LIVER Trauma very good notes -2024.pptx

Summarised notes on liver trauma

1. LIVER TRAUMA OJALE MOSES.

2. Background Largest organ, 2nd most common injured, Blunt trauma most common MOSES OJALE

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5. Why the liver … Friable parenchyma, thin capsule, fixed position in relation to spine  prone to blunt injury . Right lobe larger, closer to ribs. more injury In children compliant ribs, transmitted force MOSES OJALE

6. Simple compression against ribs, spine, Ligamentous attachment to diaphragm and the posterior abdominal wall , shear forces during deceleration injury. Mechanisms of injury:- MOSES OJALE

7. High-velocity bullet injuries Burst injuries with distant contusions and parenchymal disruption. Associations Occasionally, these injuries are associated with aortic and renal injuries. All of the angiographic findings of blunt liver trauma can be seen in this group of patients. Mechanisms of injury:- MOSES OJALE

8. Low-velocity penetrating injury Stab wounds Percutaneous biopsy Cholangiography Biliary drainage, (TIPS), Capsular tears, hematoma, bile leaks, arteriobiliary fistulas, and hemoperitoneum, arterial aneurysms. Mechanisms of injury:- MOSES OJALE

9. Isolated liver injury occurs in less than 50% of patients. Blunt trauma  45% with spleen Rib fracture  33% with Liver injury Associations: MOSES OJALE

10. Injuries Parenchymal damage Subcapsular hematoma Laceration Contusion Hepatic vascular disruption Bile duct injury MOSES OJALE

11. Injuries Mild injuries heal in 3 months. Moderate injuries heal in 6 months. Sever e injuries in 9-15 months. MOSES OJALE

12. Clinically Symptoms & signs of injury are Blood loss, Peritoneal irritation, RUQ tenderness, and guarding. Delayed abscess . Signs of blood loss may dominate the picture. Biliary peritonitis. MOSES OJALE

13. Labs & Radiology Elevated LFTs DPL -- high sensitivity CT scan is the diagnostic procedure of choice. US. MRI ?? MOSES OJALE

14. USS Ultrasonography is the initial examination of choice in the pediatric age group who are ill and in whom the clinical condition is too unstable to allow transport to a CT facility. In a neonate with a decreasing hematocrit level and increasing abdominal distension, ultrasonography may rapidly help in confirming a diagnosis of liver trauma. Because most children with hepatic trauma are treated conservatively, most children can be monitored by using sonography. MOSES OJALE

15. Angiography Active bleeding Transcatheter embolization Embolization & stenting for fistulas. MOSES OJALE

16. CT Scan Localization. Monitor healing. Grades 1-6 MOSES OJALE

17. Classification (AAST) I- Subcapsular hematoma<1cm, superficial laceration<1cm deep. MOSES OJALE

18. II- Parenchymal laceration 1-3cm deep, subcapsular hematoma1-3 cm thick. MOSES OJALE

19. III- Parenchymal laceration> 3cm deep and subcapsular hematoma> 3cm diameter. MOSES OJALE

20. IV-Parenchymal/supcapsular hematoma> 10cm in diameter, lobar destruction , MOSES OJALE

21. V- Global destruction or devascularization of the liver. MOSES OJALE

22. VI- Hepatic avulsion MOSES OJALE

23. Gallbladder injuries Gallbladder injuries are classified as contusions, lacerations or perforations, and avulsions; contusions are most common. Avulsion injuries are the second most common; the gallbladder is torn partially or completely from the gallbladder fossa. Healing takes 1-15 months, and the rate of healing correlates with the severity of trauma. MOSES OJALE

24. Most of these injuries were treated surgically. However, surgical literature confirms that as many as 86% of liver injuries have stopped bleeding by the time surgical exploration is performed, and 67% of operations performed for blunt abdominal trauma are nontherapeutic. Management MOSES OJALE

25. Management Imaging techniques, particularly CT scanning, have made a great impact on the treatment of patients with liver trauma, and use of these techniques has resulted in marked reduction in the number of patients requiring surgery and nontherapeutic operations. Almost 80% of adults and 97% of children are treated conservatively by using careful follow-up imaging studies. MOSES OJALE

26. Management… Remember associated injuries Resuscitate Assessment of injury Spiral CT Laparotomy Treatment 4Ps- Plugging, P ringle, Packing, Push MOSES OJALE

27. 4Ps Push  (to approximate the rough wound-edges towards each other for compression) Pack  (to ensure tight packing and compression of the liver parenchyma) Pringle  (to temporize and reduce the inflow of the portal vein and hepatic artery to the liver) Plugging (use of angioembolization to control bleeding in severe liver injuries  MOSES OJALE

28. Illustration MOSES OJALE

29. Management… Consider cryoprecipitate, FFP Rooftop incision Control blood loss MOSES OJALE

30. Suturing of Lacerations Resection Packing Recurrent parenchymal bleeding  trans catheter embolization MOSES OJALE

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32. BASICS Resuscitative endovascular balloon occlusion of the aorta (REBOA ) R esuscitative endovascular balloon occlusion of the vena cava (REBOVC ) Trauma grading by WSES Minor (WSES grade I) Moderate (WSES grade II) Severe (WSES grade III and IV) World Society of Emergency Surgery (WSES) MOSES OJALE

33. THANK YOU MOSES OJALE