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.

RoundsRx

Dashboard

Overview

Recent

Rotations

Quick Reference

Antibiotic Guide Analgesia Guide Sedation Guide Bowel Regimen Electrolyte Replacement Pain Management & Conversions Drug Interactions Anticoag Reversal IV Fluid Guide Inotropes Guide Vasopressors Insulin Guide Code Blue & Rapid Response Procedures Guide ECG Interpretation Lab Interpretation Radiology Quick Ref GCS Pocket Card Admission Orders & I-PASS Landmark Trials

Tools

💎 Clinical Pearls 🧠 Pimp Me Quiz 🧮 Clinical Calculators 📰 What's New 🎓 Intern Survival Guide ✅ Rounding Checklists 🩺 Procedure Guides ⚡ Electrolyte Replacement 💧 IV Fluids Guide 🩸 Transfusion Guide 💓 ECG Pattern Guide 🧪 Lab Interpretation Guide 📱 QR Poster 🔗 Resources 🎙️ Channels & Podcasts 🎮 Medical Games 🏛️ Famous Cases 🎬 Media Library

ℹ️ About

Available offline

EmergentRheumatology

Vasculitis

Inflammation of blood vessel walls → ischemia and organ damage. Classified by vessel size. The ANCA-associated vasculitides (GPA, MPA, EGPA) are the ones you'll see on the wards. Pulmonary-renal syndrome = treat immediately.

🔍 Classification by Vessel Size

Size	Disease	Key Features	Antibody	Treatment
Small vessel (ANCA-associated)	GPA (Granulomatosis with Polyangiitis)	Upper airway (sinusitis, saddle-nose, subglottic stenosis) + lungs (cavitary nodules, DAH) + kidneys (RPGN). Classic triad.	c-ANCA / PR3	Pulse steroids + rituximab or cyclophosphamide RAVE, 2010. Plasmapheresis if severe renal or DAH.
	MPA (Microscopic Polyangiitis)	Kidneys (RPGN -most common presentation) + lungs (DAH). No upper airway involvement (distinguishes from GPA). No granulomas on biopsy.	p-ANCA / MPO	Same as GPA.
	EGPA (Eosinophilic GPA / Churg-Strauss)	Asthma (adult-onset, severe) + eosinophilia (> 1500) + sinusitis + neuropathy (mononeuritis multiplex) + cardiac involvement.	p-ANCA / MPO (40–60%)	Steroids (often sufficient for mild). Mepolizumab (anti-IL5) MIRRA, 2017. Cyclophosphamide if organ-threatening.
Medium vessel	PAN (Polyarteritis Nodosa)	ANCA-negative. Microaneurysms on angiography. Skin (livedo, nodules, ulcers), renal (HTN, infarction -but NOT glomerulonephritis), GI (mesenteric ischemia), neuropathy. Associated with HBV.	Negative	Steroids + cyclophosphamide. Treat HBV if associated.
Large vessel	Giant Cell Arteritis (GCA)	Age > 50. Temporal headache, jaw claudication, scalp tenderness, vision loss (anterior ischemic optic neuropathy). ESR often > 100.	Negative	Start steroids BEFORE biopsy (don't wait -vision loss is irreversible). Prednisone 40–60 mg/day. Tocilizumab for steroid-sparing GiACTA, 2017.
Large vessel	Takayasu arteritis	Young women (< 40). Aorta + branches → limb claudication, BP discrepancy, absent pulses, bruits. "Pulseless disease."	Negative	Steroids + methotrexate/tocilizumab.

Pulmonary-Renal Syndrome

DAH (hemoptysis + bilateral infiltrates + dropping Hgb) + RPGN (rising Cr + active sediment) = pulmonary-renal syndrome. This is a medical emergency. Differential: GPA, MPA, anti-GBM (Goodpasture's), SLE. Send ANCA, anti-GBM, ANA, complement. Start pulse methylprednisolone 1g IV × 3 days + cyclophosphamide or rituximab + plasmapheresis (especially if anti-GBM positive). Do NOT wait for biopsy to start treatment.

