Ebook Decision making in emergency critical care: Part 2

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26 Pancreatitis Susan Y Quan and Walter G Park BACKGROUND The pancreas is approximately 6 to 10 inches long, is located directly behind the stomach, and has distinct endocrine and exocrine functions The endocrine portion of the pancreas is composed of islets of Langerhans cells that constitute about 2% of the organ These cells produce and secrete hormones including insulin, glucagon, and somatostatin The exocrine portion of the pancreas is composed of acinar cells (80% of the organ) and ductal cells (18% of the organ) Acinar cells produce digestive enzymes that are sequestered until physiologic impulses stimulate their release into the pancreatic ductal system where they are transported to the small intestine The digestive enzymes are enzymatically inert until activated in the small intestine by various peptides Disruption of this physiologic process, by any of a variety of etiologies, is the basis for our current understanding of acute and chronic pancreatitis This chapter primarily focuses on acute pancreatitis, which is more commonly seen in emergency care Pertinent aspects of chronic pancreatitis are also addressed ACUTE PANCREATITIS The incidence of acute pancreatitis is estimated to be as high as 38 per 100,000 patients and accounts for more than 220,000 hospital admissions in the United States annually.1 Most cases are clinically mild and self-limited; a minority of cases are severe and are associated with critical illness, prolonged hospitalization, infection, organ failure, and death Acute pancreatitis occurs from premature activation of digestive enzymes within the pancreatic parenchyma leading to an autodigestive and inflammatory process Evolution into a life-threatening systemic process begins when acinar cell injury leads to expression of endothelial adhesion molecules that further potentiates the inflammatory response Local microcirculatory failure and ischemia–reperfusion injury ensue, with some patients developing systemic complications such as systemic inflammatory response syndrome (SIRS), acute respiratory distress syndrome, and multiorgan failure The most common causes of acute pancreatitis are gallstones and excess alcohol ingestion These account for about 45% and 35% of cases, respectively.2,3 Hypertriglyceridemia accounts for up to 5% of cases Other causes include hypercalcemia, autoimmune diseases, infections, medications, trauma, and complications after endoscopic retrograde cholangiopancreatography (ERCP) (Table 26.1) Controversial etiologies include pancreatic divisum and sphincter of Oddi dysfunction Idiopathic pancreatitis occurs in up to 20% of patients, and by definition, the cause is not established by history, physical exam, routine laboratory tests, or imaging TABLE 26.1 Causes of Acute Pancreatitis History and Physical Exam The typical presentation includes a constant (as opposed to waxing and waning) upper abdominal pain located primarily in the epigastric area with radiation to the back The onset of pain is rapid and typically reaches maximum intensity within 10 to 20 minutes Pain that lasts only a few hours is unlikely to be pancreatitis About 90% of patients will also complain of nausea and vomiting Mild pancreatitis may involve minimal abdominal tenderness without guarding In severe disease, abdominal tenderness can be elicited with superficial palpation Abdominal distention and reduced bowel sounds can occur secondary to ileus Extravasation of hemorrhagic pancreatic exudate can lead to ecchymosis in one or both flanks (Turner sign) or the periumbilical regions (Cullen sign) Severe disease should be suspected with abnormal vital signs that can include fever, tachycardia, tachypnea, and hypotension These signs represent a transition from localized retroperitoneal inflammation to one of systemic inflammation Pleural effusions and mental status changes are also hallmarks of severe disease The presence of jaundice may suggest an underlying alcoholism or choledocholithiasis Diagnostic Evaluation Acute pancreatitis is diagnosed when two of the following three criteria are met: (1) characteristic abdominal