ITP does not need plasma exchange. TTP needs plasma exchange.
That distinction is classic board bait. ITP is isolated thrombocytopenia; TTP is thrombocytopenia + MAHA/schistocytes ± neuro/renal/fever, and you start urgent plasma exchange before ADAMTS13 comes back. Acute TTP is treated with daily therapeutic plasma exchange plus immunosuppression such as steroids; ITP first-line therapy is corticosteroids, with IVIG/platelets for major bleeding.
Life-or-death ABIM management hits
1. TTP: the “PLEX now” thrombocytopenia
Thrombocytopenia + MAHA/schistocytes
± neuro changes, renal injury, fever
=
TTP until proven otherwise
↓
Start plasma exchange NOW
Do not wait for ADAMTS13
Board move: urgent plasma exchange + steroids. Add rituximab/caplacizumab depending on setting, but ABIM’s key answer is PLEX.
Trap: Do not transfuse platelets unless life-threatening bleeding. Platelets can worsen thrombosis in TTP/HIT-type consumptive disorders.
Contrast:
ITP
Isolated thrombocytopenia
No schistocytes, no MAHA
↓
Steroids ± IVIG
Platelets only if life-threatening bleed
TTP
Thrombocytopenia + hemolysis/schistocytes
↓
Plasma exchange immediately
2. Brugada syndrome: fever + sodium-channel problem = sudden death risk
Young/middle-aged patient
Syncope or nocturnal agonal respirations
Family history sudden death
ECG: coved ST elevation V1-V3
=
Brugada syndrome
Board move: symptomatic Brugada, especially syncope/cardiac arrest → ICD. The AHA/ACC/HRS guideline notes ICD therapy reduces mortality in symptomatic Brugada syndrome.
Acute management pearls:
Brugada + fever
↓
Treat fever aggressively
Electrical storm / recurrent VT/VF
↓
Isoproterenol acutely
Quinidine can be used for prevention/adjunct
Trap drugs: avoid sodium-channel blockers and other Brugada-provoking meds. Fever can unmask/worsen Brugada.
3. C1 esterase inhibitor deficiency: angioedema that does not care about epinephrine
Recurrent angioedema
No urticaria
Abdominal pain episodes
Family history
Low C4
=
Hereditary angioedema
Board move for acute attack: C1 inhibitor concentrate, icatibant, or ecallantide. WAO/EAACI guidelines recommend IV C1-INH, icatibant, or ecallantide as on-demand treatments of choice for hereditary angioedema attacks.
Airway is life/death.
Tongue/laryngeal edema
↓
Secure airway early
Give HAE-specific therapy
Trap: This is bradykinin-mediated, not histamine-mediated. Epinephrine, steroids, and antihistamines may be given if unclear/anaphylaxis possible, but they are not the definitive treatment for hereditary angioedema.
4. Adrenal crisis: do not wait for cortisol
Shock/hypotension
Hyponatremia ± hyperkalemia
Hypoglycemia
Abdominal pain/vomiting
Known steroid use or adrenal insufficiency
=
Adrenal crisis
Board move: hydrocortisone immediately + isotonic fluids. Endocrine guidance recommends immediate IV/IM hydrocortisone 100 mg with rapid IV 0.9% saline rehydration.
Trap: Draw cortisol/ACTH if easy, but do not delay steroids.
Suspect adrenal crisis
↓
Hydrocortisone now
Normal saline
Dextrose if hypoglycemic
Treat trigger
5. Myxedema coma: hypothyroid ICU patient dies without empiric steroids
Hypothermia
Bradycardia
Hypoventilation/hypercapnia
Hyponatremia
Altered mental status
Delayed reflexes
=
Myxedema coma
Board move:
IV levothyroxine
+ IV hydrocortisone first or with it
+ supportive ICU care
Why hydrocortisone? You can precipitate adrenal crisis if there is concomitant adrenal insufficiency.
6. Thyroid storm: block synthesis before release
Fever
Severe tachycardia/AF
Agitation/delirium
Diarrhea
Heart failure
Known Graves/toxic nodule
=
Thyroid storm
Board sequence:
1. Beta blocker
2. PTU or methimazole
3. Iodine one hour later
4. Steroids
5. Supportive care / treat trigger
Key order trap: Give thionamide before iodine. Iodine first can provide substrate for more hormone synthesis.
PTU bonus: decreases peripheral T4→T3 conversion, so often preferred in thyroid storm.
7. DKA/HHS: potassium determines whether insulin kills
DKA/HHS
↓
Check K before insulin
Board move:
K <3.3
Hold insulin
Replete K first
K 3.3-5.2
Insulin + K in fluids
K >5.2
Insulin, monitor K closely
Trap: Starting insulin when K is severely low can cause fatal arrhythmia.
