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  • • Blunt versus penetrating trauma

    • High velocity vs low velocity trauma

    • Lacerations vs bursting injuries

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Epidemiology

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  • • Liver is most commonly injured organ in blunt abdominal trauma

    • Second most common injury in penetrating abdominal trauma

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Symptoms and Signs

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  • • Shock

    • Abdominal pain

    • Distended abdomen

    • Penetrating wounds

    • Ecchymosis

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Laboratory Findings

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  • • Leukocytosis

    • Anemia (later in course)

    • Elevated transaminases

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Imaging Findings

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  • Focused abdominal sonography for trauma (FAST) US: Shows intraperitoneal fluid, hepatic laceration, or hepatic hematoma

    CT: Shows extravasation of blood, hematoma, laceration, or parenchyma injury; grade poor predictor of operative findings

    Angiography: Helpful in diagnosing and treating active hemorrhage

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  • • Retrohepatic cava or hepatic vein injury

    • Portal triad injury

    • Coagulopathy

    • CT grade a poor predictor of outcome unless major vascular injury present

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Rule Out

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  • • Additional abdominal injuries

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  • • FAST US if blunt trauma

    • CT if blunt trauma

    • Diagnostic peritoneal lavage if blunt trauma not stable for CT

    • Laparotomy if penetrating trauma

    • Other ATLS protocol

    • Angiography occasionally useful for stable patients

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When to Admit

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  • • All hepatic traumas

    • ICU for unstable patients or those with high injury severity scores

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  • • Observation for most blunt trauma without active blood loss (CT grade poor predictor of success)

    • Treatment of coagulopathy

    • Pringle maneuver to control bleeding

    • OR

    • Other methods to control bleeding include:

    • -Drainage

      -Debridement

      -Hemostasis using clips or ligatures

      -Damage control laparotomy with packing of abdomen and plans for later removal of packs

      -Partial hepatic resection

      -Caval-atrial shunt

      -Angiography with embolization

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Surgery

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Indications

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  • • Shock and positive FAST or diagnostic peritoneal lavage after blunt trauma

    • Penetrating abdominal trauma

    • Possible major vascular injury on CT

    • Continued active bleeding following blunt trauma and absence of coagulopathy

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Medications

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  • • Blood products

    • Passive and active warming

    • Calcium if large transfusion requirement

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Treatment Monitoring

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  • • ICU monitoring

    • Liver function tests

    • CT for suspicion of infection or hemorrhage

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Complications

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  • • Hemorrhage

    • Sepsis

    • Liver failure

    • Biliary leak

    • Multi-organ failure

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Prognosis

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  • • 1% mortality for penetrating trauma

    • 10-20% mortality for blunt trauma

    • 70% mortality if 3 major organs including liver involved

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References

Asensio JA et al: Approach to the management of complex hepatic injuries. J Trauma 2000;48:66.  [PubMed: 10647567]
Asensio JA et al: Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angioembolization ...

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