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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com





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Peri-Mortem C-Section

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sábado, 27 de agosto de 2016

Rising Lactate & the Art of VBG Interpretation

PulmCCM - August 26, 2016 - By JE
.."The distinction between the A-type lactate and B-type lactate in this post will rest on the notion of true oxygen deficiency. Oxygen deficiency will be defined as cessation of oxidative phosphorylation and the Krebs Cycle. When oxygen is unable or unavailable to act as the terminal electron accepter within the mitochondrion, the electron transport chain ceases to function and protons within the mitochondrial inner membrane diffuse out. Pyruvate levels rise, lactate levels rise and acidosis ensues. This is true anaerobic biochemistry! This is the A-type lactate elevation [see figure 1A].
Slide2            Slide1

However, “oxygen deficiency” is often invoked at the bedside when the electron-transport chain is actually fully functional – just slow. What is imperative to understand here, is that the breakdown of glucose to pyruvate is much faster than the Krebs Cycle can handle. When pyruvate levels rise in this situation – as occurs in response to the stress response [e.g. sepsis, exercise] and/or adrenergic tone – pyruvate is converted to lactate in a proton-neutralprocess [i.e. degrading glucose to pyruvate produces 2 protons and 2 pyruvate molecules and converting 2 molecules of pyruvate to lactate consumes 2 protons]. Lactate levels rise, but the Krebs Cycle slowly lumbers along – without oxygen deficiency! This is a B-type lactate..."

Thrombosed Hemorrhoids

Resultado de imagen de emergency medicine news
EMN blog, The Procedural Pause. Roberts J & Roberts M - Augustt 1, 2016
"We are going to get up close and personal this month to talk about hemorrhoids. You should be familiar with these painful offenders because half to two-thirds of people between 45 and 65 will suffer from their cruelty. (Am Surg 2009;75[8]:635.) Patients may seek emergency department care if they experience bleeding or severe pain from hemorrhoids.
Hemorrhoids are highly vascular structures that are round or oval in shape. They arise from the rectal and anal canal, and sometimes appear around the anus itself. It is important to note that hemorrhoids do not have arteries and veins but special blood vessels called sinusoids, connective tissue, and smooth muscle. (Beck, DE, et al. The ASCRS Textbook of Colon and Rectal Surgery, Second Edition. New York, NY: Springer New York, 2015, p. 175.) Hemorrhoids at times can exist within the anal canal and be completely painless because sensory innervation to the rectum is primarily visceral. (Roberts JR, Hedges JR, et al. Clinical Procedures in Emergency Medicine. Elsevier, Philadelphia, PA, 2015, p. 880.)
Hemorrhoids protrude around the anus and swell, causing significant pain, when they become inflamed or irritated. The straining from constipation and poor diet choices may be the main cause of hemorrhoids, although lack of exercise, aging, pregnancy, and hereditary may also contribute to their formation. Very rarely are hemorrhoids cancerous. Fissures or tears in the skin around the rectum may occasionally accompany hemorrhoids.
Not all external hemorrhoids contain clots; some are just swollen and irritated and not amenable to incision. Some hemorrhoids are swollen, soft, and compressible, and may be tender. If the hemorrhoid is not tense or a clot is not palpated, topical corticosteroids and sitz baths are the best intervention.
Thrombosed external hemorrhoids are readily drained in the ED. Surgical intervention for internal hemorrhoids is not an outpatient procedure and usually is a last resort. Hemorrhoid surgery can be a difficult procedure for many to endure, and patients who suffer from long-term hemorrhoid complaints may benefit from a visit to a colorectal surgeon. A colonoscopy or sigmoidoscopy may assist in ruling out more complicated or serious diagnoses..."

viernes, 26 de agosto de 2016


Tonna J et al. Resuscitation 2016; (107): 38–46
Screen Shot 2016-08-25 at 2.21.01 PM


emDocs - August 25, 2016 - Author: Phipps A - Edited by: Robertson J and Koyfman A
DIC is an important clinical entity seen in critically ill patients. Laboratories studies may demonstrate low platelets, an elevated INR, an elevated d-dimer, and low fibrinogen levels. Rapid identification and treatment of the underlying cause as well as supplementation with blood products is important to reduce mortality in these patients."


emDocs - August 25, 2016 - Authors: End B and Conroy M
Edited by: Koyfman A and Alerhand S
While an uncommon presenting complaint, priapism is a urologic emergency requiring fast and effective management by emergency physicians to prevent significant morbidity. Defined as a persistent, painful erection lasting greater than four hours beyond, or in the absence of, sexual stimulation, priapism was first documented as a case by Tripe in 1845 [1]. In the following write-up, we will examine the initial evaluation and management of patients presenting to the emergency department...
  • Ischemic priapism is a time-sensitive diagnosis and urologic emergency, time is tissue and erectile function!
  • History and physical exam may help delineate ischemic vs. non-ischemic, but cavernous blood gas is paramoun
  • Remember to provide adequate analgesia, either with oral medications or through local anesthesia/penile block (https://www.youtube.com/watch?v=3p0qEfISggs)
  • Aspiration should be performed laterally to avoid damage to the dorsal neurovascular bundle (https://www.youtube.com/watch?v=KWf5MAobWoM)
  • A stepwise approach (aspiration, injection of vasoactive agent, emergent urologic consultation for shunt) is the key to success
  • Not obtaining a cavernous blood gas sample to differentiate between ischemic and non-ischemic priapism
  • Aspiration at the dorsum of the penis (avoid the neurovascular bundle!)
  • Only one attempt at vasoactive injection (may repeat at 5-10 minute intervals until detumescence is achieved)"

jueves, 25 de agosto de 2016

Peri-Mortem C-Section

emDocs - August 24, 2016 - Originally published at CoreEM.net -  By Swaminathan A
Written by: Boyd A - Edited By: Bhandari S
Definition: A cesarean section preformed either during maternal cardiac arrest or during impending maternal cardiac arrest the primary goal of which is to increase the chance of successfully resuscitating the mother and, potentially, improving fetal survival.
Take home points:
  • Think of PCS as a resuscitative hysterotomy primarily aimed at saving the life of the mother
  • If you think PCS will improve maternal resuscitation, act quickly to start and complete the procedure
  • The optimal surgical approach for a PCS is via a large vertical incision.

Rectal prolapse

Resultado de imagen de SINAIEM
SinaiEM - By Randy Sorge - 23 August, 2016 
Glasses with a pink cocktail
"How to reduce a rectal prolapse
Step One: Apply gentle steady pressure with a gloved hand
Step Two: If you have difficulty reducing the prolapse, apply granulated sugar to the prolapse.
Step Three: Let the sugar sit for 15 minutes and then reattempt the reduction. The sugar will absorb the extra water and cause the prolapse to shrink.
Step Four: If “sugaring the rim” fails, the next step is surgical reduction – so call your consult and pass that baton!
Pro Tip: Yes, you must use granulated sugar. A sugar substitute will not work! (Sorry, no Splenda!)"

Fractura frágil

Hemos leído... 24 de agosto de 2016
"Se define como fractura por fragilidad ósea la que se produce por traumatismos de poca energía, los cuales serían insuficientes para fracturar el hueso normal, como puede ser una caída desde una altura correspondiente a una persona de pie o sentada, o incluso en ausencia de un traumatismo identificable. Son más frecuentes en las personas de edad avanzada.
Los pacientes que han tenido una fractura por fragilidad se encuentran en un alto riesgo de sufrir fracturas posteriores. Y los medicamentos prescritos representan uno de los factores de riesgo que podría ser modificado fácilmente para reducir el riesgo de fractura posterior.
Se acaba de publicar en JAMA un estudio de cohortes retrospectivo dónde los investigadores han estudiado los patrones de prescripción durante 4 meses antes y después de que 168.000 beneficiarios del Medicare sufrieran una fractura frágil de cadera, hombro o muñeca..."
Tabla med más prescritos

miércoles, 24 de agosto de 2016

Lactating Mothers in the ED

AMP EM - August 23, 2016 - By Liz Rozyki
..."When determining medication therapy for lactating mothers, first, determine if your standard or first-line therapy to treat a condition is considered safe with breastfeeding. This can be accomplished by utilizing drug information resources, such as LactMed® or consulting your clinical pharmacist. Second, if the standard therapy is not safe or the data is unclear, consider alternatives that may be safe – think out of the box if needed, alternative drug classes, routes of administration, timing medication administration apart from feedings, etc. Drug information resources, such as LactMed®, often provide alternative medications options to aid in your evaluation. Finally, if no appropriate alternative can be found, counsel the patient on risks and benefits of treatment and provide an appropriate education on how long the drug may be in the system and possibly transferred in breast milk..."

