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Ppt for liver injury

1. INJURIES TO LIVER CHANCHAL M.SC NURSING 2nd YEAR

2. Table of contents 01 04 02 05 03 06 ANATOMY OF LIVER LIVER TRAUMA Etiological factors Management and treatment Diagnostic Evaluation Complications

3. Anatomy of Liver 01 In RUQ ▶ 5 th ICS in midclavicular line to the Rt cos tal margin. ▶ Weighs 1400 g n women and 1800g n men . ▶ Span 10 cm +/-2

4. Anterior and Posterior Surface

5. Ligaments Liver supported by: ▶ Coronary lig ament ▶ Rt & Lt Triangular lig ament ▶ Falciform lig ament

6. Classically; liver divided to 4 lobes and 8 segments : ▶ Right lobe - I ▶ Left lobe - II, III, ▶ Caudate lobe - V, VI, VII, VIII ▶ Quadrate lobe - IV Segmental Anatomy

7. The Couinaud classification of liver anatomy then further divides the liver into eight functionally independent segments. Each segment has its own vascular inflow, outflow and biliary drainage.

8. Which of the 4 Lobes of the Liver can NOT be palpated? CAUDATE

9. Blood Supply(Hepatic Vein) ▶ Rt hepatic vein Drain seg 5,6,7,8 . ▶ Middle hepatic vein  Drain seg 4,5,8 ▶ Lt hepatic vein Drain seg 2,3 [ seg 1 drain by short hepatic  vena cava]

10. Right hepatic vein divides the right lobe into anterior and posterior segments. Middle hepatic vein divides the liver into right and left lobes (or right and left hemiliver). This plane runs from the inferior vena cava to the gallbladder fossa. The Falciform ligament divides the left lobe into a medial- segment IV and a lateral part - segment II and III. The portal vein divides the liver into upper and lower segments. The left and right portal veins branch superiorly and inferiorly to project into the center of each segment. LIVER CONTAINS 15% OF TOTAL BLOOD VOLUME OF THE BODY.

11. G uarding refers to voluntary contraction of the abdominal wall musculature, usually the result of fear, anxiety, or the laying on of cold hands. Rigidity refers to involuntary contraction of the abdominal musculature in response to peritoneal inflammation, a reflex that the patient cannot control. What is the difference between guarding and rigidity in abdomen?

12. CASE REPORTS OF BLUNT HEPATIC TRAUMA IN POLYTRAUMA PATIENTS: A 27-year-old male was brought to Emergency Room(ER) with a history of Road traffic accidents (RTA). On examination, he was conscious, oriented, and tachypneic with a pulse rate of 110/min and BP of 80/60 mm Hg . Examination of the abdomen revealed diffuse tenderness . Guarding was present in the entire abdomen. He also had a fracture of the right lower end of the radius with tenderness over the lower back. Neurological examination was normal. Ultrasound revealed free fluid in the abdomen and solid viscera were normal. X-ray of the lumbar spine revealed multiple transverse process fractures in L1 – L5 level. Despite adequate resuscitation with crystalloids and whole blood, the patient did not improve. Emergency laparotomy was done when liver laceration 5 x 3 x 2 cm on the anterolateral surface with active hemorrhage was noted. Hepatic packing did not stop the bleeding and so hepatorr h aphy with omental packing was done to achieve hemostasis. Hepatorrhaphy: T echnique which involves passing deep parenchymal sutures to bring disrupted tissue together compressing bleeding vessels and reducing dead space.

13. CASE REPORTS OF BLUNT HEPATIC TRAUMA IN POLYTRAUMA PATIENTS: CONTD.. A contusion in the neck of the pancreas 2 x 2 cm was found which was left alone. The lumbar spine and radial injuries were managed conservatively. The patient was in the hospital for 2 weeks in all. He was started on oral liquids from the 4 th postoperative day(POD), the drain was removed on the 6 th POD, and suture removal was done on the 10th POD. The patient did well postoperatively and was discharged on the 14th POD.

14. Case vignette -2 A 28-year-old male patient was brought to ER following an RTA with a BP of 80/60 mm Hg. The patient was conscious, oriented, and had pallor. Urinary catheterization revealed frank hematuria . Abdomen was distended. Guarding, rigidity and diffuse tenderness were present over the entire abdomen. The patient was resuscitated with crystalloids and whole blood when BP improved to 130/80 mm Hg and pulse rate of 100/min. Initial Ultrasound revealed grade 2 renal injury with moderate hemoperitoneum,and other viscera were normal. As CT was nonfunctional on the day, an urgent Intravenous Pyelogram (IVP) was done which showed a non-enhancing Right Kidney. The patient was shifted to the Intensive care unit( ICU) and managed conservatively. Due to a progressive drop in Hemoglobin despite adequate blood transfusion, a repeat Ultrasonogram(USG) was done which picked up an additional injury, a liver laceration of 3 x 2 cm .

