1. Prognostic factors of liver trauma in polytraumatic patients. Results from 895 abdominal trauma cases Seven Lendemans et al. the trauma registry of the DGU.German society for trauma surgery. Prepared by: Hana Thabet Bin Azzan. Supervisor:Abdulhakim Altamimi.

3. Introduction Isolated trauma of the liver is a rare event in blunt injuries of severely injured patients. It is associated with clear increase in the post – trauma mortality due to the complex functioning of this organ.

4. As the liver injury increase in severity, other organ systems become involved. Liver involvement super proportionally increase the total mortality. Mortality rate after liver trauma ranges between 7 and 36%.

5. early mortality → blood loss. Late mortality  intensive medical  intensive medical treatment. treatment.  immunological failure:  immunological failure: ► sepsis /SIRS. ► sepsis /SIRS. ► multi-organ failure. ► multi-organ failure.

6. The liver is crucial to post traumatic recovery of severely injured patients.

7. 71 – 89% of all patients with blunt liver trauma can be successfully conservatively treated. Hemodynamically unstable patients must still be operated on.

9. GRADE I

10. GRADE II

11. GRADE III

12. GRADE IV

13. GRADE V

14. Objectives Whether the participating liver injury in polytraumatized patient super proportionally increase the incidence of sepsis multi – organ failure and whether survival after poly trauma is definitively decreased when the liver is involved.

15. Methods Between 1993 – 2005, a total of 24,771 patients from 113 hospitals were documented prospectively in the trauma registry of the German society of trauma surgery (DGU).

16. The eligibility criteria were used: Injury severity score (ISS) ≥ 16; Direct admission from the scene to a trauma center; No isolated head injury.

17. The studied groups are: “ liver trauma ” group: (abbreviated injury scale -AIS- (abbreviated injury scale -AIS- abdomen< 3 and liver 2 – 5). abdomen< 3 and liver 2 – 5). “ abdominal – non liver injury ” group: (AIS abdomen 2 – 5 and (AIS abdomen 2 – 5 and liver < 3). liver < 3).

18. “ non abdominal trauma ” or control group: control group: (AIS abdomen or liver <3). (AIS abdomen or liver <3).

19. The prognosis was made depending on: 1993 – 2002  TRISS score. 2003 – 2005  revised injury severity classification. (RISC)

20. The RISC takes into consideration: The age, anatomical pattern of injuries, the head injury, the sever pelvic trauma, clotting factors (PTT), the base excess, three indirect signs of bleeding (hypotension, low Hb – value, transfusion), as well as cardiac arrest.

21. The relation between actual mortality and prognosis  the standardized mortality ratio.

22. Statistics 1993 – 2001  data collected and entered on paper sheets. Since 2002  internet - based data entry soft ware with integrated plausibility checks.

23. Analysis with the statistical program (SPSS ). Incidence are presented by count and percentage. Continuous values with mean and standard deviation (SD). and standard deviation (SD). Descriptive statistics.

24. Statistical tests were avoided except in selected situation (chi square test for the incidence rate & U- test for continuous values).

30. Discussion Liver injuries almost always accompany injuries to other organ systems. There is clear liver specific increase in the incidence of sepsis from MOF and early and late mortality.

31. Publication by Strong and Trunkey reported: Mortality of over 11% in isolated liver injuries. there are significantly higher survival rates in patients with isolated liver injuries in comparison to poly traumatized patients. there are significantly higher survival rates in patients with isolated liver injuries in comparison to poly traumatized patients.

32. Dangleben et al, proved that the cirrhosis of the liver is an independent prognosis maker of mortality in poly trauma. Mortality increase as the degree of cirrhosis increase( according to Child – pugh). 55% of patients with cirrhosis of liver died from sepsis.