pain, (2) serum amylase or lipase greater than three times the upper limit of normal, and, if needed, (3) radiologic imaging consistent with the diagnosis.4 Amylase and lipase are the most frequently used serumbased tests for pancreatitis The most common source of amylase is not the pancreas, but salivary glands In contrast, 90% of lipase is made from the pancreas, making it a more specific marker Amylase rises within 6 to 24 hours of acute pancreatitis and peaks in 48 hours, normalizing in 3 to 7 days Lipase has a longer half-life than amylase, with levels increasing within to hours, peaking at 24 hours, and falling over 8 to 14 days.5 The degree of elevation is not a marker of disease severity, and mild elevation of these serum markers— less than three times the upper limit of normal—is not specific for pancreatitis The use of computed tomography (CT) or magnetic resonance imaging (MRI) should only be considered when the first two diagnostic criteria are not met and (1) the pretest probability for pancreatitis remains high or (2) there is a high pretest probability for another abdominal process Otherwise, CT and MRI have no role and may exacerbate renal injury from use of intravenous contrast.6 Such imaging can be considered days later should the diagnosis remain uncertain or to assess disease severity and identify complications related to severe pancreatitis Following clinical and laboratory parameters allows adequate initial assessment of disease severity For patients with an established history of chronic pancreatitis or recent acute pancreatitis, imaging may be considered as part of the initial emergency department assessment for specific treatable complications of pancreatitis including, but not limited to, enlarging pseudocysts, arterial pseudoaneurysms, and/or new common bile stones Differential Diagnosis The differential diagnosis includes biliary colic, acute cholecystitis, acute cholangitis, biliary dyskinesia, peptic ulcer disease, dyspepsia, acute mesenteric ischemic, and bowel obstruction Nongastrointestinal disorders, including acute myocardial infarction, aortic dissection, pulmonary embolism, acute spinal disorders, and renal calculi, should also be considered Complications The majority of cases (80% to 90%) of pancreatitis are mild and self-limiting; 10% of cases, however, develop severe disease, defined as the presence of significant fluid collections, infectious complications including abscess formation, infected necrosis, and/or extrapancreatic organ failure These patients typically exhibit SIRS or sepsis physiology Fluid collections around the pancreas affect over half of patients Most will resolve, but for those that persist, a fibrogenic anti-inflammatory response will lead to containment of these fluid collections, resulting in the formation of a pseudocyst A pancreatic pseudocyst is a fluid collection that persists beyond 4 weeks Other complications include infections (arising from pancreatic necrosis or within pseudocysts), thrombosis (splenic, superior mesenteric, and/or portal vein), arterial pseudoaneurysms, and gastrointestinal bleeding The mortality rate for patients with severe pancreatitis is approximately 30% Death within the first weeks of illness is usually due to multiorgan failure Death after weeks typically stems from infection Management Guidelines Once a diagnosis of acute pancreatitis is made, a risk stratification calculation should be performed Clinical risk scoring systems, such as Ranson's and APACHE II, have traditionally been used However, both are cumbersome and require 48 hours before a meaningful interpretation can be made The Bedside Index for Severity in Acute Pancreatitis (BISAP) score is a newer validated scoring system that requires five data points of collection in the emergency room.7,8 This includes a blood urea nitrogen (BUN) >25 mg/dL, impaired mental status, SIRS, age >60, and the presence of a pleural effusion (Table 26.2) The presence of three or more features at admission is associated with a 7- to 12-fold increase in organ failure Such patients should be managed in the intensive care unit TABLE 26.2 Risk Stratification Scoring System for Severity of Acute Pancreatitis Initial treatment is primarily