15. Contrast CT Abdomen was done (18 hours after admission) which showed liver laceration and grade 5 renal injury . In view of increasing transfusion requirements, an emergency laparotomy through a midline abdominal incision was done. Right Kidney was shattered with renal vein injury. A right Nephrectomy was done. The laceration in segment 5 of the liver on the anterolateral surface of the right lobe was packed with greater omentum and hemostasis was secured. Postoperatively, a right chest drain was placed for the right hemothorax. On 1st Postoperative day, the abdominal drain revealed 200 ml of fresh blood with elevated INR and PT. Despite adequate resuscitation with whole blood and FFP, the patient did not improve. Emergency CT Angiogram was done which showed hemoperitoneum with liver laceration in the anterior and posterior surfaces.

16. The patient was reexplored . After making a T-shaped incision with a horizontal limb through the right coastal margin, a liver laceration in the posterior surface was found actively bleeding. The greater omentum was fixed to the laceration and tagged to the diaphragm. A perihepatic pack was kept and the same was brought through a separate stab incision in the right hypochondrium . Post-operatively left chest drain was also placed in view of the left hemothorax. He was on ventilatory support and coagulation abnormalities were corrected. The patient was reexplored on 4th day after packing and pack removal were done . Postoperatively patient developed pneumonia and anasarca with hypoalbuminemia. These were aggressively treated with infusion of IV albumin, intravenous antibiotics, chest physiotherapy, and nebulization. The patient was extubated. The chest drains were removed after the drain volume decreased and lung expansion improved. The overall transfusion requirement for the patient including all blood components was over a hundred units. The patient was in the hospital for about 5 weeks prior to discharge. CONTD…

17. LIVER INJURY

18. 2 nd most commonly injured organ in Penetrating abdominal trauma after Bowel. Motor vehicle collision is the most common injury mechanism The posterior portion of the right lobe is the most common site of hepatic injury in blunt trauma Hemorrhage represents the leading cause of death in liver injuries . INTRODUCTION

19. INJURIES Parenchymal damage Subcapsular hematoma Laceration Contusion Hepatic vascular disruption Bile duct injury

20. Traumatic liver laceration L iver gunshot wound with a dumdum bullet (expanding bullet)

21. Sureka, B., & Mukund, A. (2017). Review of imaging in post-laparoscopy cholecystectomy complications. The Indian journal of radiology & imaging, 27(4), 470–481. https://doi.org/10.4103/ijri.IJRI_489_16

22. Liver injuries make up approximately 5% of all trauma admissions. Mortality from hepatic trauma depends on the degree of injury. Minor liver injuries make up most hepatic trauma, with 80% to 90% being grades 1 or II. Mortality increases with the grade of injury, and grade VI liver injuries are often fatal. Liver injury is the primary cause of death in severe abdominal trauma and has a 10% to 15% mortality rate. EPIDEMIOLOGY

23. Mechanism of injury •Crushing •Deceleration •Sudden increase in intra abdominal pressure because of seat belt Injury types • Subcapsular hematoma • Lacerations (± disruption of hepatic lobes/ segments) •Deeper injuries + vascular (IVC/ hepatic vein) injuries Blunt abdominal or lower thoracic trauma Penetrating trauma to Right Hypochondrium and epigastric areas Blunt injury produces contusion, laceration and avulsion injuries to the liver, often in association with splenic, mesenteric or renal injury. Penetrating injuries, such as stab and gunshot wounds, are often associated with chest or pericardial involvement. Blunt injuries are more common and have a higher mortality than penetrating injuries. ETIOLOGY

24. PATHOLOGY The main immediate consequence is hemorrhage. The amount of hemorrhage may be small or large, depending on the nature and degree of injury. Many small lacerations, particularly in children, cease bleeding spontaneously. Larger injuries hemorrhage extensively, often causing hemorrhagic shock. Mortality is significant in high-grade liver injuries.

25. PATHOPHYSIOLOGY

26. GRADING The AAST (American Association for the Surgery of Trauma) liver injury scale, recently revised in 2018, is the most widely used liver injury grading system .

