Hospital Medicine Unplugged

In this episode of Hospital Medicine Unplugged, we demystify PFO workup and closure after ischemic stroke—who to test, who to close, and how to run a tight inpatient pathway.We open with the right patients: nonlacunar, embolic-appearing infarcts in adults 18–60 with no better cause on initial workup. Everyone gets vascular imaging, inpatient rhythm monitoring, DVT screening, and risk-factor assessment before we even say “PFO.”Then the diagnostics that matter: start with TTE + agitated-saline bubble, but plan for TEE with bubble to define shunt size, tunnel length, and atrial septal aneurysm (ASA)—the anatomy that changes decisions. Transcranial Doppler is your most sensitive shunt detector and pairs well with TEE. We highlight how to do Valsalva right (timing counts) and why a clean aortic arch and carotids are as important as the septum.Causality tools you’ll actually use: RoPE score to gauge how likely the PFO caused the stroke, and PASCAL to combine RoPE with anatomy so you can label a PFO “likely,” “possible,” or “unlikely” culprit. High RoPE + large shunt/ASA = the sweet spot for closure benefit.Next, the shortlist for closure:• Age 18–60, nonlacunar stroke, no alternative mechanism, high-risk PFO anatomy (large shunt and/or ASA).• >60 or vascular risk–heavy? Individualize—the bar is higher.• Clear competing cause (AF, large-artery stenosis, true lacune)? Don’t close.Therapy playbook: begin antiplatelet now; if DVT or another indication for anticoagulation exists, anticoagulate and rethink closure. When closing, we cover timing (typically 2–6 weeks post-stroke once stabilized), device expectations, and how to manage the peri-procedural window without pausing secondary prevention.What closure buys you: lower recurrent ischemic stroke, especially with large shunts/ASA—at the cost of more peri-procedural atrial fibrillation (usually transient) and rare device issues. We give you the numbers you’ll quote on rounds and the talking points for shared decision-making.Post-closure meds and follow-up: DAPT (aspirin + clopidogrel) for 1–3 months, then single antiplatelet long-term (device-specific nuance included). If a patient needs anticoagulation for another reason, use that instead of DAPT. Plan rhythm surveillance (30-day patch or equivalent) and echo to check for residual shunt.Special situations you’ll actually encounter: concurrent DVT (paradoxical embolism), pregnancy, hypercoagulability, TIA without infarct (why evidence is thinner), migraine with aura (not an indication), and older adults with borderline benefit—how we navigate each.We close with the system moves: a Heart–Brain pathway that bundles TEE/TCD orders, DVT ultrasound, extended rhythm monitoring, RoPE/PASCAL documentation, and default post-closure antithrombotics. Add a templated note for “PFO-likely” vs “PFO-unlikely” and track AF after closure as a quality metric.Crisp, guideline-driven, and bedside-ready—everything your team needs to make smart, safe decisions about PFO diagnosis and closure in ischemic stroke.

In this in-depth episode of Hospital Medicine Unplugged, we tackle the evidence-based inpatient management of lower gastrointestinal bleeding (LGIB)—from first contact in the ED to secondary prevention at discharge.We start with stabilization and triage: ABCs, two large-bore IVs, targeted labs, and a restrictive transfusion strategy—generally transfuse at Hb <7 g/dL (aim >7), or >9 g/dL if significant cardiovascular disease or ongoing instability. We cover how to separate brisk UGIB from true LGIB, when an NG lavage helps, and how to use (but not overtrust) tools like the Oakland score alongside clinical judgment and ICU criteria.Diagnostics and timing—what actually changes outcomes: for stable patients, colonoscopy after adequate prep remains first-line for diagnosis and therapy, but routine “urgent” colonoscopy hasn’t shown better mortality, rebleeding, or LOS. In the unstable or unprepped patient, CT angiography leads for localization and can hand off directly to IR embolization. We map a clean pathway for when to escalate to surgery.Therapeutics by etiology:• Diverticular bleeding—clips or band ligation; how we choose and why.• Angiodysplasia—argon plasma coagulation, with notes on recurrence and when octreotide enters the chat.• Post-polypectomy bleeding—injection, thermal, clips.• Ischemic colitis/IBD flares—supportive care or anti-inflammatory escalation rather than hemostasis.Medications that matter (and those that don’t): PPIs have no role in LGIB; tranexamic acid (HALT-IT) offers no benefit and potential harm. We give a practical, risk-balanced approach to antithrombotics: when to reverse, when aspirin should stop (primary) or continue (secondary), and why most anticoagulated patients should restart within ~7 days once safe.We close with system moves that improve care—multidisciplinary pathways, 24/7 colonoscopy/CTA/IR access, and standardized algorithms that shorten time-to-diagnosis and reduce resource waste.Concise, guideline-driven, practical medicine—no fluff, just the evidence for safer, more effective inpatient management of LGIB.

