EMS Hepatic Emergencies - Scleral Icterus v Jaundice

For EMS providers, understanding the nuances of scleral icterus and jaundice is essential for accurate assessment and early intervention.

1. Scleral Icterus

Definition: Yellowing of the sclera (whites of the eyes) without concurrent skin yellowing.

Clinical Significance: Often the first visible sign of elevated bilirubin levels and an early indicator of liver dysfunction or hemolysis.

Implications: Identifying scleral icterus can suggest underlying conditions such as hepatitis, cirrhosis, or hemolytic anemia. 

Early detection can prompt the EMS Provider to prioritize further evaluation and expedite transport to the appropriate care facility.

2. Jaundice

Definition: Yellowing of both the skin and the whites of the eyes due to high levels of bilirubin in the blood.

Progression: Jaundice usually follows scleral icterus if the underlying cause continues or worsens.

Causes:

Pre-Hepatic: Conditions causing excessive breakdown of red blood cells (e.g., hemolysis).

Hepatic: Liver conditions impairing bilirubin processing (e.g., hepatitis, cirrhosis).

Post-Hepatic: Obstructions in bile flow (e.g., gallstones, tumors).

Symptoms & Associated Signs: Patients may also have dark urine, pale stools, fatigue, abdominal pain, and pruritus (itching).

Key Points for EMS Providers:

Assessment: Use adequate lighting when checking for scleral icterus or jaundice. Assess the patient’s history for recent liver disease, alcohol use, or risk factors for hemolysis.

Documentation: Record any visible signs and associated symptoms such as abdominal pain, confusion, or changes in consciousness, which could indicate worsening liver function or biliary obstruction.

Critical Situations: Rapidly progressive jaundice with symptoms such as altered mental status or significant abdominal pain may indicate acute liver failure or biliary sepsis, requiring urgent care.

Communication: Inform receiving facilities of the findings, which can be crucial for directing lab tests (e.g., liver function tests) and determining appropriate interventions.

Understanding these conditions allows EMS Providers to recognize early signs of potentially serious illnesses and ensure timely and effective patient management. 

Further Reading

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). Hoboken, New Jersey: Pearson Education

Bledsoe, B. E., Cherry, R. A. & Porter, R. S (2023) Paramedic Care: Principles and Practice (6th Ed) Boston, Massachusetts: Pearson

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). Hoboken, New Jersey: Pearson Education

Peate, I. & Sawyer, S (2024) Fundamentals of Applied Pathophysiology for Paramedics. Hoboken, New Jersey: Wiley Blackwell