supportive and includes adequate fluid resuscitation, pain control, and bowel rest.6 Fluid resuscitation is necessary to replace intravascular volume depletion that occurs from third-space losses The amount of fluid should be calibrated to a urine output of 0.5 mL/kg/h Initial resuscitation may begin with to L of normal saline within the first several hours of presentation Early resuscitation appears to be clinically important in reducing downstream complications In a large retrospective analysis of 434 patients with acute pancreatitis, early compared to late resuscitation was associated with less organ failure at 72 hours (5% vs 10%), a lower rate of admission to the intensive care unit (6% vs 17%), and a reduced length of hospital stay (8 vs 11 days).9 After early initial bolus treatment of intravenous fluids, maintenance fluids should be titrated (up or down) to urine output In severe disease, aggressive fluid resuscitation is important to maintain adequate vascular volume in the setting of SIRS or sepsis physiology.9 Pain can be controlled with intravenous short-acting narcotic pain medications Nausea and vomiting can be controlled with antiemetic medications as needed Acute pancreatitis is a hypercatabolic state, and initiating nutrition at 48 hours from onset is important In mild disease, patients can be started on an oral diet For those with severe disease, enteral nutrition by nasojejunal feeding should be started The current rationale for nasojejunal feeding is that bypassing the duodenum minimizes pancreatic stimulation Enteral nutrition is superior to parenteral nutrition because it carries a lower risk for infectious complications and mortality.10 Documented infections associated with pancreatitis require prompt treatment with carbapenem-based antibiotics to ensure optimal penetration Antibiotic prophylaxis, however, is not indicated.11,12 Endoscopy is indicated for removing common bile duct stones and secondary cholangitis, and cholecystectomy should be planned during hospitalization for those with gallstone-related pancreatitis identified by right upper quadrant ultrasound For some patients who have no clinical or laboratory evidence to suggest severe disease (i.e., a BISAP score of 0, no other laboratory abnormalities), discharge from the emergency room can be considered These patients should also have mild enough pain to be managed with PO pain medications, have the ability to consume liquids without vomiting, and be considered adequately competent and compliant to follow instructions to return to the emergency room for worsening signs and/or symptoms CHRONIC PANCREATITIS Chronic pancreatitis is characterized by chronic inflammation and fibrosis with destruction of exocrine and endocrine cells The incidence is estimated to be 6 cases per 100,000 people, and it affects about 0.04% of the US population.13 Although relatively uncommon, chronic pancreatitis is associated with a high level of morbidity and use of health care resources.14 In the United States, the most common cause is chronic alcohol use, accounting for nearly 70% of cases It should be noted that only approximately 10% of heavy drinkers ever develop pancreatitis, suggesting an underlying genetic predisposition In up to 20% of patients, the etiology is idiopathic The remaining 10% are due to obstructive causes, metabolic derangements, autoimmune diseases, and hereditary disorders.15 History and Physical Exam The most common complaint is chronic abdominal pain that is often associated with nausea and vomiting In advanced disease, maldigestion develops from pancreatic exocrine insufficiency and presents as chronic diarrhea with unintentional weight loss The stool is particularly odorous as most is maldigested fat (also known as steatorrhea) Other late findings include symptoms and signs of diabetes Mild abdominal tenderness with palpation may be elicited An abdominal mass may represent a pseudocyst or splenomegaly Splenomegaly occurs in the setting of splenic vein thrombosis—the result of chronic (or recurrent acute) pancreatic inflammation in proximity to the splenic vein—and can compromise venous return from the spleen with subsequent splenic engorgement and splenomegaly As