In this episode of Hospital Medicine Unplugged, we unpack the evidence-based inpatient management of upper gastrointestinal bleeding (UGIB)—from triage at the door to secondary prevention at discharge.We open with stabilization: airway protection when mental status or torrential hematemesis threatens, two large-bore IVs, targeted labs (CBC, CMP, coagulation studies, type & cross), and a restrictive transfusion strategy (Hb <7 g/dL for most; <8 g/dL if CAD or ongoing massive bleed). We cover when to reverse coagulopathy and why platelets <50k with active bleeding warrant transfusion.Next, risk tools that actually change what you do: Glasgow-Blatchford Score to decide ED discharge vs admission and to prioritize endoscopy; how AIMS65 and Rockall complement mortality prognostication.Then the meds—started early:High-dose IV PPI (bolus + infusion, or guideline-supported intermittent high-dose) for suspected peptic ulcer bleeding.Erythromycin 250 mg IV pre-scope to clear the stomach.For suspected varices: vasoactive therapy (e.g., octreotide) and ceftriaxone prophylaxis right away.Why tranexamic acid is out in UGIB.Endoscopy timing and technique: perform within 24 hours in most, sooner (≈12 h) if unstable after resuscitation. For non-variceal bleeds, we highlight combination therapy (epinephrine plus thermal or clips) over epinephrine alone; when to reach for over-the-scope clips or hemostatic powder. For varices: band ligation for esophageal, cyanoacrylate for gastric.Post-endoscopic care that prevents rebleeding: 72 hours of high-dose PPI, early enteral nutrition, and criteria for repeat endoscopy if rebleeding occurs. For variceal hemorrhage: continue vasoactives and antibiotics, start NSBBs, and plan serial EVL.Rescue playbook: when to call IR for arterial embolization in refractory non-variceal bleeding; balloon tamponade as a bridge in uncontrolled variceal hemorrhage; early or salvage TIPS in high-risk cirrhotics who keep bleeding despite optimal therapy.We round out with special situations—cirrhosis (infection risk, renal vulnerability), patients on anticoagulants/antiplatelets (who to reverse, and how/when to resume), and the elderly with multimorbidity. Plus the system moves: GI-bleed pathways, early GI/hepatology involvement, ICU vs ward triage, and why standardized order sets improve outcomes.Concise, guideline-driven, practical medicine—no fluff, just the evidence for safer, more effective inpatient management of UGIB.

In this in-depth episode of Hospital Medicine Unplugged, we walk through the evidence-based hospital management of decompensated cirrhosis. From triage to discharge, we cover the full playbook hospitalists need on the wards.We start with rapid assessment and risk stratification—how to find precipitating factors (infection, GI bleed, alcohol, meds/nephrotoxins), what to order up front (CBC, CMP, INR, cultures), and how to use MELD-Na and ACLF scores to guide level of care.Next, we hit the time-critical moves:Early diagnostic paracentesis for any new/worsening ascites—don’t delay. If SBP (PMN ≥250): ceftriaxone 2 g IV daily plus albumin 1.5 g/kg day 1 and 1 g/kg day 2.Hepatic encephalopathy: lactulose titrated to 2–3 soft stools/day; add rifaximin for recurrence; always fix triggers (bleed, infection, constipation, electrolytes, sedatives).Ascites/volume: Na <2 g/day; combined spironolactone:furosemide (≈100:40, titrate). Hold diuretics in AKI/hypovolemia. Large-volume paracentesis needs albumin 6–8 g/L removed (>5 L). Hyponatremia: optimize diuretics; fluid restrict only if Na <125 and unresponsive.Variceal hemorrhage: cautious resuscitation (Hgb ~7), antibiotic prophylaxis (ceftriaxone), vasoactive therapy (octreotide/terlipressin), and urgent EGD with banding. Secondary prevention: nonselective β-blocker (carvedilol/propranolol) + repeat banding. Consider early TIPS in refractory/high-risk bleeds.Hepatorenal syndrome: albumin plus vasoconstrictor (terlipressin where available; norepinephrine in ICU), avoid nephrotoxins, and start early transplant evaluation.We then zoom out to supportive care and systems:Nutrition first—no routine protein restriction; aim 30–35 kcal/kg and 1.2–1.5 g/kg protein with a late-evening snack. Replete thiamine/folate and fat-soluble vitamins when indicated. Use EMR order sets/care bundles to hard-wire best practices and reduce 30-day mortality.Special populations get focused guidance: ICU/ACLF, pregnancy (protocol tweaks, but standard principles), advanced renal disease, and infection-prone patients—where decisions about vasoconstrictors, antibiotics, and procedures demand tailoring.We close with transition and long-term care: concrete discharge plans (diuretics, lactulose targets, SBP prophylaxis), linkage to hepatology/transplant, alcohol cessation and viral therapy when appropriate, HCC surveillance every 6 months, vaccinations, and when to loop in palliative care.No fluff—just a concise, guideline-driven path to safer inpatient cirrhosis management.

In this in-depth episode of Hospital Medicine Unplugged, we walk through evidence-based inpatient care for opioid use disorder (OUD)—from triage to transition of care—so hospitalists can start, continue, and optimize medications for opioid use disorder (MOUD) on the wards.We start with bedside assessment and risk stratification—confirming OUD by history and DSM-5, using the Clinical Opiate Withdrawal Scale (COWS) to time inductions, and ordering high-yield labs (CBC, CMP, HIV/HBV/HCV, pregnancy when relevant) plus an ECG when methadone is on the table.Next, the core moves:Make MOUD the default. Continue pre-admission methadone/buprenorphine and offer initiation to all eligible inpatients. We contrast options:Buprenorphine: first-line for many; standard induction once in mild–moderate withdrawal, or micro-induction for fentanyl exposure/high tolerance or when full agonists are still required for pain.Methadone: full agonist for patients needing/wanting it, those with high tolerance, or where buprenorphine isn’t a fit; start low, titrate with close sedation and QTc monitoring.Extended-release naltrexone: a niche option once 7–10 days opioid-free—best for highly motivated patients who have already completed withdrawal.Acute stabilization & withdrawal: Treat overdose quickly with titrated naloxone and observe for recurrence (fentanyl effect). For withdrawal, prioritize buprenorphine or methadone; use adjuncts (clonidine, antiemetics, NSAIDs, loperamide) to improve comfort.Pain and peri-op care: Don’t stop MOUD. Expect higher opioid requirements; use multimodal analgesia and supplement with short-acting full agonists (e.g., hydromorphone) as needed. Avoid mixed agonist–antagonists that can precipitate withdrawal.Addiction consult services amplify success. Where available, consult teams double in-hospital MOUD starts and improve linkage after discharge. Where not, hospitalists should still initiate MOUD using standardized order sets.We then embed harm reduction and discharge planning:Naloxone for everyone at risk with overdose education.No punitive discharges for in-hospital use; practice nonjudgmental engagement.Seamless continuity: coordinate OTP intake for methadone; send patients home with enough buprenorphine and a confirmed follow-up; address housing, transport, insurance; engage peers/recovery coaches or low-barrier “bridge” clinics.Special sections tackle complex scenarios—pregnancy (methadone or buprenorphine are safe; avoid detox), adolescents/young adults, people leaving jail/prison, and advanced liver/renal disease—where protocols and dosing need tailoring.We close with systems and policy: clearing up the legality of inpatient continuation/initiations, using EMR order sets, measuring outcomes/readmissions, and making the case that hospital-based MOUD is not just lifesaving—it’s cost-effective.This episode delivers concise, guideline-driven, practical medicine—no fluff, just the evidence you need for safe, effective inpatient management of OUD.

