Hospital Medicine
Questions discussed in this category
For example, do you consider "cautious" IV fluids or otherwise consider early vasopressors?
For example, do you routinely supplement with calcium carbonate, magnesium hydroxide, aluminum hydroxide, simethicone, sucralfate, etc.?
Assume QTc is not prolonged, electrolytes are reasonably normal, and the patient is not already on heavy psychotropic polypharmacy.
Do you use the traditional strict limit of 1.5 L, or do you consider removing more volume if a patient appears to tolerate it?
For example, would you recommend using enoxaparin 30 mg BID instead of 40 mg QD?
For example, would you consider alternatives to paracentesis (Denver shunt placement, CART therapy, or permanent tunneled catheters) that might better...
If abnormal, does that data motivate you to cannulate an otherwise less ideal site like the brachial, axillary or femoral?
I have encountered varied,...
For example, do you find trending WBC, procalcitonin, CRP, etc., more or less helpful?
For example, do you think the benefits of sequential compression devices outweigh the risk of falls, delirium, etc.?
In particular, how do you reconcile situations where lung POCUS findings contradict other components of volume assessment (e.g. JVD, peripheral edema,...
O'Toole et al., PMID 36652352
Traumatic brain injury
Would your approach differ through telemedicine for small ERs without access to onsite ophthalmology or neurology?
Should we consider this as a unique point during goal of care discussions, separate from code status, comfort measures only, etc.?
Would you then opt for double vector DCCV to deliver 2, 360J shocks simultaneously, and/or bolus with amiodarone?
Is there any evidence supporting the use of heparin boluses?
If plan for ICD implantation, when would be the best timing to perform this?
Is there a threshold amount of oxygen above which you would avoid bronchoscopy?
Does the “48-hr” criteria reset itself after the patient reverts back into atrial fibrillation?
If these patients were already prescribed non-selective beta blockers outpatient, do you recommend withholding these medications in the acute phase?&n...
Considering the short half-life, at what point would it be deemed too late to administer any reversal agent, and to consider withholding it?
Is there a difference in headache management in ischemic stroke versus hemorrhagic stroke?
How to best manage patients with underlying migraine who...
In light of ANNEXA-I RCT results: Connolly et al., PMID 38749032.
Can some patients referred for TIA/stroke symptoms who have at the time of ER referral, a normal neurological exam be discharged with outpatient worku...
Estimating blood loss from hemoptysis is not always reliable. The bleeding may be due to the PE itself. Is anticoagulation with any degree of hemoptys...
Rogers & Rice, PMID 38018162
ASPs are common place. The studies supporting ASPs oversaw doctors, not specifically trained in Infectious Diseases. However, several institutions hav...
Solid tumor patients, other hematologic malignancies, patients with autoimmune diseases on immunosuppressive therapy? Do you consider workup if they a...
In patients who have decreased arousal after ischemic stroke, do you use amantadine or modafinil to aid with wakefulness and interaction with therapy ...
Is there a role for oral vancomycin in these patients, or is oral vancomycin redundant if other routes of administration are being used (i.e intracolo...
High-risk PEs are typically treated with loading doses of anticoagulants or bridging with LMWH. Do you omit the bridging/loading period and go straigh...
When would you consider using anticoagulation and for how long?
E.g., patients with small CNS mets without vasogenic edema or symptoms. Epidural disease without epidural spinal cord compression or asymptomatic low-...
Do you extend the course of fidaxomicin past initial 10 days to at least 3-7 days after completion of antibiotics?
This is based on the recent publication by Bernstein et al., PMID 38551564 which investigated the increased rate of initiation of MAUD in the hospital...
Do you increase rivaroxaban to 10 mg daily during the inpatient stay, or do you prefer to add LMWH or SC heparin?
Would you adjust your approach based on the infarct size, symptom severity, or stroke etiology?
Would your threshold to consider a device be lowered if their LVEF was also severely reduced?
Many institutions have been using droperidol in place of haloperidol due to drug shortages.
Would your management be different if the LVO was found on imaging without preceding associated symptoms?
Watchman device deployed with therapeutic ACT but required multiple recaptures. Patient went into afib during the procedure and after final deployment...
If they have been on IV heparin for 3 days, for example, would you subtract those days from the recommended loading dose time?
Would the context of prior stroke/TIA impact the decision to hospitalize or pursue expedited outpatient evaluation?
