Liver Injuries Liver - # 2 most commonly injured organ in blunt abdominal trauma Right Lobe >>> Left Lobe Posterior segment > anterior segment Caudate injury is rare, usually in assoc w/ right or left lobe injury Mortality blunt traumatic hepatic trauma – 8-25% (uncontrolled hemorrhage)

Liver Injury Forms Laceration Intrparenchymal hematoma Infarction Subcapsular hematoma

American Association of Trauma Surgery – Hepatic Injury Scale I – Capsular tear, < 1 cm parenchymal depth II – Parenchymal tear, 1-3 cm depth III – Parenchymal disruption, > 3cm depth but involving < 25% of the hepatic lobe IV – Parenchymal disruption, 25-50% of hepatic lobe V – Parenchymal disruption - > 50% of hepatic lobe VI – Hepatic avulsion

22 yr female Driver of pick up truck rear-ended by another truck @ 40mph Hemodynamically stable – BP 140’s/70’s, HR 80’s Abdomen – soft, nondistended, tender w/ voluntary guarding Also with open LE fx Hct 4334 during hospital course ALT 599, Alk phos 73, LA 1.7 CT Abd/pelvis done Grade IV Liver laceration V-shaped – occupies entire 4a segment Intact hilum Subcapsular hematoma Free fluid in pelvis No active extravasation Management – SICU observation, no transfusions, HD stable, 5 days bed rest, on floor, plan to d/c to home

CT Abd/pelvis – Grade IV Liver Laceration

CT Abd/pelvis – Grade IV Liver Laceration

CT Abd/pelvis – Grade IV Liver Laceration

CT Abd/pelvis – Grade IV Liver Laceration

Management Options Non-operative management of blunt hepatic and splenic injuries = TOC in HD stable pts, irrespective of injury grade No evidence for routine imaging of HD stable, clinically improving pt HD unstable = surgery vs. selective hepatic artery embolization (portal system supplies flow to de-arterialized tissue until collaterals develop)

References Practice Management Guidelines for the Nonoperative Management of Blunt Injury to the Liver and Spleen, 2003 Eastern Association for the Surgery of Trauma Nonoperative management of blunt hepatic trauma: The exception or the rule?, Journal Trauma 1994. Jason Zolak CC IV