alcohol is the most common precipitating cause of pancreatitis, findings of liver disease including hepatomegaly, jaundice, ascites, and hepatic encephalopathy may also be observed Because of chronic maldigestion of fat, these patients can be fat-soluble vitamin deficient (vitamins A, D, E, and K), and this can lead to related examination findings including peripheral neuropathy, fatigue, and signs of easy bruising and bleeding Diagnostic Evaluation Diagnosis begins with an assessment of clinical symptoms, signs, and risk factors for chronic pancreatitis CT can be used for diagnosing structural features associated with advanced disease including calcifications, atrophy, pancreatic duct dilation, and/or strictures CT may also show common complications including pseudocysts, splenic vein thromboses, and inflammatory masses Magnetic resonance cholangiopancreatography may be used to evaluate the pancreatic and biliary ducts without requiring ERCP Endoscopic ultrasound currently offers the most sensitive imaging for diagnosis of chronic pancreatitis Functional diagnostic tests for chronic pancreatitis include stool elastase, 72hour fecal fat, and secretin stimulation test Differential Diagnosis The differential diagnosis for chronic pancreatitis includes gastritis, dyspepsia, small bowel bacterial overgrowth, intestinal obstruction, neoplasms, mesenteric ischemia, biliary obstruction, celiac disease, inflammatory bowel disease, Zollinger-Ellison syndrome, and functional gut disorders such as irritable bowel syndrome Complications Chronic pancreatitis is associated with a nearly fourfold increase in standardized mortality rate, which stems mostly from continued alcohol and tobacco abuse.16 Common complications include pseudocysts, gastrointestinal bleeding, bile duct obstruction, duodenal obstruction, and pancreatic fistula formation Management Guidelines Management of suspected chronic pancreatitis with increased abdominal pain should include prompt and adequate analgesia (often requiring narcotic pain medications) and assessment of hydration and nutrition status.17 Evaluation of acute complications of chronic pancreatitis and nonpancreatic abdominal emergencies should also occur though with judicious use of imaging When imaging suggests a main duct stricture, pancreatic ductal stones, and/or pseudocysts, an endoscopic intervention may be appropriate During evaluation, patients should be counseled on smoking and alcohol cessation when applicable Management of chronic pain and nutritional deficiencies from long-standing pancreatitis is primarily an outpatient issue, and a referral to gastroenterology is indicated CONCLUSION Pancreatitis is a common presenting illness in the emergency department Initial management centers on early aggressive fluid resuscitation, pain control, and bowel rest All patients should be risk-stratified using a validated scoring system such as the BISAP to help direct appropriate disposition, including intensive care services Advanced imaging, although generally not required, should be used when there is diagnostic uncertainty or when there is concern for the presence of associated complications including pseudocysts, arterial pseudoaneurysms, or common bile stones LITERATURE TABLE REFERENCES DeFrances CJ, Hall MJ 2005 National hospital discharge survey Adv Data 2007;385:1–19 Sanders G, Kingsnorth AN Gallstones BMJ 2007;335:295–299 Steinberg W, Tenner S Acute pancreatitis N Engl J Med 1994;330:1198–1210 Banks PA, Freeman ML, Practice Parameters Committee of the American College of Gastroenterology Practice Guidelines in Acute Pancreatitis Am J Gastroenterol 2006;101:2379–2400 Yadav D, Agarwal N, Pitchumoni CS A critical evaluation of laboratory tests in acute pancreatitis Am J Gastroenterol 2002;97:1309–1318 Forsmark CE, Baillie J AGA institute technical review on acute pancreatitis Gastroenterology 2007:132;2022–2044 Wu BU, Johannes RS, Sun X, et al The early prediction of mortality in acute pancreatitis: a large population-based study Gut 2008;57:1698–1703 Papachristou GI, Muddana V, Yadav D, et al Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis Am J Gastroenterol 2010;105:435–441 Warndorf MD, Kurtzman JT, Bartel MJ, et al Early