Butler et al., PMID 38587237
Data from Massard et al., PMID 20181575 used an abbreviated 3-day course of EP with completion of EP and bleomycin at day 15. Should this approac...
Especially in an inpatient setting when EMG is not immediately available.
Landoni et al., PMID 38865168
In light of the publication by Ganesh et al., PMID 39503052.
Do you use steroids in the management of PJP pneumonia with severe hypoxia in HIV negative patients?
Data on the role of steroids in HIV negative patients with PJP has been conflicting.
Have recent trials (TRAIN trial and HEMOTION trial) influenced your approach?
For example, is captopril dialyzable?
Some data showed early enteral nutrition improves outcomes in DKA. Some thought that enteral nutrition could counteract the insulin gtt.
Invited Professor Series Video: Volume Management and Access Troubleshooting in Peritoneal Dialysis - Claretha Lyas, MD
Is parasitemia >10% and severe hemolysis with Hb less than 7 enough to initiate this?
The new SCCM guidelines suggest an upper limit of 200 compared to the conventional 180.
The ESC guidelines recommend obtaining at least three sets of blood cultures at 30-minute intervals before starting antibiotic therapy, each with 10 m...
Kunadian, et al., PMID 39225274
Blood pressure targets for ischemic stroke and intracerebral hemorrhage are described in several guidelines. However, in patients with acute stroke wh...
Lazarus, et al., PMID: 38913437
Hendriks, et al., PMID 38576380
REDUCE-AMI trial
Vasculitis involving aorta, subclavian, common carotid, SMA, IMA, renal artery, and celiac artery.
ACORN Randomized Clinical Trial
Levi et al., PMID 38551563
Assume thrombolytics are not indicated. Do you favor early DOAC transition after 24-48 hours of heparin gtt or do you favor LMWH for 10-14 days follow...
Would you still routinely ask for CIED removal, or would you pursue PET/CT for further evaluation and consider keeping CIED if PET/CT negative?
When do you decide to hospitalize?
If yes, what is the rationale for doing that?
Do the findings of the NICO trial influence your stance?
Are there specific mass features that would influence your treatment decision?
In light of TIMELESS and TRACE-III trials.
Miskulin, et al., PMID 38349776
If yes, which combination(s)?
Does your preferred dose change if this were in a non-ACS setting with elective outpatient PCI?
Multiple recent trials have shown higher first pass success rate with VL over DL.
Do the findings of the PROPHY-VAP trial influence your approach?
Is there a percent change in QTc in which you would consider stopping amiodarone, especially in patients who have baseline wide QRS complexes?
Do the results of the recent study (Misset et al., PMID 37889107) showing reduction in 28-day mortality in patients with high neutralizing antibody ti...
Do you favor gradual reduction in oxygen and pressure support with intermittent medication as needed or immediate extubation with peri-extubation medi...
For example, in the setting of TBI, how do you guide the duration of the medical treatment?
Does it influence your choice of antithrombotic therapy? Do you perform serial follow-up imaging?
What is your strategy for treating persistent headaches in the aftermath of subarachnoid hemorrhage?
Does your strategy change depending on whether or not it is a secured or unsecured aneurysmal SAH?
And if delayed, should chemotherapy be started?
Seethapathy et al., NEJM
In light of published data from the CAPE COD trial...
In what clinical scenarios do you utilize post-cardiac arrest targeted temperature management (TTM)?
In the span between the HACA trial and the Targeted Temperature Management in Out-of-Hospital Cardiac Arrest study (Dankiewicz et al., PMID 34133859),...
What are the sources for this and are they reliable by today’s standards? Numerous case series report various abnormal movements but how reliabl...
E.g., a patient has an intracranial hemorrhage after TBI with convulsive status epilepticus.
How does the 2HELPS2B scoring tool play a role in your decision-making?
Is it different than early mobility that we always encourage?
How about a distal occlusion? The patient was initially symptomatic but symptoms improved or mostly resolved.
Though there is data to support using both hydrocortisone and fludrocortisone, it seems to be used rarely in clinical practice. A review publishe...
Practice is variable in the community, with some hematologists frequently prescribing ESAs for severe anemia that is mostly inflammatory. Do the risks...
If delayed complete revascularization is favored, would you consider staged PCI during that same admission or PCI outpatient?
What is the maximum time that can be used (given the complexities with patient being in the hospital or needing rehab)?
Invited Professor Series Video: Volume Management and Access Troubleshooting in Peritoneal Dialysis - Claretha Lyas, MD
Do you include the amount of IV amiodarone already administered as part of the loading dose?
