EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.
Issue link: https://emsworld.epubxp.com/i/576325
36 OCTOBER 2015 | EMSWORLD.com liver failure, the liver does not produce ade- quate levels of albumin. Albumin is neces - sary to maintain the colloidal osmotic pres- sure of blood. This colloidal osmotic pressure keeps fluid in the vascular system. When albumin is not present in sufficient con- centrations, the osmotic gradient between the bloodstream and surrounding tissues is changed, and fluid flows out of the cardiovas- cular system and into the surrounding tis - sues. Abdominal ascites is the most common manifestation of third-spacing and edema, though peripheral edema in the extremities and pulmonary edema can also occur. • The liver plays an important role in the synthesis of clotting factors. When it's diseased, these factors are present in insuf- ficient amounts. As a result, patients will bruise easily, and severe bleeding can occur. • Caput medusae are dilated periumbili- cal veins. They occur as a direct result of por- tal hypertension. Blood and pressure back up in the portal circulation into the periumbili- cal and abdominal wall veins, which become distended, prominent and easily visible. • Fetor hepaticus is a condition char- acterized by a foul-smelling breath. It is observed in patients with liver failure and subsequent portal hypertension and porto- systemic shunting. A sweet, pungent odor is created on the breath when thiols, normally filtered out of the blood in the liver, enter systemic circulation and are released from the lungs with exhalation. 5 • In liver failure, increased estrogen in the blood (in males and females) results in dilation of a cutaneous arteriole and engorging of the surrounding veins, giv- ing the appearance of a central red dot and surrounding "spider legs." These angioma are most often found on the trunk, upper limbs and face. 5 • As with spider angioma, palmar ery- thema, reddening of the palms, also occurs as a result of increased estrogen levels in the blood. • Gynecomastia, an increase in breast tis - sue and gland size in males, is yet another result of increased estrogen levels in the blood. • Patients will of ten experience a decrease in mean arterial pressure as cir- rhosis progresses, and those who were previ- ously hypertensive may become normoten- sive or hypotensive. 6 • Hepatomegaly: When palpable, the cirrhotic liver will have a hard and nodu- lar surface. In healthy patients the liver is difficult to palpate, as it is protected by the rib cage. An enlarged liver, as may be the case in a patient with cirrhosis, may extend well below the rib cage. • Asterixis, also known as the flapping tremor, is the bilateral asynchronous flap- ping or jerking motions of the hands when bent up at the wrist (dorsiflexion). It is most often seen in hepatic encephalopathy. Specifc Medical Emergencies Variceal Hemorrhage A varix is an abnormally dilated vessel with a tortuous course. Varices typically occur in the venous system but may also occur in arteries or lymphatic vessels. Esophageal and gastric varices can occur in the esopha- geal and gastric veins secondary to the por- tal hypertension that results from cirrhosis. These varices do not cause any symptoms until they leak or rupture, resulting in potentially life-threatening hemorrhage. Less severe bleeding or leaking will result in signs of upper gastrointestinal bleeding such as melana (dark, tarry stool) or bloody diarrhea, dizziness, hypotension, tachycar- dia and syncope. Severe cases of variceal hemorrhage may present with the vomiting of blood (hematemesis) and the rapid onset of hypovolemic shock and death. Hepatic Encephalopathy Hepatic encephalopathy is a term used to describe a spectrum of neurologic abnormal - ities seen in patients with liver dysfunction, occurring in 10%–50% of persons with cir- rhosis. 7,8 Characteristics of hepatic encepha- lopathy include the normal signs and symp- toms characteristic of cirrhosis in addition to derangements in mental status, level of consciousness and neuromuscular function. In the early stages patients may present with insomnia or hypersomnia, lethargy, mild disorientation, a shortened attention span, disorientation to time, euphoria or depres- sion or irritability, and neurologic manifesta- tions such as tremor, muscular incoordina- tion or asterixis. In the mid stages, patients may experience somnolence or confusion, disorientation to place, decreased inhibi- tions, inappropriate behavior and anxiety. Slurred speech, ataxia, loss of reflexes and nystagmus are common neurologic findings. In late-stage hepatic encephalopathy, signs such as muscular rigidity, dilated pupils and stupor or coma are present. Spontaneous Bacterial Peritonitis SBP is an acute infection of ascitic fluid in the abdomen without a readily identifiable and surgically treatable source. It typically occurs in patients with advanced cirrhosis. 9 It is important that patients with SBP are identified early in course of infection, as there is a short window of opportunity for successful treatment. If unidentified, SBP can lead to shock, multisystem organ fail- ure and death. 9 As such, identification of these patients in the field and transport to an emergency department for evaluation and treatment is important. Suspect SBP in patients with a history of advanced cirrhosis and ascites who develop signs and symptoms such as abdominal pain, fever and altered mental status. On physical exam there will usually be diffuse abdominal tenderness. Patient Management There is no specific out-of-hospital treat- ment for cirrhosis, only for the potentially life-threatening complications described above. Treatment for the complications of cirrhosis revolves around supportive care and the maintenance of airway, breathing and circulation. EMS care also should take into account the reduced hepatic func- tion the patient has and avoid medications metabolized by the liver without discussing dosing with medical control—a simple dose of acetaminophen to treat a fever may be life- threatening, and a normal dose of a short- acting drug like midazolam may still affect a patient's mental status many hours later. Airway and Breathing Patients with suspected SBP, variceal bleeding or hepatic encephalopathy should receive oxygen at a concentration and with CONTINUING EDUCATION