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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EmergentEM

Trauma Primary & Secondary Survey

ATLS framework: ABCDE primary survey identifies life threats in minutes. Adjuncts: FAST, CXR, pelvic XR. Secondary survey is head-to-toe after stabilization. Hemorrhagic shock classification guides resuscitation.

🔍 Overview

Primary Survey (ABCDE)

Step	Assessment	Interventions
A -Airway	Patent? Speaking? Stridor? Facial/neck trauma?	Jaw thrust (maintain C-spine), suction, definitive airway if needed
B -Breathing	RR, SpO₂, breath sounds bilateral? Tracheal deviation? Chest wall movement?	Needle decompression (tension pneumo), chest tube, seal open pneumo
C -Circulation	HR, BP, skin (cool/clammy?), active bleeding? Pelvis stable?	2 large-bore IVs, tourniquets, pelvic binder, MTP if needed
D -Disability	GCS, pupils, gross motor/sensory	Treat ↑ ICP (HOB 30°, mannitol/HTS), identify herniation
E -Exposure	Fully undress, log roll, inspect everywhere	Warm blankets, prevent hypothermia

Hemorrhagic Shock Classification

Class	Blood Loss	HR	BP	Mental Status
I	< 750 mL (15%)	Normal	Normal	Normal
II	750–1500 mL (15–30%)	↑ (100–120)	Normal	Anxious
III	1500–2000 mL (30–40%)	↑ (>120)	↓	Confused
IV	> 2000 mL (>40%)	↑ (>140)	↓↓	Obtunded

Glasgow Coma Scale (GCS)

Component	Response	Score
Eye Opening (E)	Spontaneous	4
	To voice	3
	To pain	2
	None	1
Verbal (V)	Oriented	5
	Confused	4
	Inappropriate words	3
	Incomprehensible sounds	2
	None	1
Motor (M)	Obeys commands	6
	Localizes pain	5
	Withdraws from pain	4
	Abnormal flexion (decorticate)	3
	Extension (decerebrate)	2
	None	1

GCS Classification: Severe TBI = GCS 3-8 (intubate). Moderate = 9-12. Mild = 13-15. Always report components (e.g., E3V4M6 = GCS 13) not just the total.

🚨 Management

Adjuncts to Primary Survey

FAST exam -Focused Assessment with Sonography in Trauma. 4 views: RUQ, LUQ, subxiphoid, suprapubic. Identifies free fluid.
CXR (AP supine) -pneumothorax, hemothorax, mediastinal widening
Pelvic XR -pelvic fracture (hemodynamic instability source)
Foley -urine output monitoring (do NOT place if blood at meatus, high-riding prostate, scrotal hematoma)
NGT/OGT -decompress stomach. OGT if midface fracture suspected.

Secondary Survey

Head-to-toe exam AFTER primary survey and stabilization. "Fingers and tubes in every orifice." Log roll to examine spine. Complete neuro exam. Document all injuries.

Key Evidence: Balanced resuscitation with 1:1:1 ratio reduces 24h mortality from exsanguination PROPPR, 2015. TXA within 3 hours of injury reduces all-cause mortality CRASH-2, 2010. Whole blood resuscitation may be superior to component therapy PILOT, 2022. Permissive hypotension (SBP 80-90) in penetrating trauma reduced mortality vs aggressive resuscitation Bickell, 1994.

Damage Control Surgery Principles

Phase	Goal	Key Actions
Phase 1: OR	Stop hemorrhage, limit contamination	Abbreviated surgery: pack bleeding, ligate vessels, staple bowel, temporary abdominal closure
Phase 2: ICU	Correct lethal diamond	Rewarm (target ≥ 36°C), correct acidosis (resuscitate), fix coagulopathy (products), replace calcium
Phase 3: Return to OR	Definitive repair	Remove packing, definitive vascular repair, bowel anastomosis, abdominal closure (24-72h later)

🧪 Workup

FAST exam -bedside, during primary survey
CXR, pelvic XR
CT pan-scan (head, C-spine, chest, abdomen/pelvis with IV contrast) -stable patients
CBC, BMP, coags, type & crossmatch, lactate, ABG
Urine drug screen, blood alcohol, pregnancy test
Tetanus status

