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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EMERGENTEndocrinology

Thyroid Storm & Myxedema Coma

Thyroid storm: life-threatening thyrotoxicosis with mortality 10–30% even with treatment. Myxedema coma: severe hypothyroidism with altered consciousness and hypothermia. Both are clinical diagnoses -don't wait for labs to treat.

🔥 Thyroid Storm

Recognition -Burch-Wartofsky Score ≥ 45 -clinical probability of thyroid storm (≥45 highly suggestive, 25–44 impending, <25 unlikely)

Thyrotoxicosis with end-organ dysfunction: high fever, tachycardia out of proportion, AMS, HF, liver failure. Usually triggered by: infection, surgery, trauma, iodine load (contrast), medication non-adherence.

Feature	Score Range
Temperature	99–99.9°F = 5 → 104+ = 30
CNS effects	Agitation = 10, delirium = 20, seizure/coma = 30
GI-hepatic dysfunction	Diarrhea/nausea = 10, jaundice = 20
Heart rate	100–109 = 5 → 140+ = 25
CHF	Mild = 5, moderate = 10, severe = 15
Afib	Present = 10
Precipitant	Positive = 10

≥ 45: highly suggestive → treat as thyroid storm. 25–44: impending storm. < 25: unlikely.

Treatment -Order Matters

Treat in this order. Iodine must come AFTER thionamide (≥ 1h later) -otherwise iodine provides substrate for MORE thyroid hormone production (Jod-Basedow effect).

Step	Drug	Dose	Mechanism
1. Block synthesis	PTU PREFERRED	500–1000 mg PO loading → 250 mg PO q4h	Blocks new thyroid hormone synthesis (inhibits TPO). PTU preferred over methimazole in storm because it also inhibits peripheral T4→T3 conversion.
2. Block release (≥ 1h after PTU)	Iodine (SSKI or Lugol's)	SSKI 5 drops PO q6h, or Lugol's 10 drops PO q8h	Wolff-Chaikoff effect -high iodine temporarily shuts down thyroid hormone release. MUST give after thionamide or iodine becomes fuel.
3. Block peripheral effects	Propranolol	60–80 mg PO q4h (or 1 mg IV slowly)	β-blockade controls tachycardia, tremor, agitation. Propranolol also blocks T4→T3 conversion. Esmolol drip if too unstable for PO.
4. Block conversion	Hydrocortisone (Solu-Cortef)	100 mg IV q8h	Blocks peripheral T4→T3 conversion. Also treats possible concomitant adrenal insufficiency (thyroid storm increases cortisol metabolism). Also: dexamethasone 2 mg IV q6h is alternative.
5. Supportive	Cooling, IVF, acetaminophen	As needed	Avoid aspirin -displaces T4 from TBG → increases free T4. Use acetaminophen for fever. ICU admission. Treat precipitant.

❄️ Myxedema Coma

Recognition

Altered mental status (lethargy → coma) in the setting of severe hypothyroidism
Hypothermia (may be < 35°C -core temp may not register on standard thermometer)
Bradycardia, hypotension
Hypoventilation (CO₂ retention -blunted respiratory drive)
Hyponatremia (↓ free water excretion -can be severe)
Non-pitting edema (myxedema), delayed reflexes, ileus
Triggers: infection (#1), cold exposure, surgery, opioids/sedatives, medication non-adherence

Treatment

Drug	Dose	Notes
IV Levothyroxine (T4) 1ST LINE	200–400 mcg IV loading dose → 1.6 mcg/kg/day IV (50–100 mcg/day)	IV required -GI absorption unreliable in myxedema (ileus, edema). Large loading dose to replenish depleted T4 stores.
IV T3 (liothyronine) CONTROVERSIAL	5–20 mcg IV loading → 2.5–10 mcg IV q8h	Faster onset than T4 (T4 takes days to convert). Some add T3 for severe cases. Risk: arrhythmia, cardiac ischemia (especially elderly/CAD). No RCT showing mortality benefit.
Hydrocortisone (Solu-Cortef) GIVE BEFORE T4	100 mg IV q8h	Must give stress-dose steroids BEFORE thyroid hormone. Hypothyroidism masks adrenal insufficiency -giving T4 increases metabolic rate → unmasks cortisol deficiency → adrenal crisis. Always give hydrocortisone first, taper once adrenal axis confirmed normal.

