Sit upright; oxygen only if SpO₂ <90% (target ≥90%) — routine high-flow O₂ not indicated; IV access + monitoring; GTN + IV furosemide; start CPAP/BiPAP early if SpO₂ <90% or RR >25 despite O₂; treat arrhythmia/ischaemia.
Sit upright +Oxygen only if SpO₂ <90% (target ≥90%); routine high-flow O₂ not indicated; continuous oximeter
✓
Initial orders:Furosemide 40 mg IV + Nitroglycerin (paste/IV) + O₂ if SpO₂ <90%; CXR, ECG, ABG. Natriuretic peptides aid diagnosis when uncertain (rule-out BNP <100, NT-proBNP <300 pg/mL) — but never delay treatment to wait for them in florid pulmonary edema. Morphine no longer routine
✓
Move clock 15–30 min:if urine made → improving. If NOT → check response at 2 h (urine output / spot urine Na); if inadequate, double the IV dose — do not redose blindly; recheck vitals q15–30 min
✓
Most useful test = ECG→ if arrhythmia (VT/AFib/flutter) causing it → immediate synchronized cardioversion
✓
Still not responding to preload reduction:add IV nitroglycerin; consult cardiology + critical care (CCS)
✓
Max preload Rx + persistent hypoxia → ICU:Persistent hypoxia despite NIV → intubation. Inotropes (dobutamine) only if SBP <90 mm Hg WITH hypoperfusion; norepinephrine if shock
✓
Order set
Sit up; O₂ only if SpO₂ <90%
IV furosemide
GTN (paste/IV/infusion)
ECG + troponin
CXR portable
ABG/VBG
U&E, BNP/NT-proBNP (rule-out <100 / <300 pg/mL)
Monitor
0 minO₂, furosemide, nitrate; ECG, ABG
15–30 minUrine output + vitals; re-dose loop if no urine
1 hReassess oxygenation; escalate NIV → intubation if failing; dobutamine only if SBP <90 + hypoperfusion
2–6 hFluid balance, electrolytes, response
Escalate / ICU
Persistent hypoxia despite max preload reduction
Needs inotrope/vasopressor (only if SBP <90 mm Hg with hypoperfusion)
NIV (CPAP/BiPAP) failure
Rising PaCO₂ / exhaustion → intubate
Cardiogenic shock
Criteria
AdmitAll acute pulmonary oedema
ICURefractory hypoxia, shock, or NIV failure
IntubateExhaustion, ↓GCS, or refractory hypoxaemia despite NIV
DoseSL 400 mcg spray/tablet; IV 10–200 mcg/min infusion
Preparation50 mg in 250 mL D5W (200 mcg/mL) in glass bottle/non-PVC set; start 10 mcg/min, titrate q5 min
MonitorOnly if SBP >110 mm Hg; avoid with PDE5 inhibitors, RV infarction, severe aortic stenosis; BP, headache; tolerance after 24 h — nitrate-free interval
0.9% Sodium chloridecrystalloid
DoseFluids are NOT routine in cardiogenic pulmonary edema — avoid IV fluids unless true hypovolemia (e.g., RV infarct, over-diuresis); consider fluid restriction 1.5–2 L/day in dilutional hyponatremia
Preparation500/1000 mL bags; add KCl only after urine output confirmed
Combine ACE inhibitor with ARB (no benefit, ↑ harm)
Order a cardiology consult on a single-answer CHF question
Key
Mortality ↓: ACEi/ARB, β-blocker, spironolactone/eplerenone (SGLT2i now added).
HFpEF (preserved EF): SGLT2 inhibitor is Class 2a to reduce HF hospitalizations (empagliflozin 10 mg OD — EMPEROR-Preserved; dapagliflozin — DELIVER); manage congestion with diuretics and treat comorbidities (HTN, AF). Non-DHP CCB: avoid in HFrEF.
Clinical detail — differentials, red flags, pitfalls, disposition
Oxygen only if SpO₂ <90% (not routine); IV access, continuous ECG; aspirin + 2nd antiplatelet; analgesia; activate reperfusion.
Calculators:
Initial orders:ECG (≤10 min) + Troponin; Aspirin 162–325 mg chewed immediately, then 75–100 mg daily + Nitroglycerin SL (morphine only for refractory pain — not routine)
✓
Add 2nd antiplatelet:ticagrelor or prasugrel preferred over clopidogrel — DAPT unless high bleeding risk or on oral anticoagulation (then individualize)
✓
Give also:β-blocker (metoprolol) — avoid if cardiogenic shock, acute HF, bradycardia, hypotension, or high-grade AV block; ACE inhibitor; high-intensity statin (atorvastatin 80 mg or rosuvastatin 20–40 mg); anticoagulation in both STEMI and NSTEMI — agent per reperfusion strategy (UFH with PCI/fibrinolysis; enoxaparin/fondaparinux in NSTEMI)
✓
STEMI — reperfuse:Primary PCI preferred: FMC-to-device ≤90 min (≤120 min if transfer needed). If not achievable → fibrinolysis (tenecteplase preferred) up to 12 h from onset, door/FMC-to-needle ≤30 min, then routine angiography 2–24 h (pharmacoinvasive)
✓
Fibrinolysis only for:STEMI (or true STEMI-equivalent — Sgarbossa/modified Sgarbossa criteria with clinical correlation in LBBB/paced rhythm) — NOT for NSTEMI. New LBBB alone is NOT an automatic STEMI equivalent.
✓
Decision tree
STEMI criteria (incl. Sgarbossa if LBBB/paced)?
Yes
PCI available within 120 min?
Yes
Primary PCI (door-to-balloon <90 min)
No
Thrombolysis ≤12 h (door-to-needle <30 min), then transfer for PCI
TransfuseHospitalized AMI: transfusion to ~10 g/dL reasonable (2025 ACS guideline 2b, MINT; AABB 2025) — not restrictive 7–8
DischargeReperfused/pain-free, no arrhythmia, EF assessed, secondary prevention + rehab
Never
Give thrombolytics for NSTEMI
Delay aspirin — give immediately, chewed
Key
High-sensitivity troponin is the preferred biomarker — 0/1-h or 0/2-h rule-out algorithms; myoglobin/CK-MB no longer routine (CK-MB only for suspected reinfarction).
Posterior ECG V7–V9 when posterior MI suspected; right-sided ECG V3R–V4R in inferior STEMI.
Radial access preferred for PCI.
Immediate bedside echo if shock or mechanical complication (papillary muscle rupture, VSD, free-wall rupture).
NSTEMI risk-tiered angiography (<2 h very-high-risk, ≤24 h high-risk).
Clinical detail — differentials, red flags, pitfalls, disposition
Rate control:Metoprolol (↑ diastolic filling time); diuretic for congestion; AF in rheumatic MS → anticoagulate with warfarin (INR 2–3) — DOACs contraindicated (INVICTUS)
✓
Definitive:Balloon valvuloplasty (safe in pregnancy) → surgical repair/replacement if unsuitable
✓
Order set
Echo
ECG (AF/LA enlargement)
CXR
Anticoagulate if AF — warfarin (INR 2–3); DOACs NOT indicated in rheumatic MS (INVICTUS)
Criteria
AdmitDecompensation, new AF, haemoptysis
DischargeRate-controlled, anticoagulated with warfarin if AF, valvuloplasty referral
Key
Worsens with tachycardia/pregnancy (less diastolic filling time).
AF with moderate–severe rheumatic MS → vitamin-K antagonist (warfarin, INR 2–3). DOACs are contraindicated in rheumatic MS (2020 ACC/AHA VHD Class 1; INVICTUS).
Clinical detail — differentials, red flags, pitfalls, disposition
DoseLoad 5 mg OD ×2 d then INR-guided; target INR 2–3 (valves may differ)
Preparation0.5/1/3/5 mg tablets — colour-coded
MonitorINR q2–3 d until stable; diet consistency, interactions (amiodarone, antibiotics)
📖 ESC/EACTS Valvular Heart DiseaseReviewed July 2026
6. Atrial Fibrillation
EMERGENCY▸
Irregularly irregular pulse, no P waves, rapid rate
Calculators:
Unstable (chest pain, CHF, ↓SBP, confusion) →Immediate synchronized cardioversion (AF/AFL: begin at 200 J biphasic)
✓
Stable → rate control (or early rhythm control):β-blocker (metoprolol) OR CCB (diltiazem/verapamil) OR digoxin. Early rhythm control (within 12 months of diagnosis) reduces cardiovascular outcomes in selected patients (EAST-AFNET 4, Class 2a); catheter ablation is Class 1 first-line rhythm control in selected patients (younger, few comorbidities, HFrEF)
✓
Anticoagulate by CHA₂DS₂-VASc:men ≥1 / women ≥2 → consider; men ≥2 / women ≥3 → DOAC (apixaban/rivaroxaban/dabigatran) preferred over warfarin. Aspirin NOT recommended for stroke prevention
Anticoagulate for AF <48 h before cardioversion without TEE
Chemically convert before controlling rate
Key
Early rhythm control (≤12 months of diagnosis) reduces cardiovascular outcomes in selected patients (EAST-AFNET 4); rate control remains appropriate for many.
Catheter ablation is Class 1 first-line rhythm control in selected patients; LAA occlusion (Class 2a) if long-term anticoagulation contraindicated.
Pre-excited AF (WPW + AF) → procainamide or ibutilide; avoid AV-nodal blockers (see case 7).
Clinical detail — differentials, red flags, pitfalls, disposition
SVT (stable):Vagal / carotid massage → Adenosine 6 mg → 12 mg IV push → if fails, diltiazem/verapamil IV bolus
✓
VT (stable, normal BP):IV procainamide or amiodarone 150 mg IV over 10 min (co-equal — PROCAMIO favored procainamide; sotalol removed from 2025 AHA algorithm)
DoseBradycardia: 1 mg IV q3–5 min (max 3 mg). Organophosphate: 1–2 mg IV bolus, double q5 min until secretions dry, then infusion 10–20% of loading dose/h
MonitorHb in 2–4 wk (reticulocytes by day 7); GI upset, black stools — counsel
Ferric carboxymaltoseIV iron
Dose500–1000 mg IV over 15–30 min (intolerance/non-response to oral; preferred in IBD/CKD/bariatric surgery or ongoing blood loss)
PreparationDilute 1000 mg in 250 mL NS, infuse with observation
MonitorPhosphate (transient ↓), hypersensitivity; Hb at 4–8 wk
Transfusion thresholdsupportive
DoseTransfuse only if Hb very low + symptomatic/cardiac — iron repletion is the fix
PreparationCrossmatch, give 1 unit then reassess
MonitorHb increment ~10 g/L per unit
📖 BSH Iron DeficiencyReviewed July 2026
2. Thalassemia
STABLE▸
Microcytic, target cells, NORMAL iron studies; ethnicity
Most accurate:Hemoglobin electrophoresis (↑HbA₂/HbF in β-thalassemia)
✓
Minor → none. Major →chronic transfusion + iron chelation (deferasirox/deferoxamine); luspatercept reduces transfusion burden in transfusion-dependent β-thalassemia
✓
Order set
FBC, film
Hb electrophoresis/HPLC
Iron studies (to exclude deficiency)
Criteria
AdmitSevere anaemia / aplastic or haemolytic crisis
TransfuseSymptomatic anaemia per programme
DischargeStable Hb, transfusion/chelation plan
Never
Give iron
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Transfusion-dependent anaemia
Iron overload signs
Differentials
Iron deficiency
Sideroblastic anaemia
Common mistakes
Giving iron unnecessarily
Missing coexisting deficiency
Disposition & follow-up
Genetic counselling; major → transfusion + chelation program.
Discharge package
MedicationsFolate; chelation if iron-loaded
Follow-upHaematology programme
VaccinationPer hyposplenism if splenectomised
Warning symptomsWorsening anaemia symptoms
💊 Treatment detail — doses & preparation
Chronic transfusionsupportive
DoseRegular PRBC to maintain Hb ~90–105 g/L (thalassaemia major)
PreparationCrossmatched, leucodepleted units
MonitorIron loading tracked by ferritin/MRI
Deferasiroxiron chelator
Dose10–30 mg/kg OD (transfusion overload)
Preparation90–360 mg tablets on empty stomach
MonitorCreatinine, LFTs monthly; GI upset, rash
Folic acidvitamin
Dose5 mg OD (deficiency/methotrexate cover — give on non-MTX days)
Treat:Cyanocobalamin 1000 µg IM daily×1 wk → weekly×4 → monthly (lifelong if pernicious)
✓
Order set
B12, folate
MMA/homocysteine
FBC, film
Intrinsic factor/parietal antibodies
Criteria
AdmitSevere anaemia or neuro compromise
TransfuseRarely; only if severe symptomatic
DischargeReplacement started, cause identified, neuro monitored
Never
Give folate alone — corrects anemia but NOT neuro damage; replace B12 first
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Subacute combined degeneration
Pancytopenia
Differentials
Folate deficiency
Diabetic neuropathy
MDS
Common mistakes
Folate before B12 (worsens neuro)
Missing pernicious anaemia
Disposition & follow-up
IM B12 replacement; treat cause; monitor response.
Discharge package
MedicationsMaintenance B12 (IM/oral); folate if co-deficient
Follow-upRecheck response; lifelong if pernicious
Warning symptomsWorsening neuropathy, imbalance
💊 Treatment detail — doses & preparation
Cyanocobalamin (B12)vitamin
Dose1000 mcg IM daily ×1 wk → weekly ×4 → monthly lifelong (pernicious/neuro)
Preparation1000 mcg/mL ampoule IM
MonitorReticulocytes day 5–7, K⁺ (can fall early); never give folate alone first
Folate cautionsafety
DoseNever give folic acid alone before B12 corrected — worsens neurology
Preparation—
MonitorReticulocyte rise day 5–7 confirms response
📖 BSH Cobalamin & FolateReviewed July 2026
4. Sickle Cell Crisis
ICU / RESUS▸
Severe bone/chest/back pain; fever; noncompliant with hydroxyurea
ABCDE
Analgesia FIRST (within 30–60 min of triage); O₂ only if hypoxic (SpO₂ <95% or below baseline); IV fluids only if hypovolemic — target euvolemia, avoid overload (ACS/pulmonary oedema risk); septic screen if febrile; watch for chest syndrome → exchange.
FIRST — before anything else:Analgesia first (within 30–60 min of triage); O₂ only if hypoxic; IV fluids only if hypovolemic (euvolemia goal, avoid overload); antibiotics for fever
✓
Then:Analgesia (opioids)
✓
Acute chest syndrome not responding (worsening hypoxia) →Exchange transfusion (fastest)
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Severe hemolysis with hemoglobinuria
AKI
Differentials
Autoimmune hemolysis
Other oxidative hemolysis
Common mistakes
Assaying during acute hemolysis (false normal)
Re-exposing to oxidant
Disposition & follow-up
Avoid triggers; supportive; genetic counselling.
