Inpatient Management of Common Conditions

Sepsis & Septic Shock - Sepsis Shock Showdown

Sepsis: Organ dysfunction (SOFA ↑ ≥2) from infection. Septic Shock: Sepsis + vasopressors for MAP ≥65mmHg & lactate >2mmol/L despite fluids.

• qSOFA (Quick Screen): RR ≥22/min, Altered Mentation, SBP ≤100 mmHg. (Score ≥2 → sepsis workup).
• Hour-1 Bundle (📌 BUFALO):
  • Blood cultures (pre-antibiotics)
  • Urine output monitoring
  • Fluids: 30ml/kg crystalloid (hypotension or lactate ≥4mmol/L)
  • Antibiotics: Broad-spectrum within 1 hour
  • Lactate: Measure (target <2mmol/L)
  • Oxygen: Titrate to SpO2 >94%
• Source control. Vasopressors if MAP <65mmHg post-fluids (Norepinephrine 1st choice).

⭐ In septic shock, if adequate fluid resuscitation fails to restore MAP to ≥65 mmHg, norepinephrine is the first-choice vasopressor.

Acute Decompensated Heart Failure - Pump Failure Fixes

• Etiology: Ischemic Heart Disease (IHD), Hypertension (HTN), Valvular defects, Arrhythmias.
• Diagnosis: Clinical; ↑BNP/NT-proBNP; Echo (↓EF, diastolic dysfunction).
• Goals: Relieve congestion (dyspnea, edema), optimize perfusion, maintain O2 Sat >90%.
• 📌 LMNOP (Acute Pulmonary Edema): Lasix, Morphine (cautious), Nitrates, Oxygen, Position (upright).

• Pharmacotherapy Focus:
  • Diuretics: IV Loop (Furosemide) for volume overload.
  • Vasodilators: Nitroglycerin (venodilator > arterial), Nitroprusside (balanced; for severe HTN).
  • Inotropes: Dobutamine (for 'cold' profile, $EF < 40%$, cardiogenic shock).

⭐ For patients with ADHF and 'warm and wet' profile (congestion without hypoperfusion), IV loop diuretics are the mainstay of therapy to relieve symptoms.

Community-Acquired Pneumonia - CAP Crackdown Crew

📌 CURB-65: Confusion, Urea >7mmol/L, RR ≥30/min, BP <90 SBP / ≤60 DBP, Age ≥65.

• Severity Scores & Site of Care:
  • CURB-65: 0-1 (Outpatient), 2 (Hospitalize), ≥3 (Consider ICU).
  • PSI (Pneumonia Severity Index) also used.
• Common Pathogens: S. pneumoniae (most common), H. influenzae, Atypicals (Mycoplasma, Chlamydia, Legionella).
• Empiric Antibiotics (Site-Dependent):
  • Outpatient (no comorbidities/risk factors for MRSA/Pseudomonas): Amoxicillin OR Doxycycline OR Macrolide (if local pneumococcal resistance <25%).
  • Inpatient (non-ICU): Beta-lactam (e.g., Ceftriaxone) + Macrolide; OR Respiratory Fluoroquinolone.
  • Inpatient (ICU): Beta-lactam + Macrolide; OR Beta-lactam + Respiratory Fluoroquinolone.
• Supportive Care: Oxygen therapy (target SpO2 >92%), fluid management.
• Hospitalization/ICU Indications: CURB-65 score ≥2, PSI Class IV-V, hypoxemia (SpO2 <90% on room air), RR ≥30/min, SBP <90 mmHg.

⭐ Empiric antibiotic therapy for CAP should be initiated promptly, ideally within 4 hours of presentation, after obtaining appropriate cultures if possible.

Acute Kidney Injury - Kidney Crisis Care

• Definition (KDIGO):
  • ↑ Serum Cr by $\ge \textbf{0.3}$ mg/dL within 48 hrs
  • ↑ Serum Cr $\ge \textbf{1.5x}$ baseline (within 7 days)
  • Urine output < 0.5 mL/kg/hr for >6 hrs
• Types:
  • Pre-renal (e.g., hypovolemia)
  • Intrinsic (e.g., ATN, AIN)
    • 📌 ATN Causes: 'I S T' - Ischemia, Sepsis, Toxins
  • Post-renal (e.g., obstruction)
• Investigations:
  • Urinalysis (casts, cells)
  • FENa: $FENa = \frac{(U_{Na} \times P_{Cr})}{(P_{Na} \times U_{Cr})} \times 100$ (if oliguric)
  • Renal Ultrasound (obstruction)
• Management Principles:
  • Treat underlying cause
  • Fluid balance; avoid nephrotoxins
  • RRT indications (AEIOU: Acidosis, Electrolytes, Intoxication, Overload, Uremia)

⭐ In a patient with oliguric AKI and no signs of fluid overload, a carefully monitored fluid challenge can help differentiate pre-renal AKI from established ATN.

High‑Yield Points - ⚡ Biggest Takeaways

• CAP: Use CURB-65 for severity and admission decisions.
• AECOPD: Target SpO2 88-92%; give bronchodilators, steroids, antibiotics.
• ADHF: IV loop diuretics are key; manage precipitants.
• Ischemic Stroke: Thrombolysis if within 4.5 hours; aspirin later.
• VTE: Anticoagulation is crucial; use risk scores like Wells/PERC.
• AKI: Focus on cause, fluid balance, and avoiding nephrotoxins.
• DKA/HHS: Prioritize IV fluids, then insulin, and monitor potassium_._