💊 Medications

Drug	Dose	Purpose
Tranexamic Acid (TXA)	1g IV over 10 min → 1g over 8h	Antifibrinolytic -within 3h of injury
pRBC / FFP / Platelets	1:1:1 ratio	MTP for hemorrhagic shock Class III–IV
Ketamine (Ketalar)	1–2 mg/kg IV	RSI induction -hemodynamically stable, bronchodilator
Rocuronium (Zemuron)	1.2 mg/kg IV	Paralytic for RSI -longer duration but sugammadex reversible
Norepinephrine (Levophed)	0.1–0.5 mcg/kg/min	Vasopressor -AFTER volume resuscitation, not as substitute

📋 On Rounds

Pimp Questions

When is a FAST exam unreliable?

FAST detects free fluid (≥ 200 mL) but cannot identify retroperitoneal bleeding (renal, vascular, pelvic fractures), hollow viscus injury, or diaphragmatic injury. Sensitivity is operator-dependent (~85–96% for hemoperitoneum). A negative FAST does NOT rule out intra-abdominal injury -if clinical suspicion remains high, proceed with CT.

Why do you NOT place a Foley if there is blood at the urethral meatus?

Blood at the meatus, high-riding prostate on DRE, or scrotal/perineal hematoma suggest urethral injury. Blindly inserting a Foley could convert a partial urethral tear into a complete transection. Get a retrograde urethrogram (RUG) first. If positive, urology places a suprapubic catheter instead.

What is the "lethal diamond" in trauma?

Extension of the lethal triad: hypothermia + acidosis + coagulopathy + hypocalcemia (from massive transfusion). Citrate in blood products chelates calcium → cardiac dysfunction. The damage control resuscitation approach addresses all four: warm products, limit crystalloid (worsens acidosis), 1:1:1 ratio, and replace calcium (1g CaCl per 4 units pRBC).

What is damage control resuscitation?

Limit crystalloid (worsens acidosis/coagulopathy), use 1:1:1 blood products, permissive hypotension (target SBP 80-90 until surgical hemostasis), and damage control surgery (abbreviated laparotomy, pack and close, ICU resuscitate, return to OR). Holcomb JAMA Surg, 2015.

What are indications for emergent thoracotomy in trauma?

Penetrating thoracic trauma with loss of vital signs in ED or en route (within ~15 min). >1500 mL initial chest tube output or >200 mL/hr ongoing. Cardiac tamponade. Survival is ~35% for stab wounds but <5% for blunt trauma. EAST Guidelines, 2015.

What is the MARCH mnemonic for tactical trauma?

M = Massive hemorrhage (tourniquet), A = Airway, R = Respiration (needle decompress, chest seal), C = Circulation (IV access, TXA, blood products), H = Hypothermia prevention. Prioritizes hemorrhage control before airway, unlike traditional ABCDE.

When do you activate massive transfusion protocol (MTP)?

ABC score ≥ 2 (penetrating mechanism, SBP ≤ 90, HR ≥ 120, positive FAST). Also: estimated blood loss > 1500 mL, anticipated need for > 10 units pRBC in 24h, hemodynamic instability despite 2L crystalloid. Cotton, 2009.

What is the difference between primary and secondary brain injury in TBI?

Primary = mechanical damage at time of impact (contusion, diffuse axonal injury, epidural/subdural hematoma). Cannot be reversed. Secondary = preventable cascade: hypotension, hypoxia, hyperthermia, hyperglycemia, seizures. A single episode of SBP < 90 doubles mortality. Focus is preventing secondary injury.

What is permissive hypotension and when is it contraindicated?

Target SBP 80-90 in hemorrhagic shock to minimize ongoing bleeding until surgical control. Reduces dilutional coagulopathy from excess crystalloid. Contraindicated in TBI (need SBP > 100 for cerebral perfusion) and spinal cord injury. Bickell, 1994.