Supportive: passive rewarming only (active rewarming causes vasodilation → cardiovascular collapse). Avoid sedatives/opioids (blunt already-depressed respiratory drive). Intubate if hypoventilating. Treat hyponatremia cautiously (fluid restrict, may need hypertonic saline if symptomatic). Treat precipitant.

📋 On Rounds

Why must iodine come AFTER the thionamide in thyroid storm?

Iodine is the substrate for thyroid hormone synthesis. If you give iodine to a thyrotoxic gland without first blocking the synthesis machinery (TPO enzyme), the gland uses the iodine to produce even more T3/T4 -the Jod-Basedow phenomenon. The thionamide (PTU or methimazole) blocks TPO first, ensuring the gland cannot use the incoming iodine for new hormone synthesis.

Why give steroids before thyroid hormone in myxedema coma?

Hypothyroidism slows cortisol metabolism, so the body's cortisol "lasts longer" and masks underlying adrenal insufficiency. When you give T4 and increase the metabolic rate, cortisol is suddenly metabolized faster → cortisol drops → adrenal crisis (hypotension, shock, death). Up to 5–10% of myxedema patients have concomitant adrenal insufficiency (Schmidt syndrome -autoimmune polyglandular syndrome).

Why do you give iodine 1 HOUR AFTER PTU and not at the same time?

PTU blocks thyroid hormone synthesis (inhibits thyroid peroxidase → can't organify iodine → can't make T3/T4). Iodine acutely blocks thyroid hormone RELEASE (Wolff-Chaikoff effect -excess iodine paradoxically inhibits hormone release).

Why do you give hydrocortisone in thyroid storm even without adrenal insufficiency?

Two reasons: (1) Thyroid storm increases cortisol metabolism -the hypermetabolic state accelerates cortisol clearance, creating a state of relative adrenal insufficiency. The adrenals can't keep up with demand. Without supplementation → adrenal crisis → refractory hypotension. (2) Hydrocortisone blocks peripheral T4 → T3 conversion (same enzyme that PTU and propranolol block -deiodinase type 1).

Why must you give PTU BEFORE iodine in thyroid storm?

Iodine is a substrate for new thyroid hormone synthesis. If given before blocking synthesis with a thionamide, it feeds the storm (Jod-Basedow effect). Always give PTU ≥ 1 hour before SSKI/Lugol's.

Why is aspirin contraindicated in thyroid storm?

Aspirin displaces T4 from thyroid-binding globulin (TBG), acutely increasing free T4 levels and worsening the storm. Use acetaminophen for fever instead.

Name 3 drugs that block T4→T3 peripheral conversion.

PTU, propranolol (high-dose), and corticosteroids. This is why all three are part of the thyroid storm treatment protocol. Methimazole does NOT block peripheral conversion.

What is the Burch-Wartofsky score and when do you use it?

A scoring system using temperature, CNS effects, GI dysfunction, HR, CHF, and AF to diagnose thyroid storm. Score ≥ 45 = thyroid storm, 25-44 = impending storm. Lab values alone can't distinguish thyrotoxicosis from storm.

Clinical Examples

📋 Case 1, Graves' Disease with Surgical Trigger

Patient: 34F, known Graves disease (non-adherent to methimazole x 3 weeks), presents post-emergency appendectomy with fever 40.2°C, HR 168, agitation, tremor, and vomiting.

Key findings: BP 160/70, RR 28, T 40.2°C. TSH < 0.01, free T4 6.8 (normal 0.8-1.8). Burch-Wartofsky score 60. Diffuse goiter with bruit. New atrial fibrillation on telemetry.

