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HEPATITIS: EM Perspective - Dr. Yavorcik

10/3/2013

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It’s the history and physical that is going to guide you for clues to hepatitis.
  • History: alcohol use, recent drug ingestions, IV drug use, blood transfusions.
  • Physical Exam: RUQ pain, palpable liver, jaundice, icterus, ascites, encephalopathy
Orders matter... (at least where we work they do)
  • "Costs": BMP - $180, POC CHEM 8 - $408, COMP - $230, LFTs - $200, Fractionated Bili $123.
  • Order COMP instead of CHEM 8 if you plan on ordering a CBC anyway to be most cost effective if you can wait an extra 30 minutes for electrolytes.
Picture
Dr. Yavorcik -- at least according to G+
Liver Function Tests are more indicative of liver damage... not "function."
  • AST/ALT released from parenchymal cells in liver into serum.
  • PT/INR, aPTT, albumin, bilirubin show synthetic capabilities of the liver.
Be aware of different ranges of aminotransferases.
  • Non-alcoholic fatty liver: AST and ALT up to 4x upper limit (150-200s)
  • Alcoholic: AST up to 8x normal (400-500s), ALT up to 5x upper limit (200-250s)
  • Chronic Hep B, C: may be normal, may be up to 10x limits (50-400s)
  • Toxin-mediated or Acute Viral: AST and ALT up to 25x (can be around 1,000)
  • Ischemic injury / shock liver: AST ALT up to 50x (1,000-2,000s)
  • If AST/ALTs >10x normal limits think about obtaining acetaminophen level, serum pregnancy test, UA, toxicology screen, U/S of abdomen for vascular occlusion/Budd-Chiari Syndrome, ascites.
  • ADMIT high-risk patients which includes pregnant and elderly who are not responding to supportive care. Look closely at total bilirubin if over 20 mg/dL, PT 50% above normal.
  • ADMIT: Ascites with respiratory distress, abdominal pain as well as fever, acidosis, leukocytosis. Also admit new or worsening encephalopathy, coagulopathy with bleeding, severe hyponatremia, hyper/hypo-volemia.
  • Aspects of hepatitis we can treat in the ED include ascites with paracentesis, albumin, SBP with cefotaxime, albumin, encephalopathy with lactulose, coagulopathy - vitamin K, FFP, donor platelets.

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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction