Pediatric emergency medicine trisk 2085 2085
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in the presence of near-normal intravascular pressures. Metabolic acidosis
occurs in approximately 30% of patients who have liver failure, and the risk of
sepsis is increased secondary to the patient’s compromised immune function.
Management. All patients suspected of having liver failure should undergo a
complete physical examination, including a thorough and serial neurologic
evaluation. Laboratory testing should include serum glucose, transaminases,
total and direct bilirubin, albumin, PT, GGT, CBC count with differential,
electrolytes, blood culture, and fibrinogen.
Infection can be both the cause and a complication of ALF and is a major
cause of morbidity and mortality. Infection may be the cause of death in up to
20% of patients. Patients with ALF may not present with an elevated WBC
count and fever, so the ED clinician should have a very low threshold for
empiric broad-spectrum antibiotics.
Patients with hypoglycemia should receive IV fluids with 10% dextrose,
with additional dextrose boluses as necessary, and should undergo frequent
blood glucose monitoring (every 1 hour) until their blood glucose level
stabilizes. Metabolic acidosis should be corrected; however, correction of
hyponatremia should be gradual in patients with ascites.
Patients who have a life-threatening coagulopathy should be given IV
vitamin K (2.5 mg in infants; 5 mg in older children and adolescents). In the
case of non–life-threatening coagulopathy, vitamin K should be given
subcutaneously because of the risk of infusion reactions. A repeat PT should
be performed 6 to 8 hours after administration. An uncorrectable PT is
suggestive of severe hepatocyte damage. Clinicians should be cautious about
aggressive management of coagulopathies in patients without active bleeding,
as this may quickly lead to difficulties with patient volume status without
significant improvement in the patient’s coagulopathy. Recombinant factor
VII may help correct a coagulopathy without the need for significant volume,
however the data of its efficacy in children is lacking. In addition, there is a
decrease in both procoagulant and anticoagulant factors, so an elevated PT
and INR may not accurately reflect a patient’s risk of bleeding. Patients also
often exhibit thrombocytopenia secondary to decreased production and
increased consumption. Platelet dysfunction is also seen in liver failure.
Therapeutic management of ascites should occur only in the face of
respiratory distress or renal failure. In these cases, IV 25% albumin (1 g/kg)
followed by IV furosemide can be used. Otherwise, the introduction of a