fluid resuscitation reduces morbidity among patients with acute pancreatic Clin Gastroenterol Hepatol 2011;9:705–709 10 Petrov MS, van Santvoort HC, Besselink MG, et al Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials Arch Surg 2008;143:1111–1117 11 Bai Y, Gao J, Zou DW, et al Prophylactic antibiotics cannot reduce infected pancreatic necrosis and mortality in acute necrotizing pancreatitis: evidence from a meta-analysis of randomized controlled trials Am J Gastroenterol 2008;103:104–110 12 Jafri NS, Mahid SS, Idstein SR, et al Antibiotic prophylaxis is not protective in severe acute pancreatitis: a systematic review and meta-analysis Am J Surg 2009;197:806–813 13 Jupp J, Fine D, Johnson CD The epidemiology and socioeconomic impact of chronic pancreatitis Best Pract Res Clin Gastroenterol 2010;24:219–231 14 Gardner TB, Kennedy AT, Gelrud A Chronic pancreatitis and its effect on employment and health care experience: results of a prospective America multicenter study Pancreas 2010;39:498–501 15 Braganza JM, Lee SH, McCloy RF, et al Chronic pancreatitis Lancet 2011;377:1184–1197 16 Lowenfels AB, Maisonneuve P, Cavallini G Prognosis of chronic pancreatitis: an international multicenter study International Pancreatitis Study Group Am J Gastroenterol 1994;89:1467–1471 17 Warshaw AL, Banks PA, Fernández-Del Castillo C AGA technical review: treatment of pain in chronic pancreatitis Gastroenterology 1998;115:765–776 (mRS) Modifying the Incidence of Delirium (MIND) Trial Monoamine oxidase inhibitor (MAOI) Monochloramine Monocytic leukemias Mortality Probability Model (MPM) Myasthenia gravis (MG) clinical features and diagnostic evaluation differential diagnosis intubation mechanical ventilation neuromuscular respiratory failure Mycobacterium tuberculosis (MTB) diagnosis of mortality rate Myoclonus Myoglobinuria Myxedema coma differential diagnosis history and physical exam laboratory testing and radiography management guidelines physiology and organ-specific effects special populations N Naloxone Nasogastric tube (NGT) National Institutes of Health Stroke Scale (NIHSS) Necrotizing soft tissue infection (NSTI) diagnosis surgical intervention treatment guidelines Neisseria meningitidis Neoplasia Neuroleptic malignant syndrome (NMS) diagnostic evaluation history and physical examination management of vs serotonin syndrome Neurologic injury Neuromuscular blocking agents (NMBA) Neutropenic fever Neutrophil gelatinase-associated lipocalin (NGAL) New Injury Severity Score (NISS) Nitroprusside N-methyl-D-aspartate (NMDA) Nonacetaminophen drug/toxins Non-anion gap metabolic acidosis gastrointestinal etiologies iatrogenic etiologies renal etiologies Noninvasive hemodynamic monitoring background cardiac output carbon dioxide and Fick principle pulse contour analysis stroke volume and heart rate transthoracic electrical bioimpedance ultrasound USCOM device assessment fluid responsiveness arterial waveform analysis cardiocirculatory function CVP delta-down pulse oximeter waveform analysis pulse pressure variation practical fluid strategy, severe sepsis spontaneously breathing patients endtidal CO2 passive leg raise stroke volume variation ultrasound indices brachial artery peak velocity variation inferior vena cava Non-invasive positive pressure ventilation (NIPPV) acute respiratory distress syndrome asthma invasive mechanical ventilation respiratory distress Nonvariceal upper gastrointestinal bleeding (NVUGIB) background initial evaluation and risk stratification management guidelines Norepinephrine NVUGIB See Nonvariceal upper gastrointestinal bleeding (NVUGIB) O Older adults See Geriatric patients Opioids background diagnostic evaluation differential diagnosis history and physical examination management guidelines Osmolarity Out-of-hospital cardiac arrest (OHCA) acute care and diagnosis evaluation cardiac catheterization continuous EEG cooling methods hypothermia physiology of therapeutic hypothermia percutaneous hemodynamic support pulmonary embolism shivering Oxygen consumption/demand (VO2) Oxygen delivery (DO2) P Pain, agitation, and delirium (PAD Guidelines) Palliative care background communication cross-cultural communication and spirituality decision making family