In the largest U.S. study, only 29% of patients received a liver graft, while 10% of the overall group (one fourth of patients listed for transplantation) died on the waiting list. Other series have reported death rates of those listed for transplant as high as 40%. In the ALFSG, the transplantation rate was higher in the groups with lower short-term spontaneous survival, making overall survival similar in all groups: acetaminophen, 73%; drug induced, 70%; indeterminate group, 64%; and other causes, 61%. Causes of death for the 101 patients who died within the 3-week period included cerebral edema, multiorgan failure, sepsis, cardiac arrhythmia or arrest and respiratory failure. The median time to death after admission was 5 days. Acetylcysteine
Intravenous N-acetylcysteine has been found to be beneficial in both acetaminophen toxicity and non-acetaminophen-related acute liver failure. Prognosis
Historically mortality has been high, being in excess of 80%. In recent years the advent of liver transplantation and multidisciplinary intensive care support have improved survival significantly. At present overall short-term survival with transplant is more than 65%.Several prognostic scoring systems have been devised to predict mortality and to identify who will require an early liver transplant. These include Kings College Hospital criteria, MELD score, APACHE II, and Clichy criteria. Terminology
To date, no universally accepted nomenclature has been adopted.
Subgaleal hemorrhage, also known as subgaleal hematoma, is bleeding in the potential space between the skull periosteum and the scalp galea aponeurosis. Symptoms
The diagnosis is generally clinical, with a fluctuant boggy mass developing over the scalp (especially over the occiput) with superficial skin bruising. The swelling develops gradually 12–72 hours after delivery, although it may be noted immediately after delivery in severe cases. Subgaleal hematoma growth is insidious, as it spreads across the whole calvaria and may not be recognized for hours to days. If enough blood accumulates, a visible fluid wave may be seen. Patients may develop periorbital ecchymosis ("raccoon eyes").Patients with subgaleal hematoma may present with hemorrhagic shock given the volume of blood that can be lost into the potential space between the skull periosteum and the scalp galea aponeurosis, which has been found to be as high as 20-40% of the neonatal blood volume in some studies. The swelling may obscure the fontanel and cross cranial suture lines, distinguishing it from cephalohematoma, in which the bleed is confined by its subperiosteal location.Patients with subgaleal hemorrhage may also have significant hyperbilirubinemia due to resorption of hemolyzed blood. Laboratory studies may demonstrate reduced hemoglobin and hematocrit due to blood loss into the subgaleal space, and coagulation studies may reflect an underlying coagulopathy. Mortality has been reported to occur in 12-14% of cases, generally as a consequence of massive blood loss presenting with shock, often in the setting of uncorrected coagulopathy.