8. Hyperkalemia with ECG changes: calcium first
Hyperkalemia + peaked T waves / wide QRS / sine wave
↓
IV calcium gluconate immediately
Then shift and remove potassium:
Stabilize membrane: calcium
Shift K intracellularly: insulin/dextrose ± albuterol
Remove K: diuretics, binders, dialysis
Trap: Insulin lowers potassium but does not stabilize the myocardium. ECG changes need calcium first.
9. Tumor lysis syndrome: kidney and rhythm emergency
Cancer after chemo or high tumor burden
HyperK
Hyperphos
Hypocalcemia
Hyperuricemia
AKI
=
Tumor lysis syndrome
Board move:
Aggressive IV fluids
Rasburicase if established/high-risk severe TLS
Allopurinol for prevention/lower risk
Treat hyperkalemia urgently
Dialysis if refractory
Trap: Allopurinol prevents new uric acid formation but does not rapidly remove existing uric acid. Rasburicase breaks down uric acid.
10. Neutropenic fever: antibiotics within an hour
ANC <500 or expected <500
Single fever ≥38.3 C
or sustained ≥38.0 C
=
Neutropenic fever
Board move: immediate anti-pseudomonal beta-lactam.
Cefepime
or piperacillin-tazobactam
or meropenem/imipenem
Add vancomycin only for specific indications: catheter infection, skin/soft tissue infection, pneumonia, hemodynamic instability, known MRSA, etc.
Trap: Do not wait for cultures to come back before antibiotics.
11. Meningitis: antibiotics now, steroids before/with antibiotics
Fever + headache + neck stiffness + AMS
=
Bacterial meningitis until proven otherwise
Board move:
Blood cultures
Dexamethasone
Empiric antibiotics immediately
LP if safe
CT before LP only if indicated
Typical adult empiric therapy:
Vancomycin + ceftriaxone
Add ampicillin if age >50, pregnant, immunocompromised, or concern for Listeria
Trap: If CT will delay LP, give antibiotics first.
12. Necrotizing fasciitis: surgery is the treatment
Severe pain out of proportion
Rapid progression
Bullae, crepitus, skin anesthesia
Toxic appearance
=
Nec fasc
Board move:
Immediate surgical exploration/debridement
Broad-spectrum antibiotics
Add clindamycin for toxin suppression
Trap: Do not wait for imaging if clinical suspicion is high.
13. Aortic dissection: beta blocker before vasodilator
Tearing chest/back pain
Pulse/BP differential
Mediastinal widening
Neuro symptoms/syncope
=
Aortic dissection
Board move:
IV beta blocker first
Then vasodilator if BP still high
Usually esmolol/labetalol first. Then nicardipine/nitroprusside if needed.
Trap: Giving vasodilator first causes reflex tachycardia and increases shear stress.
Type A = surgery
Type B uncomplicated = medical BP control
Type B complicated = intervention
14. STEMI equivalents: do not be falsely reassured
Life-or-death ECG patterns:
STEMI
New ischemic LBBB with convincing presentation
Posterior MI: ST depression V1-V3 + tall R waves
Right ventricular MI: inferior MI + hypotension, clear lungs
Wellens: deep/biphasic T waves V2-V3 after pain resolves
Board move:
STEMI / STEMI equivalent → emergent cath
Posterior MI → posterior leads, cath
RV infarct → avoid nitrates if hypotensive, give fluids
Wellens → cath; do not stress test
Trap: Wellens gets catheterization, not a stress test.
15. Torsades de pointes: magnesium, not amiodarone
Polymorphic VT with prolonged QT
=
Torsades
Board move:
IV magnesium
Stop QT-prolonging drugs
Replete K/Mg
Unstable → defibrillate
Recurrent with bradycardia → overdrive pacing or isoproterenol
Trap: Amiodarone can prolong QT and is not the classic answer for torsades.
16. Wide-complex tachycardia: assume VT
Regular wide-complex tachycardia
Older patient or structural heart disease
=
VT until proven otherwise
Board move:
Unstable → synchronized cardioversion
Stable monomorphic VT → amiodarone/procainamide/sotalol depending context
Trap: Do not give AV nodal blockers to irregular wide-complex tachycardia, especially possible WPW with AF.
17. WPW with atrial fibrillation: avoid AV nodal blockers
Irregular wide-complex tachycardia
Very rapid rate
Delta wave history
=
AF with WPW
Board move:
Procainamide if stable
Electrical cardioversion if unstable
Avoid:
Adenosine
Beta blockers
Diltiazem/verapamil
Digoxin
These can promote conduction down the accessory pathway and cause VF.
