Hospital Medicine Unplugged

In this episode of Hospital Medicine Unplugged, we demystify acute pancreatitis—diagnose fast, hydrate smart, feed early, and know when to escalate.We open with getting the diagnosis and severity right: use the rule of 2/3 (typical pain, lipase/amylase >3× ULN, or imaging) and stage by revised Atlanta (mild, moderately severe, severe). BISAP/APACHE II help risk-stratify on day 1 without replacing judgment.Resuscitation playbook: start lactated Ringer’s early (first 12–24 h). Typical initial rate 5–10 mL/kg/h, then titrate to targets—MAP 65–85 mmHg, HR <120, UOP >0.5–1 mL/kg/h, hematocrit 35–44%. Reassess often and avoid over-hydration (watch lungs/BNP/creatinine).Feed early, not late: if they can swallow, start oral; if not, enteral beats parenteral (NG or NJ both fine). Don’t wait for enzymes to normalize. Prioritize multimodal analgesia with IV opioids while minimizing sedation.Etiology moves that change outcomes:• Biliary—index-admission cholecystectomy for mild disease; delay until inflammation settles if necrotizing. ERCP only for cholangitis or persistent biliary obstruction.• Alcohol—begin cessation counseling inpatient.• Hypertriglyceridemia—lower TG fast (IV insulin ± plasmapheresis in severe), then start long-term lipid therapy and diabetes management.Antibiotics and procedures: no prophylactic antibiotics. Treat only when infection is suspected (sepsis, gas in collections). For infected/walled-off necrosis, use a step-up approach: antibiotics → percutaneous/endoscopic drainage → delayed necrosectomy (ideally ≥4 weeks).Monitoring & escalation: trend vitals, UOP, hematocrit, electrolytes, oxygenation. ICU-level care for persistent organ failure >48 h or worsening respiratory, renal, or hemodynamic status. Bring GI, IR, and surgery in early for severe disease or evolving collections.Discharge & prevention: send home when pain is oral-controlled and diet advancing. Lock in secondary prevention—schedule cholecystectomy (if not done), alcohol treatment plan, lipid control, and follow-up for exocrine insufficiency and pancreatogenic diabetes.We close with the system moves: an AP order set (LR-first, goal-directed fluids, early feeds default), gated ERCP criteria, a biliary pathway to capture index chole, and a necrosis step-up protocol. Discharge checklist includes etiology plan, nutrition, and outpatient labs.Crisp, guideline-driven, bedside-ready—everything your team needs to run a tight pancreatitis pathway.

In this episode of Hospital Medicine Unplugged, we demystify acute choledocholithiasis—who needs urgent decompression, how to clear the duct, and how to prevent the encore.We open with the sick first: suspected cholangitis or biliary sepsis = urgent ERCP (<24 h) for decompression and cultures, alongside IV fluids and broad-spectrum antibiotics. If ERCP fails or isn’t feasible, pivot to EUS-guided or percutaneous drainage.Then the risk tiers that steer the workup (ASGE):High risk (stone seen, cholangitis, or bili >4 mg/dL plus CBD dilation) → straight to ERCP.Intermediate risk → EUS or MRCP (pick by availability/expertise) or IOC.Low risk → lap chole with selective IOC.Diagnostics that matter: RUQ ultrasound first; MRCP/EUS confirm stones when the pretest probability is mid-range. Use IOC intraop when pre-op imaging is equivocal—if stones are there, you’ve got options.Therapy playbook—choose your lane:• Endoscopic lane (two-stage): pre-op ERCP + sphincterotomy + extraction, then same-admission lap chole.• Single-stage surgical lane: lap chole + ductal clearance via LCBDE (transcystic or transductal) or intraoperative ERCP (rendezvous). When available, this shortens LOS and avoids a second anesthesia.• Big stones/difficult duct: add papillary balloon dilation, mechanical lithotripsy, or place a temporary stent with plan for delayed clearance.Aftercare that prevents bounce-backs: index-admission cholecystectomy is the rule after clearance (delay only for unstable or necrotizing pancreatitis). If a stent was placed, schedule removal/exchange in 2–6 months—don’t lose the patient to follow-up. Monitor LFTs and symptoms; educate on when to call.What ERCP buys you: rapid source control and high clearance, at the cost of post-ERCP pancreatitis, bleeding, infection, perforation (mitigate with rectal indomethacin and wire-guided cannulation; PD stent if high risk).Special situations you’ll actually encounter:• Gallstone pancreatitis: ERCP only for cholangitis or ongoing obstruction; otherwise straight to same-admission chole with selective IOC.• Elderly/frail or nonsurgical candidates: ERCP ± stent as definitive therapy; plan structured stent exchanges.• Altered anatomy/failed ERCP: EUS-BD (if expertise) or PTC.We close with the system moves: a Choledocholithiasis pathway that (1) auto-tiers ASGE risk, (2) default-orders EUS/MRCP for intermediates, (3) fast-tracks urgent ERCP for cholangitis, (4) hardwires same-admission chole post-clearance, and (5) creates a stent registry/tickler with due dates. Add an ERCP note template with stone size/number, clearance status, and explicit chole plan.Crisp, guideline-driven, and bedside-ready—exactly what your team needs to clear the duct and keep it cleared.

