immediate critical care management and contacting the transplant team Liver transplant patients, however, typically present to triage in a more stable fashion Clinical Assessment History should be focused on assessment of medical adherence as well as a complete review of systems Physical examination is mainstay of diagnosis at this stage For cardiac transplant patients, tachycardia, gallop rhythm, orthopnea, tachypnea, congested breath sounds and rales, pallor, low blood pressure, jugular venous distention, abdominal ascites, and hepatomegaly may all be seen Chest radiograph may reveal cardiomegaly and pulmonary congestion ECG may show low voltage, strain pattern, and even ischemia An echocardiogram obtained in the ED is helpful to determine ventricular function and the presence of a pericardial effusion or valvar insufficiency, which are common in rejection Laboratory findings compatible with rejection include elevated BNP (as a marker of cardiac failure); immunosuppression drug levels that are very low (as in noncompliance) or very elevated (as in diminished metabolism due to decreased cardiac output); elevated LFTs and renal indices, as the result of low cardiac output Liver transplant patients develop fever from bile duct inflammation and cholangitis This may be accompanied by graft-site tenderness Other possible physical examination findings include encephalopathy, jaundice, bruising, and a tendency for bleeding Initial assessment for concern of rejection should include LFTs (AST, ALT, bilirubin, GGT) as well as measures of synthetic liver function values such as INR, prothrombin time, albumin, glucose, and ammonia level If there is a coagulopathy, vitamin K should be administered A Doppler ultrasound of the hepatic allograft is indicated in settings of fever Management First-line management for cardiac rejection is intravenous solumedrol, 10 mg/kg (max dose 500 mg) as a bolus If there is hemodynamic compromise, milrinone is an appropriate addition to therapy, as is intravenous furosemide for pulmonary congestion Therapy should be discussed with the transplant team For liver, intestinal, and renal transplant patients, if there is concern for rejection, a biopsy of the transplanted organ is indicated Assessment of patient safety for biopsy should include a hemoglobin level, a coagulation panel, and a type and screen POSTTRANSPLANT LYMPHOPROLIFERATIVE DISORDER