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Hepatic Failure: An Evidence- Based Approach In The Emergency Department

April 2010

Abstract

Hepatic failure presents with a variety of acute manifestations, most of which will be seen at some point during the ED clinician’s career. At the most critical end of the spectrum is the syndrome of acute liver failure (ALF), in which hepatic function is suddenly lost in a person with no previous liver dysfunction. Currently, the most widely accepted definition of ALF is the presence of both coagulopathy (international normalized ratio [INR] > 1.5) and altered mental status consistent with hepatic encephalopathy of less than 26 weeks’ duration (a change from the previously defined timeline of 8 weeks).1,2 This disorder is rare, with an annual incidence in the US of 2300 to 2800 cases, and results in 0.1% of all deaths and 6% of all liver-related deaths in the US.3,4 However, this condition can deteriorate rapidly and is associated with high morbidity and mortality. Precipitating etiologies must be quickly identified and disease-specific interventions implemented in order to prevent further decompensation or death. Early transfer to a tertiary care facility with transplant capability may also be necessary.

More common than ALF is chronic liver failure (CLF) with cirrhosis, the 12th leading cause of death in the US.5 While primarily a disorder of long-term outpatient management, acute decompensation of CLF may bring the patient to the ED because of variceal hemorrhage, symptomatic ascites, spontaneous bacterial peritonitis, hepatorenal or hepatopulmonary syndrome, and hepatic encephalopathy. The ED clinician must confront these manifestations and guide management within the broader context of the patient’s chronic care.

This issue of Emergency Medicine Practice focuses on the management of ALF and the acutely symptomatic cirrhotic patient.
Table Of Contents:

Emergency Medicine Practice

Alcohol Withdrawal Syndrome: Improving Outcomes Through Early Identification And Aggressive Treatment Strategies

This issue reviews the pathophysiology of the alcohol withdrawal syndrome, describes the 4 manifestations of alcohol withdrawal, and looks at the available evidence for optimal treatment of alcohol withdrawal in its diverse presentations. An aggressive front-loading approach with benzodiazepines is proposed and the management of benzodiazepine-resistant disease is addressed.

Pediatric Emergency Medicine Practice

Best Practices In The Emergency Department Management Of Children With Special Needs

Children with special needs often have medical de­vices, subtle presentations, and behavioral or psychiatric issues that demand consideration when delivering emergency care. Complications in gastrostomy/jejunostomy feeding tubes, cerebroventricular shunts, and tracheostomy tubes, as well as impediments to the performance of common emergency procedures on children with devel­opmental or behavioral disorders are reviewed in this issue.

Hospital Medicine Practice

HCAHPS And The Metrics Of Patient Experience: A Guide For Hospitals And Hospitalists

This issue of Hospital Medicine Practice reviews the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, its role in determining reimbursement rates for inpatient care by the Centers for Medicare and Medicaid Services, and how hospitals and hospitalists can apply the data and best practices to improving patient experience, outcome, and reimbursement rates.



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