In this in-depth episode of Hospital Medicine Unplugged, we discuss acute coronary syndromes (ACS)—why minutes matter, how to sort risk fast, and the exact moves from triage to discharge.We frame the stakes (plaque rupture → thrombus → myocardium at risk), then run a time-zero checklist: 12-lead ECG within 10 minutes (repeat if nondiagnostic), high-sensitivity troponin on a 0/1–2-hour pathway, telemetry, and GRACE/TIMI to separate low/intermediate/high risk. Use bedside echo for wall-motion clues; consider CT-coronary angiography only in selected low–intermediate-risk uncertainty.The treatment playbook:ABCs, two IVs, monitors; oxygen only if SpO₂ <90% or distress.Chew aspirin immediately; add a P2Y12 (ticagrelor/prasugrel for PCI-bound, clopidogrel when bleeding/OAC issues).Anticoagulation: UFH/bivalirudin for PCI; enoxaparin/fondaparinux if medically managed.Nitrates for pain/ischemia (mind RV infarct/PDE-5 use); beta-blocker within 24h unless shock/HF/brady; high-intensity statin up front.Reperfusion decisions:STEMI → primary PCI (door-to-balloon ≤90 min; ≤120 from first medical contact if transfer). If not feasible, give fibrinolysis (check contraindications) and transfer for early angiography/rescue PCI.NSTE-ACS → early invasive for high risk; conservative strategy reasonable for low risk.Complications to catch: VT/VF and AF, cardiogenic shock (culprit-only PCI; selective mechanical support), mechanical ruptures, and post-MI pericarditis (aspirin ± colchicine).We land on discharge that sticks: a clear DAPT plan (with de-escalation for high bleeding risk), statin + ACEi/ARB (± MRA for LV dysfunction), rehab referral, smoking cessation, risk-factor targets, depression screening, and a 7–14-day follow-up with labs and ownership for med titration.Lean, practical, 3 a.m.–ready.

In this in-depth episode of Hospital Medicine Unplugged, we tackle alcohol withdrawal syndrome (AWS)—why it’s high-stakes on the wards, how to risk-stratify fast, and exactly what to do from triage through discharge.We open with the “why”: AWS is common, dangerous, and time-sensitive. We review the pathophysiology (rebound CNS hyperexcitability after abrupt cessation) and the clinical spectrum—from mild tremor and autonomic surge to seizures and delirium tremens—framing why early recognition changes outcomes.Diagnosis and risk stratification come next. We show how to get the story that matters (prior DTs/seizures, daily quantity, last drink, polysubstance use, comorbids, electrolytes). We explain using CIWA-Ar the right way—as a monitoring tool, not a diagnostic test—and when it breaks down (ICU, delirium, non-communicative patients). We introduce objective alternatives (e.g., MINDS/mMINDS, vital-sign–driven checks) and map patients to the right setting: ambulatory for low-risk, floor/step-down for moderate, ICU for severe or refractory cases.Then the treatment playbook:• Benzodiazepines are first-line. Long-acting (diazepam, chlordiazepoxide) for most; lorazepam/oxazepam when liver disease or frailty raise the stakes.• Symptom-triggered dosing wherever frequent reassessment is feasible; fixed-schedule or front-loading when monitoring is limited or the patient can’t participate.• Escalation for severe AWS: IV lorazepam or diazepam; phenobarbital as monotherapy or adjunct in experienced hands; dexmedetomidine/propofol as ICU adjuncts (not seizure prophylaxis).• Mild/outpatient cases: gabapentin or carbamazepine as alternatives when benzos are contraindicated—paired with daily check-ins.Supportive care is non-negotiable: high-dose parenteral thiamine early (and don’t delay glucose if hypoglycemic—give both), multivitamins/folate, aggressive electrolyte repletion (Mg, K, PO₄), fluids and nutrition, quiet/light-stable environment, fall/aspiration precautions. We highlight red flags for delirium tremens (48–72 hours, agitated delirium, hallucinations, autonomic instability), seizure management (benzodiazepines first; antiepileptics only for non-AWS status), and clear triggers for ICU transfer.Special populations get a focused walkthrough: advanced hepatic dysfunction (prefer lorazepam/oxazepam; avoid long-acting benzos and phenobarbital if decompensated), older adults (lower doses, delirium prevention), and pregnancy (benzos remain first-line for severe AWS; use the lowest effective dose).We close with transition and long-term care: concrete discharge criteria (symptoms controlled, stable vitals, no recent seizures, eating/drinking, safe plan), addiction medicine consults, and starting relapse-prevention meds before discharge (naltrexone when liver allows; acamprosate for liver disease; disulfiram in highly selected/supervised patients). We build a follow-up bundle—early appointments, counseling/peer support, and return-precautions—that keeps patients safe after the protocol ends.No fluff—just a ward-ready, guideline-driven path to safer alcohol withdrawal management.