Discharge package
Medications—
Follow-upCounselling on triggers
LifestyleAvoid oxidant drugs/fava beans
Warning symptomsDark urine, pallor, jaundice after trigger
💊 Treatment detail — doses & preparation
Stop oxidantsdefinitive
DoseWithdraw the trigger: primaquine, rasburicase, sulfa, nitrofurantoin, fava beans
Preparation—
MonitorSelf-limiting once trigger stopped; transfuse only if severe
📖 BSH / WHO G6PDReviewed July 2026
7. Paroxysmal Nocturnal Hemoglobinuria
URGENT▸
Hemolysis + thrombosis (DVT) + pancytopenia; dark morning urine
Most accurate:Flow cytometry — CD55 / CD59 deficient
✓
Treat:Eculizumab — or ravulizumab (long-acting C5, q8 wk, often preferred) — vaccinate against meningococcus first; pegcetacoplan (C3 inhibitor) an option for breakthrough hemolysis; anticoagulate thrombosis
DoseDaily PLEX (1–1.5 plasma volumes) until platelets >150 ×2 d
PreparationCentrifugal line, FFP replacement
MonitorADAMTS13 level, platelets daily
Prednisone (ITP/AIHA)corticosteroid
Dose1 mg/kg OD until platelets/Hb recover, then slow taper over weeks
PreparationTablets with food
MonitorGlucose, BP, mood; bone + gastric protection if prolonged
Rituximabanti-CD20
Dose375 mg/m² IV weekly ×4 (ITP/AIHA/cold agglutinin)
PreparationDilute in NS to 1–4 mg/mL; slow ramped infusion with premedication (paracetamol/antihistamine/steroid)
MonitorInfusion reactions (first dose), hepatitis B reactivation — screen first
Platelets contraindicatedsafety
DoseDo NOT transfuse platelets in TTP (microthrombi) unless life-threatening bleed
Preparation—
MonitorCaplacizumab add-on per haematology
📖 BSH TTP & HUSReviewed July 2026
9. Immune Thrombocytopenic Purpura
URGENT▸
Isolated ↓platelets, mucocutaneous bleeding; diagnosis of exclusion
Asymptomatic >30k →observe
✓
Treat:Dexamethasone 40 mg PO ×4 d PREFERRED (ASH 2019); or prednisone 1 mg/kg, ≤6–8 wk max including taper (↓ macrophage affinity for platelets)
✓
Active bleeding / very low →IVIG 1 g/kg (works fastest)
✓
Chronic →TPO receptor agonists (eltrombopag/romiplostim) generally preferred before splenectomy; rituximab; defer splenectomy ≥1 year from diagnosis (ASH 2019)
✓
Order set
FBC, film
Exclude pseudothrombocytopenia
HIV/HCV/H. pylori screen
Criteria
AdmitBleeding or platelets very low
ICUMajor/intracranial bleeding
TransfusePlatelets only for life-threatening bleeding + IVIG/steroids
DischargePlatelets safe, bleeding stopped, on therapy + follow-up
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Mucosal/intracranial bleeding
Platelets <10–20k
Differentials
TTP/HUS
Drug-induced
Marrow failure
DIC
Common mistakes
Missing secondary causes
Over-treating asymptomatic mild ITP
Disposition & follow-up
Steroids/IVIG per severity; haematology follow-up.
Dose1 mg/kg OD until platelets/Hb recover, then slow taper over weeks
PreparationTablets with food
MonitorGlucose, BP, mood; bone + gastric protection if prolonged
IVIGimmunoglobulin
Dose1 g/kg/day ×2 d (ITP bleeding, GBS total 2 g/kg over 2–5 d)
Preparation50/100 mL ready bottles; start slow (30 mL/h), escalate per tolerance
MonitorHeadache/aseptic meningitis, renal function, thrombosis; live vaccines after
Tranexamic acidantifibrinolytic
Dose1 g IV/PO TDS (bleeding in VWD/haemophilia adjunct, menorrhagia)
Preparation500 mg tablets; IV 1 g in 50 mL NS over 10 min
MonitorAvoid with PCC/combined hormonal contraception (thrombosis); haematuria caution (clot colic)
Thrombopoietin agonistsecond-line
DoseEltrombopag 50 mg OD (romiplostim SC weekly alternative) for chronic ITP
PreparationTablets on empty stomach (chelates with Ca²⁺/dairy)
MonitorPlatelets weekly during titration; LFTs
📖 ASH / BSH ITPReviewed July 2026
10. Von Willebrand Disease
URGENT▸
Mucosal bleeding, ↑aPTT, ↑bleeding time, normal platelets
Confirm:VWF antigen + ristocetin cofactor
✓
Minor / type 1 →Desmopressin (DDAVP) 0.3 µg/kg (releases stored VWF) — contraindicated in type 2B; tranexamic acid useful adjunct for mucosal bleeding/menorrhagia
✓
Major →VWF / Factor VIII concentrate
✓
Order set
VWF antigen + activity
Factor VIII
FBC, coags
Blood group (type O lower VWF)
Criteria
AdmitSignificant bleeding
TransfuseVWF/FVIII concentrate for major bleed
DischargeBleeding controlled, prophylaxis/plan for procedures
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Significant procedural/menstrual bleeding
Differentials
Haemophilia
Platelet function disorder
Common mistakes
Relying on bleeding time
Missing acquired VWD
Disposition & follow-up
DDAVP trial; VWF concentrate for major bleeds; haematology.
Discharge package
MedicationsDDAVP/VWF plan for bleeds/procedures
Follow-upHaematology; pre-procedure planning
Warning symptomsProlonged/heavy bleeding
💊 Treatment detail — doses & preparation
DDAVP (haemostasis)VWF releaser
Dose0.3 mcg/kg IV (max 20 mcg) over 30 min — type 1 VWD/mild haemophilia A
PreparationDilute in 50 mL NS; test-dose response before reliance
MonitorNa⁺, fluid restriction 24 h; tachyphylaxis with repeated doses
Factor VIII concentratefactor replacement
DoseDose = weight × desired % rise × 0.5; major bleed target 100% then 50% ×3–7 d
PreparationReconstitute vial with supplied diluent; slow IV push
MonitorFactor level post-dose; inhibitor screen if no response
Tranexamic acidantifibrinolytic
Dose1 g IV/PO TDS (bleeding in VWD/haemophilia adjunct, menorrhagia)
Preparation500 mg tablets; IV 1 g in 50 mL NS over 10 min
MonitorAvoid with PCC/combined hormonal contraception (thrombosis); haematuria caution (clot colic)
📖 ASH-ISTH-NHF-WFH VWDReviewed July 2026
11. Clotting Factor Deficiency (Hemophilia)
URGENT▸
↑aPTT, normal PT; hemarthrosis / deep bleeds; X-linked male
Order first:Mixing study (corrects) → then Factor VIII (A) / IX (B) assay
✓
Treat:Factor VIII / IX concentrate to target level; mild A → DDAVP
✓
Order set
aPTT, PT
Mixing study
Factor VIII/IX assay
Criteria
AdmitSignificant/deep/CNS bleed
ICUCNS bleed, airway/compartment
TransfuseFactor replacement to target; blood if major loss
DischargeBleed controlled, factor plan, haemophilia centre
Key
Factor level must drop 70–80% before aPTT even rises.
Emicizumab prophylaxis is now standard for hemophilia A (with or without inhibitors) — aPTT and FVIII one-stage assays are unreliable on emicizumab (use chromogenic); treat breakthrough bleeds with factor per inhibitor status (WFH 2020).
Clinical detail — differentials, red flags, pitfalls, disposition
DoseDose = weight × desired % rise × 0.5; major bleed target 100% then 50% ×3–7 d
PreparationReconstitute vial with supplied diluent; slow IV push
MonitorFactor level post-dose; inhibitor screen if no response
DDAVP (haemostasis)VWF releaser
Dose0.3 mcg/kg IV (max 20 mcg) over 30 min — type 1 VWD/mild haemophilia A
PreparationDilute in 50 mL NS; test-dose response before reliance
MonitorNa⁺, fluid restriction 24 h; tachyphylaxis with repeated doses
Tranexamic acidantifibrinolytic
Dose1 g IV/PO TDS (bleeding in VWD/haemophilia adjunct, menorrhagia)
Preparation500 mg tablets; IV 1 g in 50 mL NS over 10 min
MonitorAvoid with PCC/combined hormonal contraception (thrombosis); haematuria caution (clot colic)
Factor IX (haemophilia B)replacement
DoseDose = weight × desired % rise × 1; target 100% for major bleeds/surgery
PreparationReconstitute, slow IV push
MonitorFactor level; inhibitor screen
📖 WFH HaemophiliaReviewed July 2026
12. Thrombophilia / DVT / HIT
URGENT▸
Unilateral leg swelling/pain
Calculators:
Best initial:Lower-extremity duplex ultrasound
✓
Treat DVT:DOAC first-line — apixaban 10 mg BD ×7 d → 5 mg BD, or rivaroxaban 15 mg BD ×21 d → 20 mg OD (no LMWH bridge). LMWH→warfarin (INR 2–3) if DOAC unsuitable (antiphospholipid syndrome, mechanical valve, severe renal failure CrCl <15–30); 3 mo if provoked, then reassess (ASH 2020; AHA/ACC 2026)
✓
HIT (platelets ↓>50% day 5–10 + thrombosis) →STOP all heparin → Argatroban/fondaparinux; a DOAC (rivaroxaban/apixaban) is an accepted alternative in stable HIT (ASH 2018)
✓
Order set
Duplex ultrasound
D-dimer (if low pretest)
FBC (platelet trend)
Baseline coags
Criteria
AdmitExtensive VTE, PE, or HIT with thrombosis
ICUMassive PE
DischargeAnticoagulated, HIT agent if applicable, duration defined
Never
Order thrombophilia workup for a first clot
Give warfarin alone in acute HIT (→ skin necrosis)
Thrombophilia testing during the acute event or on anticoagulation (unreliable)
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Signs of PE
Phlegmasia
HIT with thrombosis
Differentials
Cellulitis
Ruptured Baker cyst
Post-thrombotic syndrome
Common mistakes
Thrombophilia testing for first provoked clot
Warfarin alone in acute HIT
Disposition & follow-up
Anticoagulate; HIT → non-heparin agent; provoked VTE 3 months.
Discharge package
MedicationsAnticoagulation (duration per provocation); non-heparin agent in HIT
Follow-upAnticoagulation clinic; review at 3 months
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Rising ACR
Foot ulcer
Rapid eGFR decline
Differentials
—
Common mistakes
Combining ACEi+ARB
Neglecting foot/eye screening
Disposition & follow-up
BP <130/80, statin, ACEi for albuminuria; annual screening.
Discharge package
MedicationsACEi for albuminuria, statin, BP control; SGLT2i for CKD with ACR ≥30 or HF; finerenone for T2D + CKD (albuminuria despite ACEi/ARB, eGFR ≥25) — ADA 2026/KDIGO 2024
Follow-upAnnual eye/foot/renal screening
VaccinationInfluenza, pneumococcal
LifestyleGlycaemic + BP + lipid targets, foot care
A-B secure; large-bore IV, NS bolus if shocked; check K⁺ before insulin; monitor + catheter; treat precipitant.
Diagnosis (2024 Int'l Consensus)
Glucose ≥200 mg/dL (or known diabetes regardless of glucose) + β-hydroxybutyrate (BOHB) ≥3.0 mmol/L — venous/capillary BOHB preferred over urine ketones — + pH <7.30 and/or HCO₃ <18; anion gap only supportive if ketones unavailable; severe = BOHB >6.0 mmol/L
Calculators:
FIRST:Normal saline bolus (fluids) — pH/bicarbonate matter more than glucose
✓
Check K⁺ BEFORE insulin:K <3.3 → replace K first & hold insulin; 3.3–5.2 → add K to fluids; >5.2 → monitor
✓
Start:IV regular insulin continuous drip 0.1 U/kg/h (effect within 30 min; if none → re-bolus NS + insulin)
✓
When glucose <250 mg/dL →add dextrose and reduce infusion to 0.05 U/kg/h; continue until resolution = glucose <200 mg/dL AND venous pH >7.3 AND/OR bicarb ≥18 AND BOHB <0.6 mmol/L — anion gap is no longer a resolution criterion
✓
Bicarbonate:NOT recommended in DKA at any pH (no benefit on resolution, LOS, or outcomes; worsens hypokalemia — 2024 Int'l Consensus, ADA 2026)
✓
Decision tree
K⁺ before insulin?
K⁺ <3.3
Hold insulin; replace K⁺ first
K⁺ 3.3–5.2
Add K⁺ to fluids; start insulin
K⁺ >5.2
Start insulin; monitor, replace K⁺ when it falls
Order set
VBG/ABG
Glucose, serum/POC β-hydroxybutyrate (BOHB — not urine ketones)
Stopping insulin before resolution/basal SC overlap
Bicarbonate routinely
Disposition & follow-up
HDU/ICU if severe; transition to SC insulin when resolved.
Discharge package
MedicationsResume/adjust insulin; sick-day rules
Follow-upDiabetes team review
LifestyleNever omit insulin; ketone monitoring when unwell
Warning symptomsVomiting, high glucose/ketones, drowsiness
💊 Treatment detail — doses & preparation
0.9% Sodium chloridecrystalloid
DoseBolus 500 mL over 15–30 min, reassess; maintenance 1–1.5 mL/kg/h
Preparation500/1000 mL bags; add KCl only after urine output confirmed
MonitorHyperchloraemic acidosis with large volumes — prefer balanced (LR) for resuscitation
Insulin regular IV (Actrapid)DKA infusion
Dose0.1 U/kg/h IV (0.05 if mild); never <1 U/h until acidosis resolves; add early basal insulin 0.15–0.3 U/kg alongside infusion; when glucose <250 mg/dL → add dextrose & reduce to 0.05 U/kg/h; stop only at resolution (BOHB <0.6 + pH >7.3/HCO₃ ≥18 + glucose <200) after basal SC overlap 1–2 h (2–4 h per ADA 2026). Mild uncomplicated DKA: SC rapid-acting insulin q1–2h is an alternative (non-ICU)
Preparation50 units in 50 mL NS (1 U/mL) via syringe pump; prime line (insulin binds plastic)
MonitorGlucose hourly, K⁺ q2–4 h — shift drops K⁺; never stop before ketones cleared
Potassium chlorideelectrolyte
DosePO 40–100 mmol/day divided. IV: 10 mmol/h peripheral, 20 mmol/h central with cardiac monitor
PreparationIV: NEVER undiluted push — 10 mmol in 100 mL or 40 mmol/L bag via pump
MonitorK⁺ q4–6 h during replacement, ECG, urine output >0.5 mL/kg/h
Dextrose 10% infusionhypoglycaemia/ALF
Dose100–200 mL/h of 10% titrated to glucose 5–8 mmol/L
Preparation500 mL/1 L bags; give with thiamine in at-risk patients
MonitorCapillary glucose q1–2 h in liver failure
📖 2024 Int'l DKA Consensus (Umpierrez) + ADA SoC 2026 §16Reviewed July 2026
4. Hypothyroidism
STABLE▸
Fatigue, cold, weight gain, constipation, hyponatremia
Confirm:Free T4 low + TSH high (Hashimoto → anti-TPO)
✓
Treat:Levothyroxine 1.6 µg/kg/day PO empty stomach; start low (25–50 µg) in elderly/CAD; recheck TSH q6wk
✓
Myxedema coma →IV levothyroxine + hydrocortisone (rule out adrenal insufficiency first — adrenal crisis can occur with ANY glucocorticoid route incl. inhaled/topical); passive rewarming + treat precipitant
✓
Order set
TSH, free T4
Anti-TPO
Lipids, FBC
Cortisol if adrenal concern
Criteria
AdmitMyxoedema coma
ICUMyxoedema coma (hypothermia, ↓GCS, shock)
VasopressorsRefractory hypotension in myxoedema
DischargeLevothyroxine started, stable, TSH recheck plan
Clinical detail — differentials, red flags, pitfalls, disposition
Dose2.5–15 mg/day divided (alternative; preferred if pregnancy planned)
Preparation2.5 mg tablets with food
MonitorNausea, orthostasis, impulse control
📖 Endocrine Society HyperprolactinaemiaReviewed July 2026
4
Neurology
1. Stroke (Ischemic)
ICU / RESUS▸
Sudden focal deficit; ↑BP
ABCDE
Airway/O₂; glucose; non-contrast CT; BP within limits; thrombolysis/thrombectomy clock.
