#465 Hospital Medicine Recap Extravaganza: Diabetic Foot, Sepsis, Syncope, Acute Coronary Syndrome, and more!

December 30, 2024 | By Meredith Trubitt

Audio

Video

Transcript available via YouTube

Join us as Monee and Meredith with the rest of the hospital medicine team reflect on the past year, discussing some favorite insights gained covering a range of topics, including diabetic foot infections, sepsis, sickle cell inpatient management, syncope, psychiatry for the hospitalist, and acute coronary syndrome. 

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Show Segments

• Introduction
• Picks of the Year
• Diabetic Foot Infections 
• Sepsis
• Sickle Cell Inpatient Management 
• Psychiatry Primer
• Syncope 
• Acute Coronary Syndrome 
• Reflections from the Year 

Part 1: Picks of the year

Movie, TV, books, podcasts, social media channels, etc. 

1. RJ–Only Murders in the Building on Hulu
2. Caroline–Everyone Watches Women’s Sports 
3. Meredith–Something Corporate Concert; Snoop Dogg 
4. Monee–University of Michigan football; of course, My Heart Will Go On cover by Kelly Clarkson

Part 2: Top Pearls

#410 Diabetic Foot Infections with Dr. Andrew Webster 

1. The four pillars of care for diabetic foot infections are: debridement, antibiotics, adequate blood flow, and good wound healing environment (e.g., offloading, tobacco cessation, good glycemic control). 
2. Pathogens growing superficially may not be the culprit in a diabetic foot infection; obtain a tissue culture at time of debridement  (Senneville, 2023).
3. Holding empiric antibiotics until cultures are obtained is reasonable in stable patients or patients with a plan for upcoming debridement. 
4. Risk factors for MRSA that may warrant empiric coverage include prolonged or recent hospitalisation, ICU admission, recent antibiotic use, invasive procedures, HIV infection, admission to skilled nursing facilities, open wounds, haemodialysis, discharge with long-term central venous access. 
5. All patients with diabetic foot infection need an x-ray, but beware that x-ray evidence of osteomyelitis may not be apparent for weeks. Probing-to-bone is still a useful test, and reserve MRI for cases where the presence of osteomyelitis remains unclear (Senneville, 2023).

#419 Rapid Response Series: Sepsis With Dr. Mohleen Kang

1. Screening tools have their strengths and weaknesses: NEWS/MEWS are the most comprehensive, but can be difficult to perform at the bedside, so qSOFA continues to have a practical edge (Liu, 2020; Evans, 2021). 
2. Antibiotics should be given in the first hour after identifying sepsis (Evans, 2021).
3. Fluid resuscitation of at least 30 mL/kg should be delivered within the first three hours after identifying sepsis (Evans, 2021).
4. POCUS is helpful for differentiating types of shock, but not for predicting fluid responsiveness.
5. Vasopressor support may be indicated for patients who remain hypotensive despite adequate fluid resuscitation. Vasopressors can safely be administered peripherally through proximal veins for short durations. 
6. Determine goals of care early during hospitalization, not during the chaos of a rapid response. 

#422 Live! Inpatient Management of Sickle Cell Crisis, Acute Pain, RBC Transfusions & Acute Chest Syndrome with Dr. Yoo Mee Shin 

1. ASH Guidelines recommend a door-to-analgesia time of 60 minutes with reassessment every 30 – 60 minutes until adequate pain control is achieved (Brandow, 2020).
2. Concerns about increased rates of opioid misuse and overdose in the sickle cell population are not supported by available evidence (Ruta, 2016), and opioids are an important component of multimodal pain control in sickle cell crises. 

#446 Psychiatry Primer for the Hospitalist with Dr. Aaron Gluth 

1. Patients with severe mental illness have a life expectancy that is 10-20 years shorter than the general population, primarily driven by metabolic disorders, a concept referred to as the “mortality gap” (Fiorillo, 2019). Therefore, it is important to check A1c and lipid panel to help risk stratify this vulnerable population group. 
2. To diagnose delirium, assess attention in addition to orientation. 
3. If patients require chemical restraints for agitation, tailor therapy to the patient and their comorbidities. Young patients with few medical conditions may require higher doses; older or more frail patients should receive low doses and increase as needed (Wolfe, 2023).
4. Vitamin D deficiency may predispose patients to delirium (Pilling, 2021), so consider checking vitamin D in patients receiving anti-epileptic medications for mood stabilization (Siniscalchi, 2020). 

#442 Live from SHM #Converge24 Syncope with Dr. Dan Dressler

1. The history and physical exam are the foundation of a good syncope evaluation.
2. The Canadian Syncope Risk Score is a helpful tool to identify patients at low risk for serious outcomes after syncope (Zimmerman, 2022). 
3. Lateral tongue biting is more suggestive of seizures, with a high positive likelihood ratio in unwitnessed loss of consciousness events (Brigo, 2012).
4. Every patient does not need an echocardiogram; consider it in patients with cardiac symptoms, abnormal physical exam findings, or ECG abnormalities (Madeira, 2017). 
5. Consider testing for pulmonary embolism in the patients who are neither low-risk nor with clear alternative diagnoses. 

# 450 and #451 Acute Coronary Syndrome Part 1 and 2

1. Auscultate the carotids! Bruits suggest atherosclerosis and a higher likelihood for coronary atherosclerosis as well. 
2. Fifth-generation high-sensitivity troponin testing allows classification of patients as either having normal levels of troponin, abnormal troponin suggestive of cardiac damage other than ACS, and abnormal troponin suggesting myocardial necrosis (Garg, 2017).
3. Cardiac CTs provide non-invasive anatomic testing of the coronaries, and are now able to measure fractional flow reserve to provide a better estimate of disease severity.
4. The “warranty” on a stone-cold normal cardiac CT is about 2 years. Plaque rupture and thrombosis could occur at any time; however, so don’t ignore a history and physical suggestive of ischemia (Gulati, 2021). 

Links

Included in the text above.

Goal

Listeners will recall top pearls from Curbsiders HM series podcast 2024.

Learning objectives

After listening to this episode listeners will…

1. Hospital Med is cool.
2. Enjoy the best hospital med pearls from last year.
3. Get excited for more hospital med pearls for 2025.

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Blackburn, RJ, Coleman, C, Amin, M, Trubitt, M. “#465 Hospital Medicine Recap Extravaganza”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date December 30, 2024.