In this episode of Hospital Medicine Unplugged, we cut through inpatient COPD exacerbations—how to stabilize fast, choose the right meds, and know when to put the mask on.We open with the do-firsts: grab a chest X-ray and ABG to rule in AECOPD and rule out the mimics (pneumonia, HF, PE) and acute respiratory acidemia. Start controlled O₂ targeting SpO₂ 88–92%. Hit bronchi with short-acting bronchodilators—albuterol ± ipratropium via neb or MDI+spacer, front-loaded and frequent. Systemic steroids for all inpatients: prednisone 40 mg PO daily × 5 days (or equivalent IV if NPO). Loop in RT early; reassess after each treatment set.Antibiotics—use them when they matter: prescribe if sputum purulence + (↑ volume or ↑ dyspnea) or if the patient needs ventilatory support. Go short course (≈5 days). First-line: doxycycline, TMP-SMX, or amoxicillin; save amox-clav/fluoroquinolone for frequent exacerbators or suspected resistance. Skip sputum cultures unless they’re failing therapy or look severe/atypical.NIV: when to mask up. If pH < 7.35 (hypercapnic acidosis), severe dyspnea with accessory-muscle use, or persistent hypoxemia despite optimal meds/O₂—start BiPAP. Expect lower intubation rates and mortality when started early. Contra red flags: inability to protect airway, copious secretions, facial trauma, hemodynamic instability—then intubate. HFNC can be an adjunct but NIV is first-line for hypercapnic failure.What not to do (and what to do instead):• Don’t routinely order mucolytics, chest physiotherapy, magnesium, or theophylline in the acute phase—no benefit, more harm.• Don’t overshoot oxygen—keep it in the 88–92% lane.• Do mobilize early, monitor closely (vitals, mental status, I/Os), and repeat gases if the course isn’t improving.• Do watch for complications: pneumonia, arrhythmia, PE, steroid-induced hyperglycemia; escalate fast if CO₂ narcosis or acidosis worsens.Discharge and aftercare (reduce the bounce-back): step patients down to their maintenance inhalers (ensure LAMA/LABA, consider ICS for frequent exacerbators/eosinophilic phenotype), teach inhaler technique, provide a written action plan, and book follow-up in 7–14 days. Pulmonary rehab kicks in after discharge, not during the acute stay.We close with the system moves: a COPD bundle that (1) defaults ABG+CXR on admit; (2) autopopulates SpO₂ 88–92%, SABA/SAMA q2–4h PRN, and prednisone 40×5; (3) triggers antibiotics only when Anthonisen criteria are met (5-day stop date baked in); (4) prompts early NIV for pH <7.35; (5) hardwires no mucolytics/theophylline; (6) sets up discharge inhaler optimization, rehab referral, and rapid follow-up.Fast, guideline-driven, and bedside-ready—everything your team needs to control symptoms, avert vents, and prevent the readmit.