27. G rade I hematoma: subcapsular, <10% surface area laceration: capsular tear, <1 cm parenchymal depth

28. G rade II hematoma: subcapsular, 10-50% surface area hematoma: intraparenchymal <10 cm diameter laceration: capsular tear 1-3 cm parenchymal depth, <10 cm length

29. G rade III hematoma: subcapsular , >50% surface area; ruptured subcapsular or parenchymal hematoma hematoma: intraparenchymal >10 cm laceration: capsular tear >3 cm parenchymal depth vascular injury with active bleeding contained within liver parenchyma

30. G rade IV laceration: parenchymal disruption involving 25-75% of a hepatic lobe or involves 1-3 Couinaud segments vascular injury with active bleeding breaching the liver parenchyma into the peritoneum

31. G rade V laceration: parenchymal disruption involving >75% of hepatic lobe vascular: juxtahepatic venous injuries (retrohepatic vena cava / central major hepatic veins

32. WSES(World Society of Emergency Surgery) Classification

33. CLINICAL FEATURES

34. Peritonism Symptoms Abdominal Pain Radiation to shoulder Altered Sensoium Signs Hypotension RUQ tenderness, and guarding Generalized Peritonism Hemoperitoneum Biliary Peritonitis Delayed – Intra- abdominal abscess

35. DIFFERENTIAL DIAGNOSIS Other causes for hemoperitoneum Splenic injury Ruptured ectopic pregnancy Ruptured abdominal aortic aneurysm Acute hemorrhagic pancreatitis

36. DIAGNOSTIC MODALITIES Focused Assessment with Sonography for Trauma (FAST) scan is a point-of-care ultrasound (POCUS) examination performed at the time of presentation of a trauma patient.

37. CT scan Accurate in 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

38. CT Grading of Liver Injury

39. Diagnostic peritoneal lavage (DPL) DPL is fast, sensitive, accurate and simple to perform I nvasive, cannot diagnose retroperitoneal injury DPL is positive whe n more than 10 ml of frank blood in the aspirated fluid F ecal matter or bile >100,000 RBC/micL >500 WBC/micL https://www.youtube.com/watch?v=aRw3qQGjTzI

40. DIAGNOSTIC LAPROSCOPY

41. Remember associated injuries Spleen Pancreas Bowel Resuscitate Consider Cryoprecipitate, FFP Assessment of injury Spiral CT Laparotomy The key to the management of liver trauma is hemodynamic stability and the absence of another abdominal organ injury. O perative M anagement Non-operative Management Management

42. Management according to WSES(World Society of Emergency Surgery) 2020 guidelines for Liver Trauma Coccolini, F., Coimbra, R., Ordonez, C. et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 15, 24 (2020). https://doi.org/10.1186/s13017-020-00302-7

43. (SW: stab wound )

44. (DCS: damage control surgery, ICU: intensive care unit, REBOA-C: REBOA-cava)

45. Non-Operative Management Initial management is done according to ATLS protocol. Criteria for non Operative Management: (1) haemodynamic stability, or stability achieved with minimal resuscitation(1- 2 litres of crystalloid) (2) absence of other abdominal injuries requiring laparotomy (3) preserved consciousness allowing serial examination of abdomen (4) absence of peritonism (5) absence of ongoing bleeding on CT scan

46. Management of Non-Operative Blunt Liver Injury Journal of Trauma and Acute Care Surgery67(6):1144-1149, December 2009.

47. Non-operative management (NOM) consists of : C lose observation of the patient complemented with angioembolization , if necessary. Observational management involves : admission to a unit and the monitoring of vital signs, strict bed rest, frequent monitoring of hemoglobin concentration , serial abdominal examinations .

48. Operative management In the hemodynamically unstable patient Grade IV, V , and VI injuries Goal is to arrest Hemorrhage Initial control of hemorrhage is attained by Perihepatic packing Mannual compression

49. 4 Ps of operative management Operative management can be summarized as PUSH PRINGLE PLUG PACK 50

50. PERIHEPATIC PACKING Lobes of the liver must be compressed back to normal position . Packs should never be inserted into the hepatic wound . Packs are removed after 36 to 48 hours provided the patient is stable . Should NOT be removed before 24 hours as there are chances of rebleed . Perihepatic packing can control profuse haemorrhage in up to 80% of patients A Pringle maneuver can help delineate the source of hemorrhage. 51

51. PRINGLE MANEUVER 52 C lamping the hepatoduodenal ligament (the free border of the lesser omentum ). This interrupts the flow of blood through the hepatic artery and the portal vein, which helps to control bleeding from the liver. The common bile duct is also temporarily closed during this procedure. https://www.youtube.com/watch?v=u8ZaySpohFA

52. Suture Hepatorrhaphy M ass closure, with the placement of large sutures through the liver parenchyma to arrest bleeding by coapting the two edges. The suture of choice is an 0 chromic. If the laceration is 1–3 cm in depth, a standard (CT-21) needle is used to loosely approximate the edges of the laceration in an interrupted fashion. 53

53. Advanced Technique of Repai r These account for approximately 10 % of all penetrating injuries and less than 40 % of blunt injuries. Such injuries require a more advanced technique of repair involving the following six critical steps: 54