🧪 Workup

Workup

ANCA -c-ANCA/PR3 (GPA/Wegener's), p-ANCA/MPO (MPA, EGPA). Send BOTH ELISA (PR3, MPO) AND IFA (c-ANCA, p-ANCA).
CBC, BMP, LFTs, ESR, CRP -baseline organ function + inflammatory markers
UA with microscopy -dysmorphic RBCs, RBC casts = glomerulonephritis (RPGN). This is an emergency -needs urgent renal biopsy.
Cr + GFR -rapidly rising Cr = RPGN
CXR / CT chest -pulmonary hemorrhage (DAH), nodules/cavities (GPA), infiltrates
Renal biopsy -pauci-immune crescentic GN (hallmark of ANCA-associated vasculitis). Also classifies severity.
Tissue biopsy -skin, sural nerve, temporal artery (GCA), lung -shows granulomatous inflammation (GPA) or necrotizing vasculitis
Complement levels (C3, C4) -low in complement-mediated vasculitis (cryoglobulinemic, anti-GBM, SLE). Normal in ANCA vasculitis.
Cryoglobulins + HCV -HCV-associated cryoglobulinemic vasculitis (type II mixed)
Anti-GBM antibodies -Goodpasture syndrome (pulmonary-renal syndrome with linear IgG on biopsy)
Eosinophil count -markedly elevated in EGPA (eosinophilic granulomatosis with polyangiitis / Churg-Strauss)

⚡ Management

Treatment -ANCA-Associated Vasculitis

Phase	Regimen	Details
Induction	Pulse methylpred 1g IV × 3d → pred 1 mg/kg taper + Rituximab (Rituxan) 375 mg/m² × 4 wks	Rituximab preferred over cyclophosphamide RAVE, 2010. Especially for PR3+/relapsing.
Alternative	Cyclophosphamide IV 15 mg/kg q2–4 wks	If rituximab unavailable. Limit cumulative dose (bladder CA risk). Mesna for cystitis prevention.
Severe renal/DAH	Add plasmapheresis	PLEX for Cr > 5.7 or DAH requiring ventilation.
Maintenance	Rituximab (Rituxan) 500 mg q6 months or azathioprine (Imuran)	Maintain ≥ 2 years. PR3+ = longer maintenance (higher relapse).

💊 Medications

Medications

Drug	Dose	Route	Notes
ANCA-Associated Vasculitis -Induction
Rituximab	375 mg/m² weekly × 4 or 1000 mg × 2	IV	First-line induction (equal to cyclophosphamide). RAVE, 2010. Preferred in relapsing disease. Fewer side effects than CYC. Screen HBV.
Cyclophosphamide	15 mg/kg IV q2 weeks × 3 then q3 weeks	IV	Alternative induction. Effective but more toxicity (bladder cancer, infertility, myelosuppression). Mesna for bladder protection. Limit cumulative dose.
Methylprednisolone	500-1000 mg IV × 3 days	IV	Pulse steroids with induction. Then prednisone 1 mg/kg taper over 3-6 months. [PEXIVAS: reduced-dose glucocorticoid non-inferior, 2020]
Avacopan	30 mg BID	PO	C5a receptor inhibitor -steroid-sparing. ADVOCATE, 2021. Can replace prednisone during induction (add to RTX or CYC). Superior sustained remission at 52 weeks.
Maintenance
Rituximab	500 mg q6 months × 2-4 years	IV	Preferred maintenance. MAINRITSAN, 2014 -superior to azathioprine. Duration: minimum 2 years, possibly longer for PR3+.
Azathioprine	2 mg/kg/day	PO	Alternative maintenance. Check TPMT. Less effective than rituximab for relapse prevention.
Giant Cell Arteritis (GCA)
Prednisone	40-60 mg daily	PO	Start IMMEDIATELY if clinical suspicion -do NOT wait for biopsy. Taper over 12-24 months. Visual loss = methylprednisolone 1g IV × 3d.
Tocilizumab	162 mg SQ weekly	SQ	Steroid-sparing for GCA. GiACTA, 2017. Sustained remission with 26-week taper vs 52-week steroid-only taper. Now first-line adjunct.