Calculators:
First — before any anticoagulation:Head CT WITHOUT contrast (exclude hemorrhage) within 15 min; + CBC, PT/aPTT, ECG
✓
Control BP:labetalol / nicardipine — BP must be <185/110 mm Hg before IV thrombolysis; maintain ≤180/105 for 24 h after IVT (AHA/ASA 2026)
✓
If within window →IV thrombolysis for disabling deficits ≤4.5 h: alteplase 0.9 mg/kg (max 90 mg) OR tenecteplase 0.25 mg/kg IV single bolus (max 25 mg) — co-equal Class 1 (TNK 0.4 mg/kg NOT recommended — harm); minor non-disabling stroke within 4.5 h → DAPT ×21 days, NOT thrombolysis; extended-window IVT 4.5–9 h / wake-up with DWI-FLAIR or perfusion mismatch (Class 2a); LVO → thrombectomy ≤24 h (Class 1 large-core ASPECTS 3–5, 2a ASPECTS 0–2; basilar occlusion NIHSS ≥10 ≤24 h now Class 1)
✓
If after 4.5 h / no tPA →Aspirin (give after 24 h if tPA given); statin; workup carotid US + echo
✓
Decision tree
Haemorrhage on CT?
Yes
Haemorrhage pathway — reverse anticoagulation, BP control, neurosurgery referral
No
Within 4.5 h and no contraindication?
Yes
Thrombolysis; assess for thrombectomy if large-vessel occlusion (≤24 h)
No
Aspirin, admit to stroke unit; thrombectomy if LVO in window
Order set
Non-contrast CT head ≤15 min
Glucose
BP control (thresholds)
FBC, coags
ECG
Swallow screen
Suspected LVO → direct transport to EVT-capable center
DoseStroke: 0.9 mg/kg (max 90 mg) — 10% bolus, 90% over 1 h. Massive PE: 100 mg over 2 h (or 50 mg bolus in arrest)
PreparationReconstitute 50 mg vial with 50 mL sterile water (1 mg/mL); dedicate a line
MonitorBP <185/110 pre-lysis, ≤180/105 ×24 h post-lysis; neuro exam q15 min ×2 h; no antiplatelets ×24 h; adjuvant argatroban/eptifibatide with IVT not recommended
Tenecteplase (TNK)thrombolytic — co-equal Class 1
Dose0.25 mg/kg IV single bolus (max 25 mg) — no infusion needed; ≤4.5 h window; 0.4 mg/kg NOT recommended (harm)
PreparationReconstitute with sterile water; single IV bolus over 5–10 s
MonitorAs alteplase: BP <185/110 pre-lysis, ≤180/105 ×24 h; no antiplatelets ×24 h
Labetalol IVIV α+β-blocker
Dose20 mg IV over 2 min, repeat 20–80 mg q10 min (max 300 mg) or 0.5–2 mg/min infusion
Preparation200 mg in 160 mL (1.25 mg/mL) for infusion; boluses undiluted (5 mg/mL vial)
MonitorAvoid in asthma/decompensated HF; postural hypotension
Aspirinantiplatelet
DoseACS: 150–325 mg chewed once, then 75 mg OD. PV/stroke prevention: 75 mg OD
Preparation300 mg dispersible (chew/dissolve for loading); 75 mg enteric-coated maintenance
MonitorBleeding, dyspepsia; avoid in viral illness in children
Atorvastatinstatin
Dose20–80 mg OD (post-ACS 80 mg)
Preparation10/20/40/80 mg tablets, any time of day
MonitorInteractions: SSRIs/tramadol (serotonin), tyramine less relevant
📖 NICE / MDS Parkinson'sReviewed July 2026
3. Myasthenia Gravis
EMERGENCY▸
Fatigable weakness, ptosis, diplopia worse in evening
ABCDE
Assess FVC/bulbar; airway support early; avoid precipitant drugs; IVIG/PLEX in crisis.
Most accurate:Anti-AChR antibodies (edrophonium/ice less specific); + CT chest for thymoma
✓
Treat:Pyridostigmine 60 mg PO q4–6h → add steroids (daily, not alternate-day, now standard) / azathioprine; early thymectomy for AChR+ non-thymomatous gMG
✓
Myasthenic crisis (respiratory) →IVIG or plasmapheresis + intubate; start corticosteroids a few days AFTER IVIG/PLEX initiation (immediate high-dose steroids can transiently worsen weakness)
MonitorCholinergic excess (cramps, secretions, bradycardia); stress-dose before surgery
Prednisolonecorticosteroid
DoseMG: start low and titrate (e.g. 10–20 mg OD, increase gradually toward ~1 mg/kg if needed); in crisis delay a few days after IVIG/PLEX initiation; daily (not alternate-day) dosing now standard (ABN 2025)
Preparation5/25 mg tablets; gastro-resistant or plain with food
MonitorGlucose, BP, mood; bone protection if >3 mo (Ca²⁺/D ± bisphosphonate)
Azathioprinethiopurine immunosuppressant
Dose2–2.5 mg/kg OD (IBD, myositis, MG)
Preparation25/50 mg tablets with food
MonitorFBC + LFT weekly ×4 then q8–12 wk; TPMT before starting; avoid allopurinol combination
Rescue biologics (refractory gMG)C5 / FcRn
DoseC5 inhibitors (eculizumab/ravulizumab) or FcRn antagonists (efgartigimod, rozanolixizumab) for refractory AChR+ gMG; early rituximab esp. MuSK+
PreparationPer specialist protocol; meningococcal vaccination before C5 inhibitors
Monitor FVC; airway if bulbar/falling FVC; cardiac monitor (autonomic); early IVIG/PLEX.
Calculators:
Monitor in ICU:Forced vital capacity (FVC) — do NOT wait for desaturation to intubate
✓
LP:albuminocytologic dissociation (↑protein, normal cells) — excludes infection
✓
Treat:IVIG 0.4 g/kg/day ×5 d — start within 2 weeks of weakness onset if unable to walk unaided (may consider up to 4 wk) — OR plasma exchange 12–15 L in 4–5 exchanges over 1–2 wk, within 4 weeks (equal efficacy; EAN/PNS 2023)
Dose1 g/kg/day ×2 d (ITP bleeding, GBS total 2 g/kg over 2–5 d)
Preparation50/100 mL ready bottles; start slow (30 mL/h), escalate per tolerance
MonitorHeadache/aseptic meningitis, renal function, thrombosis; live vaccines after
Plasma exchangedefinitive
DoseAlternate to IVIG: 5 exchanges over 1–2 wk (equal efficacy)
PreparationCentrifugal line, albumin replacement
MonitorFVC/NIF trend — choose ONE modality: PE followed by IVIg NOT recommended; do NOT switch to the other modality after failure of the first (EAN/PNS 2023)
Gabapentinneuropathic analgesia
Dose300 mg OD day 1 → BD day 2 → TDS; titrate to 600–1200 mg TDS — gabapentinoids/TCAs are first-line for GBS neuropathic pain
Dose5 mg OD, ↑weekly by 5 mg to 10 mg BD (moderate–severe dementia)
Preparation5/10/20 mg tablets
MonitorConfusion, dizziness; renal dosing
📖 NICE DementiaReviewed July 2026
7. Meningitis (Bacterial)
ICU / RESUS▸
Fever, stiff neck, headache, photophobia, ΔMS
ABCDE
A-B-C; blood cultures then antibiotics + dexamethasone without delay; treat shock/seizures; LP when safe.
Calculators:
First (do NOT delay):Blood cultures + Dexamethasone + empiric antibiotics
✓
Head CT before LP only if:focal deficit / ↑ICP signs / immunocompromised
✓
Then LP(bacterial CSF: ↑neutrophils, ↑protein, ↓glucose)
✓
Empiric antibiotics:Ceftriaxone 2 g IV q12h + Vancomycin; add Ampicillin if >50 y (IDSA — kept; WHO 2025 uses >60 y) / immunocompromised (Listeria); acyclovir if HSV
✓
Decision tree
Signs of raised ICP / focal deficit / immunocompromised?
Yes
Blood cultures → antibiotics + dexamethasone NOW → CT → LP when safe
No
Blood cultures → LP → antibiotics + dexamethasone without delay
Dose450 mL blood removed weekly until ferritin <50 µg/L, then maintenance 3–4×/yr
PreparationLarge-bore needle, 15 min
MonitorFerritin + transferrin saturation q3 mo
Deferasiroxiron chelator
Dose10–30 mg/kg OD (transfusion overload)
Preparation90–360 mg tablets on empty stomach
MonitorCreatinine, LFTs monthly; GI upset, rash
📖 AASLD HaemochromatosisReviewed July 2026
9. Acute Pancreatitis
EMERGENCY▸
Epigastric pain → back, N/V; gallstones / alcohol
ABCDE
IV access, moderately aggressive LR fluids (~1.5 mL/kg/h after bolus if hypovolemic); analgesia; O₂; monitor for organ failure; catheter.
Calculators:
Confirm:Lipase (>3× ULN); CT for complications/severity
✓
Treat:Moderately aggressive LR (10 mL/kg bolus if hypovolemic, then ~1.5 mL/kg/h; reassess within 6 h and at 24–48 h — do not continue aggressive hydration beyond 48 h) + analgesia + early oral feeding (low-fat solids within 24–48 h in mild AP; NPO only for ileus/severe nausea; NG enteral over parenteral in severe AP)
✓
Gallstone + cholangitis →ERCP; cholecystectomy same admission
✓
Order set
Lipase
FBC, U&E, Ca, glucose, LFTs
Moderately aggressive LR ~1.5 mL/kg/h (NOT 30 mL/kg)
USS (gallstones)
CT only if diagnosis unclear or no improvement at 48–72 h (not routine on admission)
Rectal indomethacin (± PD stent) for post-ERCP pancreatitis prophylaxis
Escalate / ICU
Persistent SIRS / organ failure >48 h
Hypoxia, oliguria, hypotension
High-volume resuscitation → HDU/ICU
Criteria
AdmitAll acute pancreatitis
ICUPersistent organ failure, severe SIRS, necrosis
IntubateARDS / respiratory failure
VasopressorsDistributive shock despite fluids
DialysisAKI with AEIOU
DischargePain controlled, eating, organ failure resolved, cause addressed
Never
Give prophylactic antibiotics unless infected necrosis
Early (<72 h) ERCP for biliary pancreatitis WITHOUT cholangitis — medical therapy first (ACG 2024)
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Persistent SIRS/organ failure
Hypocalcaemia
Necrosis
Differentials
Perforated ulcer
Cholangitis
Mesenteric ischaemia
AAA
Common mistakes
Prophylactic antibiotics
Under-resuscitation
Delaying feeding
Disposition & follow-up
Severity scoring; HDU/ICU if organ failure; ERCP if cholangitis.
Discharge package
MedicationsAnalgesia; treat cause
Follow-upCholecystectomy if gallstones; alcohol support
DoseAcute pancreatitis: moderately aggressive — 10 mL/kg bolus if hypovolemic, then ~1.5 mL/kg/h; reassess at 6 h and 24–48 h; do NOT continue aggressive hydration beyond 48 h (fluid overload/respiratory failure — WATERFALL; ACG 2024)
Preparation500/1000 mL bags; contains K⁺ 4–5 mmol/L — still safe in most hyperK resuscitation
MonitorPerfusion (cap refill, urine, lactate) vs pulmonary oedema every aliquot
Morphineopioid analgesic
Dose2.5–10 mg IV q1–2 h PRN; PCA 1 mg bolus, 5–10 min lockout
Preparation10 mg/mL ampoule — dilute to 1 mg/mL for titration
Treat:Aggressive IV fluids (rhabdo: isotonic fluids targeting urine output ~200–300 mL/h until CK falling; no proven role for routine bicarbonate/mannitol); avoid nephrotoxins; dose-adjust drugs; dialysis if AEIOU — deferred, indication-driven RRT start (no early/pre-emptive dialysis absent urgent indications; STARRT-AKI)
✓
Order set
U&E, CK
Urinalysis (casts, myoglobin)
K⁺, Ca, PO₄
ECG
IV fluids
Criteria
AdmitAll established AKI
ICUHyperkalaemia with ECG changes, refractory overload/acidosis
Confirm:anti-PLA2R (positive serology can replace biopsy in classic nephrotic syndrome with preserved eGFR; monitor titers for immunologic response); urine protein; biopsy if atypical/declining GFR = membranous
Anticoagulation:prophylactic only when serum albumin <25 g/L (<20–25 with membranous, KDIGO 2021) plus additional risk, unless bleeding risk high; therapeutic anticoagulation for any thromboembolic event
MedicationsACEi/ARB, statin, diuretic ± immunosuppression; anticoagulation if high-risk
Follow-upNephrology
Warning symptomsLeg/chest pain or SOB (clots), severe oedema
💊 Treatment detail — doses & preparation
LisinoprilACE inhibitor
DoseStart 2.5–5 mg OD, target 20–40 mg OD
Preparation2.5/5/10/20 mg tablets
MonitorCreatinine + K⁺ 1–2 wk after each titration
Furosemide POloop diuretic
Dose20–80 mg OD/BD, titrate to dry weight
Preparation20/40/500 mg tablets; take morning/midday
MonitorDaily weight, K⁺, renal function
ImmunosuppressionKDIGO 2021
DoseMembranous nephropathy (moderate/high risk): rituximab 1 g IV ×2 (2 wk apart) or modified Ponticelli (alternating monthly methylprednisolone + cyclophosphamide ×6 mo); cyclophosphamide-rituximab combo for very high risk
Preparation5/25 mg tablets; gastro-resistant or plain with food
MonitorGlucose, BP, mood; bone protection if >3 mo (Ca²⁺/D ± bisphosphonate)
Atorvastatinstatin
Dose20–80 mg OD (post-ACS 80 mg)
Preparation10/20/40/80 mg tablets, any time of day
DischargeNa corrected safely (≤8/24 h), cause treated, restriction plan
Never
Correct Na faster than ~8 mEq/L/24 h → osmotic demyelination
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Na <120 with seizures/↓GCS
Differentials
Hypovolaemia
Hypothyroidism
Adrenal insufficiency
Cerebral salt wasting
Common mistakes
Rapid correction (osmotic demyelination)
Fluids worsening hyponatraemia
Disposition & follow-up
Fluid restriction; hypertonic saline if severe; treat cause.
Discharge package
MedicationsTreat cause; fluid limits
Follow-upRecheck sodium
LifestyleFluid restriction as advised
Warning symptomsConfusion, seizures, drowsiness
💊 Treatment detail — doses & preparation
Fluid restrictionfirst-line
DoseRestrict to 800–1000 mL/day (all fluids)
Preparation—
MonitorNa⁺ daily initially; strict input chart
Hypertonic saline 3%severe hyponatraemia/ICP
DoseSymptomatic hypoNa: 100–150 mL of 3% over 10–20 min, repeat ×2–3 until symptoms settle (target Na +4–6 in first 6 h). ICP: 250 mL bolus
Preparation3% NaCl via pump, central or large peripheral vein
MonitorNa⁺ q2–4 h — max rise 8–10 mmol/L/24 h (osmotic demyelination); overcorrection → DDAVP clamp/rescue: desmopressin 2 µg IV (± D5W) to halt the rise
Furosemide POloop diuretic
Dose20–80 mg OD/BD, titrate to dry weight
Preparation20/40/500 mg tablets; take morning/midday
MonitorDaily weight, K⁺, renal function
TolvaptanV2 antagonist
Dose15 mg OD, titrate q≥24 h to max 60 mg OD (SIADH, selected)
Preparation15/30 mg tablets
MonitorNa⁺ q6–8 h initially (rapid correction risk), thirst/dehydration, LFTs
📖 European Hyponatraemia GuidelineReviewed July 2026
7. Central Diabetes Insipidus
EMERGENCY▸
Hypernatremia + voluminous dilute urine (osm ~80)
Calculators:
Confirm:water deprivation → responds to desmopressin (central) not nephrogenic
ECG now; calcium to stabilise myocardium; insulin/dextrose + salbutamol to shift; remove K⁺; dialysis if refractory.
Calculators:
Prevent (TLS):Hydration + Allopurinol (Rasburicase if high-risk / allopurinol-allergic)
✓
Hyperkalemia + ECG changes →Calcium gluconate/chloride IV (protect heart)
✓
Shift:Insulin 10 U IV + D50; nebulized salbutamol 10–20 mg; bicarbonate only if concurrent significant metabolic acidosis (not routine)
✓
Remove:loop diuretic (if making urine); sodium zirconium cyclosilicate (SZC) 10 g PO TID up to 48 h (then 5–10 g/d) or patiromer 8.4–25.2 g PO as adjuncts; dialysis if refractory. Avoid SPS/Kayexalate acutely
✓
Decision tree
ECG changes or K⁺ >6.5?