33. Child – Pugh Classification 3 points 2 point 1 point parameter > 3 2 -3 < 2 Serum biluribin (mg\dl) < 2.8 2.8 – 3.5 > 3.5 Serum albumin (g\dl) >6 4 – 6 1 - 3 Prothrombin time ( ↑-s) Moderate slight slightnoneascitis 3 – 4 1 – 2 noneencephalopathy

34. 33% of patients with cirrhosis died compared to only 1%in the non cirrhosis control group. The effect of liver resection resemble those of traumatic liver destruction in causing complications

35. →so depending on the quantity of liver tissue removed: Restriction of synthesis efficiency. e.g. coagulation products. e.g. coagulation products. ↓↓ clearance function of bacterial ↓↓ clearance function of bacterial endotoxin. endotoxin. →→ disseminated intravascular →→ disseminated intravascular coagulation, sepsis and multi coagulation, sepsis and multi organ failure or refractory shock. organ failure or refractory shock.

37. several studies on animal by Perdrizet and Perl et al showed: Increase in the early mortality in blunt liver trauma with hemorrhagic shock as aresult of continuous post ischemic shock. response to thorax trauma by the liver without liver it self being traumatized by production of kupffer cells, IL-6, IL-10 and TNF in higher concentration.

38. After poly trauma, immune modulating substances ( GM – CSF and gamma interferon) can contribute to improvement in post traumatic immunoparalysis.

39. in The group with severe liver trauma, there was clear increase in the number of ECs in the early and late phases of trauma. in The group with severe liver trauma, there was clear increase in the number of ECs in the early and late phases of trauma. There was clear connection between the number of transfused erythrocytes and the occurrence of post traumatic organ failure.

40. The blood products increase the incidence of sepsis due to their antigenicity. The blood products increase the incidence of sepsis due to their antigenicity. The number of transfused blood products is always a marker for injury severity, incidence of shock and length of ischemia time.

41. the number of transfused ECs is independent prognosis factor in the post traumatic period after liver trauma. in the post traumatic period after liver trauma.

42. Despite similar ISS and number of transfused ECs, the patients with severe liver participation continue to predominate, with regard to mortality, sepsis and MOF.

43. Conservative therapy of blunt liver trauma in hemodynamically stable patient associated with decrease in the mortality rate by 2.4% blunt liver trauma in hemodynamically stable patient associated with decrease in the mortality rate by 2.4%

44. In some series of 495 conservatively treated patients, the Success rate was 94% and the average hospital treatment was 13 days, where only 1.9 ECs / patients had to be given a transfusion. The complication rate was 6.2%, where there was only 2.8% with hemorrhage. liver related death or overlooked intestinal injuries were not observed. Success rate was 94% and the average hospital treatment was 13 days, where only 1.9 ECs / patients had to be given a transfusion. The complication rate was 6.2%, where there was only 2.8% with hemorrhage. liver related death or overlooked intestinal injuries were not observed.

45. Laprotomy is probably an over treatment in most patients with type I –III injuries and seem to be of no real advantage regarding survival, morbidity and duration of treatment. Time from arrival at the ER. To the laparotomy has crucial effect on the outcome

46. Parameter of unstable patients: Location of the source of bleeding. Volume loss. → substitution is required when Bp≤ 90. Signs of systemic hypo perfusion → negative base excess & pH. → negative base excess & pH. → initial Hb under 8. → initial Hb under 8. → consumptive coagulopathy. → consumptive coagulopathy.

47. The immunological changes expected from a liver injury in the meantime may possibly the meantime may possibly even reinforce the frequently even reinforce the frequently described post trauma described post trauma immunosuppression. immunosuppression.

48. conclusion Severe liver trauma is independent predictor for severe hemorrhage with substantially increased risk of sepsis MOF and trauma related death.

49. While conservative treatment of patients with liver trauma but no Hemorrhage is effective, patients with hemodynamic instability seem to be from a sub group where contemporary treatment modalities are not yet sufficient. Hemorrhage is effective, patients with hemodynamic instability seem to be from a sub group where contemporary treatment modalities are not yet sufficient.

50. Thanks