In this week’s episode, Eric is joined by Dr. Tark, now 3rd year resident, to break down the recognition and management of acute heart failure exacerbation.

Key Discussion Points:

• Patient Presentation: Common symptoms include peripheral edema, pulmonary congestion with dyspnea, and paroxysmal nocturnal dyspnea. Physical exam findings such as S3/S4 gallops, jugular venous distension, and hepatic jugular reflux play a critical role in making a clinical diagnosis.
• Workup: While BNP is frequently ordered, heart failure remains a clinical diagnosis. Supportive labs include CMP, renal function, troponins, ECG, and occasionally lactate in suspected shock. Chest X-ray can confirm pulmonary congestion, and echocardiography helps define the type of HF (HFrEF vs. HFpEF).
• Management:
  • Diuretics remain the cornerstone—IV loop diuretics with escalation as needed, targeting 2–3 L of diuresis in the first 24 hours.
  • Acetazolamide has emerged as a promising adjunct. The ADVOR Trial (Mullens et al., NEJM 2022) showed that adding acetazolamide to loop diuretics in acute decompensated HF increased decongestion rates and reduced hospital stay.
  • Non-invasive ventilation (CPAP/BiPAP) provides symptomatic relief in flash pulmonary edema by improving oxygenation and reducing preload/afterload.
• Guideline-Directed Medical Therapy (GDMT):
  • Beta-blockers should be continued in stable patients but held in cardiogenic shock.
  • ACE inhibitors/ARBs/ARNIs and SGLT2 inhibitors are central pillars of therapy in chronic HFrEF, with trials like DAPA-HF and EMPEROR-Reduced demonstrating mortality and hospitalization benefits.
  • SGLT2 inhibitors also benefit patients with HFpEF, as shown in EMPEROR-Preserved

Pearls and Pitfalls:

• BNP should be interpreted in context
• Always rule out mimickers such as pulmonary embolism, ischemic events, arrhythmias, thyroid disease, and infections.
• Early and aggressive diuresis in the first 24–48 hours can shape the patient’s entire trajectory of recovery.

Takeaway: Acute heart failure requires a careful balance of clinical recognition, judicious use of diagnostics, and evidence-based diuretic strategies. Early intervention, guided by both bedside exam and trial evidence, makes the difference between stabilization and deterioration.

References:

1. Felker GM, et al. "Diuretic Strategies in Patients with Acute Decompensated Heart Failure" NEJM. 2011;364:797–805. (DOSE Trial)
2. Mullens W, et al. "Acetazolamide in Acute Decompensated Heart Failure with Volume Overload." NEJM. 2022;387:1185–1195. (ADVOR Trial)
3. McMurray JJV, et al. "Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction." NEJM. 2019;381:1995–2008. (DAPA-HF)
4. Packer M, et al. "Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure." NEJM. 2020;383:1413–1424. (EMPEROR-Reduced)
5. Anker SD, et al. "Empagliflozin in Heart Failure with a Preserved Ejection Fraction." NEJM. 2021;385:1451–1461. (EMPEROR-Preserved)

In this episode of "IM Basics," host Dr. Eric Acker is joined by Dr. Michael Bass to tackle the frequently encountered topic of alcohol withdrawal. They provide a comprehensive overview, starting with the fundamental definitions and pathophysiology, moving through patient presentation, workup, and the nuances of treatment. Learn to look beyond simply ordering a protocol and gain a deeper understanding of how to manage these complex patients dynamically.

In this episode, you will learn about:

• Defining and Scoring Alcohol Withdrawal:
  • Symptoms are categorized as mild (anxiety, tremors, insomnia, palpitations) or severe (hallucinations, seizures, delirium tremens). Only about 20% of patients develop severe symptoms.
  • The DSM-5 criteria for diagnosis require two or more specific symptoms following the cessation or reduction of alcohol use.
  • The CIWA is a common scoring system used by nursing staff to guide treatment based on symptom severity.
• The Pathophysiology of Withdrawal:
  • Chronic alcohol use enhances the effect of the inhibitory GABA receptors and inhibits the excitatory NMDA receptors.
  • The body adapts by decreasing the sensitivity of GABA receptors and increasing the sensitivity of NMDA receptors.
  • When alcohol is stopped, the brain is left in a state of uninhibited excitatory stimulation.
• Timeline of Symptoms:
  • 6-36 hours after last drink: Mild symptoms like tremors, sweats, and agitation may appear.
  • 6-48 hours: Seizures can occur.
  • 12-48 hours: Hallucinations (visual, auditory, or tactile) may develop.
  • 48-96 hours: The most severe manifestation, delirium tremens (DTs), can set in.
• Patient Workup:
  • A thorough history is the most critical part of the workup, especially the timing of the last drink and the quantity consumed.
  • Labs are essential to rule out other conditions and should include a blood glucose, CBC, electrolytes, and blood cultures.
  • An ethanol level can be checked, but a patient can be in withdrawal even with a detectable alcohol level.
• Treatment Strategies:
  • Symptom-Triggered Therapy: This is the most recommended approach, where benzodiazepines are given based on a CIWA score threshold (e.g., a score greater than 8 or 10).
  • Benzodiazepines: These are the mainstay of treatment and work by stimulating the GABA receptor.
    • Lorazepam (Ativan): Slower onset (15-30 mins) but shorter duration.
    • Diazepam (Valium): Faster onset (2-3 mins) but longer half-life, which can lead to accumulation.
  • Refractory Withdrawal: For patients who don't respond to high doses of benzodiazepines, phenobarbital is an option. It can be used as a dual therapy with benzos or as a monotherapy.
  • Front-Loading: For patients at high risk of severe withdrawal (e.g., history of DTs), proactively administering high doses of benzodiazepines can be considered.
• Pearls and Pitfalls:
  • Be aware that benzodiazepines can cause paradoxical agitation in elderly patients,
  • Don't get anchored on alcohol withdrawal, especially considering hepatic encephalopathy in patients with cirrhosis.
  • Remember supportive care: thiamine, along with a multivitamin and electrolyte repletion
  • Always reassess your patient if the treatment isn't working.

In this episode of "IM Basics," host Dr. Acker is joined by Dr. Harmandip Parmar, an intern with an interest in cardiology, to break down the essentials of heart block. They cover the full spectrum of atrioventricular (AV) blocks, from incidental findings on an ECG to symptomatic emergencies. Tune in to learn how to identify, investigate, and manage these crucial cardiac conditions.

What You'll Learn in This Episode:

• Patient Presentation:
  • While many patients with heart block are asymptomatic, some may present with symptoms like fainting (syncope), lightheadedness, or chest pain.
  • Myocardial infarction (MI) can be an underlying cause of these symptoms and the heart block itself.
• ECG Findings for Different Heart Blocks:
  • First-Degree AV Block: Identified by a prolonged PR interval of more than 0.20 seconds.
  • Second-Degree AV Block, Mobitz Type I (Wenckebach): Characterized by a PR interval that gets progressively longer until a QRS complex is "dropped".
  • Second-Degree AV Block, Mobitz Type II: Features a constant PR interval length with intermittently dropped beats. These patients are often more symptomatic.
  • Third-Degree (Complete) AV Block: Shows a complete dissociation between P waves and QRS complexes, with each marching out at its own regular rate.
• Investigating the Causes:
  • A thorough workup is essential to find the underlying cause.
  • Potential causes include MI, electrolyte imbalances (like hyperkalemia), and thyroid issues.
  • A patient's medication list should be reviewed for drugs like beta-blockers, digoxin, amiodarone, and certain calcium channel blockers.
  • Other causes can include Lyme disease, inherited conditions like sarcoidosis, or recent cardiac procedures.
• Treatment and Management:
  • First-Degree and Mobitz I: Often asymptomatic and may not require urgent intervention, aside from investigating the cause.
  • Mobitz Type II: These patients are at high risk of progressing to a third-degree block and require admission. Atropine should be avoided. Definitive treatment is often a permanent pacemaker.
  • Third-Degree Block: This is an urgent condition. Management includes:
    • Giving atropine.
    • Using beta-adrenergic agonists like dopamine or epinephrine.
    • Initiating temporary cardiac pacing, followed by evaluation for a permanent pacemaker.

    Special Cases: In patients with Lyme carditis, a permanent pacemaker is often avoided as the condition typically improves within weeks.