conferences family reactions general considerations VALUE Pancreatitis acute pancreatitis complications diagnostic tests differential diagnosis history and physical exam management guidelines chronic pancreatitis complications diagnostic tests differential diagnosis history and physical exam management guidelines Passive leg raise (PLR) fluid responsiveness PLR-induced change in cardiac output (PLR-cCO) technique PLR-induced changes in arterial pulse pressure (PLR-cPP) Penicillin Percutaneous coronary intervention (PCI) Phencyclidine (PCP) Phenylephrine Phosgene (COCl2) Phosphodiesterase inhibitors Pike-and-dome waveform Plasma exchange (PE) Platelet disorders HELLP syndrome hemolytic uremic syndrome heparin-induced thrombocytopenia idiopathic thrombocytopenic purpura thrombotic thrombocytopenic purpura Pleural effusion ARDS/ALI characterization detection quantification ultrasound-guided thoracentesis Pneumocystis jirovecii pneumonia (PJP) HIV-negative patients diagnosis treatment incidence of Pneumonia Pneumonia severity index (PSI) Pneumothorax AAA chest radiography (CXR) FAST (E-FAST) protocol lung point lung sliding examination M-mode US pipes evaluation probe position stratosphere sign (bar-code sign) Polypharmacy PORT score See Pneumonia severity index (PSI) Positive end-expiratory pressure (PEEP) in ARDS clinical outcomes recruitment maneuvers asthma and COPD auto-PEEP extrinsic PEEP intrinsic PEEP Postpolypectomy bleeding Potassium DKA/HHS hyperkalemia diagnostic workup epidemiology history and physical exam management guidelines treatment hypokalemia diagnostic workup epidemiology history and physical exam management guidelines treatment Pressure-cycled ventilation (PCV) Priapism Procalcitonin Prognostication See also Severity of illness (SOI) scores Prophylactic antibiotics Propofol alcohol withdrawal syndrome hypotension intubation Propofol infusion syndrome (PRIS) Prothrombin complex concentrates (PCC) Prothrombin time (PT) Pulmonary arterial hypertension (PAH) pathologic feature ventilation strategies Pulmonary artery catheter (PAC) cardiac output complications contraindications indications insertion and data interpretation noncardiogenic pulmonary edema Pulmonary edema cardiogenic ED diagnostic evaluation etiology noncardiogenic ED Pulmonary embolism (PE) acute massive pulmonary embolism diagnostic evaluation management guidelines pathophysiology stabilization out-of-hospital cardiac arrest (OHCA) submassive PE Pulmonary hypertension Pulmonary toxins background pulmonary irritant gases chloramines chlorine management strategy phosgene simple asphyxiants Pulmonary ultrasonography background clinical conditions alveolar-interstitial syndrome pleural effusion pneumonia/lung consolidation pneumothorax (See Pneumothorax) in emergency protocol imaging modalities imaging technique sonographic thoracic anatomy A-lines/pleural line B-lines lung sliding training requirements transducer selection Pulse oximeter waveform analysis Pulse pressure (PP) Pulse pressure variation (PPV) Pulsed-wave Doppler Pulsus alternans Pulsus paradoxus Pulsus parvus Pulsus tardus R Radioactive iodine uptake (RAIU) Randomized Evaluation of Mechanical Assistance for Congestive Heart Failure (REMATCH) Rapid ultrasound in shock (RUSH) examination B-mode ultrasound cardiac contractility cardiac tamponade (See cardiac tamponade) categories Doppler ultrasound echocardiography apical window parasternal long-axis view parasternal short-axis view pulmonary embolus and right ventricular enlargement subxiphoid window M-mode ultrasound pericardial effusions and cardiac tamponade grading scale parasternal long-axis view pathophysiology sonographic appearance subxiphoid view resuscitation protocols and examination components shock types society support transvenous pacemaker placement FAST and thoracic ultrasound inferior vena cava tension pneumothorax ultrasound presets ultrasound probe selection Recent-onset atrial fibrillation (ROAF) rate control vs rhythm control controversies multicenter randomized trials multicenter retrospective cohort study Ottawa Aggressive Protocol prospective controlled study Renal artery stenosis Renal replacement therapy (RRT) continuous renal replacement