Hepatic Failure

An Evidence-Based Approach In The Emergency Department

Bailey, Caitlin MD
Hern, Gene H. Jr. MD, MS, FACEP, FAAEM
Ortega, Rae Lynn MD
Sacchetti, Alfred MD, FACEP
Strayer, Reuben MD

Authors
Caitlin Bailey, MD Alameda County Medical Center, Highland General Hospital, Oakland, CA
H. Gene Hern, Jr. MD, MS, FACEP, FAAEM Program Director, Alameda County Medical Center, Highland General Hospital, Oakland, CA
Peer Reviewers
Rae Lynn Ortega, MD Attending Physician, Department of Emergency Medicine, Our Lady of Lourdes Medical Center, Camden, NJ
Alfred Sacchetti, MD, FACEP Chief of Emergency Services, Our Lady of Lourdes Medical Center, Camden NJ. Assistant Clinical Professor, Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA
Reuben Strayer, MD Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine, New York, NY

Emergency Medicine Practice 12(4):p 1-22, April 2010.

On a typical swing shift, your ED is full of patients with a chief complaint listed as “abdominal pain.” You go in to see one such patient, a 40-year-old male, after his nurse tells you he “does not look very good.” He states that he has had gradually worsening abdominal pain for over a week, and that today he felt so fatigued he was unable to go to work. Before this, he was otherwise healthy, and no one around him has been sick. On further history, he reveals that 6 weeks ago he was started on isoniazid for a positive PPD (tuberculosis) test in the absence of active chest disease. Other than mild tachycardia (to 112 beats per minute), his vital signs are normal. Physical examination reveals that his sclerae are yellow and detects marked tenderness of the right upper quadrant with mild hepatomegaly. His wife tells you she is concerned because he seems confused.

You are interrupted by a call to the resuscitation bay to evaluate a patient whose blood pressure is 78/37 mm Hg. You recognize him because of his frequent visits to the ED for tense ascites requiring large-volume paracenteses. EMS reports that twice during transit he vomited dark-red blood. He is pale and diaphoretic. This patient is obviously critically ill, and it is clear your next steps will determine his outcome.