- Patients with severe hepatic encephalopathy may require urgent airway intervention.
- Patients may demonstrate hemodynamic instability due to an acute precipitant of hepatic encephalopathy, including gastrointestinal hemorrhage or infection. Assess and resuscitate accordingly.
- Avoid the use of benzodiazepines for induction during intubation due to impaired metabolism and worsening delirium.
- Resuscitate patient and evaluate airway and hemodynamic stability.
Hepatic encephalopathy (HE) is characterized by a constellation of neuropsychiatric symptoms that occur as a result of decompensated liver disease. Although the pathology is not fully understood, it is thought to be related to an increase in neurotoxins such as ammonia, as well as changes to inflammatory mediators and cerebral blood flow.
HE can occur either in acute liver failure or as a result of worsening chronic disease (see liver cirrhosis), and it has been associated with transjugular intrahepatic portosystemic shunts (TIPS) due to changes in portal blood flow. The prevalence of HE is estimated to be 17%-20% with a 5-year incidence of more than 40%. The vast majority of patients presenting to the emergency department (ED) for HE will ultimately require admission, and morbidity and mortality are high. In 2016, an estimated 53 000 United States ED visits were related to HE.
While the signs and symptoms of HE are neuropsychiatric and range from mild confusion or disorientation to somnolence or coma, HE is frequently seen in patients with underlying chronic liver disease and associated stigmata (ie, jaundice, spider telangiectasias, ascites, hypotension).
HE is graded according to the West Haven criteria:
- Grade 1 includes mild decreased attention span, hypersomnia, slowness of thinking, mood changes, and slight confusion.
- Grade 2 includes lethargy, disorientation (especially to time), dysarthria, asterixis, and personality changes.
- Grade 3 includes disorientation to time and place, somnolence, disordered speech, memory impairment, and marked confusion.
- Grade 4 progresses to coma.
HE can be precipitated by medication or drug ingestions, including hepatotoxins such as Amanita phalloides. Pregnancy, alcohol use disorder, poor nutrition, and chronic hepatitis are all risk factors. Among the proximate causes for episodes of HE, infection (and specifically spontaneous bacterial peritonitis, or SBP) is the most common, followed by electrolyte abnormalities, bowel dysfunction or constipation, and gastrointestinal bleeding.
The emergency management of HE includes a careful history and physical examination, assessment for other possible causes of encephalopathy or altered mental status, airway assessment, and resuscitative efforts with cautious fluid management. Lactulose is a mainstay of acute care management.