18. Massive PE: shock changes everything
PE + hypotension/shock
=
Massive PE
Board move:
Systemic thrombolysis unless contraindicated
Embolectomy/catheter therapy if lytics contraindicated or fail
Submassive PE: RV strain but normotensive → anticoagulation, consider escalation if decompensating.
19. Cardiac tamponade: obstructive shock
Hypotension
JVD
Muffled heart sounds
Pulsus paradoxus
Electrical alternans
=
Tamponade
Board move:
Unstable → emergent pericardiocentesis
Give fluids as bridge
Avoid aggressive diuresis/positive pressure if possible
20. Acute cholangitis: decompress the biliary tree
Fever + RUQ pain + jaundice
± hypotension/AMS
=
Ascending cholangitis
Board move:
Broad-spectrum antibiotics
Urgent ERCP for drainage if severe or not improving
Trap: Cholecystectomy is not the immediate lifesaving move in obstructive cholangitis; decompression is.
21. Variceal bleed: antibiotics are mortality benefit
Cirrhosis + hematemesis/melena
=
Variceal bleed until proven otherwise
Board move:
Resuscitate
Octreotide
Ceftriaxone
EGD with band ligation
Restrictive transfusion target usually Hgb ~7
Trap: Always give antibiotics in cirrhotic GI bleed.
22. Acute liver failure: transfer early
INR ≥1.5 + encephalopathy
No preexisting cirrhosis
=
Acute liver failure
Board move:
N-acetylcysteine if acetaminophen or uncertain cause
ICU care
Early transplant center referral
Manage cerebral edema
Trap: NAC is not only “if proven Tylenol” on boards; give when suspected/uncertain.
23. Hypercalcemia crisis: fluids first
Severe hypercalcemia
AMS, constipation, AKI, short QT
↓
Normal saline first
Calcitonin for rapid temporary effect
IV bisphosphonate for durable effect
Dialysis if severe renal failure/refractory
Trap: Furosemide is not first-line unless volume overloaded after hydration.
24. Acute angle-closure glaucoma: painful red eye + halos
Severe eye pain
Red eye
Mid-dilated fixed pupil
Halos
Nausea/vomiting
=
Acute angle closure
Board move:
Acetazolamide + topical agents
Urgent ophthalmology
Definitive laser iridotomy
Trap: Do not treat as conjunctivitis.
25. Cauda equina / cord compression: image and decompress
Back pain
Saddle anesthesia
Urinary retention/incontinence
Weakness
Cancer history possible
=
Cord compression/cauda equina
Board move:
MRI spine urgently
Steroids if malignant cord compression suspected
Urgent neurosurgery/radiation depending cause
Quick “don’t die” table
| Presentation | Diagnosis to not miss | Immediate management |
|---|---|---|
| Thrombocytopenia + schistocytes | TTP | Plasma exchange + steroids |
| Isolated platelets low | ITP | Steroids ± IVIG; platelets if life-threatening bleed |
| Coved ST V1-V3 + syncope | Brugada | ICD if symptomatic; treat fever; isoproterenol for storm |
| Angioedema without hives | C1-INH deficiency | C1-INH/icatibant/ecallantide; airway |
| Shock + hyponatremia/hyperK | Adrenal crisis | Hydrocortisone + saline |
| Hypothermia + bradycardia + AMS | Myxedema coma | IV levothyroxine + hydrocortisone |
| Fever + thyrotoxicosis + AMS | Thyroid storm | BB → PTU/MMI → iodine → steroids |
| HyperK + ECG changes | Fatal arrhythmia risk | Calcium first |
| DKA with K <3.3 | Insulin-induced arrest risk | Replete K before insulin |
| Fever + ANC <500 | Neutropenic fever | Anti-pseudomonal antibiotic now |
| Meningitis signs | Bacterial meningitis | Dex + antibiotics; do not delay |
| Pain out of proportion | Nec fasc | Surgery + broad antibiotics |
| Tearing chest pain | Dissection | Beta blocker first; Type A surgery |
| Wellens pattern | Critical LAD | Cath; no stress test |
| Long QT polymorphic VT | Torsades | Magnesium |
| Irregular wide-complex tachy | AF with WPW | Procainamide/cardioversion; avoid AV nodal blockers |
| PE + shock | Massive PE | Thrombolysis |
| Cirrhosis + GI bleed | Variceal bleed | Octreotide + ceftriaxone + EGD |
| RUQ fever jaundice | Cholangitis | Antibiotics + ERCP |
| INR + encephalopathy | Acute liver failure | NAC + transplant center |
The highest-yield correction from your examples is: TTP gets PLEX; ITP does not.
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