Management:

PTU 200 mg PO/PR q4h (blocks synthesis AND peripheral T4→T3 conversion)
SSKI 5 drops q6h started 1 HOUR after first PTU dose (Wolff-Chaikoff effect blocks release)
Propranolol 60-80 mg PO q4-6h (symptom control + blocks T4→T3 conversion)
Hydrocortisone 100 mg IV q8h (prevents relative adrenal insufficiency + blocks conversion)
Acetaminophen for fever (NOT aspirin, displaces T4 from TBG)
ICU admission, cooling blankets, aggressive IV fluids

Teaching point: The order of therapy is critical: thionamide FIRST (block synthesis), then iodine ≥ 1 hour later (block release). Giving iodine before blocking synthesis fuels more hormone production (Jod-Basedow phenomenon). ATA Guidelines, 2016

📋 Case 2, Thyroid Storm Mimicking Sepsis

Patient: 52F, no known thyroid history, presents with fever 39.5°C, tachycardia to 150, confusion, and diarrhea. Initially treated as sepsis with broad-spectrum antibiotics, but cultures negative at 48h.

Key findings: Weight loss of 20 lbs over 3 months (per family). Fine tremor, lid lag, exophthalmos. TSH < 0.005, free T4 8.2, free T3 22. Burch-Wartofsky 55. LFTs elevated (AST 180, ALT 145, thyroid hepatopathy).

Management:

Initiate thyroid storm protocol: PTU + iodine (1h later) + propranolol + hydrocortisone
Continue antibiotics until infection definitively ruled out (storm can coexist with sepsis)
Monitor LFTs closely, hepatic dysfunction is a poor prognostic indicator in thyroid storm
Avoid esmolol in decompensated patients; propranolol preferred (also blocks T4→T3)

Teaching point: Thyroid storm and sepsis share many features (fever, tachycardia, AMS, hypotension). Always check TSH in unexplained tachycardia or sepsis not responding to antibiotics. Liver failure in thyroid storm carries mortality > 50%.

📋 Case 3, Amiodarone-Induced Thyrotoxicosis

Patient: 68M, on amiodarone for AF x 2 years, presents with worsening AF with RVR (HR 142), weight loss, and anxiety. Previously well-controlled.

Key findings: TSH < 0.01, free T4 4.8. No goiter, no exophthalmos. CRP 45. Thyroid ultrasound: normal-sized gland with decreased vascularity.

Management:

Amiodarone-induced thyrotoxicosis type 2 (destructive thyroiditis), decreased vascularity + elevated CRP
Prednisone 40 mg daily (first-line for type 2 AIT)
Type 1 (excess iodine substrate) would get thionamide + potassium perchlorate
If unclear type 1 vs 2, treat both simultaneously (combined PTU + prednisone)
Discuss with cardiology whether to stop amiodarone (long half-life of 40-55 days)

Teaching point: Amiodarone contains 37% iodine by weight. Type 1 AIT occurs in patients with underlying thyroid disease, excess substrate. Type 2 occurs in normal glands, direct thyroid destruction. Doppler ultrasound vascularity helps distinguish: increased = type 1, decreased/absent = type 2. ETA Guidelines, 2018

📣 Sample Presentation

One-Liner

"Ms. Santos is a 32-year-old with known Graves disease (non-adherent to methimazole) presenting with fever 39.8°C, HR 162, agitation, and tremor after a dental extraction. TSH <0.01, free T4 7.8. Burch-Wartofsky score 55. Thyroid storm."

Key Points to Cover on Rounds

Thyroid storm (BW score 55, ≥45 = storm). Precipitant: dental surgery + medication non-adherence. Treatment ORDER matters: (1) PTU 200 mg PO/PR q4h (blocks synthesis + peripheral T4→T3 conversion), (2) SSKI (iodine) started 1 HOUR AFTER first PTU dose (blocks thyroid hormone release -Wolff-Chaikoff), (3) propranolol 60 mg PO q6h (symptom control + blocks T4→T3), (4) hydrocortisone 100 mg IV q8h (prevents adrenal crisis + blocks conversion), (5) acetaminophen for fever (NOT aspirin -displaces T4 from binding proteins). ICU. Cooling blankets. IV fluids.

