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| ===Common Causes=== | | ===Common Causes=== |
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| ==Management==
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| {{familytree/start |summary=PE diagnosis Algorithm.}}
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| {{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | |A01=Altered mental status & PT prolongation by 4-6 sec or INR ≥1.5<BR>presenting w/ nonspecific abdominal Sx<BR>w/o preexisting chronic liver disease, cirrhosis & any illness of <26 wks duration}}
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| {{familytree | | | | | | | | | | | | | | | |!| | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | | B01 | | | | | | |B01=Acute liver failure}}
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| {{familytree | | | | | | | | | | | | | | | |!| | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | | C01 | | | | | | |C01=Mandatory hospital admission}}
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| {{familytree | | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | | |}}
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| {{familytree | | | | | | | | D01 | | | | | | | | | | | | D02 | | |D01=w/o altered mental status, significant coagulopathy & abnormal LFT|D02=w/ altered mental status}}
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| {{familytree | | | | | | | | |!| | | | | | | | | | | | | |!| | | |}}
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| {{familytree | | | | | | | | E01 |-|-|-|-| E02 |-|-|-|-| E03 |-|-| E04 |-|-| E05 |E01=High dependency ward admission|E02=Worsening mental status|E03=ICU admission|E04=w/ or progression to grade I/II hepatic encephalopathy|E05=Transfer to transplant center}}
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| {{familytree | | | | | | | | |`|-|-|-|-|-|-|v|-|-|-|-|-|-|'| | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | | F01 | | | | | | | | | | |F01='''Initial evaluation:'''<BR>Detailed H/o and PE<BR>Labs: CBC, PT/INR, serum BCH, ABG, ammonia, acetaminophen & tox screen for other drugs/toxins, viral serology (A-E), autoimmune markers, amylase, lipase, bilirubin:alkaline phosphatase, blood grouping & typing, HIV status}}
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| {{familytree | | | | | | | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| |}}
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| {{familytree | | | | | | | | |!| | | | | | |!| | | | | | |!| |}}
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| {{familytree | | | | | | | | G01 | | | | | G02 | | | | | G03 |G01=General management|G02=Etiology specific management|G03=Complication specific management}}
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| {{familytree/end}}
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| ===General Management===
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| {{familytree/start |summary=PE diagnosis Algorithm.}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | |A01=Continuous monitoring under quite environment w/ preventive treatment strategies}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | |}}
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| {{familytree | |,|-|-|-|-|v|-|-|-|-|v|-|-|-|-|v|-|-|-|-|v|-|-|-|-|+|-|-|-|-|v|-|-|-|-|v|-|-|-|-|v|-|-|-|-|v|-|-|-|-|.| |}}
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| {{familytree | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| |}}
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| {{familytree | B01 | | | B02 | | | B03 | | | B04 | | | B05 | | | B06 | | | B07 | | | B08 | | | B09 | | | B10 | | | B11 |B01=Cerebral edema & increased ICP|B02=Coagulopathy|B03=Drugs|B04=GI bleeding|B05=Hemodynamic instability|B06=Hepatic encephalopathy|B07=Infections|B08=Metabolic disturbances|B09=NAC|B10=Nutritional deficiency|B11=Renal failure}}
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| {{familytree | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| |}}
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| {{familytree | C01 | | | C02 | | | C03 | | | C04 | | | C05 | | | C06 | | | C07 | | | C08 | | | C09 | | | C10 | | | C11 |C01=*Monitor ICP, CPP & cerebral oxygenation<BR>*Elevate head end to 30°<BR>*Monitor fluid status<BR>*3% NS<BR>*Avoid NGT and suction|C02=*Platelet count & coagulation profile (12th hourly)<BR>*Inj. Vit. K<BR>*Cryoprecipitate|C03=*Discontinue medications<BR>*Avoid nephrotoxic & hepatotoxic drugs|C04=*Ranitidine|C05=*Monitor CVP w/ central venous catheter|C06=*Frequent monitoring of mental status|C07=*CBC (12th hourly)<BR>*CXR; sputum, blood & urine cultures (daily)<BR>*Cefotaxime, meropenem, fluconazole or vancomycin|C08=*Serum BCH, ABG, lactate (12th hourly)<BR>*Serum glucose (2nd hourly)|C09=*NAC (i.v × 2d then P.O.)|C10=*Eternal feeding<BR>*Parental feeding|C11=*Urinary I/O}}
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| ===Etiology Specific Management===
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| {{familytree/start |summary=PE diagnosis Algorithm.}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | |A01=Etiology specific management}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | |}}
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| {{familytree | |,|-|-|-|-|v|-|-|-|-|v|-|-|-|-|v|-|-|-|-|v|-|-|-|-|+|-|-|-|-|v|-|-|-|-|v|-|-|-|-|v|-|-|-|-|v|-|-|-|-|.| |}}
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| {{familytree | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| |}}
