The EM Educator Series: The Sick Patient with Cirrhosis

Author: Alex Koyfman, MD (@EMHighAK) // Edited by: Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER)

Welcome to this week’s EM Educator Series. These posts provide brief mini-cases followed by key questions to consider while working. The featured questions provide important learning points for those working with you, as well as vital items to consider in the evaluation and management of the specific condition discussed.

This week has another downloadable PDF document with questions, links and answers you can share with learners as educators in #MedEd. Please message us over Twitter and let us know if you have any feedback on ways to improve this for you. Enjoy!

Case #1:

A 43-year-old male with past history of cirrhosis presents after several episodes of hematemesis. He is hypotensive at 73/42 mm Hg and HR 124 bpm. 

Case #2:

A 51-year-old female with a history of alcohol abuse and cirrhosis presents with abdominal pain and fever. You detect a fluid wave on exam with shifting dullness, and she is diffusely tender.

Considerations:

• Are there typical lab and imaging findings in patients with cirrhosis?
• How do you organize the resuscitation in the sick patient with cirrhosis? What are your priorities?
• How do you manage the airway in the patient with severe hematemesis?
• What about the patient with severe GI bleeding and cirrhosis?
• What infectious disease considerations are there? What about spontaneous bacterial peritonitis?
• What causes hepatic encephalopathy? What are alternative etiologies for altered mental status in these patients? How do you treat hepatic encephalopathy?
• What do you need to consider regarding liver disease and the coagulation pathway?
• Pearls & Pitfalls

Suggested Resources:

• Articles:
  • emDOCs – Approach to the Sick Cirrhotic Patient
  • emDOCs – Spontaneous Bacterial Peritonitis – Pearls & Pitfalls
  • emDOCs – EM@3AM: Hepatic Encephalopathy
  • PulmCrit – Coagulopathy management in the bleeding cirrhotic: Seven pearls and one crazy idea
  • R.E.B.E.L. EM – Should You Give Albumin in Spontaneous Bacterial Peritonitis (SBP)?
  • First 10 EM – Management of the Massive GI Bleed
• Podcast/Vodcast:
  • EMCrit – EMCrit Podcast 5 – Intubating the Critical GI Bleeder
  • EMCrit – Podcast 196 – Having a Vomit SALAD with Dr. Jim DuCanto – Airway Management Techniques during Massive Regurgitation, Emesis, or Bleeding
  • CORE EM – Episode 24.0 – Hepatic Encephalopathy
  • EM Cases – Episode 101 GI Bleed Emergencies Part 1
  • EM Cases – Episode 102 GI Bleed Emergencies Part 2