In this in-depth episode of Hospital Medicine Unplugged, we walk through the evidence-based inpatient management of acute decompensated heart failure (ADHF)—from the ED door to safe discharge and early follow-up. We frame every step around two goals: rapid, complete decongestion and in-hospital optimization of guideline-directed medical therapy (GDMT) to change long-term outcomes.We start with triage and diagnosis: how to profile “wet/warm” vs “wet/cold,” read the neck veins like a pro, and use point-of-care ultrasound, chest imaging, and natriuretic peptides (BNP/NT-proBNP) without overcalling confounders (obesity, CKD, ARNI use). We cover the top precipitants to search for on day 1—ischemia, AF with RVR, hypertensive surge, infection, thyroid disease, NSAIDs/nonadherence—and how fixing these early prevents the next readmission.Next, the decongestion playbook. IV loop diuretics as first-line (smart starting doses, when to double, and how to judge response with urine output and spot urine Na). What to do when loops stall: sequential nephron blockade with thiazides (metolazone/IV chlorothiazide) or acetazolamide, plus pearls for electrolyte/renal monitoring. When to add vasodilators (nitroglycerin) for hypertensive pulmonary edema, when noninvasive ventilation is lifesaving, and when inotropes/pressors and advanced therapies enter the picture.Once the flood is fixed, we pivot to disease-modifying therapy—started in the hospital, not “after clinic catches up.” We lay out practical sequences for initiating the four pillars in HFrEF (ARNI/ACEi/ARB, evidence-based beta-blocker, MRA, SGLT2 inhibitor) without tanking the blood pressure, plus who qualifies for add-ons (hydralazine–isosorbide in selected patients, ivabradine for persistent tachycardia in sinus rhythm). For HFpEF, we highlight diuretics for symptoms and SGLT2 inhibitors for outcomes, and where IV iron and vericiguat fit for the right phenotypes.We make diuretic transitions simple: when to switch IV→PO (only after clinical euvolemia), how to pick the oral dose, and why every patient needs at least 24 hours of observation on the discharge regimen. We spell out the day-to-day basics that actually keep people home: consistent daily weights, tailored fluid/salt guidance (who truly needs restriction), a written “diuretic self-titration” plan, and labs scheduled to catch the first bump in creatinine or potassium.Special sections tackle high-yield comorbidities (CKD, diabetes, COPD, anemia, depression), inpatient IV iron for iron deficiency, and device/advanced therapy triggers. We close with clean, actionable discharge criteria (no residual congestion, stable vitals/renal function/electrolytes, PO diuretics proven to work), plus the must-have elements of a great handoff: med reconciliation, teach-back education, cardiac rehab referral when appropriate, and follow-up within 7–14 days (sooner if high-risk).This episode is practical, guideline-driven, and ward-ready—no fluff. Just the moves that lower BNP, lighten the lungs, and keep your patients out of the hospital.