Thursday, February 14, 2008

Vol 1:1

Introducing a new section to NY Emergency Medicine. Each month we will post PEARLS from the monthly publication Emergency Medicine Practice - the only resource that helps emergency medicine practitioners integrate evidence-based decision-making into routine clinical practice. We are excited for this partnership and hope our readers benefit from the new content. Find out what other people think about Emergency Medicine Practice.

Jaundice: An ED Approach To Diagnosis & Management
Jaundice is not a diagnosis per se but rather a physical manifestation of elevated serum bilirubin. It is not a common chief complaint. Instead, the jaundiced patient often presents with a related symptom, (e.g., abdominal pain, pruritis, vomiting, or substance ingestion). Hyperbilirubinemia is only dangerous in and of itself in neonates, where it can cross the blood brain barrier and deposit in the brain tissue, causing encephalopathy (kernicterus). In adults, jaundice serves as a marker for potentially serious hematologic or hepatobiliary dysfunction such as massive hemolysis, fulminant hepatic failure, or ascending cholangitis. Indeed, these are the cases where the emergency physician must intervene aggressively in order to maximize good outcomes. Fortunately, the majority of jaundiced patients have a more indolent course and the emergency physician serves as a facilitator in the diagnostic work-up, initiating management and ensuring that an appropriate disposition is made.

Key Points: The Management of Jaundice in the ED

• All patients require a thorough history (including medications, drug and alcohol use, family history, and travel history) and a careful physical examination for the manifestations of liver disease.

• Check at least a total and direct bilirubin level on all patients. Most patients will also need a chemistry panel with liver function tests, a CBC with differential, and a PT/INR.

• Patients with jaundice and anemia due to massive hemolysis or dyserythropoiesis require admission.

• Patients with elevated alkaline phosphatase and gamma-glutamyl-transferase likely have a biliary tract obstruction. They should get an imaging procedure in the ED (CT or US) and have a surgical or gastrointestinal consult, depending on the findings.

• Patients with primarily elevated aminotransferases (AST and ALT) have hepatocellular injury. They should be admitted if there is evidence of coagulopathy, sepsis, mental status changes, intractable pain, or nausea.

• Patients with the triad of hepatocellular injury, coagulopathy, and mental status changes have acute liver failure. They should be admitted to an ICU or transferred to the nearest liver transplant center.

• Any pregnant patient with jaundice should be managed in conjunction with the obstetrician. Patients who present with jaundice in the third trimester may require delivery and may need to be transferred to a center with high-risk obstetric and neonatal facilities.

• Well-appearing neonates with a serum bilirubin below 15 mg/dL can be discharged home with close follow-up.

• NAC is 100% hepatoprotective if given within eight hours of acute acetaminophen ingestion; it may also be of benefit in late or chronic ingestions, and poison center consultation is recommended.

Emergency Medicine Practice is the only resource that helps emergency medicine practitioners integrate evidence-based decision-making into routine clinical practice. Each single-topic, peer-reviewed monthly issue is exhaustively researched to give the most definitive, up-to-date protocols and advice. Earn up to 48 AMA/ACEP, AAFP prescribed, or AOA Category 2B CME credits—plus 144 CME credits from archived issues. The evidence-based recommendations, abundant clinical pathways, and risk management perspectives will improve your clinical skills—and your confidence—in the ED. Guaranteed.

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