Yes
Calcium gluconate NOW → insulin/dextrose + salbutamol → remove K⁺ (SZC/patiromer/diuretic) → dialysis if refractory
Rasburicase contraindicated in G6PD deficiency (hemolysis/methemoglobinemia)
Escalate / ICU
K⁺ >6.5 or ECG changes
Refractory to medical therapy → dialysis
Oliguric AKI
Criteria
AdmitAll significant hyperkalaemia/TLS
ICUECG changes, refractory hyperkalaemia
DialysisK⁺ >6.5 refractory, oliguric AKI, severe TLS
DischargeK⁺/uric acid controlled, renal function stable, prophylaxis ongoing
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
ECG changes
K⁺ >6.5
Oliguria
Differentials
Pseudohyperkalaemia
AKI
Acidosis
Drugs
Common mistakes
Treating number not ECG
Forgetting to remove K⁺ (only shifting)
Disposition & follow-up
Stabilise → shift → remove; dialysis if refractory.
Discharge package
MedicationsReview K⁺-raising drugs; TLS prophylaxis if ongoing; do NOT stop RASi solely for K⁺ — use binders/diuretics to enable continuation (KDIGO 2024)
Follow-upRecheck K⁺/renal
LifestyleLow-potassium diet if advised
Warning symptomsPalpitations, weakness
💊 Treatment detail — doses & preparation
Calcium gluconate 10%membrane stabiliser
Dose10–30 mL of 10% IV over 2–5 min for hyperK ECG changes; repeat q10 min ×3 PRN
Preparation10 mL ampoules (2.2 mmol Ca²⁺ each), undiluted slow push with cardiac monitor
MonitorECG immediately (QRS narrows); effect 1–3 min, lasts 30–60 min — shift/remove K⁺ in parallel
Insulin + dextrose (hyperK)K⁺ shift therapy
Dose10 units regular insulin IV + 25 g dextrose (50 mL of 50%), onset 15–30 min, lasts 4–6 h
Preparation50 mL 50% dextrose push + 10 U insulin; if glucose >14, give insulin alone; add 10% dextrose infusion if needed
MonitorCapillary glucose q15–30 min ×2 h (hypoglycaemia), K⁺ at 1–2 h
Salbutamol (albuterol)SABA
DoseHyperkalemia: 10–20 mg nebulized over 10 min (adjunct to insulin; onset ~30 min, lowers K ~0.5–1 mmol/L). Asthma: 2.5–5 mg q15–20 min ×3 then q1–4h
Preparation2.5/5 mg nebules + O₂-driven nebuliser at 6–8 L/min
MonitorHR, tremor, K⁺ (shifts intracellularly — used in hyperK), SpO₂
Sodium bicarbonate 8.4%alkalising agent
DoseTCA: 1–2 mmol/kg IV bolus then infusion to pH 7.50–7.55. Salicylate: urine alkalinisation pH 7.5–8.5
PreparationBolus 50–100 mL of 8.4% (1 mmol/mL); infusion 150 mmol in 1 L D5W + 20–40 mmol KCl
Emergency (end-organ damage) →IV labetalol/nicardipine, ↓MAP ≤25% in 1st hour
✓
Decision tree
Acute end-organ damage (emergency)?
Yes
IV therapy (labetalol/nicardipine); lower MAP ≤25% in first hour
No
Very high BP, no end-organ damage (urgency)?
Yes
Oral agents; gradual reduction over hours–days; arrange follow-up
No
Lifestyle + oral agent by indication; outpatient titration
Order set
Confirm with repeat/ABPM
U&E, glucose, lipids
Urine ACR
ECG
Fundoscopy
Criteria
AdmitHypertensive emergency (end-organ damage)
ICUEmergency needing IV titration/monitoring
DischargeControlled/trending down (≤25% MAP in emergency), agents by indication, follow-up
Key
Investigate secondary HTN only if uncontrolled on 2–3 drugs. Goal <130/80; ESC 2024 SBP target 120–129 if tolerated; spironolactone first-line for resistant HTN.
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
End-organ damage (emergency)
Very high BP with symptoms
Differentials
White-coat
Secondary (renal, endocrine)
Medication/substance
Common mistakes
Treating a single reading
Rapid BP drop in emergency (>25% MAP)
Disposition & follow-up
Lifestyle + agent by indication; investigate secondary if resistant.
MonitorCreatinine + K⁺ 1–2 wk after each titration
Indapamide/chlorthalidonethiazide-like diuretic
DoseIndapamide 1.5 mg MR OD or chlorthalidone 12.5–25 mg OD
PreparationTablets in the morning
MonitorNa⁺, K⁺, uric acid, glucose at 2–4 wk
📖 ACC/AHA 2017 + ESC 2024 HypertensionReviewed July 2026
7
Pulmonary
1. Asthma
ICU / RESUS▸
Wheeze, dyspnea; acute attack with respiratory alkalosis
ABCDE
Supplemental O₂ only if SpO₂ <92% (target ≤95%, GINA 2026); back-to-back salbutamol + ipratropium; steroids; IV magnesium if severe; senior/ICU if life-threatening.
Calculators:
As soon as wheezing →Albuterol nebulizer (no contraindication)
✓
Exacerbation:Albuterol + Ipratropium + IV Magnesium + Oxygen + Prednisone 40–60 mg ×5 d
✓
Rising/normalizing PCO₂ (tiring) →ICU + intubate
✓
Controller step-up:inhaled corticosteroid → ICS + LABA → biologics. GINA 2026 Track 1 (preferred): low-dose ICS–formoterol is the preferred reliever (MART/AIR); SABA-only treatment no longer recommended for adults/adolescents
✓
Decision tree
Life-threatening features (silent chest, exhaustion, normal/high CO₂)?
Yes
ICU + intubation; continuous salbutamol, ipratropium, IV magnesium, steroids
Warning symptomsIncreasing reliever use, night symptoms, breathlessness not relieved
💊 Treatment detail — doses & preparation
Salbutamol (albuterol)SABA
DoseNebuliser 2.5–5 mg q15–20 min ×3 then q1–4h; MDI 2–10 puffs via spacer
Preparation2.5/5 mg nebules + O₂-driven nebuliser at 6–8 L/min
MonitorHR, tremor, K⁺ (shifts intracellularly — used in hyperK), SpO₂
Ipratropium bromideSAMA
Dose500 mcg nebulised q4–6h (acute severe asthma/COPD)
Preparation500 mcg nebules; MDI 20 mcg/puff 2 puffs QID maintenance
MonitorDry mouth, glaucoma caution (mask seal)
Prednisolonecorticosteroid
DoseFlares: 40 mg OD ×1–2 wk then taper over 6–8 wk; COPD/asthma: 40–50 mg ×5 d (no taper)
Preparation5/25 mg tablets; gastro-resistant or plain with food
MonitorGlucose, BP, mood; bone protection if >3 mo (Ca²⁺/D ± bisphosphonate)
Magnesium sulfate IVelectrolyte/antiarrhythmic
DoseTorsades: 2 g over 10–15 min. Asthma: 2 g over 20 min. Eclampsia: 4 g load then 1 g/h
Preparation2 g in 100 mL NS via pump; eclampsia 4 g in 100–200 mL
MonitorReflexes/RR if high doses (toxicity), Mg²⁺ level, renal function
Aminophyllinemethylxanthine — NOT recommended in acute asthma (GINA 2026)
DoseNot recommended for acute asthma exacerbations — no benefit over standard therapy and increased adverse effects; reserve only under specialist/ICU direction
PreparationIf ever used (specialist only): 5 mg/kg IV load over 20 min (omit if on theophylline), then 0.5–0.7 mg/kg/h; 250 mg/10 mL dilute in 100 mL NS/D5W
Maintenance initiation (GOLD 2026):LABA+LAMA is the preferred initial therapy for exacerbating patients (Group E, ≥1 moderate/severe exacerbation/yr); add ICS to LABA+LAMA if blood eosinophils ≥300/µL. Ipratropium is for acute nebulized use, not chronic monotherapy
Acute monoarthritis (1st MTP), after NSAID failure
Most accurate:Joint aspirate — negatively birefringent needle crystals (uric acid normal in 25%)
✓
Acute:Colchicine, NSAID, OR glucocorticoid — co-equal strong first-line options (ACR 2020), chosen by patient factors; low-dose colchicine preferred over high-dose
✓
Chronic (may start during flare with cover):Allopurinol — strongly recommended first-line ULT for ALL patients including CKD ≥3 (ACR 2020) → titrate to urate <6 (colchicine prophylaxis during initiation)
✓
Order set
Joint aspiration + crystals
Serum urate (after flare)
U&E
Exclude septic arthritis
Criteria
AdmitCannot exclude septic joint or severe polyarticular
DischargeFlare settling, urate-lowering plan with cover
Never
Diagnose gout as gout before crystal analysis
Stop allopurinol during a flare — never stop it; STARTING ULT during a flare is acceptable (ACR 2020, conditional) provided anti-inflammatory cover is given; low-dose start, titrate to target
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Fever + hot joint (exclude sepsis)
Differentials
Septic arthritis
Pseudogout
Cellulitis
Reactive arthritis
Common mistakes
Diagnosing before aspiration
Stopping allopurinol mid-flare
Disposition & follow-up
Treat flare; urate-lowering after settling with cover.
Discharge package
MedicationsFlare therapy; allopurinol first-line ULT with cover; pegloticase for refractory gout (frequent flares/tophi despite XOI ± uricosuric)
Warning symptomsRecurrent flares, hot swollen joint with fever
💊 Treatment detail — doses & preparation
NaproxenNSAID
Dose500 mg BD with food (gout flare until settled; pain)
Preparation250/500 mg tablets; add PPI if risk factors
MonitorRenal function, GI bleeding, BP; avoid in CKD/HF
Colchicineanti-gout flare
Dose1 mg then 0.5 mg 1 h later (day 1), then 0.5 mg OD–BD until flare settles
Preparation0.5/0.6 mg tablets
MonitorGI upset (dose-limiting), avoid with clarithromycin in CKD; marrow in overdose
Prednisolonecorticosteroid
DoseGout flare: 30–35 mg OD ×~5 d (no taper needed)
Preparation5/25 mg tablets; gastro-resistant or plain with food
MonitorGlucose, BP, mood; bone protection if >3 mo (Ca²⁺/D ± bisphosphonate)
Allopurinolxanthine oxidase inhibitor
DoseStart ≤100 mg OD (lower in CKD), titrate q2–4 wk to urate <0.36 mmol/L (max 900 mg); may start during flare with anti-inflammatory cover; HLA-B*5801 testing before starting in high-risk ancestries (Southeast Asian, African American)
Preparation100/300 mg tablets; co-prescribe colchicine/NSAID cover ×3–6 mo (initiation flares)
Treat:Hydroxychloroquine (all patients, ≤5 mg/kg/day) + steroids for flares — GC are bridging only: maintenance ≤5 mg/day and withdrawn when possible (EULAR 2023); consider belimumab or anifrolumab EARLY when HCQ alone insufficient or GC cannot be tapered
✓
Nephritis →renal biopsy → triple immunosuppression (2024 ACR LN): GC + MMF or low-dose IV CYC (Euro-Lupus) + belimumab or voclosporin; IV GC pulses then oral ≤0.5 mg/kg/d, taper to ≤5 mg/d by 6 mo; target proteinuria ≤0.5 g by 6–12 mo
✓
Order set
ANA → dsDNA/anti-Sm
Complement (C3/C4)
FBC, U&E, urinalysis
Antiphospholipid antibodies
Criteria
AdmitMajor organ flare (nephritis, cerebritis, cytopenia, serositis)
DischargeCRAB controlled, induction + bone protection, follow-up
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Hypercalcaemia
AKI
Cord compression
Hyperviscosity
Differentials
MGUS
Metastatic bone disease
Primary amyloid
Common mistakes
Missing CRAB features
NSAIDs/contrast worsening renal function
Disposition & follow-up
Treat CRAB; induction ± transplant; bone protection.
Discharge package
MedicationsInduction regimen (D-VRd); bisphosphonate; analgesia — type & screen BEFORE first daratumumab dose (anti-CD38 interferes with transfusion crossmatch)
MonitorBleeding, dyspepsia; avoid in viral illness in children
Hydroxycarbamideantimetabolite
DosePV/sickle cell: 15–20 mg/kg OD titrated to counts
Preparation500 mg capsules
MonitorFBC 2–4 wkly during titration; leg ulcers, skin cancer risk long-term
📖 BSH / ELN MPNReviewed July 2026
5. Tumour Lysis Syndrome
EMERGENCY▸
Day 2 after first chemo for Burkitt lymphoma — K⁺ 6.4, phosphate 2.8, creatinine doubling. Cell death is flooding the blood: fluids, rasburicase, treat the potassium.
ABCDE
Cardiac monitor; aggressive IV fluids (no K⁺); rasburicase if high-risk (check G6PD first); treat hyperkalaemia immediately; avoid anything nephrotoxic.
Recognise (Cairo-Bishop):↑uric acid, ↑K⁺, ↑phosphate, ↓Ca²⁺ ± AKI within 12–72 h of chemo (or spontaneously in high-turnover tumours — Burkitt, ALL, high WBC)
✓
Volume first:isotonic saline 3 L/m²/day (≈200–250 mL/h) targeting urine output 100 mL/h — NO potassium in fluids, no routine alkalinisation
✓
Hyperkalaemia NOW:calcium gluconate 10% 10–30 mL IV (cardiac protection) → insulin 10 units + 25 g dextrose → salbutamol nebs; dialysis if refractory
After rasburicase:do NOT send serial uric acid (ex-vivo degradation gives false lows); treat hyperphosphataemia with binders; calcium ONLY if symptomatic (tetany/QT — risk of Ca-phosphate precipitation)
✓
Dialysis triggers:refractory hyperkalaemia, hyperphosphataemia with symptomatic hypocalcaemia, oliguria/overload, severe metabolic acidosis — call renal early
✓
Order set
Cardiac monitor + 12-lead (K⁺)
0.9% saline 200–250 mL/h, no K⁺
Rasburicase 0.15–0.2 mg/kg (G6PD checked)
Calcium gluconate 10% 10 mL IV if K⁺ ≥6/ECG changes
Dose300 mg OD–BD PO (start 24–48 h BEFORE chemo in intermediate risk); febuxostat is the alternative when allopurinol contraindicated (e.g., G6PD-deficient high-risk patients who cannot take rasburicase)
Preparation100/300 mg tablets
MonitorUric acid, rash; NOT for established high-risk TLS (rasburicase instead)
Calcium gluconate 10%membrane stabiliser
Dose10–30 mL of 10% IV over 2–5 min for hyperK ECG changes; repeat q10 min ×3 PRN
Preparation10 mL ampoules (2.2 mmol Ca²⁺ each), undiluted slow push with cardiac monitor
MonitorECG immediately (QRS narrows); effect 1–3 min, lasts 30–60 min — shift/remove K⁺ in parallel
Insulin + dextrose (hyperK)K⁺ shift therapy
Dose10 units regular insulin IV + 25 g dextrose (50 mL of 50%), onset 15–30 min, lasts 4–6 h
Preparation50 mL 50% dextrose push + 10 U insulin; if glucose >14, give insulin alone; add 10% dextrose infusion if needed
MonitorCapillary glucose q15–30 min ×2 h (hypoglycaemia), K⁺ at 1–2 h
📖 Cairo-Bishop criteria + textbook Ch.31Reviewed July 2026
6. Febrile Neutropenia
EMERGENCY▸
Chemo 8 days ago, now T 38.6 °C, ANC 0.2 — treat as sepsis with an hour on the clock: cultures then piperacillin-tazobactam immediately.