Resultado de imagen de lactMEd

Diagnostic Reasoning

An online community of practice for Canadian EM physicians
CanadiEM - By Jonathan Sherbino - August 23, 2016
"On May 24th, 2016, Dr. Jonathan Sherbino of McMaster University was invited to speak at Grand Rounds at the University of Saskatchewan on the topic of diagnostic reasoning. His presentation explained how physicians think of a diagnosis and how we can teach learners cognitive strategies to improve their diagnostic reasoning. This blog post has taken that wisdom and (hopefully) captured it in blog post form as the first blog edition of CanadiEM National Rounds...
When it comes to a diagnosis, your gut might be right. Teach your learners and give them more experience in the ED.
What to take away:
  • Hindsight bias can mislead us into overestimating the rate of cognitive bias.
  • Going slow makes you slow
  • Structured Reflection Strategies do not help the Junior Learner but may help the experienced clinician
  • There is no evidence that cognitive forcing strategies help in the ED
  • Ensure your learners gain experience in the ED!!!"

martes, 23 de agosto de 2016

Drug Rashes

emDocs - August 23, 2016 - Author: Chavez S - Edited by: Koyfman A and Long B
  • Morbilliform Drug Eruptions
  • Erythema Multiforme
  • Drug Rash with Eosinophilia and Systemic Symptoms Syndrome (DRESS)
  • Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
  • Drug-Specific Rashes
  • Most (90%) drug rashes are morbilliform drug eruptions. Treat symptomatically with topical steroids and oral antihistamines.
  • Patients with DRESS will have hepatic or renal involvement, usually eosinophilia and are treated with antipyretics and antipruritics.
  • SJS/TEN involve mucous membranes and are a life-threatening rash not to miss!"

Cognitive theory in medicine

"Emergency medicine, despite our love of action and procedures, is primarily a cognitive profession. We see patients with vague, undifferentiated symptoms and have to rapidly and accurately arrive at a diagnosis and management plan. Unfortunately, despite our best efforts, we occasionally err. Cognitive biases, rather than knowledge deficits, are thought to be the primary cause of our errors..."
First 10 EM Cognitive errors title

Clinical Handover

"In a busy emergency department, there are days when all the beds are occupied by patients and your emergency gates are flooded with incoming patients; your duty is about to start and the scenario is overwhelming. You are anxious to know every essential detail of each patient before you take over the responsibility. Clinical handovers are an important responsibility of every Emergency Physician. Handovers can range from ED physician to ED physician during shift change, ambulance doctor to ED physician, ED physician to an intensivist during patient transfer. ED physician should be well versed with giving as well as receiving a thorough, concise, handover for benefit of patient, hospital and self...
Take Home Points
  • Use a checklist like SBAR for transferring information from one team to other along with ‘read back’.
  • Handovers as team can have better continuity of care.
  • Simulate handover technique to become well versed at it. 
  • Use the dedicated handover time as a teaching tool.

lunes, 22 de agosto de 2016

Intrapenile or intracavernosal catheter

Everyday E(B)M - August 19, 2016 - Submitted by Kolinsky D - Edited by Dr. Chan P
Faculty reviewed by Dr. Naunheim R

"Clinical Question: Is it safe and effective to place intrapenile or intracavernosal catheter to achieve access?
Conclusion: “In conclusion, the CC can serve as a simple, easy, rapid, and safe method for vascular access in conditions for administration of fluid or blood when other conventional routes are inaccessible.”
BOTTOM LINE: While it may not be first, second, or even third line, intracavernosal cannulation is a potential means to facilitate rapid access in a male patient with limited options; and although intraosseous access is typically the mainstay for emergent vascular access in resuscitation, intracorporal access can be an option when an intraosseous needle is not available, such as in a resource limited or mass casualty situation. Although the risk of hematoma formation or other penile injury was low in these studies, their small sample size makes it difficult to draw strong conclusions regarding potential complications."