If LHC is deferred, would you consider loading with plavix and treating for ACS for 48 hours (assuming acceptable bleeding risk) and optimizing GDMT p...
Given the risk of elevated ICP, would you attempt a brain MRI to further characterize the lesion? Or would CT imaging suffice prior to intervention?
Aside from suctioning, what are other measures could be helpful?
Patient became acutely flushed, developed severe and prolonged hypotension with brief loss of consciousness, dizziness, nausea, dry heaves and headach...
Elderly male with primary hypothyroidism, HTN, and progressive worsening cognition over several months. PCP has been increasing LT4 dose as outpatient...
How would you treat? Would you view tocilizumab as an option in the future?
If PPCM is suspected, what are your targeted hemodynamic goals during the delivery phase?
Many recent studies cast doubt on continuous vs repeated routine EEG.
For the first time in my 27-year career, I was asked to consult on a patient in his early 40s with immersion pulmonary edema from scuba diving. &...
While the current guidelines favor early surgery (within 48 hrs of diagnosis) for this population based on the results of the EASE trial (link attache...
Do you favor awake intubation in these cases?
Is there literature to support superiority of levophed over dobutamine, or vice versa?
Current guidelines (AHA, ESO, etc.) are not clear. In addition, if a patient arrives with BP>240 how do you balance the risk of hypoperfusion with ...
Fibrinogen level >200.
For patients with ischemic stroke status-post decompressive hemi-craniectomy, when should they start aspirin for secondary stroke prevention? POD 5? P...
What factors do you consider while deciding between bronchoscopic vs surgical management?
What’s your threshold to get the three AFBs and place the patient in airborne isolation?
Would you proceed with CABG procedure or treat the aortitis first?
There are some data supporting the use of IV lidocaine as an abortive treatment for migraine, NDPH, and some trigeminal autonomic cephalalgias, when d...
To help interpret clinical applications of the CAPE COD (2023) and DEXA ARDS (2020) trials.
Are there any quantitative indices (eg. volume, pleural fluid hematocrit) that would impact your decision to stop subsequent TPA/dornase treatments?
Do you do start therapy at a certain vasopressor requirement?
The EVEREST Outcome trial (Konstam et al., PMID 17384437)
If hydroxyurea modifies the course of sickle cell disease by increasing fetal hemoglobin, is there any benefit to using it in patients with fetal hemo...
If the patient is in burst-suppression once EEG is connected, how long do you keep patient in burst-suppression before weaning sedation?
If so, how frequently should we measure iron saturation/ferritin levels post-iron infusion?
How do you decide between starting infliximab, MMF, or IVIG? If a patient presents in respiratory failure (nearing or requiring intubation), woul...
E.g. in a patient with tenuous cardiac function, would starting treatment several weeks earlier potentially improve outcomes?
Is there any role of tube thoracostomy as opposed to only antibiotics?
For patients who are unable to have complete brain stem testing, would you recommend apnea testing prior to ancillary tests in case of suspected brain...
For patients undergoing outpatient MR imaging for other indications who have instantly found acute stroke, do you typically recommend the patient be a...
Do your respiratory therapists independently adjust ventilator settings without direct physician involvement?
How do you approach which risk to accept given that steroids have evidence for use in COVID-19 while is suggestion for harm in using steroids in influ...
Or love to share personal experiences/articles?
For instance, if the patient doesn’t tolerate apnea testing, is too unstable to go for ancillary testing outside the ICU, and TCDs/EEG are unava...
Do you use hydrocortisone 200 mg/day as studied in ADRENAL/APROCCHSS or dexamethasone 20 mg/day as studied in DEXA-ARDS?
Given the substantial risks associated with transporting an intubated and ventilated patient to Radiation Oncology, is there any evidence to support t...
Please comment on temperature recommendations and role of exchange transfusion.
For example, a patient with 2 Hz GPDs with hepatic or uremic encephalopathy.
What is your preferred agent (DOAC, warfarin, enoxaparin), and is periprocedural bridging necessary?
Does timing relative to initiation of antibiotics matter?
What modality do you prefer?
If so, for how long?
C diff infection ruled out and CT abdomen pelvis shows diffuse enterocolitis extending far beyond the bowel-sparing IMRT radiotherapy field.
Is there any data supporting this?
Please specify your approach in elective and emergency surgical situations
Do you have a particular cutoff?
