Downloaded 118 times
More Related Content
LIVER TRAUMA
- 1.
- 2. Case 1: Blunttrauma ● 29 year old female ● Driver of a car, wearing seatbelt ● Collision heavy vehicle ● Airbags activated ● Managed as per ATLS protocols ● GCS 15 /15, haemodynamically stable ● RUQ pain, left wrist fracture-dislocation
- 3. Radiology ● Bi-malleolar leftankle fracture ● Ultrasound abdomen: free fluid, splenic contusion ● CT abdomen – oblique tear through right lobe of the liver – right adrenal gland contusion – blood in peritoneum
- 4. Management ● Transferred toICU with IV fluids & blood ● Ankle dislocation reduced, back slab applied ● Laparotomy: full assessment performed – Large volume of intraperitoneal blood – 2 liver lacerations – Small haematoma at splenic hilum – Small contusion of tail of pancreas – No active bleeding ● Surgicel to splenic hilum and liver lacerations ● Washout performed and drains placed
- 5. Post-operative course ● Remainedhaemodynamically stable ● MRI brain: confirmed small contusion near internal capsule
- 6. Case 2: Penetratingtrauma ● 24 year old male ● Stab wounds – Three in upper abdomen – Left side of neck
- 7. Clinical findings ● GCS13/15, haemodynamically stable ● 3cm wound over the right zygoma ● 1.5cm wound zone 2 left side of the neck ● Abdomen: 1.5cm wound over the right and left upper quadrants breaching rectus sheath and muscles ● Managed as per ATLS protocol ● IV Fluids, Catheterized ● Hb = 13.5
- 8. Management ● Chest x-raynormal ● Ultrasound abdomen: No free fluid ● Admitted to ICU pre laparotomy ● Became haemodynamically unstable with increasing abdo pain ● Responded to IV fluids and blood transfusion
- 9. Emergency laparotomy findings ●Haemoperitoneum ● Wound in the right upper quadrant obliquely traversed both lobes of liver, through the 1st part of duodenum into pancreas ● Bleeding from D1 and pancreas ● Haemostasis achieved ● Duodenum repaired with interrupted PDS ● Wash out performed, drain placed
- 10. Management ● Neck wound:fascia breached but no vascular injuries, closed in layers ● Managed with NG tube, antibiotics and parenteral nutrition ● Developed bile leak, conservatively managed ● Small pelvic collections were managed with antibiotics ● Discharged on 31st post-operative day
- 11. Background ● Largest solidabdominal organ, fixed position ● Liver injury is the most common cause of death after abdominal trauma ● Blunt injury due to road traffic accidents most common ● 80% adults, 97% children have successful conservative management ● Liver injured more easily in children
- 12. Anatomy of theinjury
- 13. Liver anatomy ● Cantiledescribed main divisions along axis from gallbladder fossa to the IVC ● This divides the liver into equal halves ● Couinaud divided the liver into 8 segments.
- 14. Liver segments • Dividedvertically by the 3 main hepatic veins and transversely by the right and left portal branches.
- 15. Types of liverinjuries ● Haematoma: subcapsular or intrahepatic ● Laceration ● Contusion ● Hepatic vascular disruption ● Bile duct injury ● 86% of injuries have stopped bleeding at time of surgical exploration ● Transfusion requirements are reduced with conservative management
- 16. Management ● Initial resuscitationas per ATLS protocol ● It is important to note the mechanism of injury ● Clinical picture may vary from mild RUQ pain through to peritonism to haemorrhagic shock ● Stable patients undergo CT imaging ● Unstable patients require resuscitation and laparotomy
- 17. CT Scans ● Accuratein localizing the site of liver injury and any associated injuries ● Used to monitor healing ● CT criteria for staging liver trauma uses AAST liver injury scale ● Grades 1-6
- 18. Classification ● I- Subcapsularhematoma<1cm or superficial laceration<1cm deep ● II- Parenchymal laceration 1-3cm deep or subcapsular hematoma1-3 cm thick ● III- Parenchymal laceration >3cm deep and subcapsular hematoma >3cm diameter ● IV- Parenchymal/supcapsular hematoma >10cm in diameter, lobar destruction or devasularization ● V- Global destruction or devascularization of the liver ● VI- Hepatic avulsion
- 19. Example of agrade 3 injury Subcapsular hematoma Parenchymal hematoma and laceration
- 20. Angiography ● May beuseful in localizing the site of haemorrhage in stable patients ● Transcatheter embolization of bleeding sites
- 21. Treatment ● Conservative – Bluntliver trauma, – Haemodynamically stable – No other injuries requiring surgery ● Surgical – Penetrating injuries – Haemodynamically unstable – Other injuries requiring surgery
- 22. Surgical management ● Fulllaparotomy ● Pringles manoeuvre to occlude the portal triad ● Packing of the liver ● Treat other intra-abdominal injuries as appropriate
- 23. Learning points! ● Liverinjuries frequently are associated with multiple other injuries ● Most liver injuries can be managed conservatively ● Essential Skills: Laparotomy, Pringles, Ligament mobilisation and liver packing ● As with all trauma, the ATLS protocol is the foundation of treatment