Clinical Examples

📋 Case 1, Blunt Polytrauma with Hemorrhagic Shock

Patient: 28M MVC unrestrained driver, GCS 13 (E3V4M6). HR 132, BP 78/42, RR 28. Distended abdomen, pelvic instability on exam. FAST positive (Morrison's pouch).

Key findings: Class IV hemorrhagic shock (tachycardic, hypotensive, AMS). FAST positive = intra-abdominal hemorrhage. Unstable pelvis = likely pelvic fracture with venous plexus bleeding.

Management:

Activate massive transfusion protocol, 1:1:1 (pRBC:FFP:platelets) PROPPR, 2015
Pelvic binder immediately (reduces venous bleeding volume by ~50%)
TXA 1g IV over 10 min → 1g over 8h (must give within 3h of injury) CRASH-2, 2010
Permissive hypotension: target SBP 80-90 until surgical control
OR for exploratory laparotomy, damage control surgery

Teaching point: In penetrating/blunt trauma with hemorrhagic shock, the ED goal is stop the bleeding, not normalize vitals with crystalloid. Crystalloid worsens coagulopathy, hypothermia, and acidosis.

📋 Case 2, Tension Pneumothorax

Patient: 35F stab wound to left chest. Initially stable, now HR 140, BP 62/40, SpO₂ 82%. Absent breath sounds on left. Tracheal deviation to the right. JVD.

Key findings: Classic tension pneumothorax: hypotension + absent breath sounds + tracheal deviation + JVD. This is a clinical diagnosis, do NOT wait for CXR.

Management:

Needle decompression IMMEDIATELY, 14g angiocath, 2nd intercostal space midclavicular line (or 5th ICS anterior axillary)
Follow with tube thoracostomy (chest tube 28-32 Fr) in left 5th ICS anterior axillary line
Reassess: expect rapid improvement in BP and SpO₂ after decompression
If persistent hemorrhage (> 1500 mL initial output or > 200 mL/hr) → thoracotomy
Serial CXR to confirm lung re-expansion

Teaching point: Tension pneumothorax is a clinical diagnosis treated before imaging. The classic triad (hypotension, absent breath sounds, tracheal deviation) may not all be present, decompress based on high clinical suspicion.

📋 Case 3, Traumatic Brain Injury

Patient: 55M fall from ladder, GCS 7 (E1V2M4). Right pupil 6 mm fixed. Left-sided hemiplegia. HR 58, BP 190/100. CT: right-sided epidural hematoma with 8 mm midline shift.

Key findings: Cushing triad (HTN + bradycardia + irregular breathing) = elevated ICP. Ipsilateral fixed dilated pupil + contralateral hemiplegia = uncal herniation. Epidural = "talk and die" lesion if not evacuated.

Management:

Intubate for airway protection (GCS ≤ 8), avoid hypotension during RSI
Mannitol 1 g/kg IV or hypertonic saline 23.4% 30 mL IV push (temporizing for herniation)
Emergent neurosurgery consult for craniotomy and evacuation
Target SBP > 100 (avoid hypotension, single episode doubles mortality in TBI)
Head of bed 30°, avoid hyperthermia, maintain PaCO₂ 35-40 mmHg

Teaching point: In TBI, the secondary injury (hypotension, hypoxia, hyperthermia) is preventable. Maintaining SBP > 100 and SpO₂ > 90% is the single most impactful intervention for TBI outcomes.

⚡ Summary

Primary Survey

ABCDE: Airway (c-spine), Breathing, Circulation, Disability (GCS), Exposure. Fix life threats as found.

FAST

4 views: RUQ, LUQ, subxiphoid, suprapubic. Detects free fluid ≥ 200mL. Cannot detect retroperitoneal bleed.

Shock Classes

I: <15%, normal. II: 15-30%, tachy. III: 30-40%, ↓BP, confused. IV: >40%, obtunded.

MTP

1:1:1 pRBC:FFP:Platelets. TXA within 3h. Calcium replacement. Permissive hypotension.

Secondary Survey

Head-to-toe after stabilization. Log roll. Complete neuro exam. "Tubes and fingers in every orifice."

Foley Contraindications

Blood at meatus, high-riding prostate, scrotal hematoma → RUG first before Foley.