Hepatic Trauma

• • Blunt versus penetrating trauma

  • High velocity vs low velocity trauma

  • Lacerations vs bursting injuries

Epidemiology

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

  • Second most common injury in penetrating abdominal trauma

Symptoms and Signs

• • Shock

  • Abdominal pain

  • Distended abdomen

  • Penetrating wounds

  • Ecchymosis

Laboratory Findings

• • Leukocytosis

  • Anemia (later in course)

  • Elevated transaminases

Imaging Findings

• • 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

• • Retrohepatic cava or hepatic vein injury

  • Portal triad injury

  • Coagulopathy

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

Rule Out

• • Additional abdominal injuries

• • 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

When to Admit

• • All hepatic traumas

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

• • 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

Surgery

Indications

• • 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

Medications

• • Blood products

  • Passive and active warming

  • Calcium if large transfusion requirement

Treatment Monitoring

• • ICU monitoring

  • Liver function tests

  • CT for suspicion of infection or hemorrhage

Complications

• • Hemorrhage

  • Sepsis

  • Liver failure

  • Biliary leak

  • Multi-organ failure

Prognosis

• • 1% mortality for penetrating trauma

  • 10-20% mortality for blunt trauma

  • 70% mortality if 3 major organs including liver involved

References