Geriatric Trauma an Medical Illness

emDocs - August 21, 2016 - Authors: Levine M and Alkhawam L
Edited by: Simon E and Koyfman A
Resuscitation of the elderly trauma patient must be thoughtful but aggressive:
  • Heighten awareness that with age, signs and symptoms may be minimal, and that the outcome is often initially unclear, and commonly, but not necessarily poor.
  • Up to 85% of elderly trauma survivors return to baseline or independent function.
  • This justifies initial aggressive approach which can be reassessed later when patient/family wishes and prognosis becomes increasingly clear.
  • Less physiologic reserve leaves little time for delays in diagnosis and under- or over- resuscitation.
  • Blood is the fluid of choice.
  • The principles of diagnosis and management in trauma are the same regardless of age, but the incidence of physiologic changes and disease states mandates a different overall approach.
  • You may be the only one in the room who knows how sick the patient really is.

Lithium poisoning

The Poison Review - August 19, 2016
Ref: Lithium Poisoning: State of the Art. Baird-Gunning J et al. J Intensive Care Med 2016 Aug 11 [Epub ahead of print]
This is a very good paper, the best comprehensive review I can remember reading on lithium. It is up to date, with 78 references as recent as 2015. A major reason I liked it so much is that the authors are quire frank about how much we don’t know, and resist giving, for instance, mandates about when to start hemodialysis based on lithium levels. This is a temptation that the authors of the recent ExTRIP review succumbed to. Interestingly, the two papers share an author (Sophie Gosselin).
However, I think the authors missed — or at least failed to emphasize — a key point. With lithium poisoning, as with all toxicology cases, the key to successful treatment begins with basic ABCs and supportive care. This includes adequate hydration, which is crucial..."

domingo, 21 de agosto de 2016

Bi-Level ventilation

emDocs - August 19, 2016 - Authors: Goodnough R, Canseco C and Juarez M 
Edited by: Robertson J and Koyfman A
"Noninvasive Positive Pressure Ventilation (NIPPV) is mechanical ventilation that is provided via nasal prongs, a full or oral-nasal facemask, or mouthpiece. Different modes of mechanical ventilation are available, but the most commonly used methods are CPAP and BiPAP1. The majority of evidence in NIPPV does not differentiate between CPAP and bi-level, or other modes of NIPPV, and the majority of outcomes and data are applied to NIPPV as a generalized intervention..."

Phlegmasia cerulea dolens

The Original King of County - by awong - August 19, 2016 - Board Review
  • What is Phlegmasia cerulea dolens?
  • What are three warning signs of cerulea dolens?
  • What are risk factors for this condition?
  • What are the major complications?
  • How do we manage cerulea dolens?

Hypertensive Urgency

EMLoN Logo
Ref: “Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting” http://archinte.jamanetwork.com/article.aspx?articleid=2527389
"And you don’t need to be sent to “time out” – i.e., referred to the Emergency Department – solely because of it.
This is a retrospective, single-center report regarding the incidence of adverse events in patients found to have “hypertensive urgency” in the outpatient setting. This was defined formally as any systolic blood pressure measurement ≥180 mmHg or diastolic measurement ≥110 mmHg. Their question of interest was, specifically, whether patients referred to the ED received clinically-important diagnosis (“major adverse cardiovascular events”), with a secondary interest in whether their blood pressure was under better control at future outpatient visits..." (Spoiler answer: Nooop!)  Jama. Conclusions and relevance: "Hypertensive urgency is common, but the rate of MACE in asymptomatic patients is very low. Visits to the ED were associated with more hospitalizations, but not improved outcomes. Most patients still had uncontrolled hypertension 6 months later."


Resultado de imagen de American college of physicians
From the August 2016 ACP Hospitalist -  By Diab M and Imran N
"Thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) represent 2 of many diverse thrombotic microangiopathy (TMA) syndromes that have in common clinical and pathological features (Table 1). Systemic conditions, including infections, malignancy, vitamin deficiency, and autoimmune disorders, can manifest similarly to primary TMAs, making diagnosis challenging. Furthermore, primary TMAs may sometimes remain indolent until precipitated by secondary conditions. The triad of microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and end-organ damage dominates all TMA syndromes...
Early recognition of TTP and ST-HUS by hospitalists is crucial as poor outcomes result from delayed diagnosis and treatment. While plasma exchange is the standard of therapy for TTP, treatment of ST-HUS remains supportive. Plasma exchange has markedly improved the outcomes of TTP patients but not their survival. Furthermore, plasma exchange is not without risks. Future studies are needed to better identify approaches to improve outcomes in this patient population."