⚡ Summary

Summary

ANCA Types

c-ANCA/PR3: GPA (granulomatosis with polyangiitis). p-ANCA/MPO: MPA (microscopic polyangiitis) and EGPA (eosinophilic GPA).

Induction

Pulse steroids + rituximab (PR3+/relapsing RAVE, 2010) or cyclophosphamide (severe renal/DAH). PLEX if Cr > 5.7 or DAH.

Maintenance

Rituximab 500 mg q6 months × 2 years MAINRITSAN, 2014 OR azathioprine. PCP prophylaxis (TMP-SMX) for all on immunosuppression.

GPA Classic Triad

Upper airway (sinusitis, saddle nose, bloody nasal discharge), lungs (nodules, cavitations, DAH), kidneys (RPGN, RBC casts).

Emergency

Pulmonary-renal syndrome (DAH + RPGN): life-threatening. Pulse steroids + rituximab/cyclophosphamide + PLEX. Don't wait for biopsy to treat.

Monitor Relapse

ANCA titers, Cr, UA with microscopy, CRP q3-6 months. Rising ANCA may precede clinical relapse -consider preemptive treatment.

📄 One Pager

VASCULITIS -AT A GLANCE

🔍 Classify: c-ANCA/PR3 = GPA, p-ANCA/MPO = MPA, eosinophilia = EGPA
🧪 Workup: ANCA, UA, Cr, CRP, CT chest, biopsy
⚡ Induction: Pulse steroids + rituximab (or cyclophosphamide)
🚨 Emergency: DAH/RPGN → treat before biopsy. PLEX if Cr > 5.7.
💊 Maintenance: Rituximab q6 months or azathioprine ≥ 2 years
📈 Monitor: Cr, UA, ANCA, CRP, CBC

📋 On Rounds

Why start steroids before temporal artery biopsy in suspected GCA?

Vision loss from GCA is irreversible. Anterior ischemic optic neuropathy (AION) from inflammation of the ophthalmic or posterior ciliary arteries can cause sudden permanent blindness -and once one eye is affected, the other is at high risk within days. The biopsy remains diagnostic even 2–6 weeks after starting steroids (the inflammatory infiltrate takes weeks to resolve).

What's the difference between c-ANCA/PR3 and p-ANCA/MPO and why does it matter?

c-ANCA (anti-PR3) is associated with GPA (granulomatosis with polyangiitis, formerly Wegener's) -upper/lower respiratory tract + kidneys (sinusitis, cavitary lung lesions, RPGN). p-ANCA (anti-MPO) is associated with MPA (microscopic polyangiitis) -kidneys + lungs (RPGN, pulmonary hemorrhage, no upper airway involvement) and EGPA (eosinophilic GPA, formerly Churg-Strauss) in ~50%. Why it matters

What is the ANCA-associated vasculitis treatment algorithm?

Induction: Pulse methylprednisolone 1g IV × 3 days → prednisone 1 mg/kg (max 80 mg) tapered over 6 months. PLUS rituximab 375 mg/m² weekly × 4 (preferred for PR3+/relapsing disease RAVE, 2010) OR cyclophosphamide (preferred for severe renal disease or DAH). If Cr > 5.7 or DAH → add plasmapheresis (removes pathogenic ANCA antibodies).

When do you use plasmapheresis in ANCA-associated vasculitis?

PLEX indications: (1) Severe renal failure (Cr > 5.7 mg/dL or dialysis-dependent) -though PEXIVAS, 2020 showed PLEX did NOT reduce death or ESKD overall, subgroup analysis and clinical practice still support it for dialysis-dependent patients where there may be salvageable renal function. (2) Diffuse alveolar hemorrhage (DAH) -PLEX removes pathogenic ANCA antibodies and can be life-saving in severe pulmonary hemorrhage

What is the initial treatment for suspected GCA with visual symptoms?

IV methylprednisolone 1g × 3 days IMMEDIATELY -do NOT wait for biopsy. Temporal artery biopsy can be done up to 2 weeks after starting steroids. Visual loss is often irreversible if treatment delayed even hours.