• Additional Insights:
  • The discussion touches on "Stokes-Adams attacks," which are episodes of fainting linked to heart block.
  • The hosts explore the theory that rate control in atrial fibrillation might bombard the AV node, potentially leading to third-degree heart block over time

This episode of "IM Basics" provides a concise yet comprehensive overview of Multiple Myeloma. Dr. Eric Acker and Dr. Vinh Dao discuss the disease's non-specific presentation, diagnostic criteria (CRAB and SLIM), and essential workup procedures, including laboratory tests and imaging. The podcast also differentiates between MGUS, smoldering myeloma, and full-blown Multiple Myeloma, outlining when treatment is initiated for each. Key aspects of managing Multiple Myeloma, such as treatment modalities, handling complications like hypercalcemia and lytic lesions, and addressing immunocompromise, are covered in detail. The episode concludes with practical "pearls and pitfalls," emphasizing the importance of recognizing the disease despite its subtle presentation in an older demographic.

Don't forget to check out Dr. Dao's podcast, "Bloom Pod," which focuses on oncology and its links to other medical fields!

In this episode of "IM Basics," Dr. Amulya Anumolu provides a comprehensive overview of managing GI bleeds.

Patients often present with signs of volume loss like hypotension, tachycardia, pallor, altered mental status, or dizziness. Common complaints include vomiting blood (hematochezia) or dark, sticky, foul-smelling stools (melena). Melena specifically indicates an upper GI bleed because blood darkens as it passes through the GI tract. A disproportionately high BUN (e.g., 30:1 ratio) on CMP can also suggest an upper GI bleed. Bright red blood per rectum can be a lower GI bleed or as simple as hemorrhoids.

Initial Assessment & Stabilization:

• Ensure the patient has two large-bore IVs (16 or 18 gauge) in both forearms for rapid fluid and blood product administration. Central lines are too thin for emergencies.
• Cross-matching and blood typing are essential.
• Transfuse blood for hemoglobin below seven or with active bleeding, as hemoglobin can appear normal due to hemoconcentration from significant volume loss.
• Provide supplemental oxygen to all GI bleed patients to enhance the oxygen-carrying capacity of blood.
• Intubate altered patients unable to protect their airway immediately.

Workup & Management:

• Initial workup includes CBC, CMP, and INR.
• History taking should cover NSAID use, history of ulcers, prior scopes, and anticoagulant use.
• The Glasgow-Blatchford score can help risk stratify patients to determine if ICU admission is needed.
• For upper GI bleeds, administer an initial bolus of 80 mg IV Protonix, followed by 40 mg BID; there's no evidence a drip is better.
• For suspected variceal bleeds (e.g., in cirrhosis), give octreotide (50-100 mcg bolus followed by 25-50 mcg/hour infusion for 3-5 days) to reduce portal pressures. Terlipressin can also be used.
• Administer ceftriaxone for SBP prophylaxis (1g) or treatment (2g) in cirrhotic patients with ascites.
• Erythromycin (150-200 mg IV) can aid gastric emptying for better scope visualization in upper GI bleeds, but monitor for QTC prolongation.
• Correct coagulopathies. Stop anticoagulants like Eliquis or Warfarin in severe bleeds.

Diagnostic & Interventional Procedures:

• An EGD is used for upper GI bleeds to band varices or cauterize ulcers. A colonoscopy is used for lower GI bleeds and requires bowel prep.
• If the source isn't found endoscopically, a CT angiography (CTA) during active bleeding can localize it for IR embolization. Ensure it's a three-phase CT angiography, not just a CT with contrast.
• A tagged RBC scan can also help locate blood pooling.
• In severe, unstable upper GI bleeds where endoscopy is not feasible, a Blakemore or Minnesota tube can be placed to tamponade varices.

Pearls & Pitfalls:

• Hemoglobin should be considered as a concentration, not just a volume.
• For cirrhotic patients, have a lower threshold to start lactulose and rifaximin if hepatic encephalopathy is suspected.
• Bright red blood per rectum could also indicate mesenteric ischemia.
• Test for H. pylori if ulcers are found, ideally after being off PPIs for two weeks.
• Be aware of atrial-esophageal fistulas as a rare, serious complication post-AFib ablation.
• Constantly monitor GI bleeders, even stable ones, as they can decompensate rapidly

Sources:

• Washington Manual
• Up-to-date

In this episode of IM Basics, Dr. Eric Acker and Dr. Tark break down the essentials of recognizing and managing hyperkalemia, a potentially life-threatening electrolyte disturbance. They discuss common presentations—ranging from dialysis patients to those with tumor lysis syndrome—and highlight key decision points in diagnosis and management.