EM Pills - By Davide Tizzani - 19 Ago 2016
..."DRESS è l’eponimo di Drug Reaction/Rash with Eosinophilia and Systemic Symptoms (rash da farmaci con eosinofilia e sintomi sistemici, nota anche comeDISH, Drug-Induced..."
Hypersensivity Syndrome); è una rara reazione da ipersensibilità a seguito della assunzione di un nuovo farmaco caratterizzata da febbre, rash cutaneo, anomalie ematologiche (eosinofilia e linfocitosi atipica), linfoadenopatie e coinvolgimento viscerale di organi bersaglio (epatico, polmonare, renale, cardiaco ma anche SNC, tiroide, muscolo e pancreas). E’ una sfida diagnostica dovuta alla aspecificità delle sue manifestazioni che si può superare solo conoscendola prima e pensandoci dopo.
Il riconoscimento di tale sindrome tuttavia è di fondamentale importanza dato che circa il 10 – 20% dei casi risultano mortali..."
Tabella_1. Farmaci responsabile della DRESS

sábado, 20 de agosto de 2016

Subtle STEMI

The Bottom Line - August 19, 2016 - By David Slessor
Ref: Electrocardiographic Differentiation of Early Repolarization from Subtle ST-Segment Elevation Myocardial Infarction - Smith S; Annals of Emergency Medicine 2012; 60(1):45-56, doi:10.1016/j.annemergmed.2012.02.015
"Clinical Question
Are there specific ECG characteristics that can differentiate between anterior ST-elevation myocardial infarction (STEMI) and early repolarisation?
Authors’ Conclusions
R-wave amplitude is lower, ST-segment elevation greater, and QTc longer for subtle anterior STEMI versus early repolarisation. In combination with other clinical data, this derived and validated ECG equation could be an important adjunct in the diagnosis of anterior STEMI.
subtle stemi
The Bottom Line
This study derived and validated an ECG score that can help differentiate anterior ST elevation from early repolorisation.
Current on-line apps and calculators are available to help calculate this score but need to be used in the right patient by a clinician who understands this score in the context of the whole patient presentation."

US and Sepsis

Making horrible doctors decent and good doctors GREAT at Ultrasound
Ultrasound Podcast - August 11, 2016
"We all know that ultrasound helps us be more accurate and fast in making diagnosis and getting our sick patients appropriately treated. Now we have proof! THIS study proves just how much quicker we are with ultrasound. Let’s discuss exactly how much of a difference it can make for you and your patients."

Ultrasound Podcast - August 18, 2016
"Last week we showed you how to be 22% more accurate in diagnosing Sepsis in 10 minutes.
NOW, you’re not done! You’re treating the source, but you also have to manage their fluid status. Well, we figured since we’ve only done 87 episodes on fluid responsiveness we needed one more. Seriously, sometimes it requires explaining in a few different ways to really get a complicated subject like that. Let us explain…….."

Hemolytic Anemias

emDocs - August 19, 2016 - Authors: Robertson J, Brem E and Koyfman A - Editor: Long B
Hemolytic anemia is defined as the premature destruction of red blood cells (RBCs). Under normal conditions, the RBCs are in circulation approximately 120 days and then are destroyed via the mononuclear phagocyte system. The most pressing concerns for the emergency medicine physician are the acute hemolytic anemias that may cause immediate, life-threatening complications. The primary goal for the EM physician is of course, resuscitation. However, an important secondary goal is for the provider is recognition of the hemolytic process and initiation of appropriate therapy. Some anemias are chronic, while others can cause acute and devastating complications. Hemolysis can occur extravascularly or intravascularly, and typically, intravascular hemolysis causes more rapid and devastating hemolysis.."

