This chapter discusses the diagnosis, evaluation and management of fulminant hepatic failure. Patients can present with hypotension due to generalized systemic inflammatory response, coagulopathy, and encephalopathy with progression to coma and brain herniation. Diagnosis is based on clinical presentation and laboratory findings. Critical care management should be performed for cardiovascular, pulmonary, and infectious complications and other comorbidities. Prognosis and treatment decisions can be based on Rumack-Matthew nomogram. Renal failure occurs in up to 50% of cases, even more frequently in acetaminophen toxicity. In most cases continuous renal replacement therapy is indicated. Intermittent hemodialysis should be avoided as some evidence suggests rapid fluid shifts lead to brain herniation. Patients should be transferred to a transplantation facility as soon as possible. If a transplantation center is not readily available, consider transfer to a center that utilizes molecular adsorbents recirculation system (MARS) or artificial extracorporeal liver support therapy.

Primary survey of a patient suspected of having an increased intracranial pressure (ICP) consists of a brief neurological examination and establishment of a Glasgow Coma Scale (GCS) score. Brain herniation, an end-stage manifestation of increased ICP, refers to displacement of brain tissue from one intracranial compartment to another through an opening in the dural sheath. A herniation syndrome is a neurosurgical emergency; if immediate intervention is not taken, death can ensue rapidly. Initial therapy is aimed at lowering ICP while determining and treating the underlying cause. Common conditions resulting in increased ICP include traumatic brain injury (TBI), cerebrovascular events, hydrocephalus, brain tumor, central nervous system infections, metabolic and hypoxic encephalopathies, and status epilepticus. Mannitol, an osmotic diuretic, is currently the diuretic of choice for treating increased ICP. Barbiturate therapy is effective in lowering ICP in a select subset of patients such as those with persistently high ICP despite aggressive management.