Dr Richard Downey

 3 patients  7am  Single vehicle RTA  Head on collision with side of house  Speed unknown, DFB cut patients from car  Multidisciplinary care from arrival- ED team with referrals to General, Neuro and Orthopaedic surgeons

 RC, 52 yr old male  Unrestrained-Steering wheel broken  Injuries ◦ Traumatic SAH (no intervention) ◦ Suspected tension pneumothorax ◦ Flail chest and haemo-pneumothorax ◦ T1 facet joint # ◦ L2, L3, L4 TP # ◦ Left foot Lis Franc # (ORIF) ◦ Pancreatic collection

 33 yr old male  Front seat passenger-restrained  A-Airway patent  B-Air entry bilaterally, Chest drain inserted  C- BP 86/55, HR 79, IV access  D- No focal neurology  E- No thoracic wall tenderness  Trauma series Xrays, IV fluids, IV abx, Analgesia

 CT C spine ◦ NAD  CT Thorax ◦ Right 7 th and 8 th rib #’s, chest drain in situ ◦ Left 1 st and 2 nd rib #’s  CT Abdomen ◦ Segment 8 of liver laceration extending deeply to lie close to IVC, no vascular injury ◦ Fluid around GB and into pelvis (blood) ◦ Undisplaced # of right acetabulum

 Hepatobiliary team consulted  Conservative management, close monitoring of vitals and haematology/biochemistry markers  HB 12.5  CT 1/52 post injury ◦ Liver lac with residual fluid filled cleft in segment 8 of the liver. Appearances have improved, less peri hepatic fluid than on previous study

 21 yr old female  Back seat passenger-unrestrained  A-Airway patent  B-Air entry bilaterally, Chest drain inserted  C-BP 92/39, HR 116, IV access  D-Deformed shortened right lower limb  E- Teeth loss  Trauma series Xrays, IV fluids, IV abx, Analgesia

 CT C spine ◦ # Right mandible ◦ Mildly displaced  CT Brain ◦ NAD  CT Thorax ◦ # left 5 th and 6 th ribs ◦ Small to moderate pneumothorax  Plain film left Upper limb ◦ Non displaced humeral head # (Neer 2)

 CT Abdomen ◦ Segment 5 of liver-3cm irregular hypodensity consistent with grade 2-3 liver laceration ◦ Right kidney contusion ◦ Pericholecystic fluid, fluid within hepatorenal pouch of Morrison and a small amount of right perinephric fluid ◦ Spleen, pancreas, adrenals, left kidney-NAD ◦ No extravasation of contrast on delayed scan ◦ Undisplaced # of right acetabulum and left inferior pubic ramus

 Conservative management of liver laceration  Monitoring of vital signs and bloods  IM nailing right femur  Conservative management of renal contusion, catheterised  Physio and immobilisation of shoulder #

 Classical anatomical descriptions based on hepatic vasculature  Couinaud divided the liver into 4 sectors and 8 segments  Divided by 3 vertical and oblique planes defined by 3 main hepatic veins and a transvers plane through right and left portal branches

 Liver is largest solid abdominal organ with a relatively fixed position  Second most commonly injured organ in abdominal trauma after spleen  Most common cause of death after abdominal injury  Mechanism of injury-blunt abdominal trauma, particularly decelerating injuries in RTAs  Associated with rib #’s, pneumothorax, kidney and adrenal injuries

 Subscapular haematoma  Laceration  Intrahepatic haematoma  Contusion  Right lobe > Left lobe  Left lobe injuries associated with injury to duodenum,pancreas and transverse colon  45% of all liver injuries have splenic injury

 MECHANISM OF INJURY ◦ Penetrating wound to head, neck or chest ◦ Ejection of a patient from vehicle ◦ A fall greater than 6m ◦ Burns involving the head and neck  PHYSIOLOGY ◦ Systolic blood pressure less than 90mmhg ◦ Glasgow Coma Scale less than or equal to 8 ◦ Trauma patients requiring intubation  EMERGENCY DEPARTMENT ◦ Senior ED doctor discretion

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