What drug has replaced cyclophosphamide as first-line induction for ANCA vasculitis?

Rituximab RAVE, 2010 -equally effective for induction with fewer side effects. Preferred in relapsing disease. Cyclophosphamide still used but carries bladder cancer, infertility, and myelosuppression risks.

What is avacopan and why is it important?

C5a receptor inhibitor ADVOCATE, 2021 -the first approved steroid-sparing agent for ANCA vasculitis. Can replace prednisone during induction (used with rituximab or cyclophosphamide). Superior sustained remission at 52 weeks.

How do you differentiate GPA from MPA?

GPA (Wegener's): upper + lower respiratory + renal. Cavitary lung nodules, sinusitis, saddle nose deformity. c-ANCA/PR3+. MPA: renal + pulmonary (DAH) without upper airway. No granulomas. p-ANCA/MPO+.

Clinical Examples

📋 Case 1, GPA (Granulomatosis with Polyangiitis)

Patient: 52M with chronic sinusitis refractory to antibiotics, new hemoptysis, and Cr rising 1.1 → 3.6 over 10 days. UA: RBC casts, proteinuria. CT chest: bilateral cavitary lung nodules.

Key findings: Classic GPA triad: upper airway (sinusitis) + lower airway (cavitary nodules, hemoptysis) + renal (RPGN with RBC casts). c-ANCA/PR3 positive.

Management:

Urgent renal biopsy, expect pauci-immune crescentic GN
Induction: rituximab 375 mg/m² weekly × 4 (preferred over cyclophosphamide for GPA) RAVE, 2010
Pulse methylprednisolone 500-1000 mg IV × 3 days → prednisone 1 mg/kg taper
Plasma exchange if severe renal involvement (Cr > 5.7) or DAH PEXIVAS, 2020
PJP prophylaxis with TMP-SMX (also prevents GPA relapse in upper airway)

Teaching point: c-ANCA/PR3 = GPA. Rituximab is now preferred over cyclophosphamide for induction in GPA, equal efficacy with better safety profile and superior for relapsing disease.

📋 Case 2, Giant Cell Arteritis with Vision Threat

Patient: 74F with new temporal headache × 2 weeks, jaw claudication, and 4 hours of monocular vision loss in right eye that resolved. ESR 98, CRP 8.4. Temporal artery tender and non-pulsatile.

Key findings: GCA with amaurosis fugax, ophthalmologic emergency. If untreated, permanent bilateral blindness occurs in 20% within days. ESR > 50 + age > 50 + new headache + jaw claudication = high probability.

Management:

IV methylprednisolone 1g daily × 3 days (vision-threatening GCA = IV steroids STAT)
Then prednisone 1 mg/kg daily with slow taper over 12-18 months
Temporal artery biopsy within 2 weeks (steroids do not alter biopsy for 10-14 days, do NOT delay steroids for biopsy)
Urgent ophthalmology consult
Tocilizumab 162 mg SQ weekly as steroid-sparing agent GiACTA, 2017

Teaching point: Never delay steroids in suspected GCA to wait for biopsy. Permanent blindness is the feared complication, treat first, biopsy second. Tocilizumab is now standard steroid-sparing therapy.

📋 Case 3, Eosinophilic Granulomatosis with Polyangiitis (EGPA)

Patient: 38F with severe asthma (diagnosed age 30), new peripheral neuropathy (foot drop), purpuric rash on lower extremities, eosinophils 4,200/μL. p-ANCA/MPO positive. CT chest: patchy GGOs.

Key findings: EGPA (Churg-Strauss): late-onset asthma + eosinophilia (> 1500) + extra-pulmonary organ involvement (mononeuritis multiplex, skin). Five-Factor Score determines prognosis.