therapy hemodialysis rhabdomyolysis sustained low-efficiency daily dialysis Renin-angiotensin-aldosterone system (RAAS) Resistant Alcohol Withdrawal (RAW) Respiratory acidosis Respiratory alkalosis Respiratory failure See Acute respiratory failure (ARF) Revised Trauma Score (RTS) Revolutions per minute (RPMs) Rhabdomyolysis diagnostic evaluation anion gap/coagulation BUN/creatinine CK and serum myoglobin creatine kinase phosphate and calcium potassium urinalysis epidemiology etiology history and physical exam management guidelines choice of fluid fluid administration recommendations renal replacement therapy sodium bicarbonate and mannitol timing and volume of fluids Richmond Agitation Sedation Scale (RASS) Right ventricular failure (RVF) afterload reduction background classification and epidemiology diagnostic evaluation chest radiography echocardiography electrocardiogram laboratory investigation differential diagnosis history and physical exam inotropic support management guidelines antiarrhythmics diuretics nitric oxide oxygen vasopressors and inotropes pathophysiology therapeutic approach volume resuscitation RUSH exam See Rapid ultrasound in shock (RUSH) examination RV end- diastolic volume (RVEDV) S Sedation agitated patient acute undifferentiated agitation atypical antipsychotics background benzodiazepines choice of medication dexmedetomidine ketamine management guidelines typical antipsychotics and induction agents for intubation (See Induction of intubation) in mechanically ventilated patients benzodiazepines choice of sedation agent dexmedetomidine propofol “Wake Up and Breathe” protocol RASS Seizures aneurysmal subarachnoid hemorrhage ED diagnostic evaluation history of epilepsy resolved seizure episode epidemiology management guidelines first-time seizure LEV and LCS medical therapy phenobarbital (PHT) refractory status epilepticus second-line agents prehospital evaluation and management Sepsis adrenal insufficiency antimicrobial therapy and source control background biomarkers background cardiac markers cortisol C-reactive protein diagnostic approach emerging biomarkers lactate procalcitonin role of blood transfusion definitions diagnostic evaluation glucocorticoids history and physical examination hyperglycemia inotropes intravenous fluids mechanical ventilation protocol-guided hemodynamic resuscitation solid tumors vasopressors Sequential organ failure assessment (SOFA) score Sequential Organ Failure Score (SOFA) Serotonin syndrome diagnostic evaluation history and physical examination management of symptoms vs NMS Serum myoglobin Severity of illness (SOI) scores APACHE system coma discrimination gastrointestinal ischemic stroke MPM pneumonia PREEDICCT project SAPS system subarachnoid hemorrhage trauma Shunt Sickle cell disease (SCD) background diagnostic evaluation uncomplicated VOC acute chest syndrome acute sequestration acute stroke analgesia fluid replacement gallbladder disease priapism Silibinin Simplified Acute Physiology Score (SAPS) system Skin and soft tissue infections (SSTIs) complicated infections diagnostic evaluation treatment guidelines uncomplicated infections SMART-COP score Smptom-triggered treatment (STT) Sodium bicarbonate Sodium disorders hypernatremia diagnostic workup epidemiology history and physical exam management guidelines treatment hyponatremia diagnostic evaluation epidemiology history and physical exam management guidelines treatment Sodium thiosulfate Solid organ transplantation (SOT) Clostridium difficile infections, intermediate posttransplant period common infectious conditions immune defects invasive fungal diseases diagnosis of early to intermediate posttransplant period treatment timeline of infections Solid tumors breast cancer catheter-related blood stream infections common infectious conditions gastrointestinal cancer genitourinary cancer head and neck cancer HIV-negative patients immune defects lung cancer neutropenic fever opportunistic infections, corticosteroid use and risks sepsis Spontaneous awakening trials (SATs) Spontaneous breathing trials (SBTs) Spontaneous intracerebral hemorrhage diagnostic evaluation etiology initial stabilization intraventricular hemorrhage and hydrocephalus patient