{"id":5438,"date":"2011-07-14T20:26:32","date_gmt":"2011-07-15T00:26:32","guid":{"rendered":"http:\/\/crashtext.org\/misc\/hepatic-trauma.htm\/"},"modified":"2014-07-15T18:18:28","modified_gmt":"2014-07-15T22:18:28","slug":"hepatic-trauma","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/trauma\/hepatic-trauma.htm\/","title":{"rendered":"Hepatic Trauma"},"content":{"rendered":"
West 2011 Guidelines<\/a> <\/a><\/a> <\/p>\n Level 1 1. Patients who are hemodynamically unstable or who have diffuse peritonitis after blunt abdominal trauma should be taken urgently for laparotomy. Level 2 1. A routine laparotomy is not indicated in the hemodynamically stable patient without peritonitis presenting with an isolated blunt hepatic injury. 2. In the hemodynamically stable blunt abdominal trauma patient without peritonitis, an abdominal CT scan with intravenous contrast should be performed to identify and assess the severity of injury to the liver. 3. Angiography with embolization may be considered as a first-line intervention for a patient who is a transient responder to resuscitation as an adjunct to potential operative intervention. 4. The severity of hepatic injury (as suggested by CT grade or degree of hemoperitoneum), neurologic status, age of more than 55 years, and\/or the presence of associated injuries are not absolute contraindications to a trial of nonoperative management in a hemodynamically stable patient. 5. Angiography with embolization should be considered in a hemodynamically stable patient with evidence of active extravasation (a contrast blush) on abdominal CT scan. 6. Nonoperative management of hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Level 3 1. After hepatic injury, clinical factors such as a persistent systemic inflammatory response, increasing persistent abdominal pain, jaundice, or an otherwise unexplained drop in hemoglobin should prompt reevaluation by CT scan. 2. Interventional modalities including endoscopic retrograde cholangiopancreatography, angiography, laparoscopy, or percutaneous drainage may be required to manage complications (bile leak, biloma, bile peritonitis, hepatic abscess, bilious ascites, and hemobilia) that arise as a result of nonoperative management of blunt hepatic injury. 3. Pharmacologic prophylaxis to prevent venous thromboembolism can be used for patients with isolated blunt hepatic injuries without increasing the failure rate of nonoperative management, although the optimal timing of safe initiation has not been determined. <\/p>\n Biloma Bile peritonitis The Journal of Trauma: Injury, Infection, and Critical Care Volume 70(3), March 2011, pp 626-629 Conclusions: The length of observation should be based solely on clinical criteria. Patients with liver injuries may be safely discharged home in the presence of a normal abdominal examination and stable hemoglobin, regardless of the grade of injury. This guideline is safe and reduces LOS without increasing morbidity or mortality. <\/p>\n (The Journal of Trauma and Acute Care Surgery 2012;72(2):321\u2013329) <\/p>\n Under normothermic conditions, the safe cross-clamping time has been thought to be no more than 15 to 20 consecutive minutes. Topical hypothermia, on the other hand, has been shown to be highly beneficial in preventing ischemia\/reperfusion injuries to the liver. Specifically, topical hypothermia has been shown to (i) decrease hepatic PMN infiltration and necrosis; (ii) decrease serum TNF-alpha levels; and (iii) attenuate pulmonary PMN infiltration and microvascular leakage. <\/p>\n The salient feature which makes the use of this treatment modality attractive lies in the ability of the omentum to (i) effectively exert a hemostatic tamponade effect; (ii) fill \u201cdead space\u201d with vascularized tissue; (iii) introduce peritoneal macrophages, the first line of defense in the peritoneal cavity, into a potential area of sepsis; and (iv) provide stromal call-derived factor 1-alpha, which may be vital to recruiting chemokine receptor cells vital to healing. <\/p>\n High-energy bilobar liver injuries present a unique challenge onto themselves. Hepatotomy via the finger fracture technique for selective ligation of lacerated blood vessels and bile ducts is not applicable to deep bilobar hepatic injuries because the zone of tracheotomy would be far too extensive while simultaneously running the risk of sacrificing multiple uninvolved vessels and bile ducts in both lobes of the liver or in multiple segments. As such, a different approach is required and the improvised balloon technique seems to offer a simple, safe, and effective solution to this problem.The balloon when blown up effectively tamponades lacerated vessels. When the balloon is deflated, usually at 24 hours to 36 hours, if no further bleeding ensues it can safely be removed. If, on the other hand, bleeding is evident when the balloon is deflated, reinflation and angioembolization can be lifesaving. <\/p>\n A critical review of the management strategies when confronting a juxtahepatic venous injury by Buckman et al (J Trauma. 2008;65:1264\u20131270). has identified a serious flaw in the previous conception that wide hepatic mobilization is an essential maneuver. On the contrary, injudicious disruption of the natural containing structures such as the suspensory ligaments that surround the hepatic venous segments may lead to rapid exsanguinating hemorrhage which inevitably proves to be fatal. The better part of valor would be to dispense with the concept of \u201cwide hepatic mobilization\u201d and embark on other treatment strategies designed to arrest bleeding. <\/p>\n Several factors have been delineated as having a high correlation rate with failure of nonoperative management of blunt hepatic injuries: <\/p>\n Angio after Hepatic Trauma?<\/span><\/h2>\n Retrospect trial (J Trauma 2011;70:1032) two indications stable pts with active art bleeding on ct or pts with suspected bleeding continuing after E Lap III and above may benefit from combined surg and angio approach ` | | |<\/p>\n","protected":false},"excerpt":{"rendered":" Array<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[7],"tags":[],"yoast_head":"\n<\/span>East 2012 Guidelines<\/span><\/h3>\n
<\/span>Post-liver Sequelae<\/span><\/h3>\n
<\/span>Operative Management<\/span><\/h2>\n
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Portal Triad Occlusion Time<\/h4>\n
Omental Pedicle<\/h4>\n
IMPROVISED BALLOON TAMPONADE<\/h4>\n
Juxtahepatic Venous Injury<\/h4>\n
PREDICTORS OF FAILURE IN NONOPERATIVE MANAGEMENT<\/h4>\n
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<\/span>Who needs <\/p>\n