Hepatic Encephalopathy

- [Jim] Welcome to MicroED, quick facts for big issues. I'm Jim Neuenschwander. I'm an emergency physician at Doctors Hospital in Columbus, Ohio. Today, we're gonna be talking about the ALTERD emPOC app and how to better help patients that might have hepatic encephalopathy, also known as HE. There are so many issues that can cause altered mental status. If I read the patient has liver failure, I hope the next thing I read is patient refused to take their lactulose for the last four days because they were tired of pooping during their reruns of "Bonanza."

- Stopping at the post office. See if a package has arrived from Adam.

- Bingo, diagnosis made. But unfortunately, it's not always that easy. That's where we need ALTERD. Many times, it's difficult to assess these patients because they are ALTERD and they can't give us much history. That's where we need to incorporate family, and nursing homes, and other providers when we're able to. Let's look at the A for assess. Medication issues, such as non-adherence, or new meds that affect metabolism. Are they constipated, having a GI bleed, infected, or have something else that pushed them over the edge? The L stands for look. This is where a physical assessment comes in. Do they have ascites or nystagmus? My go-to is asterixis. If they're shaking, I'm taking HE for $200, and the answer to the question of what's making this patient ALTERD. The L also stands for labs. Get a CMP, an ammonia, and you know the others. Remember, a normal ammonia does not preclude the diagnosis of HE. There's plenty of strong data that will show that patients can still be ALTERD with normal ammonia levels. Likewise, I've seen plenty of patients with ammonia levels in the 40s and 50s and be clear as a bell. The T is for treatment. Obviously, infections get treated appropriately, and we always address GI bleeds and electrolyte abnormalities. The new kid on the block is Rifaxamin, which has been shown in conjunction with lactulose to be very helpful in curtailing HE symptoms and recurrence. Our trick is we start the Rifaxamin in the emergency department. And if the hospital is insistent that the patient gets lactulose, we let them drink it on the elevator on the way to the floor. The E is for evaluate the risk. The app has all the West Haven criteria laid out for you, detailing the different grades for corresponding symptoms. It also helps us make a decision on how to treat and disposition the patient. The R is for reassess, which is to take a look at the patient's social needs prior to discharge. When we're sending these folks home, it's important to make sure that they have follow up and help with adherence to their treatment. The D is for disposition. A West Haven score of one can be discharged home in most cases, and anything more than that will need special intervention. This is a quick run through and I hope it helps you manage patients with liver failure that are ALTERD on your next shift.