In this episode of Hospital Medicine Unplugged, we cut through acute infective endocarditis—how to confirm it fast, start the right drugs, and know when the valve team needs to move.We open with the do-firsts: draw three sets of blood cultures from separate sticks, then start empiric IV therapy—vancomycin + ceftriaxone for most native valves (daptomycin if vanc-intolerant). TTE now; TEE early (prosthetic/device, nondiagnostic TTE, or high suspicion). If cultures stay negative, send serologies/PCR (Coxiella, Bartonella, Brucella) and consider FDG-PET/CT for prostheses or suspected paravalvular infection. Loop in ID, cardiology, and cardiac surgery upfront.Directed therapy playbook (count duration from first negative culture):• Viridans/S. gallolyticus: penicillin G or ceftriaxone × 4 wk (short 2-wk ÷ select low-risk cases ± gentamicin).• Enterococcus: ampicillin + ceftriaxone × 6 wk (avoid gent unless clearly indicated).• MSSA: nafcillin/oxacillin (or cefazolin) × 6 wk.• MRSA: vancomycin (AUC-guided) or daptomycin (high dose) × 6 wk.• HACEK: ceftriaxone × 4 wk.• Staph prosthetic valve: vancomycin + rifampin (entire course) + gentamicin (first 2 wk) ≥ 6 wk.Surgery—call it early for the big three:• Heart failure from valve destruction/severe regurgitation.• Uncontrolled infection: persistent bacteremia/fever, abscess, fistula, heart block, fungi or highly resistant bugs, prosthetic dehiscence.• Embolic prevention: large (>10 mm) mobile vegetations, especially after an embolus or on the anterior mitral leaflet (S. aureus high risk).Timing: emergent if shock/flash pulmonary edema; otherwise urgent (days, not weeks). Remove all infected hardware (CIEDs) completely.Complications you’ll watch for—and what to do: stroke (get neuro; avoid thrombolysis; surgery timing individualized), mycotic aneurysm, splenic abscess, AKI (dose-adjust; minimize aminoglycosides), and heart block (think abscess → TEE ± surgery). Repeat cultures q24–48 h to document clearance. Hold routine anticoagulation at presentation; restart only for clear indications with team consensus.Can you go oral? Yes, in select stable patients (left-sided IE, no abscess/heart failure, susceptible organism, ≥10 days of effective IV, reliable follow-up) using guided combination oral therapy—ID must quarterback.We close with the system moves: an IE bundle that (1) autopopulates 3 culture sets, vanc+ceftriaxone, and TTE→TEE; (2) triggers ID + CT surgery consults; (3) adds culture-negative panels and PET/CT when appropriate; (4) hardwires “Day 1 = first negative culture” in the note; (5) routes to OPAT/oral-step-down with adherence checks; (6) defaults dental eval and addiction medicine when relevant.Fast, guideline-driven, and bedside-ready—everything your team needs to diagnose, treat, and escalate acute endocarditis without missing the surgical window.

In this episode of Hospital Medicine Unplugged, we cut through inpatient hyponatremia—how to triage by symptoms and acuity, push 3% safely, prevent overcorrection, and fix the cause.We open with the do-firsts: confirm it’s true hypotonic hyponatremia (check measured serum osmolality; correct Na for glucose), assess duration (<48 h vs >48 h), and stratify symptoms. Severe symptoms (seizure, coma, cardiorespiratory distress) or moderate symptoms with high-risk context (post-op, intracranial disease) → treat now. Place in a monitored setting; q2–4 h Na checks.Hypertonic saline—how to do it without hurting anyone• Give 3% NaCl 100–150 mL IV bolus, repeat up to 2–3 times aiming +4–6 mEq/L in 1–2 h and clinical improvement.• Stop-lights: ≤10 mEq/L in 24 h (≤8 if high-risk: chronic, alcoholism, malnutrition, liver disease, hypokalemia); ≤18 mEq/L in 48 h.• Bolus beats drips for speed and control; switch to slower correction once stabilized.Clamp the overcorrection• Desmopressin (DDAVP) clamp: 2 mcg IV/SC q6–8 h proactively in high-risk chronic cases, or reactively at the first sign of rapid aquaresis.• If you overshoot: relower with D5W and/or DDAVP; re-check Na q2 h until back on track.Etiology playbook (hypotonic only)• Hypovolemic (GI losses, diuretics, adrenal): 0.9% saline to restore volume → ADH shuts off → watch for brisk water diuresis (have DDAVP ready). Stop offending meds; check cortisol if unclear.• Euvolemic (SIADH): start fluid restriction (500–1000 mL/day), remove triggers (SSRIs, carbamazepine, pulmonary/CNS insults). If refractory:– Oral urea (effective, predictable, low ODS risk).– Vaptan (tolvaptan) for carefully selected inpatient use with close Na checks (watch overcorrection, liver cautions).– Salt tabs + loop diuretic are optional adjuncts when urine is highly concentrated.• Hypervolemic (HF, cirrhosis, nephrosis): fluid ± Na restriction, optimize underlying disease, loop diuretics; consider vaptan if truly refractory (short course, monitored). In cirrhosis, albumin can help in select scenarios.Severity & pace—what changes with chronicity• Acute (<48 h) severe → you can correct faster initially (still obey 24/48 h caps).• Chronic (>48 h) → go slow, set the 8 mEq/24 h guardrail in high-risk patients from the start.Monitoring that prevents ODS• During active correction: Na q2–4 h, strict I/O, frequent neuro checks; track urine osmolality/Na (early fall in Uosm = impending aquaresis).• Pre-write orders for DDAVP PRN and D5W relowering; add potassium early if low (correcting K raises Na).Math you’ll actually use (only if needed)• 3% NaCl ≈ 513 mEq/L Na. One 100 mL bolus raises serum Na by ~1–2 mEq/L in many adults; verify with labs, not math.