Rocky Mountain Spotted Fever

Pediatric EM Morsels
Pediatric EM Morsels - BY Sean Fox - August 19, 2016
"Ticks are disgusting (no offense ticks). They engorge themselves on our blood, becoming bloated sloth-like sacs of our serum. While that is certainly not appealing, what makes them most offensive is their tendency to transmit awful diseases to us. These diseases (and unique conditions – Tick Paralysis) are numerous, but one of the most important to review (especially for those of us in North Carolina, USA) is Rocky Mountain Spotted Fever..."
Moral of the Morsel
  • RMSF is deadly, but initially presents with non-specific symptoms, making it challenging to detect.
  • Classic triad of fever, rash, and tick exposure should not be relied upon.
  • Relying on history of tick exposure (often not known) can obscure diagnosis.
  • Doxycycline is safe and effective in children! Don’t worry about the teeth!
  • Treat RMSF empirically!
  • Be vigilant during peak seasons: Summer-time “Headache and Fever” needs to have RMSF on the top of the DDx."

The Six Trigger Patients

Emergency Physicians Monthly
Emergency Physicians Monthly - By Greg Henry - August 17, 2016
"There are certain patients who push your buttons and cause you to lose your cool. It’s up to you to anticipate these triggers and come up with a plan to manage their care with compassion and poise...
  • The Drug Seeker
  • Mr. 11/10 Pain
  • The Whiner
  • The Unfixable Medical Problem
  • The Patient with Poorly Defined Ailments
  • The Patient Who Calls for Reinforcements"

viernes, 19 de agosto de 2016

Outpatient Treatment of DVTs

ACEP Now - August 14, 2016 - By Garber B and Glauser J
"Emergency physicians have been tasked not only with providing safe and accurate care but also with stewardship of society’s scarce resources. Among other things, this means outpatient management of some disease entities traditionally managed in an inpatient setting...
The emergency physician has a variety of options for managing patients with DVT as outpatients. Clearly, patients’ renal function, reliability, and support system will dictate the optimal treatment course."
Table 1: Options for Outpatient Anticoagulation in Patients with DVT.1,9

Acute coronary Syndromes

August 18, 2016

August 18, 2016
Here is a pdf of all the slides (parts I and 2). This contains some extra slides which were "hidden" in the presentation.
Part 1: Overview and Non-STE-ACS
Part 2 (STEMI)

HEENTs Procedures

emDocs. August 18, 2016 - Author: Simon E - Edited by: Koyfman A and Alerhand S
"It has been a long night in the department. After ordering supplies for your patient with an auricular laceration, you sit down at your desk to review the landmarks for an auricular block. Within minutes, “trauma team to the trauma room” is paged overhead. As you don your PPE, an intoxicated 32 year-old male wheels by, profusely bleeding from his scalp. The patient is post-assault with a beer bottle. Initial VS: BP 81/56, HR 120.
If either of these scenarios make you wish that you had consulted Roberts & Hedges recently, have no fear – we will take a minute to review the basics and offer tips for success in addressing a number of commonly encountered HEENT procedures...
  • Head
    • Repair of Facial Wounds
    • Mandibular Dislocations
  • Ears
    • Auricular Lacerations
    • Auricular Hematomas
    • Auricular Foreign Bodies (FBs)
  • Eyes
    • Eyelid Laceration Repair
    • Lateral Canthotomy and Cantholysis
  • Nose
    • Epistaxis Management
    • Nasal Bridge Fracture Reduction
    • Nasal Septal Hematoma
    • Nasal Foreign Bodies
  • Throat
    • Peri-Tonsillar Abscess (Quinsy) Needle Aspiration/Incision and Drainage"

miércoles, 17 de agosto de 2016

Acute Liver Failure

Resultado de imagen de New England Journal of med
Bernal W, Wendon J. N Engl J Med 2013; 369: 2525-34. DOI: 10.1056/NEJMra1208937
"Acute liver failure is a rare but life-threatening critical illness that occurs most often in patients who do not have preexisting liver disease. With an incidence of fewer than 10 cases per million persons per year in the developed world, acute liver failure is seen most commonly in previously healthy adults in their 30s and presents unique challenges in clinical management. The clinical presentation usually includes hepatic dysfunction, abnormal liver biochemical values, and coagulopathy; encephalopathy may develop, with multiorgan failure and death occurring in up to half the cases (Fig. 1). The rarity of acute liver failure, along with its severity and heterogeneity, has resulted in a very limited evidence base to guide supportive care. However, rates of survival have improved substantially in recent years through advances in critical care management and the use of emergency liver transplantation. In this review, we outline the causes and clinical manifestations of acute liver failure and discuss current approaches to patient care..."