ABCDE
Single T ≥38.3 °C (or ≥38.0 ×1 h) + ANC <0.5 = emergency; cultures ×2 + CXR + urine, then antipseudomonal β-lactam within 1 h; vancomycin only for specific indications.
Define + act fast:ANC <0.5×10⁹/L + single T ≥38.3 °C or ≥38.0 °C sustained 1 h — mortality rises with every hour of antibiotic delay
✓
Workup in 30 min:blood cultures ×2 (peripheral + each line lumen), CXR, urinalysis, lactate, FBC/U&E/LFT/CRP — do not delay antibiotics for results
✓
Empiric antibiotics within 1 h:piperacillin-tazobactam 4.5 g IV q6–8 h (or cefepime 2 g q8h / meropenem 1 g q8h if severe/ESBL risk)
✓
Add vancomycin ONLY if:suspected line infection, skin/soft-tissue infection, hypotension/septic shock, MRSA colonisation, or severe mucositis — stop at 48 h if cultures negative
VOLUME FIRST:0.9% saline 200–300 mL/h targeting urine output 100–150 mL/h — restores GFR and calciuresis; furosemide ONLY after fully volume-repleted if overloaded
✓
Calcitonin — the fast arm:4 IU/kg SC/IM q12h — onset 2–4 h, drops Ca²⁺ ~0.5 mmol/L; tachyphylaxis after 48 h (bridge only)
✓
Bisphosphonate — the durable arm:zoledronic acid 4 mg IV over 15 min (onset 2–4 days, lasts weeks; renal dose-adjust); severe CKD → denosumab 120 mg SC instead
✓
Special cases:calcitriol-driven (lymphoma/granuloma) → prednisolone 40–60 mg; refractory + CKD/HF → haemodialysis with low-calcium bath
✓
Fix the cause:PTHrP/myeloma workup; disease control (chemo, SCT, radiotherapy) is the only lasting cure; avoid thiazides, lithium, Ca²⁺/vitamin D supplements
✓
Calculators:
Order set
Corrected Ca²⁺, phosphate, Mg²⁺, PTH, creatinine
0.9% saline 200–300 mL/h
Calcitonin 4 IU/kg SC q12h
Zoledronic acid 4 mg IV (or denosumab 120 mg SC if CKD)
ECG — QT shortens
Strict fluid balance + urine output
Monitor
q12–24 hCorrected Ca²⁺ until <3.0 and falling
HourlyUrine output — target 100–150 mL/h
DailyCreatinine, phosphate, Mg²⁺; confusion score
Day 2–4Bisphosphonate effect lands — wean fluids as Ca²⁺ falls
Escalate / ICU
Corrected Ca²⁺ >3.5 or severe symptoms at any level
Correct for albumin or check ionised Ca²⁺ — hypoalbuminaemia hides true levels
PTH suppressed + high Ca²⁺ in malignancy = PTHrP or osteolytic (myeloma)
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Confusion, coma
Corrected Ca²⁺ >3.5
Short QT on ECG
Oliguria
Differentials
Primary hyperparathyroidism (check PTH!)
Vitamin D toxicity, granulomatous disease
Thiazides, lithium, milk-alkali
Myeloma vs PTHrP solid tumour
Common mistakes
Treating a number without correcting for albumin
Fluids forgotten while waiting for zoledronate
Hypophosphataemia ignored during repletion
No malignancy treatment plan — Ca²⁺ will recur
Disposition & follow-up
Step down when Ca²⁺ <3.0 and stable on maintenance hydration; oncology for disease-modifying therapy; dental review before ongoing bisphosphonates (ONJ risk).
💊 Treatment detail — doses & preparation
0.9% Sodium chloridecrystalloid
DoseBolus 500 mL over 15–30 min, reassess; maintenance 1–1.5 mL/kg/h
Preparation500/1000 mL bags; add KCl only after urine output confirmed
MonitorHyperchloraemic acidosis with large volumes — prefer balanced (LR) for resuscitation
Calcitoninhypocalcaemic agent
Dose4 IU/kg SC/IM q12h (hypercalcaemia) — onset 2–4 h
Preparation100 IU/mL ampoule SC/IM
MonitorCa²⁺ q12 h; tachyphylaxis after 48 h — bridge to bisphosphonate
Zoledronic acidIV bisphosphonate
Dose4 mg IV over ≥15 min (hypercalcaemia, myeloma bone); renal dose-adjust (3–3.5 mg if CrCl 30–60)
Preparation4 mg/5 mL ready solution or vial dilute in 100 mL NS
📖 Endocrine Society hypercalcaemia guidance + textbook Ch.31Reviewed July 2026
10
Infectious Disease
1. Osteomyelitis
URGENT▸
Localized bone pain/tenderness, ± overlying ulcer
Imaging:X-ray (late — needs 50% bone loss) → MRI (earliest, most sensitive)
✓
Before antibiotics:Bone biopsy + culture (start antibiotics after biopsy obtained); if septic, take blood cultures and start empiric IV antibiotics without delaying for biopsy
✓
Treat:Culture-directed IV antibiotics ×4–6 wk; surgical debridement
✓
Order set
MRI
Bone biopsy + culture
ESR/CRP, FBC
Blood cultures
Criteria
AdmitSystemic sepsis or need for IV therapy/surgery
ICUSeptic shock
DischargeSource controlled, on directed antibiotics, OPAT plan
Never
Give antibiotics based on a bone scan alone — get the biopsy first
Clinical detail — differentials, red flags, pitfalls, disposition
Prophylaxis (amoxicillin before dental) ONLY for:prosthetic valve / prior IE / certain congenital heart disease
✓
Order set
3 sets blood cultures
Echo (TTE→TEE)
FBC, CRP, U&E
ECG (conduction)
Criteria
AdmitAll
ICUHeart failure, emboli, conduction abnormality
DischargeAfebrile, cultures cleared, IV course defined, surgical decision made
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Heart failure
Embolic events
New AV block (abscess)
Differentials
Sepsis other source
Atrial myxoma
Marantic endocarditis
Common mistakes
Single culture set
Delaying antibiotics after cultures
Wrong prophylaxis indication
Gentamicin NOT used for staphylococcal native-valve IE (nephrotoxicity; synergy gent reserved for selected enterococcal/streptococcal cases — ESC 2023)
Disposition & follow-up
Empirical then targeted IV antibiotics; surgery for complications.
Dose2 g IV OD (meningitis 2 g q12h); gonorrhoea 500 mg–1 g IM once
PreparationIV: 2 g in 50–100 mL NS over 30 min; IM: reconstitute with lidocaine 1%
MonitorBiliary sludging; avoid with calcium-containing IV fluids in same line
Surgery triggersdefinitive
DoseValve surgery for: heart failure, uncontrolled infection, large vegetations with emboli
PreparationCardiothoracic review early
MonitorEcho response, inflammatory markers
📖 ESC 2023 / AHA 2021 Infective Endocarditis (Duke-ISCVID 2023 criteria)Reviewed July 2026
3. Pyelonephritis
EMERGENCY▸
Fever, flank pain, CVA tenderness, dysuria
ABCDE
Fluids, antibiotics within 1 h if septic; relieve obstruction urgently if present.
Order:Urinalysis (WBCs, nitrites) + urine culture
✓
Treat (no imaging needed first):Ceftriaxone IV (or fluoroquinolone — avoid empiric FQ if local resistance >10%); oral cipro/levo if outpatient; duration 5–7 d levofloxacin / 10–14 d others
Bacterial (Campylobacter most common) →Azithromycin 500 mg OD ×3 d preferred; ciprofloxacin only if susceptible (rising FQ resistance — IDSA 2017)
✓
C. difficile →fidaxomicin 200 mg PO BID ×10 d preferred; vancomycin 125 mg PO QID ×10 d alternative (IDSA/SHEA 2021); metronidazole only if neither available and non-severe
✓
Order set
Rehydrate
Stool culture/PCR + C. diff if indicated
U&E
Avoid empirical antibiotics in most
Criteria
AdmitSevere dehydration, sepsis, or HUS features
ICUSeptic shock / HUS with complications
DialysisHUS-AKI with AEIOU
DischargeRehydrated, tolerating oral, cause addressed
Never
Give antibiotics for EHEC O157:H7 (↑ HUS risk)
Clinical detail — differentials, red flags, pitfalls, disposition
Under-dosing children <20 kg — artesunate 3 mg/kg/dose (WHO)
Rectal artesunate 10 mg/kg pre-referral for children <6 y when IV impossible (WHO)
Disposition & follow-up
Uncomplicated → oral ACT; severe → IV artesunate + ICU; single-dose primaquine 0.25 mg/kg with ACT for P. falciparum in low-transmission settings (WHO, optional).
Discharge package
MedicationsComplete antimalarial course
Follow-upRepeat films if relapse; travel advice
LifestyleFuture prophylaxis + bite avoidance
Warning symptomsFever recurrence, drowsiness, dark urine
💊 Treatment detail — doses & preparation
Artesunate IVantimalarial (severe)
Dose2.4 mg/kg IV at 0, 12, 24 h then OD until oral tolerated (children <20 kg: 3 mg/kg/dose — WHO); then complete with a full 3-day ACT once oral tolerated
Preparation60 mg vial: reconstitute with bicarbonate then NS, slow push 3–5 min
MonitorParasite count 12-hourly; post-artesunate delayed haemolysis (Hb at 1–2 wk)
Start ART ASAP:Integrase-based — bictegravir/emtricitabine/tenofovir alafenamide OR dolutegravir + 2 NRTIs
✓
OI prophylaxis:CD4 <200 → TMP-SMX (PCP); CD4 <50 → MAC prophylaxis (azithromycin) ONLY if not on/not responding to effective ART (rule out disseminated MAC first — DHHS OI)
✓
Advise partner notification
✓
Order set
HIV Ag/Ab + confirmatory
CD4 + viral load
Genotype
OI + TB + hepatitis screen
Criteria
AdmitOpportunistic infection or severe presentation
ICURespiratory failure, shock, severe OI
DischargeOI treated, ART started/continued, prophylaxis + follow-up
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
CD4 <200 with symptoms
IRIS
Opportunistic infection
Differentials
Seroconversion illness
Other immunodeficiency
OIs
Common mistakes
Delaying ART
Forgetting OI prophylaxis
Not screening HBV before TAF/TDF; check HLA-B*5701 only if abacavir considered
Not offering rapid/same-day ART initiation (now standard — DHHS/IAS-USA)
Disposition & follow-up
Start ART promptly; OI prophylaxis by CD4; adherence support.
Discharge package
MedicationsART + OI prophylaxis by CD4
Follow-upHIV clinic; adherence support
VaccinationInactivated vaccines; avoid live if CD4 low
A-B-C; continuous ECG; sodium bicarbonate for wide QRS; benzodiazepines for seizures.
QRS >100 ms →Sodium bicarbonate IV (narrows QRS, prevents arrhythmia)
✓
Seizures →Benzodiazepines
✓
Intubate when indicated —for ↓GCS, refractory seizures, or hypoventilation; do NOT withhold for fear of arrhythmia; if intubated, hyperventilate mildly (target pH ~7.50)
DischargeAsymptomatic ≥6 h, normal ECG, normal mental state, psych review
Never
Give flumazenil — precipitates seizures
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
QRS widening
Arrhythmia
Seizures
Hypotension
Differentials
Other Na-channel blocker OD
Anticholinergic toxidrome
Common mistakes
Flumazenil
Delaying bicarbonate
Withholding a needed airway for fear of arrhythmia
Hypertonic saline if QRS widening persists despite bicarbonate; whole-bowel irrigation not recommended — single-dose charcoal only if <1–2 h and airway protected
Disposition & follow-up
Monitored bed/ICU until ECG normal + asymptomatic.
Discharge package
Medications—
Follow-upPsychiatry/crisis assessment before discharge
Warning symptomsReturn if palpitations, drowsiness
💊 Treatment detail — doses & preparation
Sodium bicarbonate 8.4%alkalising agent
DoseTCA: 1–2 mmol/kg IV bolus then infusion to pH 7.50–7.55. Salicylate: urine alkalinisation pH 7.5–8.5
PreparationBolus 50–100 mL of 8.4% (1 mmol/mL); infusion 150 mmol in 1 L D5W + 20–40 mmol KCl
Follow-upPsychiatry review; hepatology if LFT/INR abnormal
Warning symptomsVomiting, jaundice, confusion
💊 Treatment detail — doses & preparation
N-acetylcysteine (NAC)paracetamol antidote
Dose150 mg/kg in 200 mL D5W over 1 h → 50 mg/kg in 500 mL over 4 h → 100 mg/kg in 1 L over 16 h (150/50/100 protocol); continue if still acidotic/INR rising
Preparation200 mg/mL ampoules — dilute in D5W as above; weight-capped at 110 kg
DischargeSecretions dry, stable off atropine, observed for intermediate syndrome
Never
Delay intubation in bronchorrhea/respiratory failure or coma — intubate EARLY; AVOID succinylcholine (prolonged paralysis via inhibited pseudocholinesterase) — use rocuronium for RSI
Under-dose pralidoxime — 2 g (≥30 mg/kg) IV over 20–30 min, then ≥8 mg/kg/h (≈650 mg/h) infusion, continued ≥24 h after atropine no longer needed (WHO/Eddleston)
Clinical detail — differentials, red flags, pitfalls, disposition
DoseBradycardia: 0.5 mg IV q3–5 min (max 3 mg). Organophosphate: 1–2 mg IV bolus, double q5 min until secretions dry, then infusion 10–20% of loading dose/h
MonitorHR, secretions, pupils (not a target in OP); tachycardia, urinary retention
Pralidoximecholinesterase reactivator
Dose2 g (≥30 mg/kg) IV over 20–30 min, then ≥8 mg/kg/h (≈650 mg/h) infusion (or 1 g q1h), continued ≥24 h after atropine no longer needed (WHO/Eddleston)
Preparation1 g vial in 20 mL water, then further dilute for infusion
MonitorGive WITH atropine (atropine first); most effective early before ageing
Lorazepambenzodiazepine
DoseStatus: 0.1 mg/kg IV (max 4 mg/dose), may repeat ×1
Preparation4 mg/mL vial dilute 1:1 with NS; slow push
MonitorRR, SpO₂; flumazenil caution in chronic users
📖 WHO / poisons-centre guidanceReviewed July 2026
7. Spider Bite
EMERGENCY▸
Black widow: muscle rigidity/cramps. Brown recluse: necrotic ulcer
Black widow →opioids + benzodiazepines for cramps (IV calcium gluconate is NOT effective and no longer recommended); antivenom for severe envenomation
✓
Brown recluse →supportive wound care ± delayed debridement
✓
Order set
Wound assessment
Analgesia
Opioids + benzos (widow) — NO IV calcium
Tetanus status
Criteria
AdmitSystemic envenomation
ICUSevere systemic envenomation
DischargeSymptoms controlled, wound care, tetanus updated
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Systemic envenomation
Necrotic spreading lesion
Rhabdo/hemolysis
Differentials
Cellulitis
Other envenomation
Abscess
Common mistakes
Over-treating minor bites
Missing systemic envenomation
IV calcium for latrodectism (outdated, ineffective)
Early excision of recluse lesions — NO; dapsone controversial (harm in G6PD deficiency)
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Life-threatening arrhythmia
K⁺ >5 (acute)
Hemodynamic instability
Differentials
Other bradyarrhythmia causes
Electrolyte disturbance
Common mistakes
Ignoring Mg
Over-fearing calcium — the "stone heart" concern is a historical caution not supported by modern case-series data; if hyperkalaemia needs membrane stabilisation, calcium is acceptable — but Fab remains definitive
Disposition & follow-up
Fab for severe toxicity; correct electrolytes; monitor.
