Pediatric emergency medicine trisk 0880 0880
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the emergency department. Empiric therapy for sepsis or urinary infection is often
warranted, pending culture results.
EVALUATION OF THE OLDER CHILD
In the evaluation of conjugated hyperbilirubinemia beyond infancy, it is necessary
to know if there has been exposure to an infectious agent or if the potential for
sexual or vertical transmission of infections such as hepatitis or human
immunodeficiency virus exists. Other risk factors for hepatitis (e.g., needle sticks,
hemodialysis, transplant, transfusion of blood products, or factor use) need to be
elicited. The physician should also ask about possible exposure to industrial
toxins or foods previously implicated in hepatic injury (e.g., carbon tetrachloride,
yellow phosphorus, tannic acid, alcohol, mushrooms of the Amanita species). The
emergency provider must inquire about use of hepatotoxic medications including
acetaminophen, salicylates, nonsteroidal anti-inflammatory drugs, iron salts,
erythromycin, ceftriaxone, rifampin, nitrofurantoin, oxacillin, tetracycline,
trimethoprim-sulfamethoxazole, ketoconazole, diphenylhydantoin, isoniazid, and
chlorpromazine. Further studies to consider include infectious titers, thyroid
studies, autoimmune antibodies, plasma amino acids, urine organic acids, PI
phenotyping, hemoglobin electrophoresis, iron profile, sweat testing, and
ceruloplasmin. These are best undertaken in consultation with a hepatologist or
gastroenterologist (see Chapter 91 Gastrointestinal Emergencies ).
LIFE-THREATENING CAUSES NOT TO MISS
Acute Liver Failure
Acute liver failure presents with both liver inflammation and dysfunction, and can
be quite severe and progress rapidly to shock and multiorgan failure. The most
common etiologies are toxin related (such as acetaminophen poisoning),
infection, and idiopathic. Signs of acute failure include coagulopathy with
elevated PT and PTT levels, and hepatic encephalopathy with an elevated
ammonia level. Symptoms include vomiting, bruising, abdominal pain, jaundice,
rash, and altered mental status. Common complications include gastrointestinal
bleeding, electrolyte imbalances, renal failure, infection, and cerebral edema.
Aggressive therapy is needed as soon as acute liver failure is identified, and
includes supportive care to maintain cardiac, cerebral, renal, and pulmonary
function. N-acetylcysteine (NAC) should also be given in cases of acetaminophen
toxicity. Procoagulation blood products are not necessarily recommended,
because even though patients with acute liver failure have low levels of