🔍 Overview

Overview

Thyroid storm is a life-threatening exaggeration of thyrotoxicosis with multi-organ dysfunction. Mortality 10-30% even with treatment. Diagnosis is clinical -do not wait for labs. Use the Burch-Wartofsky Point Scale (BWPS): score ≥ 45 = thyroid storm, 25-44 = impending storm. Classic triggers: surgery, infection, trauma, iodinated contrast, medication non-compliance, DKA in a patient with underlying Graves' disease. Key features: fever > 104°F (40°C), tachycardia out of proportion, altered mental status, GI dysfunction (diarrhea, jaundice -liver failure is a poor prognostic sign). Treatment follows a specific order: (1) beta-blocker → (2) thionamide → (3) iodine (≥ 1h after thionamide) → (4) steroids → (5) supportive care. The delay of iodine after thionamide is critical -giving iodine first fuels more hormone synthesis (Jod-Basedow effect).

🧪 Workup

Workup

TSH + free T4 + free T3 -TSH suppressed (< 0.01), T4/T3 elevated. T3 often disproportionately high.
Burch-Wartofsky Score -≥ 45 = thyroid storm. 25-44 = impending storm. Scores: temp, CNS effects, GI/hepatic, HR, CHF, AF, precipitant.
CBC, BMP, LFTs, lipase -hepatic dysfunction common (elevated AST/ALT/bilirubin). Leukocytosis.
Blood cultures -infection is the #1 precipitant. Must rule out.
Cortisol / ACTH stim -relative adrenal insufficiency common in storm. Stress-dose steroids given empirically.
CXR, UA, lipase -search for precipitant (infection, surgery, trauma, iodine load, DKA, PE)
ECG -AF in 10-35% of thyroid storm. Look for rate, ischemia.
Pregnancy test -in women of childbearing age (PTU preferred in 1st trimester)

⚡ Management

Management

Order of treatment matters: (1) Thionamide first → (2) Iodine 1 hour later → (3) Beta-blocker → (4) Steroids → (5) Supportive. Never give iodine before thionamide (Jod-Basedow effect -iodine feeds the storm).
1. Block new hormone synthesis: PTU 200 mg PO/PR q4h (preferred -also blocks T4→T3 conversion) or methimazole 20 mg PO q4-6h
2. Block hormone release (1h after thionamide): SSKI 5 drops q6h or Lugol's iodine 10 drops q8h. Lithium 300 mg q8h if iodine allergic.
3. Block peripheral effects: Propranolol 60-80 mg PO q4h (also blocks T4→T3) or esmolol drip if can't take PO
4. Block T4→T3 conversion: Hydrocortisone 100 mg IV q8h (also treats relative adrenal insufficiency) [Burch & Wartofsky]
5. Supportive: Cooling (acetaminophen, cooling blankets -NOT aspirin which displaces T4 from TBG), IVF, electrolyte repletion, ICU admission
Treat the precipitant: antibiotics if infection, etc.
Cholestyramine 4g QID -binds thyroid hormone in gut (adjunctive in refractory storm)

Do NOT give aspirin -it displaces T4 from thyroid-binding globulin, increasing free T4 and worsening storm. Use acetaminophen for fever.

📋 Clinical Example -Thyroid Storm Management

Patient: 35F with known Graves' disease (non-compliant with methimazole), presents with fever 39.8°C, HR 162, agitation, vomiting, diarrhea. Burch-Wartofsky Score: 65 (>45 = thyroid storm).
Treatment ORDER matters (block synthesis → block release → block conversion → block effects):
- Step 1 -Block new hormone synthesis: PTU 500-1000mg loading → 250mg q4h (preferred over methimazole in storm because PTU also blocks T4→T3 conversion). Give rectally if vomiting.
- Step 2 -Block hormone RELEASE (give ≥1 hour AFTER PTU): SSKI 5 drops q6h or Lugol's iodine 10 drops q8h. If given BEFORE antithyroid drugs, iodine will fuel more hormone production (Jod-Basedow effect).
- Step 3 -Block peripheral T4→T3 conversion: Hydrocortisone (Solu-Cortef) 100mg IV q8h (also treats possible relative adrenal insufficiency).
- Step 4 -Block peripheral effects: Propranolol (Inderal) 60-80mg PO q4-6h (preferred β-blocker -also inhibits T4→T3 conversion). Use esmolol drip if unable to take PO or hemodynamically tenuous.
Supportive: Cooling blankets for fever (avoid aspirin -displaces T4 from binding proteins), IV fluids, acetaminophen. ICU admission.
Key: Mortality of untreated thyroid storm is 20-30%. The sequential approach (PTU first, THEN iodine) is critical.

💊 Medications

Medications

Drug	Dose	Route	Notes
PTU	200 mg q4h	PO/PR	First-line thionamide. Blocks synthesis AND peripheral T4→T3 conversion. Risk: hepatotoxicity, agranulocytosis.
Methimazole (Tapazole)	20 mg q4-6h	PO/PR	Alternative. More potent per mg. Does NOT block T4→T3. Preferred long-term but PTU preferred in storm and 1st trimester.
SSKI	5 drops q6h	PO	Give ≥ 1h AFTER thionamide. Blocks hormone release (Wolff-Chaikoff effect).
Propranolol	Burch-Wartofsky, 1993 60-80 mg PO q4h	PO	Non-selective BB. Also inhibits T4→T3 conversion at high doses. Controls tachycardia, tremor, diaphoresis.
Esmolol	500 mcg/kg bolus → 50-200 mcg/kg/min	IV	If can't take PO or hemodynamically unstable. Ultra-short acting.
Hydrocortisone	ATA, 2016 100 mg IV q8h	IV	Blocks T4→T3. Treats relative adrenal insufficiency. Empiric in all storm patients.
Cholestyramine	4g PO QID	PO	Adjunctive -binds thyroid hormone in gut, interrupts enterohepatic circulation.
Acetaminophen	1g IV/PO q6h	IV/PO	Antipyretic. NOT aspirin (displaces T4 from TBG).

⚡ Summary

Summary

Diagnosis

Burch-Wartofsky score ≥ 45 = storm. Fever + tachycardia + AMS + precipitant (surgery, infection, non-adherence) + known thyroid disease.

Treatment Order

(1) PTU 200 q4h → (2) Iodine 1 HOUR after PTU (Wolff-Chaikoff) → (3) Propranolol 60 q6h → (4) Hydrocortisone 100 q8h → (5) Acetaminophen (NOT aspirin).

Why Not Aspirin

Displaces T4 from TBG → increases free T4 → worsens storm. Use acetaminophen + cooling blankets for fever.

PTU vs Methimazole

PTU preferred in storm: blocks synthesis AND peripheral T4→T3 conversion. Methimazole only blocks synthesis.

Supportive

ICU. Aggressive IVF. Cooling blankets. Treat precipitant (infection, surgery). Nutritional support (high caloric needs).

Discharge

Transition to methimazole (lower hepatotoxicity). Endocrinology follow-up. Definitive treatment: RAI or thyroidectomy.

📄 One Pager

Endocrine / ICU · One Pager

Thyroid Storm

Burch-Wartofsky ≥ 45. Treatment ORDER matters: PTU → iodine 1h later → propranolol → hydrocortisone → acetaminophen (NOT aspirin). ICU.

🧪 Diagnosis

Burch-Wartofsky score ≥ 45 = storm. Fever + tachycardia out of proportion + AMS/agitation + known thyroid disease + precipitant (surgery, infection, iodine load, non-adherence).

🚨 Treatment Order

(1) PTU 200 mg q4h (blocks synthesis + T4→T3 conversion). (2) Iodine (SSKI) 1 HOUR after PTU (Wolff-Chaikoff). (3) Propranolol 60 mg q6h (symptom control + blocks conversion). (4) Hydrocortisone 100 mg q8h. (5) Acetaminophen for fever (NOT aspirin).

⚠️ Why This Order

PTU before iodine: iodine without PTU → substrate for MORE T3/T4 synthesis. Aspirin displaces T4 from TBG → increases free T4 → worsens storm. Hydrocortisone: relative adrenal insufficiency in hypermetabolic state.

💊 Key Drugs

PTU200 mg PO/PR q4h

SSKI5 drops q6h (1h after PTU)

Propranolol60-80 mg PO q6h

Hydrocortisone (Solu-Cortef)100 mg IV q8h

⚠️ Pitfalls

Iodine before PTU (substrate for more hormone)
Aspirin for fever (displaces T4 from TBG)
Not giving steroids (relative adrenal insufficiency)
Missing the precipitant (infection, surgery, non-adherence)