DoseAcute OD: 10–20 vials if arrest/life-threatening; chronic toxicity: 3–6 vials; empirical if level >10 ng/mL or K⁺ >5
Preparation40 mg vial reconstitute + dilute in 100 mL NS over 30 min
MonitorK⁺ (drops fast; watch post-Fab hyperkalaemia rebound in CKD), arrhythmia resolution; total digoxin level uninterpretable after Fab
Potassium chlorideelectrolyte
DosePO 40–100 mmol/day divided. IV: 10 mmol/h peripheral, 20 mmol/h central with cardiac monitor
PreparationIV: NEVER undiluted push — 10 mmol in 100 mL or 40 mmol/L bag via pump
MonitorK⁺ q4–6 h during replacement, ECG, urine output >0.5 mL/kg/h
Avoid pacing/calciumsafety
DoseTranscutaneous pacing poorly effective and risky; IV calcium "stone heart" fear is historical nuance — acceptable if hyperkalaemia needs membrane stabilisation; Fab definitive. Non-arrest Fab dosing: vials = serum level (ng/mL) × weight (kg) / 100, or tablets ingested × 0.8 / 0.5
Preparation—
MonitorK⁺, digoxin level (pre-Fab), ECG
📖 poisons-centre / EXTRIPReviewed July 2026
9. Drowning / Hypothermia
ICU / RESUS▸
Cold exposure; bradycardia, Osborn J waves
ABCDE
A-B-C; remove wet clothing; active rewarming; continue CPR until warm; handle gently.
Rewarm:warmed humidified air + blankets/heating pads + warm IV fluids → ECLS/VA-ECMO (reasonable, COR 2a — AHA 2025) for hypothermic arrest or core <30 °C with instability — transfer to an ECLS centre
✓
Continue CPR until warm('not dead until warm and dead'); serum K⁺ >12 mmol/L (or HOPE score <10%) supports termination/futility; while core <30 °C max 3 shocks + 3 adrenaline doses, then defer until >30 °C and space intervals 6–10 min
✓
Order set
Core temperature
ECG (Osborn J waves)
Active rewarming
Continuous CPR if arrest until warm
Electrolytes, glucose
Escalate / ICU
Core temp <30°C / arrhythmia
Cardiac arrest — continue until rewarmed
Needs ECMO / active core rewarming
Criteria
AdmitAll significant hypothermia/immersion
ICUCore <30°C, arrhythmia, arrest, ARDS risk
Intubate↓GCS / respiratory failure
DischargeRewarmed, no arrhythmia, oxygenation stable, observed for delayed ARDS
Never
Give iced IV fluids
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Core <30°C
Arrhythmia
Cardiac arrest
Differentials
Sepsis
Endocrine (hypothyroid/adrenal)
Toxins
Common mistakes
Iced fluids
Declaring death before rewarming (unless K⁺ >12 mmol/L / HOPE <10%)
Disposition & follow-up
Rewarm; ICU/ECMO for severe; observe for delayed ARDS.
Discharge package
Medications—
Follow-upObserve for delayed respiratory symptoms
Warning symptomsBreathlessness, cough, fever within 24–48 h
💊 Treatment detail — doses & preparation
Rewarmingdefinitive
DoseRemove wet clothing; passive external + active core (heated IV fluids, forced air); CPR duration extends in hypothermia — 'not dead until warm and dead'
PreparationHeated humidified O₂, warm IV 0.9% saline
MonitorCore temperature probe (oesophageal/rectal); handle gently (VF risk)
📖 ILCOR / WMS Hypothermia; AHA 2025 CPR&ECCReviewed July 2026
DischargeTemperature/CK normalised, renal stable, drug reviewed (no abrupt rechallenge)
Key
Serotonin syndrome differs (clonus, hyperreflexia) → cyproheptadine. Active cooling including cooled IV fluids is appropriate in severe hyperthermia (>40 °C with organ dysfunction); avoid shivering (benzodiazepines) — iced fluids are only discouraged as sole therapy in mild cases.
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Hyperthermia >40°C
Rhabdomyolysis/AKI
Autonomic instability
Differentials
Serotonin syndrome
Malignant hyperthermia
Sepsis
Heat stroke
Common mistakes
Withholding active cooling — cooled IV fluids are appropriate in severe hyperthermia
Confusing with serotonin syndrome (clonus)
Rechallenging too early — wait ≥2 weeks after full resolution, lowest potency, different agent, psychiatry-led
Disposition & follow-up
ICU supportive care; do not rechallenge abruptly.
Discharge package
MedicationsDo not restart the same agent abruptly; psychiatry-guided
Dose1–2.5 mg/kg IV bolus, repeat q5–10 min to max 10 mg/kg, then 1 mg/kg q6h ×24–48 h
Preparation20 mg vial reconstitute with 60 mL sterile water (slow to dissolve — warm, shake)
MonitorLFTs, muscle weakness; combine with aggressive cooling
Bromocriptinedopamine agonist
Dose2.5–5 mg PO/NG q8h (adjunct to stopping agent + cooling)
Preparation2.5 mg tablets crushed for NG
MonitorCK, renal function, rigidity trend
Lorazepambenzodiazepine
DoseStatus: 0.1 mg/kg IV (max 4 mg/dose), may repeat ×1
Preparation4 mg/mL vial dilute 1:1 with NS; slow push
MonitorRR, SpO₂; flumazenil caution in chronic users
📖 expert consensus / toxicologyReviewed July 2026
12
Critical Care / ICU
1. Sepsis & Septic Shock
ICU / RESUS▸
Fever + confusion + lactate 4.2; BP 84/50 after 2 L — suspected pneumonia. Move fast: every hour of antibiotic delay costs lives.
ABCDE
Cultures ×2 (don't delay abx >45 min for them); broad-spectrum antibiotics within 1 h; 30 mL/kg crystalloid if hypotensive or lactate ≥4; noradrenaline to MAP ≥65; early source control.
Recognise early:Screen with NEWS2/MEWS or SIRS (preferred over qSOFA — SSC 2026); confirm with SOFA ≥2 + serum lactate — sepsis = infection + organ dysfunction
✓
Hour-1 bundle:blood cultures ×2, lactate, then broad-spectrum IV antibiotics within 1 h — piperacillin-tazobactam 4.5 g (or meropenem 1 g if risk of ESBL) ± vancomycin 25–30 mg/kg load for MRSA risk
✓
Hypotension / lactate ≥4:30 mL/kg balanced crystalloid (lactated Ringer's) within 3 h — actual body weight (adjusted/ideal if BMI >30) — in 250–500 mL aliquots with reassessment (lungs, urine output, capillary refill); after the initial bolus either restrictive or liberal strategy is acceptable (CLOVERS/CLASSIC)
✓
Still MAP <65:noradrenaline 0.05–1 mcg/kg/min titrated to MAP 65 (for patients ≥65 y, initial MAP 60–65 is acceptable — SSC 2026) — start peripherally through a good proximal IV while central access is placed
✓
Source control:drain abscess, remove infected line, relieve obstruction — ideally within 6–12 h; recheck lactate every 2–4 h to guide resuscitation
✓
Refractory shock:add vasopressin up to 0.03 U/min when noradrenaline reaches 0.25–0.5 mcg/kg/min; hydrocortisone 200 mg/day (50 mg IV q6h) if still vasopressor-dependent (SSC 2026 suggests IV corticosteroids for septic shock more broadly, low certainty)
✓
Calculators:
Order set
CBC, CRP, U&E, LFT, coag
Serum lactate now + serial
Blood cultures ×2 before abx
Urine + sputum cultures, CXR
Piperacillin-tazobactam 4.5 g IV
Lactated Ringer's 30 mL/kg
Noradrenaline infusion (MAP 65)
Urinary catheter — hourly urine output
ABG / VBG
Monitor
Hour 1Cultures, antibiotics in, fluids running, lactate sent
q15–30 minMAP, HR, urine output during resuscitation
q2–4 hSerial lactate — target clearance ≥10–20%/2 h
DailyFluid balance (aim negative after day 2), renal function, de-escalate abx at 48–72 h per cultures
Escalate / ICU
Noradrenaline requirement rising or >0.25 mcg/kg/min
Lactate ≥4 or not clearing
Oliguria <0.5 mL/kg/h ×2 h or rising creatinine
Respiratory failure needing NIV/intubation
Any need for vasopressors = ICU
Criteria
AdmitEvery patient with sepsis (infection + SOFA ≥2)
ICUVasopressor support, lactate >4 with hypotension, or ≥2 failing organs
Fluids30 mL/kg for hypotension or lactate ≥4 (actual BW; adjusted/ideal if BMI >30), then reassess before more; consider active deresuscitation after the acute phase
SteroidsHydrocortisone 200 mg/day only if vasopressor-refractory
Delay antibiotics for cultures, imaging or LP — take cultures, then give drugs immediately
Push fluids blindly in heart failure/ESRD — reassess perfusion vs lungs every bolus
Use dopamine or phenylephrine first-line in septic shock
Key
Noradrenaline is the first-line vasopressor; target MAP 65, not higher (MAP 60–65 acceptable if ≥65 y)
Prolonged/extended β-lactam infusion after a loading dose is now a STRONG recommendation (SSC 2026); capillary-refill–guided resuscitation supported (ANDROMEDA-SHOCK-2)
Antibiotics within 1 h of recognition — each hour of delay raises mortality ~7%
De-escalate antibiotics at 48–72 h once cultures return — stewardship saves kidneys and resistance
Clinical detail — differentials, red flags, pitfalls, disposition
No source control — antibiotics alone fail with pus
Keeping vancomycin >48–72 h with negative cultures
Forgetting VTE and stress-ulcer prophylaxis in ICU
Disposition & follow-up
Step down to ward when off vasopressors ×24 h and improving; total antibiotic course usually 5–7 days with source control; repeat lactate normalised before downgrade.
Discharge package
MedicationsOral step-down antibiotic to complete 5–7 day course; stop all empiric broad-spectrum agents
Follow-upRepeat bloods (CRP, renal) in 48–72 h; review cultures and sensitivities; source-control wound check
Classify at the bedside:cold & wet = cardiogenic (poor LV on echo), cold & dry = hypovolaemic, warm & bounding = distributive (sepsis/anaphylaxis), obstructive = tamponade/tension PTX/massive PE on POCUS
✓
Default pressor:noradrenaline 0.05–1 mcg/kg/min to MAP 65 — start peripherally via a good proximal cannula while arranging central access; don't wait for a CVC
Obstructive:relieve the obstruction — pericardiocentesis (tamponade), needle decompression (tension PTX), thrombolysis (massive PE with shock)
✓
Wean correctly:titrate down once MAP stable ≥65 and perfusion restored; wean noradrenaline before vasopressin; monitor lactate clearance and urine output
✓
Order set
Arterial line for beat-to-beat MAP
Bedside echo + IVC + lung POCUS
Noradrenaline infusion
Central venous catheter (not a prerequisite to start)
Serial lactate q2–4 h
Catheter — strict hourly urine output
Crossmatch if bleeding suspected
Monitor
ContinuousInvasive MAP, HR, SpO₂
q2–4 hLactate, capillary refill, mottling score
HourlyUrine output — target ≥0.5 mL/kg/h
DailyFluid balance, vasopressor dose trend, renal + liver function
Escalate / ICU
Escalating pressor dose without a working diagnosis
Lactate >4 or not clearing
Signs of limb/gut ischaemia
Need for mechanical support in cardiogenic shock — Impella CP reasonable (Class 2a) in selected STEMI cardiogenic shock (DanGer Shock, NEJM 2024); routine VA-ECMO has NO benefit (ECLS-SHOCK); IABP not routine (IABP-SHOCK II)
Any shock not responding within the first hour — ICU review
Criteria
NoradrenalineFirst-line: sepsis, most shock — 0.05–1 mcg/kg/min
VasopressinAdd-on ≤0.03 U/min in refractory septic shock
AdrenalineAnaphylaxis; cold septic shock alternative
DobutamineInotrope for cardiogenic with low output — 2.5–10 mcg/kg/min
PhenylephrinePure α — only for tachyarrhythmia-limited or anaesthesia hypotension
Never
Give dopamine first-line (arrhythmias, worse outcomes)
Withhold pressors until central access — peripheral noradrenaline through a good IV is safe short-term
Bolus fluids into cardiogenic or obstructive shock
Key
MAP target is 65 — higher targets add arrhythmia, not survival
Stage cardiogenic shock with SCAI SHOCK 2022 staging (A–E); angiotensin II (Giapreza) is a third-line catecholamine-sparing option (ATHOS-3)
Bedside echo changes management in ~1/3 of undifferentiated shock
The pressor buys time; only treating the cause saves the patient
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Lactate ≥4
Cool mottled extremities
SBP <90 with oliguria
Syncope with chest pain (think PE/dissection/ACS)
Differentials
Sepsis
Acute MI / decompensated heart failure
Massive PE, tamponade, tension pneumothorax
Adrenal crisis, anaphylaxis, spinal shock
Common mistakes
Assuming sepsis in every warm patient
Chasing a MAP number while lactate climbs
Starting dobutamine in hypotension without a pressor (it vasodilates)
Missing obstruction — POCUS early
Disposition & follow-up
ICU for all vasopressor-dependent patients; review pressor dose and volume status every hour; identify and document the shock type within the first hour.
💊 Treatment detail — doses & preparation
Noradrenaline (norepinephrine)vasopressor
Dose0.05–1 mcg/kg/min IV infusion, titrate to MAP ≥65
Preparation4 mg in 250 mL D5W or NS (16 mcg/mL) via infusion pump; central line preferred — proximal peripheral vein acceptable short-term
Urticaria + stridor + BP 78/40 minutes after IV antibiotic — this is adrenaline IM now, not antihistamines first.
ABCDE
ADRENALINE 0.5 mg IM (1 mg/mL, 0.5 mL) anterolateral thigh immediately — repeat every 5 min; remove trigger; supine with legs raised; high-flow O₂; 2 large-bore IVs + rapid normal saline.
Recognise:airway (angioedema, stridor), breathing (wheeze), circulation (SBP <90 or >30% drop) compromise ± skin/mucosal signs after a trigger — skin signs absent in 20%
✓
Adrenaline IM NOW:0.5 mg (0.5 mL of 1 mg/mL) IM into the anterolateral thigh — repeat every 5 minutes if no improvement; this is the ONLY first-line drug
✓
Position + access:lie flat, legs raised (left lateral if pregnant, sit up if severe breathlessness); 2 large-bore IVs; 1–2 L 0.9% saline rapidly — adults can sequester 35% of blood volume in 10 min
✓
Airway threats:stridor/tongue swelling → nebulised adrenaline 5 mg + senior anaesthetist NOW; intubate early — angioedema makes late airways impossible
✓
Adjuncts only AFTER adrenaline:hydrocortisone 200 mg IV + cetirizine 10 mg PO/IV — these do nothing for the acute airway/shock
✓
Refractory:adrenaline infusion 0.05–1 mcg/kg/min with monitoring; on β-blockers → glucagon 1–5 mg IV; observe ≥6–24 h for biphasic reaction
✓
Order set
Adrenaline 0.5 mg IM anterolateral thigh
0.9% saline 1–2 L rapid
High-flow O₂
Mast cell tryptase (within 2 h, repeat at 24 h)
Hydrocortisone 200 mg IV (after adrenaline)
Cetirizine 10 mg (after adrenaline)
Nebulised adrenaline 5 mg if stridor
Adrenaline infusion if refractory
Monitor
q5 minBP, HR, response to IM adrenaline — redose
ContinuousSpO₂, cardiac monitor, watch for biphasic reaction
2 h + 24 hMast cell tryptase samples
6–24 hObservation window before discharge (12–24 h if severe, asthmatic, or needed 2 doses)
Escalate / ICU
Airway oedema progressing despite adrenaline
Need for adrenaline infusion
Biphasic reaction
Refractory hypotension — ICU
Criteria
AdmitAll who needed adrenaline infusion, 2+ doses, or had airway involvement
ObserveMinimum 6 h from symptom resolution; 12–24 h if severe/asthma/β-blocker
Give adrenaline IV bolus in a monitored, non-arrest patient — IM thigh first (IV bolus = arrhythmia/infarction)
Treat with antihistamines or steroids while delaying adrenaline
Discharge early or without an adrenaline auto-injector and allergy referral
Key
IM anterolateral thigh — fastest absorption, safest route; no maximum cumulative dose in true anaphylaxis
Glucagon 1–5 mg IV for patients on β-blockers with refractory anaphylaxis
Biphasic reactions occur in up to 20% — observation is treatment
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Hoarseness, tongue or lip swelling
Stridor or silent chest
SBP <90 or collapse
Trigger was parenteral (IV drug, sting) — faster and deadlier
Differentials
Vasovagal syncope (bradycardia, no skin signs)
ACE-inhibitor angioedema (no urticaria, bradykinin — adrenaline less effective)
Scombroid poisoning
Panic attack / globus
Common mistakes
Walking the patient to resus — lay them flat immediately
Underdosing adrenaline in adults (0.3 mg is paediatric thinking)
Relying on steroids to 'prevent' biphasic reactions
No auto-injector training before discharge
Disposition & follow-up
Discharge with 2 adrenaline auto-injectors, written action plan, trigger avoidance advice, and allergy/immunology referral for testing in 4–6 weeks.