Topics Covered:

• Common presentations of hyperkalemia and when to suspect it even without classic symptoms.
• ECG findings in hyperkalemia: from peaked T waves to sine waves.
• When to act and how aggressively, based on potassium levels and clinical stability.
• The three pillars of treatment:
  • Cardiac membrane stabilization with calcium gluconate.
  • Potassium shift therapies (e.g., insulin with dextrose, high-dose albuterol).
  • Potassium elimination (e.g., dialysis, Lokelma®, loop diuretics, or rarely, Kayexalate®).
• A practical discussion on the timing of interventions—why and when to delay shifting before dialysis.
• Tips on avoiding overtreatment, interpreting lab errors like pseudohyperkalemia, and reassessing post-intervention.

Clinical Pearls:

• Use calcium gluconate to stabilize membranes, not to lower potassium directly.
• Watch for hyperkalemia in AKI, rhabdomyolysis, tumor lysis syndrome, and missed dialysis.
• Lokelma® has high sodium content—consider alternatives like patiromer in volume-sensitive patients.
• Always reassess potassium after treatment to guide further interventions.

References & Citations:

• Sterns RH. "Hyperkalemia." N Engl J Med. 2022;386(15):1426–1435. DOI: 10.1056/NEJMra2110952.
• Montford JR, Linas S. "How dangerous is hyperkalemia?" J Am Soc Nephrol. 2017;28(11):3155–3165. DOI: 10.1681/ASN.2016121344.
• Kayexalate safety concerns: Patel K, et al. "Sodium polystyrene sulfonate-induced colonic necrosis." Am J Med Sci.2012;343(2):155–157.

In this educational episode of IM Basic, Drs. Eric Acker and Tark break down the complex topic of septic shock for PGY1 residents and medical students. They explore the pathophysiology, clinical presentation, and diagnostic challenges of septic shock, emphasizing the importance of recognizing atypical signs like hypothermia and bradycardia. The discussion covers essential labs (lactate, procalcitonin), imaging strategies, and the role of scoring systems like SOFA and qSOFA.

Key treatment principles are unpacked, including individualized fluid resuscitation, the timing and selection of vasopressors like norepinephrine (Levophed), and nuanced antibiotic stewardship tailored to suspected pathogens and resistance patterns. The hosts also highlight the importance of source control and the dangers of mimics like DKA and thyroid storm. This is a must-listen for those looking to build a solid clinical foundation in managing septic shock.

Citations & References:

• PulmCrit - Septic Shock
• Surviving Sepsis Campaign Guidelines (2021)
• Sepsis-3 Definitions [Singer et al., JAMA. 2016]
• VANISH Trial (Gordon et al., JAMA. 2016)
• CAT Trial [Annane et al., Crit Care Med. 2007]

Some may start off an internal medicine podcast on how to manage diabetes or hypertension, maybe even a discussion on sodium. We will get to all those topics in our podcast, but right off the bat, we wanted to start on a topic that is life or death: Shock. Recognizing a shock patient is sometimes easy and sometimes very difficult, as it can appear to be something else.

We're going to do a series on shock and its different types. We want the intern and medical student to know right off the bat about the sickest patients and know how to start intervening and saving their lives.

In this foundational episode of IM Basics, Dr. Eric Acker is joined by Dr. Tark and Dr. Bass to provide a high-yield overview of shock for PGY1 residents and medical students. They break down the clinical signs and early indicators of shock, including mental status changes, blood pressure trends, and heart rate abnormalities.

The team discusses the value of history-taking, bedside tools like point-of-care ultrasound (POCUS), and essential labs (CBC, BMP, lactate, Procalcitonin) in differentiating between types of shock. They review the four major shock categories—hypovolemic, cardiogenic, distributive, and obstructive—and stress the importance of early intervention, not just diagnostic pondering.

With practical guidance on workup strategies, resuscitation, and when to escalate to ICU support, this episode equips learners to recognize and manage shock before it's too late.

References for this episode:

• Uptodate - Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock.
• IBCC - PULMCrit - "Shock & vasoactive medications"