Sandbox: HS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Differential diagnosis

Abbreviations: COPD= Chronic obstructive pulmonary disease,

Causes of cyanosis Disease Cyanosis Clinical manifestations/association Diagnosis Additional findings Symptoms Signs Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Respiratory Airway disorder Croup ✔ + + Epiglottitis ✔ + − − − − Foreign body aspiration + + − − − Airway trauma + + ± − − Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings Parenchymal disorder Pulmonary embolism − − − − ABGs D-dimer CXR V/Q scan Spiral CT pulmonary angiogram Dyspnea Tachycardia Pleuretic chest pain Pneumonia − − − − − ABGs Leukocytosis Pancytopenia CXR CT chest Bronchoscopy Shortness of breath Cough Asthma (Late) + − − − − Cystic fibrosis ± ± − − − COPD (Emphysema) ± + Empyema ± + − − − Thoracentesis Chest X-ray Pleural opacity Localization of effusion Physical examination Crackles Egophony Increased tactile fremitus Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings Chest wall disorders Flail chest − ± − − − Pneumothorax − ± − − − Hemothorax − + ± − − Cardiovascular Congenital heart diseases Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings Atrioventricular canal defect ✔ + + Ebstein anomaly ✔ Hypoplastic left heart syndrome ✔ Pulmonary atresia ✔ Tetralogy of Fallot ✔ Pulmonic stenosis ✔ Total anomalous pulmonary venous drainage ✔ Transposition of the great vessels ✔ Truncus arteriosus ✔ Disease Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings Heart failure + − + ± + Valvular heart disease + − − − − Myocardial infarction − − − − − Hematologic Methemoglobinemia ✔ Polycythemia ✔ Central Nervous system Peripheral Central Dyspnea Fever Chest pain Clubbing Peripheral edema Auscultation Lab Findings Imaging Gold standard Additional findings Coma ✔ Seizures ✔ Head trauma ✔ Breath holding spells ✔ Miscellaneous Shock ✔ Smoke inhalation + + + Toxic gases + + + + ± Cold exposure ✔ − − − − − − Fingerstick glucose (Hyperglycemia) Electrocardiogram (ECG) may show J wave, sinus bradycardia and prolongation of all ECG intervals. Serum electrolytes (including potassium and calcium) BUN and creatinine Serum hemoglobin, white blood cell, and platelet counts ( Raised HCT due to volume contraction) Coagulation profile (clotting factors impairment) Serum lactate ( lactic acidosis) Creatine kinase (Rhabdomylosis) Arterial blood gas CXR * Mild hypothermia: core temperature 32 to 35°C ; patient presents with confusion, tachycardia, and increased shivering. Moderate hypothermia: 28 to 32°C patient presents with lethargy, bradycardia and arrhythmia and decreased shivering. Severe hypothermia: below 28°C patient presents with coma, hypotension, arrhythmia, pulmonary edema, and rigidity. Drugs† − − − − −

Classification

Acute liver failure may be classified on the basis of the duration of the symptoms between the onset of jaundice to the onset of encephalopathy. The different classification systems based on the number of weeks from the appearance of jaundice to the encephalopathy are:

Classification system	Duration
O’Grady System	Hyperacute (0 - 1 week) Acute ( From 2nd week - 4 weeks) Subacute ( From 4th week - 12 weeks)
Bernuau System	Fulminant ( 0 - 2 weeks) Subfulminant ( 2 weeks - 12 weeks)
Japanese System	Fulminant (0 - 8 weeks) Acute ( 0 - 1.5 weeks) Subacute ( 1.5 weeks - 8 weeks) Late-Onset ( 8 weeks - 12 weeks)

The 1993 classification defines three subcategories based on the severity and duration of the acute liver failure. The importance of this method of classification is that the pace of the disease evolution strongly influences prognosis. The underlying etiology causing the development of acute liver failure is the other significant determinant in regards to prognosis. This classification system is based upon the duration between onset of jaundice to onset of encephalopathy.

Classification	Time
Hyperacute	1 week
Acute	1 week - 1 month
Subacute	1 week - 3 months

Acute liver failure can also be classified into fulminant or subfulminant. Both of these forms have a poor prognosis. It is based upon the duration between onset of hepatic illness, to the development of encephalopathy.

Classification	Time
Fulminant	within 2 months
Subfulminant	within 2 months to 6 months

O’Grady System

The classification of encephalopathy according to the O’Grady system is as follows.

Hyperacute

Hyperacute encephalopathy is an encephalopathy that occurs within 7 days of onset of jaundice.

Acute

Acute encephalopathy is an encephalopathy that occurs within an interval of 8 to 28 days from onset of jaundice.

Subacute

Subacute encephalopathy is an encephalopathy that occurs within 5 to 12 weeks of onset of jaundice.

Bernuau System

The classification of encephalopathy according to the Bernuau system is as follows.

Fulminant

Fulminant encephalopathy is an encephalopathy that occurs within 2 weeks of onset of jaundice.

Subfulminant

Subfulminant encephalopathy is an encephalopathy that occurs within an interval of 2 to 12 weeks from onset of jaundice.

Japanese System

The classification of encephalopathy according to the Bernuau system is as follows.

Fulminant

Fulminant encephalopathy is an encephalopathy that occurs within 8 weeks of onset of jaundice.

Late-Onset

Late onset encephalopathy is an encephalopathy that occurs within an interval of 8 to 24 weeks from onset of jaundice.

Acute

Acute encephalopathy is an encephalopathy that occurs within 10 days of onset of jaundice

Subacute

Subacute encephalopathy is an encephalopathy that occurs within an interval of 11 to 56 days from onset of jaundice