Discharge package
MedicationsAdrenaline auto-injector ×2 (e.g., 0.3 mg) — demonstrate technique; teach second dose into the opposite leg if symptoms persist/recur (RCUK 2025 first-aid update; adrenaline nasal spray is an emerging option); short course of antihistamine
Follow-upAllergy clinic in 4–6 wk for skin/specific-IgE testing; MedicAlert bracelet
Warning symptomsAny lip/tongue tingling, widespread hives, breathing difficulty — use auto-injector immediately and call emergency services
LifestyleTrigger avoidance plan; check drug allergies before every new prescription
💊 Treatment detail — doses & preparation
Adrenaline IM (anaphylaxis)first-line anaphylaxis
Dose0.5 mg IM anterolateral thigh, repeat q5 min PRN
Preparation0.5 mL of 1:1,000 (1 mg/mL) drawn from 1 mg ampoule; no dilution needed
MonitorResponse within 5 min; have IV access + fluids ready
0.9% Sodium chloridecrystalloid
DoseBolus 500 mL over 15–30 min, reassess; maintenance 1–1.5 mL/kg/h
Preparation500/1000 mL bags; add KCl only after urine output confirmed
MonitorHyperchloraemic acidosis with large volumes — prefer balanced (LR) for resuscitation
Adrenaline infusionvasopressor/inotrope
Dose0.05–1 mcg/kg/min IV infusion, titrate to effect
Preparation4 mg in 250 mL D5W/NS (16 mcg/mL) via pump; central access for prolonged use
Exhausted, SpO₂ 82% on 15 L, PaCO₂ 9.1 kPa and climbing — type I vs type II failure, NIV or tube, and the first safe ventilator settings.
ABCDE
Position, suction, high-flow O₂ while deciding; ABG now; NIV first for COPD/pulmonary oedema if no contraindication; if intubating — preoxygenate 3–5 min, ketamine/etomidate + rocuronium, then lung-protective settings.
Classify:type I (hypoxic, low/normal PaCO₂) vs type II (PaCO₂ >6.5 with low pH) — ABG now; NIV first-line for COPD exacerbation and acute pulmonary oedema if conscious and protecting airway
✓
NIV trial:BiPAP (IPAP 10–15, EPAP 5) for COPD with pH <7.35, or CPAP for pulmonary oedema — reassess ABG at 1 h; failing pH/mental state → intubate
✓
Intubate safely:preoxygenate 3–5 min (NIV/HFNO), ketamine 1–2 mg/kg (or etomidate 0.3 mg/kg) + rocuronium 1.2 mg/kg; have fluids + noradrenaline ready for post-intubation hypotension
✓
Initial ventilator settings:AC volume control, tidal volume 6–8 mL/kg PREDICTED body weight, RR 12–16, FiO₂ 100% then wean to SpO₂ 92–96%, PEEP 5 cmH₂O
✓
Obstructive lungs (asthma/COPD):RR 8–12, high inspiratory flow, long expiratory time — tolerate hypercapnia; hypotension on vent = auto-PEEP → disconnect and allow full exhalation
✓
First 30 min:post-intubation ABG at 15–30 min; plateau pressure <30; confirm tube with continuous ETCO₂; cuff pressure 20–30 cmH₂O and head-of-bed 30–45° (VAP prevention); start analgesia-first sedation (light target RASS 0 to −1 — PADIS) and DVT/GI prophylaxis
✓
Order set
ABG before + 15–30 min after intubation
Ketamine 1–2 mg/kg + rocuronium 1.2 mg/kg
Noradrenaline/fluids primed for induction
AC/VC: VT 6–8 mL/kg PBW, PEEP 5
Continuous ETCO₂ + capnography
Sedation: propofol or fentanyl infusion
CXR to confirm tube position
DVT + stress-ulcer prophylaxis
Monitor
ContinuousETCO₂, SpO₂, airway pressures, plateau
15–30 minPost-intubation ABG — adjust RR for pH, not PaCO₂
q1–4 hAuto-PEEP check in obstructive disease; sedation depth (RASS)
DailySpontaneous awakening + breathing trials once FiO₂ ≤40% and PEEP ≤8
Escalate / ICU
pH <7.25 on NIV or falling GCS
Auto-PEEP with hypotension/barotrauma
P/F ratio <150 → ARDS pathway
Need for deep sedation/paralysis to ventilate
Criteria
IntubateGCS <8, exhaustion, refractory hypoxia, or failing pH despite NIV
VT6–8 mL/kg predicted (not actual) body weight
PlateauKeep <30 cmH₂O; driving pressure <15
ExtubateAwake, FiO₂ ≤40%, PEEP ≤8, passes SBT, cuff leak if at risk
Never
Ventilate to a 'normal' PaCO₂ in a chronic CO₂ retainer — aim for their baseline pH
Use actual body weight for tidal volume
Give a long-acting paralytic then struggle to assess neurology
Key
Predicted body weight: men = 50 + 2.3 kg per inch over 5 ft; women = 45.5 + 2.3
Post-intubation hypotension is common — preload, pressors ready, and check for auto-PEEP
ETCO₂ confirms the tube; a normal SpO₂ does not exclude oesophageal intubation
Clinical detail — differentials, red flags, pitfalls, disposition
📖 Textbook Ch.7–8; ARDSNet; DAS 2025 (unanticipated difficult intubation)Reviewed July 2026
5. ARDS
ICU / RESUS▸
Bilateral infiltrates, PaO₂/FiO₂ 110 on PEEP 5, 3 days into pneumonia — this is ARDS; the ventilator itself can injure, so set it like a lung-protective protocol.
ABCDE
Confirm not cardiogenic (echo/BNP); lung-protective ventilation 6 mL/kg PBW; plateau ≤30, driving pressure ≤15; prone ≥16 h/day if P/F <150; conservative fluids once resuscitated.
Diagnose (Berlin):new bilateral infiltrates within 1 week of an insult, not explained by cardiac failure, with PaO₂/FiO₂ ≤300 on PEEP ≥5 — classify: mild 200–300, moderate 100–200, severe <100. 2024 Global Definition also allows diagnosis on HFNO ≥30 L/min, SpO₂/FiO₂ (≤315 with SpO₂ ≤97%), and lung ultrasound — Berlin remains the trial standard
Permissive hypercapnia:accept PaCO₂ rise if pH >7.25; SpO₂ target 88–95%; use PEEP/FiO₂ ladder — higher PEEP for moderate-severe
✓
Prone if P/F <150:prone positioning ≥16 h/day — PROSEVA mortality benefit; check tube, eyes, pressure areas each turn
✓
Fluids conservative:once shock resolves, run a negative balance — diurese to the driest lungs the circulation tolerates
✓
Refractory severe:NMB infusion (cisatracurium) reserved for severe ARDS with patient–ventilator dyssynchrony or refractory hypoxaemia despite proning — not routine (ATS 2023 suggests against routine continuous NMB); consider VV-ECMO if pH <7.25 or P/F <80 despite proning — call ECMO centre early
✓
Order set
ABG q4–6 h during titration
VT 6 mL/kg PBW — recalculate PBW now
Plateau + driving pressure checks
Daily CXR / lung ultrasound
Fluid balance — target negative after resuscitation
Prone positioning schedule if P/F <150
DVT prophylaxis, enteral nutrition
Monitor
q4 hPlateau and driving pressure after every vent change
DailyP/F ratio, fluid balance, sedation minimisation (RASS 0 to −1)
Each prone cycle16 h prone / 8 h supine with full safety checklist
WeeklyTracheostomy review if not improving by day 7
Escalate / ICU
P/F <80 or pH <7.25 despite proning
Barotrauma (pneumothorax)
Need for FiO₂ >80% >24 h
Multi-organ failure — ECMO discussion
Criteria
BerlinBilateral infiltrates, ≤1 wk, non-cardiogenic, P/F ≤300 on PEEP ≥5
VT6 mL/kg PBW (4–8) — the single biggest survival lever
DoseAfter resuscitation: target negative daily balance with diuretics/vasopressor support
PreparationPer FACTT protocol
MonitorFluid balance, oxygenation daily
📖 Berlin definition; 2024 Global Definition; ATS 2023; ARDSNet; PROSEVA; EOLIAReviewed July 2026
6. Status Epilepticus
ICU / RESUS▸
Generalised tonic-clonic seizure ongoing at 7 minutes — treat the clock: benzodiazepine at 5 min, second-line loaded by 20 min, airway by 30–40 min.
ABCDE
ABC on side; fingerstick glucose + thiamine if indicated; lorazepam 0.1 mg/kg IV (max 4 mg/dose, may repeat once) — or midazolam 10 mg IM if no access; prepare second-line immediately.
0–5 min:ABC, lateral position, O₂, suction, glucose + thiamine 100 mg if malnourished; start timer — status = ≥5 min continuous or recurrent without regaining consciousness
✓
5–15 min — benzo:lorazepam 0.1 mg/kg IV (max 4 mg, may repeat ×1) or midazolam 10 mg IM/buccal if no IV — underdosing is the commonest error
✓
15–30 min — load second-line:levetiracetam 60 mg/kg (max 4500 mg) OR fosphenytoin 20 mgPE/kg OR valproate 40 mg/kg — all equivalent (ESETT); give even if seizures stop after benzo
✓
30–40 min — refractory:intubate + midazolam 0.2 mg/kg load then 0.05–2 mg/kg/h infusion, or propofol (avoid prolonged high-dose — PRIS) — target EEG suppression, not just no convulsions; ketamine is an emerging option for super-refractory status
✓
Investigate in parallel:CT head, labs (Na, Ca, Mg, glucose, AED levels, tox), EEG within the hour — treat cause: hypoglycaemia, eclampsia (MgSO₄), meningitis (abx + aciclovir)
✓
After control:maintain infusion 24–48 h then slow wean with EEG; load oral maintenance AED; admit to ICU
✓
Order set
Lorazepam 0.1 mg/kg IV (max 4 mg) ×2
Levetiracetam 60 mg/kg (max 4500 mg)
Thiamine 100 mg IV before dextrose
Glucose, Na, Ca, Mg, AED levels, tox screen
CT head once stabilised
EEG monitoring (rule out non-convulsive SE)
Intubation kit + midazolam infusion ready
Monitor
ContinuousEEG if intubated/paralysed — convulsions can stop while seizures continue
q5 minTime of each intervention — benzodiazepine at 5, second-line by 20, airway by 40
q1 hGlucose until stable; BP with infusions
24–48 hSeizure-free on infusion before weaning
Escalate / ICU
Seizure >30–40 min despite 2 agents
Need for anaesthetic infusion
Refractory hypoxia or rising ICP signs
Unknown cause with normal CT — LP after exclusion of mass
Criteria
BenzoLorazepam 0.1 mg/kg — full dose, may repeat once
PreparationDilute in 100–250 mL NS; cardiac monitor during load
MonitorBP, ECG (hypotension/arrhythmia), level 2 h post-load
Sodium valproateantiepileptic
DoseStatus: 40 mg/kg IV (max 3000 mg) at 10 mg/min; maintenance 10–15 mg/kg/day
PreparationDilute 400 mg vial per protocol over 5–10 min
MonitorLFTs, platelets, ammonia; teratogenic — avoid in pregnancy
PropofolIV anaesthetic
DoseSedation 5–50 mcg/kg/min infusion; refractory SE titrate to EEG
Preparation1% (10 mg/mL) lipid emulsion ready vial via syringe pump; change tubing q12 h
MonitorBP (vasodilates), triglycerides, PRIS if prolonged/high dose
📖 ESETT trial; textbook Ch.51Reviewed July 2026
7. Aortic Dissection
ICU / RESUS▸
Tearing interscapular pain, BP 210/120, right arm pulse weaker than left — kill the shear forces: β-block FIRST, then vasodilate, then CTA.
ABCDE
High-flow O₂; 2 large-bore IVs; esmolol or labetalol BEFORE any vasodilator; target HR <60 then SBP 100–120; urgent CTA chest/abdomen; type A = emergency surgery.
Suspect:tearing chest/back pain ± pulse deficit, aortic regurgitation murmur, widened mediastinum; mortality ~1% per hour untreated — CTA chest/abdomen/pelvis now
✓
Stabilise access + tests:2 large-bore IVs, crossmatch 6 units, ECG (dissection can occlude the right coronary — STEMI mimic), lactate, U&E
✓
Impulse control FIRST:esmolol 500 mcg/kg load then 50–200 mcg/kg/min, or labetalol 20 mg IV q10 min — target HR <60 bpm before any vasodilator
✓
Then BP 100–120 mmHg:add nicardipine 5→15 mg/h or nitroprusside ONLY after β-blockade — unopposed vasodilation raises shear stress and extends the flap
✓
Type A (any ascending):emergency cardiothoracic surgery regardless of stability — call the surgeon while scanning; type B → medical therapy unless malperfusion/rupture → TEVAR
Type AEmergency surgery — any ascending involvement
Type BMedical impulse control; TEVAR if complicated
HR target<60 bpm BEFORE SBP 100–120
DefinitiveSurvival tracked hourly until theatre/repair
Never
Vasodilate before β-blockade — reflex tachycardia extends the dissection
Thrombolyse the 'STEMI' — dissection mimics it and lysis is fatal
Wait for troponin/d-dimer to rule it in or out
Key
HR first, BP second — both controlled within the first 20 minutes of suspicion
Type A mortality rises ~1% per hour — the CT table is the bottleneck, not the diagnosis
Interarm SBP difference >20 mmHg or new AR murmur = dissection until CTA proves otherwise
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Tearing/migratory pain
Pulse deficit or interarm BP >20 mmHg
New diastolic murmur (AR)
Syncope, tamponade, stroke with chest pain
Differentials
ACS (ECG + troponin — but dissection can cause it)
Pulmonary embolism
Musculoskeletal pain
Pericarditis
Common mistakes
Nitroprusside started first
Analgesia forgotten — pain defeats every infusion
Single normal troponin = false reassurance
D-dimer used as rule-out (not validated)
Disposition & follow-up
Type A → theatre; type B → ICU 48–72 h then ward with oral β-blocker; lifelong BP control + surveillance imaging at 1, 6, 12 months.
💊 Treatment detail — doses & preparation
EsmololIV β-blocker
DoseLoad 500 mcg/kg over 1 min, then 50–200 mcg/kg/min
Preparation2.5 g in 250 mL (10 mg/mL) ready bag via pump; titrate q5–10 min
MonitorHR <60 target in dissection; watch for bronchospasm, bradycardia
Labetalol IVIV α+β-blocker
Dose20 mg IV over 2 min, repeat 20–80 mg q10 min (max 300 mg) or 0.5–2 mg/min infusion
Preparation200 mg in 160 mL (1.25 mg/mL) for infusion; boluses undiluted (5 mg/mL vial)
MonitorAvoid in asthma/decompensated HF; postural hypotension
NicardipineIV dihydropyridine
Dose5 mg/h IV, ↑2.5 mg/h q5–15 min to max 15 mg/h
Preparation25 mg in 250 mL D5W/NS (0.1 mg/mL) via pump; central line preferred (vesicant)
MonitorMAP, reflex tachycardia; change site if peripheral >12 h
Fentanylopioid analgesic
Dose25–100 mcg IV boluses; infusion 0.5–2 mcg/kg/h
Preparation100 mcg/2 mL ampoule undiluted for bolus; infusion 1 mg in 50 mL NS
MonitorRR, sedation score; less hypotension than morphine
📖 ACC/AHA aortic disease guideline + textbook Ch.21Reviewed July 2026
8. Hypertensive Emergency
ICU / RESUS▸
BP 240/130 with blurred vision, pulmonary oedema and creatinine climbing — the DAMAGE defines the emergency, not the number. Lower MAP ≤20–25% in the first 1–2 h.