Management:

Prednisone 1 mg/kg daily (first-line for EGPA)
If poor prognostic factors (cardiac, GI, renal, CNS involvement): add cyclophosphamide or rituximab
Mepolizumab 300 mg SQ q4 weeks (anti-IL-5, FDA-approved for EGPA, steroid-sparing) MIRRA, 2017
EMG/NCV to characterize neuropathy; neurology consult
Echocardiogram, cardiac involvement is the #1 cause of death in EGPA

Teaching point: EGPA is the one ANCA vasculitis with asthma and eosinophilia. Cardiac involvement (myocarditis, pericarditis) occurs in ~60% and is the leading cause of mortality, always get an echo.

📣 Sample Presentation

One-Liner

"Mr. O'Connell is a 58-year-old presenting with hemoptysis, RPGN (Cr rising 1.2→4.8 in 4 days), and CT showing bilateral GGO. c-ANCA positive, anti-PR3 positive. Consistent with GPA (granulomatosis with polyangiitis)."

Key Points to Cover on Rounds

GPA with pulmonary-renal syndrome -c-ANCA/PR3+. Cr 4.8 (RPGN -UA showing RBC casts). CT chest: bilateral GGO (DAH). Hemoptysis -life-threatening. Treatment: (1) pulse methylprednisolone 1g IV × 3 days, (2) rituximab 375 mg/m² weekly × 4 weeks RAVE, 2010 (preferred for PR3+ -lower relapse rate than cyclophosphamide for relapsing disease), (3) emergent plasmapheresis initiated (Cr >5.7 or DAH → PLEX indicated). Biopsy: renal biopsy scheduled but NOT delaying treatment. Plan: daily Cr, Hgb, CXR for DAH monitoring. PCP prophylaxis with TMP-SMX. Hepatitis B/TB screening (before rituximab infusion #2).

Monitoring in Hospice

Parameter	Approach	Notes
Symptom assessment	Each visit (RN 1-3x/week)	Pain, dyspnea, nausea, anxiety, delirium -use validated scales
Functional status	Weekly	PPS trending. Declining PPS confirms trajectory. Document for recertification
Medication review	Each visit	Are comfort meds working? Side effects? Need dose adjustment? Route change needed?
Caregiver assessment	Each visit	Burnout, coping, need for respite care, bereavement risk assessment
Labs	Generally NOT indicated	Labs rarely change management in hospice. Only draw if result will change comfort plan
Recertification	90 days, 90 days, then 60-day periods	Two physicians must certify continued eligibility. Document ongoing decline

Less is more in hospice monitoring. Stop checking labs that won't change management. Focus on symptoms, comfort, and family support -not numbers.

📄 One Pager

Rheumatology · One Pager

ANCA Vasculitis

c-ANCA/PR3 = GPA. p-ANCA/MPO = MPA/EGPA. Induction: steroids + rituximab or cyclophosphamide. PLEX for DAH or Cr > 5.7. Maintenance: rituximab q6 months.

🧪 Types

GPA (granulomatosis with polyangiitis): upper airway + lungs + kidneys. c-ANCA/PR3. MPA (microscopic polyangiitis): kidneys + lungs (no granulomas). p-ANCA/MPO. EGPA: asthma + eosinophilia + vasculitis. p-ANCA/MPO.

🚨 Induction

Pulse methylprednisolone 1g × 3d → prednisone taper. Rituximab 375 mg/m² × 4 weeks RAVE, 2010 (PR3+/relapsing) OR cyclophosphamide (severe renal/DAH). PLEX if Cr > 5.7 or DAH.

💊 Maintenance

Rituximab 500 mg q6 months × 2 years MAINRITSAN, 2014 OR azathioprine. PCP prophylaxis (TMP-SMX). Calcium + vitamin D. Screen for TB/HBV before rituximab.

💊 Key Drugs

Methylprednisolone1g IV × 3d

Rituximab375 mg/m² weekly × 4

Cyclophosphamide15 mg/kg q2wk × 3 then q3wk

TMP-SMXDS daily (PCP prophylaxis)

⚠️ Pitfalls

Waiting for biopsy to start treatment (life-threatening disease -treat empirically)
Missing pulmonary-renal syndrome (DAH + RPGN = emergent)
Not starting PCP prophylaxis on immunosuppression
Missing relapse (monitor ANCA titers, Cr, UA q3-6 months)