Instead of waiting for the antibody test to result, if you have a high suspicion for NMDAR encephalitis, is there a role for giving rituximab alongsid...
For patients clinically presenting with Transient Global Amnesia and no other focal neurologic deficits, do you always pursue work up to rule out stro...
In the absence of rhabdomyolysis is there still a need to protect the kidneys when patients with inflammatory myositis have CK over 5000 or 10000?
What precautions can be taken to limit infestation of the department?
Do you implement a treatment delay and if so how do you decide when...
What are your thoughts on the ethics of inpatient use of sedatives in these patients to help with agitation to “protect themselves from harm and...
At what disease free interval is the safest to consider this?
What effective modalities have you found for acute exacerbations of trigeminal neuralgia including in patients who present to the ED?
If not, what instructions do you give to patients regarding checking temperature at home/return precautions?
What factors influence your thinking?
The most frequently taught cause of asterixis is hepatopathy and of course hepatic encephalopathy, and has other close associations (ie, uremia), I ha...
For what duration do you use therapy?
Is there any benefit to starting hyperosmolar therapy prior to the development of depressed level of consciousness or midline shift?
e.g. DITP from eptifibatide after a cardiac intervention
How does cirrhosis and/or underlying thrombophilia affect your decision?
How do you treat refractory focal status epilepticus in an adult with history of alcoholism and traumatic bilateral subdural hematomas who is failing ...
What is the your preferred loading (and maintenance) dose for use of Perampanel in the treatment of refractory status epilepticus?
What modality do you prefer?
Would you discontinue Methotrexate and TNF inhibitors even if previously no side effects from these medications, and would you consider Cyclophosphami...
E.g. disease burden causing airway or vascular compression.
How would you treat patients with symptoms of AIS who have an allergic reaction to TPA with no evidence of large vessel occlusion on imaging? What nex...
What factors go into choosing the right patient and determining length of therapy?
In patients undergoing continuous EEG monitoring in the ICU, we often encounter EEG patterns that lie along the inter-ictal continuum (IIC). In such c...
Does manipulation of blood products (leukoreduction, irradiated) affect your approach? There is growing evidence that routine premedication (at least ...
Should systemic therapy or ISRT be utilized? Is there a risk for intrabdominal spread with perforation? If the ulcer is repaired by simple...
What is your approach for a symptomatic inpatient with locally advanced NSCLC who cannot have a PET?
Would you consider treating the full mediastinum or any mildly enlarged nodes, even contralateral? Do you have a strategy that transitions from a pall...
What are your target goals during transfusion, either prophylactically or during acute complication? Does your management change between vaginal deliv...
The use of anti-fibrinolytics is typically contraindicated in DIC, but does it have benefit in DIC states characterized by hyperfibrinolysis?
Does having a concurrent consumptive process e.g. DIC change your management?
Do you always treat with the full 21-day treatment course, or can defibrotide be stopped if certain criteria are met sooner?
Especially in a triple-positive patient with an acute ischemic stroke who may have urgency for anticoagulation with high bleeding risk and severe thro...
Does your management change based on the type of end-organ involvement at the time of diagnosis?
Are there any reports of CNS involvement with non-se...
Current guidelines do not support its use, but the EMPACTA trial suggests it may be effective in a subpopulation of patients.
How do you manage an uncomplicated DHTFR versus a hyperhemolysis?
Should we use a different dose in critically ill patients in the ICU? When should we consider intermediate-dose anticoagulation?
Would you offer this routinely or only if specific complications arise, such as distal emboli?
CT scans show omental and pelvic disease.
No known cardiac risk factors
Please see this article for referrence https://www.sciencedirect.com/science/article/pii/S0167814020301638
Should the patient be admitted for observation which will risk exposing other immunocompromised patients to COVID-19, or should the patient be quarant...
How do you assess risk of tumor lysis syndrome, and is hydration sufficient or should hypouricemic agents be used as well?
I.e., Can day 2 Rituximab (RCHOP) or day 6 Rituximab (DA-EPOCH, Hyper CVAD) be given? Or should only Day 1 Rituximab be used with chemoimmunotherapy i...
Would you treat if there is active infection? How much improvement would you expect?
What are your specific protocols for monitoring and for dosing narcotics and sedatives?
Place the patient partially on the table? Treat them on a hospital bed? Simply deny treatment until weight is reduced?
Is a biopsy needed? Do you consider treatment palliative or curative?
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