ABCDE
Arterial line + cardiac monitoring; IV agent (nicardipine/labetalol/clevidipine) titrated to ≤20–25% MAP reduction in 1–2 h; treat the damaged organ in parallel.
Emergency vs urgency:emergency = severe hypertension + acute target-organ damage (encephalopathy, retinopathy, APE, ACS, AKI, microangiopathy); severe hypertension (>180/120, no acute damage, formerly "urgency") → oral agents, no ICU — do NOT give intermittent IV or oral agents solely to acutely lower BP in asymptomatic inpatients (2025 AHA/ACC)
✓
Set up:ICU/HDU, arterial line, cardiac monitor; choose agent — nicardipine 5→15 mg/h, labetalol 20 mg IV boluses/infusion, or clevidipine 1→16 mg/h
✓
Rate of reduction:MAP down ≤20–25% in the first 1–2 h, then toward ~160/100 by 6 h, normalise over 24–48 h — faster drops cause watershed stroke
✓
Exceptions to the rule:aortic dissection → SBP <120 within 20 min; acute ischaemic stroke → permissive (treat only >220/120, or >185/110 before thrombolysis)
✓
Special situations:pheochromocytoma → phentolamine (α before β); eclampsia → MgSO₄ + labetalol/hydralazine; sympathomimetic tox → benzodiazepines first
q5–15 minBP during titration — never let MAP fall >25% in 2 h
HourlyNeurology, urine output
q4–6 hCreatinine, potassium
24–48 hTransition to oral agents before stepping down
Escalate / ICU
Encephalopathy or seizures
APE needing NIV
AKI rapidly worsening
Dissection/pheochromocytoma/eclampsia
Criteria
ICUAny acute target-organ damage
MAP drop≤20–25% first 1–2 h — never to 'normal' acutely
Stroke exceptionTreat only >220/120 (>185/110 pre-lytic)
Step-downStable on oral agents ×24 h, organ function plateaued
Never
Drop BP to normal in the first hours — cerebral hypoperfusion and watershed infarction
Use sublingual nifedipine — precipitous uncontrolled drops
Give IV drips or intermittent agents for severe hypertension without organ damage (asymptomatic) — no acute lowering at all is recommended; oral therapy and observation suffice (2025 AHA/ACC)
Key
The number never defines the emergency — encephalopathy, APE, ACS, AKI or retinopathy does
Clevidipine is the smoothest titratable agent (short half-life, lipid emulsion)
Always hunt the secondary cause later: renal artery, pheochromocytoma, primary aldosteronism
Clinical detail — differentials, red flags, pitfalls, disposition
ICH nuance: target SBP 130–<140 for presenting SBP 150–220 (2025 AHA/ACC)
Disposition & follow-up
ICU until on stable oral regimen; investigate secondary causes (renal ultrasound, aldosterone:renin, metanephrines); BP clinic within 1 week.
💊 Treatment detail — doses & preparation
NicardipineIV dihydropyridine
Dose5 mg/h IV, ↑2.5 mg/h q5–15 min to max 15 mg/h
Preparation25 mg in 250 mL D5W/NS (0.1 mg/mL) via pump; central line preferred (vesicant)
MonitorMAP, reflex tachycardia; change site if peripheral >12 h
Labetalol IVIV α+β-blocker
Dose20 mg IV over 2 min, repeat 20–80 mg q10 min (max 300 mg) or 0.5–2 mg/min infusion
Preparation200 mg in 160 mL (1.25 mg/mL) for infusion; boluses undiluted (5 mg/mL vial)
MonitorAvoid in asthma/decompensated HF; postural hypotension
ClevidipineIV dihydropyridine
Dose1–2 mg/h, double q2–5 min to max 16–21 mg/h
PreparationReady emulsion 0.5 mg/mL (50/100 mL vial) via pump — no dilution
MonitorLipid load, egg/soy allergy; ultra-short half-life = fast offset
Sodium nitroprussideIV vasodilator
Dose0.3–10 mcg/kg/min IV infusion
Preparation50 mg in 250 mL D5W (200 mcg/mL); wrap bag in foil — light sensitive; D5W only
MonitorCyanide toxicity if >72 h or renal failure; invasive MAP mandatory
Magnesium sulfate IVelectrolyte/antiarrhythmic
DoseTorsades: 2 g over 10–15 min. Asthma: 2 g over 20 min. Eclampsia: 4 g load then 1 g/h
Preparation2 g in 100 mL NS via pump; eclampsia 4 g in 100–200 mL
MonitorReflexes/RR if high doses (toxicity), Mg²⁺ level, renal function
📖 2025 AHA/ACC/Multisociety High BP guideline + textbook Ch.23Reviewed July 2026
9. Cardiac Arrest & Post-ROSC Care
ICU / RESUS▸
Collapse, pulseless — start the clockwork: quality CPR, adrenaline every 3–5 min, shock the shockable, hunt Hs & Ts, then protect the brain after ROSC.
ABCDE
High-quality CPR 100–120/min, 5–6 cm depth, minimal pauses; adrenaline 1 mg IV q3–5 min; defibrillate VF/pVT at 200 J biphasic; reversible causes in parallel.
CPR quality first:100–120 compressions/min, depth 5–6 cm, full recoil, rotate compressors q2 min, <10 s pauses; waveform capnography (ETCO₂ >10 mmHg = adequate)
✓
Shockable (VF/pVT):shock 200 J biphasic → CPR 2 min → shock; adrenaline 1 mg after initial defibrillation attempts have failed (typically after 2nd–3rd shock), then q3–5 min; amiodarone 300 mg after 3rd shock (or lidocaine 100 mg as alternative)
✓
Non-shockable (PEA/asystole):adrenaline 1 mg IV/IO as early as possible then q3–5 min; no shocks — hunt causes
✓
Reversible causes (Hs & Ts):hypoxia, hypovolaemia, hypo/hyperkalaemia, hypothermia, tension pneumothorax, tamponade, toxins, thrombosis (MI/PE) — treat in parallel, not after
✓
ROSC → 12-lead within minutes:STEMI or high suspicion → cath lab activation even if comatose; no STEMI → CT head/chest as indicated
✓
Post-ROSC bundle:SpO₂ 90–98% (avoid hyperoxia AND hypoxaemia), normocapnia, MAP ≥65, temperature control 32–37.5 °C for comatose survivors maintained ≥36 h (prevent hyperthermia), glucose 8–10 mmol/L, ICU (2025 AHA)
✓
Calculators:
Order set
Adrenaline 1 mg IV/IO q3–5 min
Amiodarone 300 mg (shock-refractory VF/pVT)
Defibrillator pads before arrival if possible
Waveform capnography
ABG + K⁺/glucose during arrest
12-lead ECG immediately post-ROSC
Temperature control 32–37.5 °C (comatose survivors, ≥36 h)
Cath lab activation if STEMI
Monitor
Peri-arrestETCO₂ (fall predicts loss of output; rise predicts ROSC)
Post-ROSC q15 minMAP, SpO₂, ETCO₂-PaCO₂ gradient
ContinuousTemperature probe — prevent fever ≥72 h
≥72 hMultimodal neuroprognostication — never earlier
Escalate / ICU
ETCO₂ <10 after 20 min quality CPR (prognosis grave)
Refractory arrest with reversible cause → E-CPR centre (reasonable, COR 2a — 2025 AHA)
Any ROSC → ICU
Post-ROSC seizures → EEG + treat as status
Criteria
Adrenaline1 mg q3–5 min; early in non-shockable
Amiodarone300 mg after 3rd shock (150 mg after 5th)
Cath labSTEMI (or shock/refractory ventricular arrhythmia/ongoing ischaemia) post-ROSC regardless of coma; not routine for comatose non-STEMI
PrognosticateNot before 72 h, multimodal only
Never
Hyperoxia after ROSC — titrate O₂ down to SpO₂ 90–98%
Vasopressin — no role in cardiac arrest (2025 AHA)
Routine immediate cath for comatose non-STEMI (COACT/TOMAHAWK) — emergent cath only for STEMI/shock/refractory ventricular arrhythmia/ongoing ischaemia
Give routine sodium bicarbonate or calcium
Stop to check pulses mid-cycle for >10 s
Prognosticate in the first 72 h — sedation and TTM confound everything
Key
ETCO₂ is your CPR quality gauge — <10 mmHg means push harder/rotate
Adrenaline + amiodarone (or lidocaine alternative) are the antiarrhythmic/evidence drugs in arrest; vasopressin has no role
Post-ROSC hypotension (SBP <90) doubles mortality — noradrenaline early
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
Witnessed vs unwitnessed + downtime
ETCO₂ <10 despite quality CPR
Post-ROSC papilloedema/fixed pupils (do not act early)
Recurrent VF — overdrive pacing/ischaemia
Differentials
Acute MI (commonest)
PE — thrombolyse intra-arrest if suspected
Hyperkalaemia (dialysis patient, peaked T)
Toxins: β-blocker, CCB, tricyclic, local anaesthetic (lipid)
Common mistakes
Freon-style interruptions for intubation
Delaying access — IV is first choice (COR 1); IO reasonable if IV unsuccessful/not feasible (COR 2a, 2025 AHA)
Hypoglycaemia missed as cause
Early withdrawal discussions before 72 h
Disposition & follow-up
All ROSC → ICU; coronary angiography if STEMI or unstable; daily sedation holds from 48–72 h for neuro assessment; family communication early and honest.
💊 Treatment detail — doses & preparation
Adrenaline 1 mg (arrest)ACLS
Dose1 mg IV/IO every 3–5 min during arrest
Preparation1 mL of 1:10,000 (0.1 mg/mL) = 1 mg in 10 mL pre-filled syringe; flush 20 mL after
MonitorETCO₂ response; give early in non-shockable rhythms
Amiodarone IVantiarrhythmic
DoseArrest: 300 mg IV/IO bolus (then 150 mg). Stable: 150 mg over 10 min, then 1 mg/min ×6 h, 0.5 mg/min ×18 h
PreparationBolus 300 mg in 20–50 mL D5W; infusion 900 mg in 500 mL D5W (glass/non-PVC)
MonitorQT, LFTs, thyroid; long half-life — interacts with warfarin/digoxin
Noradrenaline (norepinephrine)vasopressor
Dose0.05–1 mcg/kg/min IV infusion, titrate to MAP ≥65
Preparation4 mg in 250 mL D5W or NS (16 mcg/mL) via infusion pump; central line preferred — proximal peripheral vein acceptable short-term
📖 2025 AHA Guidelines for CPR & ECC / ERC ALS + textbook Ch.19–20Reviewed July 2026
10. Acute Liver Failure
ICU / RESUS▸
Paracetamol overdose 2 days ago, now INR 3.8, confused, glucose 2.1 — INR ≥1.5 + encephalopathy = acute liver failure. NAC for everyone, transplant call early.
ABCDE
NAC immediately (all causes, not just paracetamol); correct hypoglycaemia with 10% dextrose; minimal sedation; head-up 30°; early transfer discussion with transplant centre.
Define:INR ≥1.5 + any encephalopathy in acute liver injury without prior cirrhosis = ALF; grade encephalopathy I–IV (asterixis → coma)
✓
NAC for ALL:150 mg/kg over 1 h → 50 mg/kg over 4 h → 100 mg/kg over 16 h — benefits even non-paracetamol ALF (improves transplant-free survival)
✓
Find the cause:paracetamol level (can be undetectable — treat anyway), viral serologies, autoimmune, Wilson (young + haemolysis), ischaemic hepatitis, DILI, pregnancy (HELLP/fatty liver)
✓
Protect the brain:grade III–IV → intubate for airway; head up 30°, quiet room, avoid suction clusters; treat seizures; NH₃ >150 → ICP risk — hypertonic saline/mannitol if signs; prophylactic hypertonic saline to target Na 145–155 mmol/L in grade III–IV encephalopathy (Stravitz/Lee 2022)
✓
Metabolic guard:glucose q1–2 h with 10% dextrose infusion (hepatic glucose output fails); replace phosphate/Mg/K; lactate — falling is good, rising ominous
✓
Transplant criteria:King's College — paracetamol: pH <7.25 or (INR >6.5 + Cr >300 + grade III–IV); non-paracetamol: INR >6.5 or any 3 of (age <10/>40, aetiology, jaundice-encephalopathy >7 d, INR >3.5, bili >300) — transfer EARLY
✓
Order set
NAC infusion protocol
10% dextrose infusion + glucose q1–2 h
Serial INR q6–12 h, lactate, NH₃
Viral hepatitis screen, autoimmune, ceruloplasmin
Paracetamol level (undetectable ≠ excluded)
Head-up 30°, minimise stimulation
Discuss transplant centre TODAY
Monitor
q1–2 hCapillary glucose — hypoglycaemia is constant threat
DailyPhosphate (high = regeneration, low = poor prognosis), renal function
Escalate / ICU
Encephalopathy grade III–IV — intubate
NH₃ >150 µmol/L or ICP signs
King's College criteria met — transfer now
AKI / oliguria — early CRRT (preferred over intermittent HD even if haemodynamically stable when NH₃ >150 µmol/L or cerebral-oedema risk — Stravitz/Lee 2022)
Criteria
AdmitAll ALF → ICU/HDU, transplant centre if criteria approached
Avoid NSAIDs, sedatives, and protein loads; lactulose has NO role in ALF encephalopathy
Hypoglycaemia + rising INR + rising NH₃ = the triad that phones the transplant centre
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
INR rising over days, not hours
Confusion/agitation (grade II)
Glucose <3 mmol/L repeatedly
NH₃ >150 µmol/L
Differentials
Paracetamol (commonest in UK/US)
Viral hepatitis A/B/E
Autoimmune, Wilson, Budd-Chiari
DILI (isoniazid, herbals), mushroom poisoning
Common mistakes
Stopping NAC at 21 h while still acidotic/encephalopathic (continue until improving)
Normal paracetamol level = false reassurance at late presentation
Prophylactic FFP
Missing hypoglycaemia as the cause of 'encephalopathy worsening'
Choosing intermittent HD over CRRT when NH₃ >150 µmol/L
Disposition & follow-up
ICU + early transplant centre liaison; if survives with native liver — full recovery usual; psychiatry follow-up after overdose; vaccinations vs triggers.
💊 Treatment detail — doses & preparation
N-acetylcysteine (NAC)paracetamol antidote
Dose150 mg/kg in 200 mL D5W over 1 h → 50 mg/kg in 500 mL over 4 h → 100 mg/kg in 1 L over 16 h (150/50/100 protocol); continue if still acidotic/INR rising
Preparation200 mg/mL ampoules — dilute in D5W as above; weight-capped at 110 kg
Preparation10 mg/mL ampoule in 50 mL D5W over 20–30 min (anaphylaxis if fast)
MonitorINR at 4–6 h; re-warfarinisation window
📖 King's College criteria; AASLD ALF guidance + Stravitz/Lee ALF Update 2022 + textbook Ch.45Reviewed July 2026
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Distilled management sequences for rapid bedside recall · severity tags, calculators and criteria are decision aids, not directives · doses are standard adult reference · always confirm against current local guidelines and clinical judgement. Ward Pathways · 100 pathways · content reviewed July 2026 · references cite the governing society per pathway (confirm current version locally).
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