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| {{familytree | B01 | | | B02 | | | B03 | | | B04 | | | B05 | | | B06 | | | B07 | | | B08 | | | B09 | | | B10 | | | B11 |B01=*H/o acetaminophen intake<BR>*Consider if no H/o but elevated aminotransferase (>3500 IU/L)|B02=*Jaundice, coagulopathy, thrombocytopenia ± hypoglycemia<BR>*Hypertension & proteinuria<BR>*+ Steatosis during liver imaging or biopsy|B03=*Elevated aminotransferase responding to fluid resuscitation<BR>*Associated renal dysfunction & muscle necrosis|B04=*+ Serum autoantibodies<BR>*+ Liver biopsy|B05=*Abdominal pain, ascites and hepatomegaly<BR>*+ Liver imaging (CT/MRV/venogram/doppler USG)|B06=*H/o hepatotoxic drug intake (<6m)<BR>*Unlikely if H/o intake >1 or 2 years|B07=*Massive hepatomegaly<BR>*+ Liver imaging & biopsy|B08=*H/o mushroom intake<BR>*Suspect if no H/o but severe GI Sx (NVD)|B09=*+ Hepatitis serology<BR>*+ Liver biopsy for HSV<BR>|B10=*Serum bilirubin >20g/dL, bilirubin:alkaline phosphatase >2.0, low serum ceruloplasmin, elevated serum & urine copper, + KF ring, + liver biopsy|B11=Etiology undetermined}}
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| {{familytree | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| |}}
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| {{familytree | C01 | | | C02 | | | C03 | | | C04 | | | C05 | | | C06 | | | C07 | | | C08 | | | C09 | | | C10 | | | C11 |C01=Acetaminophen toxicity|C02=Acute fatty liver of pregnancy/HELLP|C03=Acute ischemic injury|C04=Autoimmune|C05=Budd-Chiari|C06=Drug induced|C07=Malignant infiltration|C08=Mushroom poisoning|C09=Viral|C10=Wilson's disease|C11=Intermediate etiology}}
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| {{familytree | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| |}}
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| {{familytree | D01 | | | D02 | | | D03 | | | D04 | | | D05 | | | D06 | | | D07 | | | D08 | | | D09 | | | D10 | | | D11 |D01=*Activated charcoal<BR>*NAC|D02=*Deliver immediately|D03=*Manage the cause of ischemia|D04=*Prednisolone<BR>*Transplantation|D05=*Transplantation|D06=*Discontinue all possible medications except essential drugs|D07=*Supportive Rx|D08=*Activated charcoal & gastric lavage<BR>*Penicillin G or Silibinin<BR>*Fluid resuscitation|D09=*Supportive Rx<BR>*Lamivudine or adefovir<BR>*Acyclovir|D10=*Dialysis or hemofiltration or plasmapheresis or plasma exchange<BR>*Transplantation|D11=*Incomplete drug or toxin intake H/O<BR>*Transjugular biopsy to R/O mailgnancy, Wilson's disease, autoimmune hepatitis or viral hepatitis}}
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| ===Complication Specific Management===
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| {{familytree/start |summary=PE diagnosis Algorithm.}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | |A01=Complication specific management}}
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| {{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | |,|-|-|-|-|v|-|-|-|-|v|-|-|-|-|+|-|-|-|-|v|-|-|-|-|v|-|-|-|-|.| |}}
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| {{familytree | | | | | | | | | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| |}}
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| {{familytree | | | | | | | | | | | B01 | | | B02 | | | B03 | | | B04 | | | B05 | | | B06 | | | B07 |B01=Ascites|B02=Cerebral edema & increased ICP|B03=Coagulopathy|B04=Hemodynamic instability|B05=Hepatic encephalopathy|B06=Metabolic disturbances|B07=Renal failure}}
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| {{familytree | | | | | | | | | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | |!| | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | C01 | | | C02 | | | C03 | | | C04 | | | C05 | | | C06 | | | C07 |C01=*Therapeutic paracentesis w/ 25% albumin<BR>*<3 mEq/Kg of Na daily<BR>*Lasix & aldactone|C02=ICP >25 mmHg|C03=+ Bleeding or prior to surgery|C04=*Colloid, dextrose in crystalloid (if hypoglycemic) & 1/2 NS w/ 75 mg/L HCO3 (if acidotic)<BR>*Norepinephrine±vasopressin<BR>*Hydrocortisone|C05=Grade|C06=*Rx acidosis, alkalosis, hypophosphatemia, hypomagnesemia, hypokalemia or hypoglycemia accordingly|C07=*Continuous venovenous hemodialysis}}
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| {{familytree | | | | | | | | | | | | | | | | |!| | | | |!| | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | | | | D01 | | | D02 | | | | D03 | | D04 | | D05 | | | | | | | | | | | | | | |D01=SjO2|D02=*Platelet transfusion (if ≤50,000/mm2)<BR>*FFP /+ rFVIIa (if INR≥1.5)|D03=I|D04=II|D05=III/IV}}
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| {{familytree | | | | | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | E01 | | | | | | | | | | | | E02 | | E03 | | E04 | | E05 | | | | | | | | | | | | | | | | |E01=<80|E02=>80|E03=2nd hourly monitoring in quiet environment in high dependency ward|E04=*ICU management<BR>*Stat CT to R/O ICH<BR>*Short acting BZD<BR>*Lactulose|E05=*ICU management<BR>*Intubation & mechanical ventilation<BR>*Propofol<BR>*Elevate head end to 30°<BR>*Quiet environment monitoring for CVP, hemodynamic & renal parameters, serum electrolytes, acid base status & neurological status}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | F01 |-|-|-|-| F02 |-|-|-|-| F03 | | F04 | | | | | | | | | | | | | | | | | | | | | | |F01=20% mannitol|F02=No improvement|F03=Hyperventillation|F04=Worsening}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | G01 | | | | | | | | | | | | | | | | G02 | | | | | | | | | | | | | | | | | | | | | | | |G01=3% NS|G02=Transfer to ICU}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | H01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |H01=Reduce core temperature to 32°-34° (monitor for arrhythmias)}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | I01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |I01=Thiopental 125 mg i.v bolus}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | J01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |J01=Improvement or refractory}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
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| {{familytree | | | | | | | | | K01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |K01=Transplantation}}
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| ==Do's== | | ==Do's== |