• Avoid formula chasing; let measured Na drive the next step.Common pitfalls (and fixes)• Treating pseudohyponatremia or hypertonic hyponatremia as hypotonic → check measured osmolality first.• Missing adrenal insufficiency → add AM cortisol if unclear etiology.• Overcorrection after volume repletion or diuretic stop → anticipate with a DDAVP clamp.• Chasing numbers instead of symptoms → target +4–6 mEq/L early for encephalopathy, then slow down.We close with the system moves: a “Hyponatremia Bundle” that (1) hardwires osmolality/urine studies before therapy; (2) defaults to 3% bolus + guardrails with q2–4 h sodium checks; (3) includes DDAVP and D5W standing orders; (4) prompts SIADH second-line options (urea/vaptan) when fluid restriction fails; (5) flags high-risk for ODS to apply the 8-mEq/24-h cap; and (6) nudges endocrine/nephrology when etiology is unclear or correction is tricky.Fast, guideline-driven, and bedside-ready—everything your team needs to rescue the brain, respect the caps, and fix the cause.

In this episode of Hospital Medicine Unplugged, we demystify inpatient cellulitis—who to admit, what to cover, and when to stop.We open with the right patients: nonpurulent, warm, tender, spreading erythema—and the red flags for a bed (systemic toxicity, rapid progression, immunocompromise, failed outpatient therapy, hand/face, or NSTI concern). Use bedside ultrasound to unmask abscess; skip routine blood cultures unless severe, immunocompromised, or unusual exposure. Mark borders and reassess at 24–48 hours.Therapy that works:• Nonpurulent: IV streptococcal coverage—cefazolin or penicillin G (ceftriaxone if once-daily helps).• Purulent/MRSA risk: drain early; add MRSA-active therapy (vancomycin; linezolid if needed).• Severe/NSTI concern: vancomycin + piperacillin–tazobactam (or a carbapenem) ± clindamycin for toxin suppression.IV-to-PO and duration: switch when improving and tolerating PO; 5 days total for uncomplicated responders, extend to 7–10 days if slow or complicated. Step-down choices: cephalexin/amoxicillin for nonpurulent; doxycycline/TMP-SMX/clindamycin for MRSA—with a β-lactam if streptococcus still likely.Adjuncts that matter: elevate, treat toe-web tinea, start compression for chronic edema, optimize glucose; consider brief NSAIDs or steroids only after NSTI is excluded.System moves: default order set (cefazolin-first, MRSA gated), auto 5-day stop with “extend if not improving,” ultrasound-to-drainage pathway for purulence, and a discharge bundle (oral step-down, compression, antifungal, return precautions).Guideline-aligned, bedside-ready—tight care without overkill.

In this episode of Hospital Medicine Unplugged, we get practical about inpatient pyelonephritis—how to stop sepsis, protect kidneys, and prevent complications.We open at the door: recognize sepsis, two IV lines + fluids, draw urine and blood cultures (don’t delay antibiotics for tough sticks), check creatinine and lactate, and assess for obstruction/retention.Then hit bugs fast—empiric IV antibiotics tailored to local resistance and risk of MDR:• Ceftriaxone (many hospitalized patients) or cefepime.• Piperacillin–tazobactam if healthcare exposure or Pseudomonas risk.• Carbapenem (ertapenem/meropenem) if ESBL risk or prior colonization.• Aminoglycoside (e.g., gentamicin) as initial coverage or add-on—data support lower mortality with similar nephrotoxicity in protocols.• Newer option with RCT data: cefepime/enmetazobactam 2 g/0.5 g IV q8h vs piperacillin/tazobactam 4 g/0.5 g IV q8h—noninferior for cUTI/pyelo.De-escalate promptly once susceptibilities return.Duration & step-down—short when you can, longer when you must:• Uncomplicated, responding: 5–7 days total (supported by meta-analysis).• Complicated or bacteremic: 7–14 days based on course/source control.• IV → PO when afebrile/improving, hemodynamically stable, taking PO, and you have an active agent. PO options: fluoroquinolone or TMP-SMX if susceptible; oral β-lactams only if clearly susceptible and patient stable. Avoid nitrofurantoin/fosfomycin for pyelo (poor renal parenchymal levels).Imaging that changes management (not everyone needs it):• Order imaging if persistent fever or no improvement at 48–72 h, diabetes, known stones, concern for obstruction, abscess, or emphysematous pyelo.• CT A/P with contrast is best for abscess/emphysematous changes; ultrasound if pregnancy or contrast/radiation concerns; non-contrast CT shines for stones.Source control saves lives:• Obstructed, infected system = emergency decompression (retrograde stent or percutaneous nephrostomy).• Drain renal/perinephric abscesses when large or not responding to antibiotics.Special situations you’ll see:• Pregnancy: admit; parenteral β-lactam–based therapy; close maternal–fetal monitoring; longer total course (often ~14 days).• Immunocompromised/MDR risk: start broader (carbapenem or novel β-lactam/β-lactamase inhibitor) and narrow quickly with ID input.Monitoring & checkpoints: expect defervescence by 48–72 h; if not, re-culture, re-image, reassess source control and spectrum. Remove or exchange indwelling catheters when feasible.Concise, guideline-driven, ward-ready—empiric IV early, culture-guided de-escalation, short courses when safe, image only when it changes care, and never miss obstruction.

