporosis admitted with a left hip fracture, currently managed with a multimodal non-opioid regimen including scheduled acetaminophen, gabapentin, lidocaine patch, and a fascia iliaca block, with pain scores improved from 9 to 3 at rest."

Key Points to Cover on Rounds

Pain: NRS 3/10 at rest (down from 9), 5/10 with PT (down from 9). Regimen: acetaminophen 1g q6h scheduled, gabapentin 100mg TID, lidocaine 5% patch x1, fascia iliaca catheter running. No opioids used in 24h. Bowels: PEG 3350 + senna ordered prophylactically, last BM yesterday. Sleep: melatonin 5mg QHS, slept 5 hours (improved from 2). Delirium screen: CAM negative. Plan: continue multimodal regimen, PT eval today, surgery tomorrow AM, pre-op anesthesia nerve block plan confirmed.

Daily Rounds Checklist

Pain score today? → NRS at rest AND with activity. Trend from yesterday? Is multimodal regimen working?
Acetaminophen scheduled? → If not, why not? This should be on every patient unless contraindicated (active liver failure).
NSAID appropriate? → Check eGFR, GI bleed history, anticoagulation status, CHF. If on ketorolac, what day are we on? (Max 5)
Bowel regimen ordered? → PEG 3350 + senna (not docusate, ineffective per AGA-ACG 2023). If on opioids, is it adequate? Last BM? Abdominal exam?
Nausea controlled? → Is antiemetic matched to mechanism? If ondansetron failing, try different receptor pathway.
Sleep last night? → Hours slept. Is environment optimized? Melatonin ordered? Avoid benzos/zolpidem in elderly.
Delirium screen (CAM)? → Sleep deprivation + uncontrolled pain + anticholinergics = delirium triad. Address all three.
Anticholinergic burden? → Count anticholinergic meds (hydroxyzine, diphenhydramine, promethazine, scopolamine). Minimize stacking.
Renal/hepatic function today? → Dose-adjust gabapentin for CKD. Reduce acetaminophen for hepatic impairment. Remove NSAIDs if AKI develops.
De-escalation plan? → Are symptoms improving? Can we step down from IV to PO? From scheduled to PRN? Discharge-ready regimen?

⚡ Summary

Pain Ladder

Scheduled acetaminophen (foundation) → add NSAID/ketorolac → add gabapentinoid/lidocaine patch → nerve block. Reserve opioids for breakthrough only.

Nausea

Match to mechanism: ondansetron (5-HT3), metoclopramide (D2/prokinetic), scopolamine (vestibular), dexamethasone (ICP/obstruction). Layer pathways if refractory.

Dyspnea

Fan to face first (trigeminal V2 pathway). O2 only if SpO2 < 90%. Positioning. Low-dose morphine for refractory air hunger (one opioid exception).

Constipation

PEG 3350 (osmotic, first-line) + senna (stimulant). Docusate is no better than placebo, removed from guidelines (AGA-ACG 2023). Methylnaltrexone for opioid-induced. Rule out obstruction first.

Insomnia

Sleep hygiene + melatonin 3–5mg QHS. Trazodone 25–50mg if needed. Never benzos or zolpidem in hospitalized patients, delirium risk.

Pruritus

Histamine → hydroxyzine. Cholestatic → cholestyramine/rifampin. Uremic → gabapentin. Opioid-induced → rotate opioid or nalbuphine.

Hiccups

Chlorpromazine (only FDA-approved). Baclofen or gabapentin as alternatives. Vagal maneuvers first for acute episodes.

Core Principle

Multimodal: combine agents with different mechanisms at lower doses. Anticipate symptoms. Schedule, don't PRN. De-escalate daily. Non-pharm always.

📄 One Pager

Palliative Care · One Pager

Non-Opioid Symptom Management

Multimodal strategies for pain, nausea, dyspnea, constipation, insomnia, pruritus, and hiccups. Layer by mechanism. Schedule, don't PRN. Anticipate before symptoms escalate.

💊 Pain, Non-Opioid Ladder

Step 1: Acetaminophen 1g q6h SCHEDULED (reduces opioid use 30%)
Step 2: Add NSAID (ibuprofen 400mg q6h or ketorolac 15–30mg IV, max 5 days)
Step 3: Add gabapentin (neuropathic), lidocaine 5% patch (localized), cyclobenzaprine (spasm)
Avoid NSAIDs if: eGFR < 30, GI bleed hx, CHF, cirrhosis, on anticoagulants

🤮 Nausea, Match to Mechanism

Chemo/post-op → ondansetron 4mg q6h (5-HT3)
Gastroparesis → metoclopramide 10mg q6h (prokinetic, max 12 wks)
Vestibular → scopolamine patch q72h
Obstruction/ICP → dexamethasone 4–8mg IV daily
Refractory → layer from different receptor classes

💨 Dyspnea + Constipation + Sleep

Dyspnea: Fan to face (trigeminal V2). O2 only if SpO2 < 90%. Morphine 2mg IV for air hunger.
Constipation: PEG 3350 17g daily + senna 2 tabs BID. Docusate is no better than placebo (AGA-ACG 2023), do not use.
Insomnia: Melatonin 3–5mg QHS → trazodone 25mg. NEVER benzos/zolpidem in hospital.

🔬 Pruritus + Hiccups

Histamine itch: hydroxyzine 25mg q6h
Cholestatic: cholestyramine 4g BID, rifampin, naltrexone
Uremic: gabapentin 100mg post-dialysis
Hiccups: chlorpromazine 25–50mg (FDA-approved), baclofen 5–10mg TID, gabapentin 300mg TID

⚠️ High-Risk Pitfalls

Ketorolac > 5 days → GI bleed + AKI
NSAIDs + ACEi + diuretic = "triple whammy" AKI
Stacking anticholinergics → delirium
Promethazine IV push → tissue necrosis
Metoclopramide in complete obstruction → perforation
Stopping gabapentin abruptly → seizure risk

📋 Quick Rounds Check

Pain score at rest + activity? Trend?
Acetaminophen scheduled? NSAID day count?
Bowel regimen ordered? Last BM?
Sleep hours? Melatonin ordered? No benzos?
CAM delirium screen done?
Anticholinergic burden count?
Renal function → dose adjustments needed?