history and physical exam primary brain injury primary injury, preventions of antiplatelet agents blood pressure management coagulopathy fibrinolytic agents risk factors risk stratification and prognostication secondary injury antiepileptic drugs disposition elevated intracranial pressure hyperglycemia seizures temperature control venous thromboembolism Standard precautions Status epilepticus (SE) ED diagnostic evaluation history of epilepsy resolved seizure episode epidemiology management guidelines first-time seizure LEV and LCS medical therapy phenobarbital (PHT) refractory status epilepticus second-line agents prehospital evaluation and management Stroke ischemic stroke (See Ischemic stroke) SCD volume variation ST-segment elevation myocardial infarction (STEMI) AD Subarachnoid hemorrhage (SAH) Submassive pulmonary embolism Surgical embolectomy Sustained low-efficiency daily dialysis (SLEDD) Swiss staging system Sympathomimetics background diagnostic evaluation differential diagnosis history and physical examination management guidelines Synchronized intermittent mandatory ventilation (SIMV) Systemic thrombolytic therapy Systemic vascular resistance (SVR) Systolic blood pressure (SBP) T Tachyarrhythmias Therapeutic hypothermia (TH) Thionamides Thrombocytopenia Thrombotic thrombocytopenic purpura Thyroid storm See Thyrotoxicosis Thyrotoxic periodic paralysis (TPP) Thyrotoxicosis diagnostic criteria differential diagnosis history and physical exam laboratory testing and imaging physiology and organ-specific effects special populations treatment Titratable acid/alkaline reserve (TAR) Toxic alcohols Toxicologic hyperthermic syndromes background causes of hyperthermic agitated delirium diagnostic evaluation history and physical examination management monitoring malignant hyperthermia (See Malignant hyperthermia (MH)) NMS (See Neuroleptic malignant syndrome (NMS)) serotonin syndrome (See Serotonin syndrome) Transfusion therapy See Blood product transfusion Transfusion-associated circulatory overload (TACO) Transfusion-related acute lung injury (TRALI) Transthoracic echocardiography (TTE) Transthoracic electrical bioimpedance (TEB) Trichloramine Tuberculosis Tumor lysis syndrome (TLS) U Ultrasonic cardiac output monitor (USCOM) Ultrasound-guided thoracentesis Uremia V Valproic acid (VPA) Valvular abnormalities Vancomycin-resistant Enterococcus (VRE) Variceal upper gastrointestinal bleeding Vascular disease Vascular pedicle width (VPW) Vasopressin Vasopressors background cardiogenic shock (CS) dopamine epinephrine norepinephrine phenylephrine physiology right ventricular failure (RVF) sepsis vasopressin Ventilation-perfusion (V/Q) mismatch Ventilator-associated pneumonia (VAP) Ventricular arrhythmias left ventricular assist devices (LVADs) Ventricular tachycardia (VT) exercise-induced VT procainamide vs amiodarone 2010 multicenter historical cohort study early studies of amiodarone early studies of procainamide lidocaine and sotalol retrospective study Viral hepatitis Viral infections cytomegalovirus infections late posttransplantation period reactivation infections, intermediate posttransplantation period respiratory viruses Vitamin K antagonists (VKAs) diagnostic evaluation history and physical examination management guidelines Volume assist-control ventilation definition and SIMV Volume-cycled ventilation Voriconazole W Wide-complex tachycardia (WCT) adenosine administration ED prospective study electrophysiology studies safety concerns VT termination Wilson disease World Federation of Neurological Surgeons (WFNS) ... complications of chemotherapy Table 27 .1 reviews pertinent clinical history and physical exam findings of patients on their initial presentation TABLE 27 .1 Pertinent Findings on Patient History and Physical... Carson JL, Grossman BJ, Kleinman S, et al Clinical Transfusion Medicine Committee of the AABB Red blood cell transfusion: a clinical practice guideline from the AABB Ann Intern Med 20 12; 157(1):49 28 Rebulla P, Finazzi G, Marangoni F, et al... in adults: clinical diagnosis and treatment Cancer 19 92; 69(1):17 23 51 Davila ML Neutropenic enterocolitis: current issues in diagnosis and management Curr Infect Dis Rep 20 07;9 (2) :116– 120 52