54. Resuscitative endovascular balloon occlusion of the aorta (REBOA) - It is an endovascular procedure in which a blocking balloon is introduced into the aorta to reduce bleeding situated distal to the balloon and simultaneously to improve cardiac and cerebral oxygenation. It may be used in hemodynamically unstable patients as a bridge to other more definitive procedures for hemorrhage control R esuscitative endovascular balloon occlusion of the vena cava (REBOVC) - It is done at the level of the retro-hepatic vena cava. It’s goal is to achieve proximal and distal vascular control of a possible retro-hepatic/supra-hepatic vessel injury . 55 https://www.youtube.com/watch?v=odNrsFae5Aw

55. Post Op Complications Post-operative hemorrhage Surgical haemorrhage (ie discrete bleeding) disseminated intravascular coagulation account for the majority of causes Chances increased if packs removed <36 hours Coagulapathy is corrected first if the hemorrhage is persistent then angiography with embolization or re laparotomy is considered .

56. Sepsis and abscess 12- 32% of patients CT with intravenous and oral contrast should be performed to diagnose the cause of sepsis . Most intraabdominal abscess can be drained percutaneously under USG or C T guidance . If not possible then operative drainage is done .

57. Kim, K. H., Kim, J. S., & Kim, W. W. (2017). Outcome of children with blunt liver or spleen injuries: Experience from a single institution in Korea. International journal of surgery (London, England), 38, 105–108. https://doi.org/10.1016/j.ijsu.2016.12.119 58

58. 59 Rozycki, G. F., Sakran, J. V., Manukyan, M. C., Feliciano, D. V., Radisic, A., You, B., Hu, F., Wooster, M., Noll, K., & Haut, E. R. (2023). Angioembolization May Improve Survival in Patients With Severe Hepatic Injuries. The American surgeon, 89(12), 5492–5500. https://doi.org/10.1177/00031348231157416

59. Pre-hospital Management - ABCDE (airway, breathing, circulation, disability, exposure) approach to assessment and treatment, where (C) stands for catastrophic bleeding. The initial aim is to identify the bleeding point and provide prompt treatment. 60

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62. ** ‘ D amage-control resuscitation’ and ‘ D amage-control surgery’ D amage-control resuscitation consists of a bundle of interventions to manage trauma patients who are bleeding. It includes the use of: Tourniquets for early haemorrhage control; Tranexamic acid; Permissive hypotension; Haemostatic resuscitation with restriction of crystalloid fluids; Aggressive correction of coagulopathy (Spahn et al, 2019). Recognize clinical signs of shock and manage accordingly. 63

63. Nursing Management Diagnosis- Acute or chronic pain related to injuring organ. 1. Investigate changes in frequency or description of pain. Rationale : May signal worsening of condition or development of complications. 2. Monitor heart rate, BP using correctly sized cuff, and respiratory rate, noting age appropriate normals and variations. Rationale : Changes in autonomic responses may indicate increased pain. 3. Administer medications, such as opioid and nonsteroidal analgesics, as indicated. Rationale : pain management may be needed to overcome or control pain. 64

64. Nursing Management D iagnosis - Anxiety related to anticipated loss of physiological well-being, change in body function perceived death of client. 1.Inform client about planning to do and why. Include client in planning process and provide choices when possible. 2. Reorient frequently. 3. Administer medications, as indicated, for example: Benzodiazepines, such as chlordiazepoxide (Librium), and diazepam (Valium) 65

65. 66 DRUG INDUCED LIVER INJURY

66. COMPLICATIONS OF HEPATIC TRAUMA B ile leak ( can occur in as many as 21% of patients managed operatively ) H epatic abscesses can develop after hepatic artery ligation or angioembolization Hepatic necrosis ( 41% of patients will have hepatic necrosis after angioembolization ) Arterio-biliary or porto-biliary fistula that results in hemobilia.

67. REFERENCES Coccolini, F., Catena, F., Moore, E.E. et al. WSES classification and guidelines for liver trauma. World J Emerg Surg 11, 50 (2016). https://doi.org/10.1186/s13017-016-0105-2 Ahmed N, Vernick JJ. Management of liver trauma in adults. J Emerg Trauma Shock. 2011 Jan;4(1):114-9. doi: 10.4103/0974-2700.76846. PMID: 21633579; PMCID: PMC3097559. Lucena-Amaro S, Zolfaghari P (2022) Trauma nursing 1: an overview of major trauma and the care pathway. Nursing Times; 118: 11, 42-45 National Institute for Health and Care Excellence (2016) Major Trauma: Assessment and Initial Management. NICE. Spahn DR et al (2019) The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Critical Care; 23: 1, 98. 68

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