In this episode of Hospital Medicine Unplugged, we tackle Clostridioides difficile infection (CDI) on the wards—fast, practical, guideline-driven care from test ordering to recurrence prevention.We open with the first moves: test only the right patient—≥3 unformed stools in 24 h (or ileus/toxic megacolon). Use a two-step algorithm: GDH + toxin EIA up front; NAAT as the tiebreaker if discordant. No “test of cure.” While labs cook, fix the basics: stop the inciting antibiotic if you can (or narrow), review meds (especially PPIs), start IV fluids/electrolytes, and avoid antimotility agents in severe/fulminant disease. Early nutrition, VTE prophylaxis, and pain control (skip NSAIDs in bad colitis).Then the therapy that actually changes outcomes—start early, pick right:Initial episode (non-severe or severe, non-fulminant):• Fidaxomicin 200 mg PO BID x10 days (preferred for lower recurrence).• Vancomycin 125 mg PO QID x10 days (solid alternative).• Metronidazole is out as first-line.Fulminant CDI (hypotension/shock, ileus, megacolon):• Vancomycin 500 mg PO/NG QID + metronidazole 500 mg IV q8h.• If ileus, add rectal vancomycin enemas 500 mg q6h.• Early surgical consult—don’t wait on deterioration.Risk tools & who gets extras: clock the high-recurrence patients (≥65, severe CDI, immunocompromise, IBD, CKD, episode within 6 months, on concomitant antibiotics). For them, consider bezlotoxumab 10 mg/kg IV once during treatment to cut recurrence.Recurrence playbook:• First recurrence: fidaxomicin again or vancomycin taper/pulse.• Multiple recurrences: fecal microbiota–based therapy (FMT or FDA-approved live biotherapeutics) after guideline-directed antibiotics.• Keep stewardship tight; re-audit PPIs/antibiotics at every turn.Infection prevention that actually prevents: enteric contact precautions (gown/gloves), soap-and-water hand hygiene on exit, and sporicidal (bleach) cleaning for rooms and gear. Educate patients on hygiene and what recurrence looks like.Rescue moves & ICU cues: escalating lactate/organ failure, peritonitis, perforation, or toxic megacolon? Get surgery and critical care to the bedside. Subtotal colectomy with end ileostomy is standard; diverting loop ileostomy with colonic lavage in selected high-risk cases. In the ICU: hemodynamics, serial abdominal exams, frequent labs/imaging, multidisciplinary huddles.Special situations you’ll see:• IBD: higher severity/recurrence—favor fidaxomicin; coordinate with GI, avoid reflex steroid escalation until CDI is controlled.• Elderly/CKD: higher recurrence—strong case for bezlotoxumab; be meticulous with fluids/electrolytes.• Heme/Onc & Transplant: prolonged shedding, drug interactions—early ID consult; plan recurrence prevention up front.Monitoring & discharge that sticks: expect symptom improvement in 48–72 h; if not, reassess for ileus/megacolon or a missed diagnosis. Don’t re-test for cure—follow the clinical course. Discharge with a documented episode/severity, drug/dose/duration, recurrence-prevention plan (stewardship, PPI review, bezlotoxumab/FMT when indicated), clear return precautions, and early follow-up.Concise, high-yield, and system-savvy—everything your team needs to deliver safer, more effective inpatient CDI management.