1. Supervisor: 鄭翰聰 Clerk: 孫慶芳 2017/04/20

2. Definition of Solid Organ Injury Injuries to the liver, spleen, kidney and pancreas Result in: − Shock − Hemodynamic instability − Evidence of continuing bleeding Indications for urgent laparotomy *Hemodynamically normal patients can often be managed nonoperatively, but should be admitted to the hospital for careful observation Referenvce: Advanced Trauma Life Support ATLS 9th Edition

3. Characters of Solid Organ Injury Difficult to diagnose on physical exam May lead to significant blood loss Grading of solid organs dependent on degree of: − Hematoma − Laceration − Avulsion AAST (American Association for the Surgery of Trauma) injury scale

4. Characters of Solid Organ Injury Injuries may present late, leading to further difficulty in assessment and management. The most common solid organs injured: Spleen and Liver

7. Diagnosis Focused Assessment with Sonography in Trauma (FAST) exam: −For hemodynamically unstable patients Intravenous contrast-enhanced computed tomography (CT): −definitively confirms the injury −defines the injury grade

8. Focused Assessment Sonography in Trauma (FAST)

9. FAST: Step 1. Pericardial view Pericardial view Start with the heart −Subxiphoid view −Parasternal view Fluid within the heart should be black

10. FAST: Step 2. RUQ view RUQ view Sagittal view in the midaxillary line 10 th, 11 th rib space Hepatorenal fossa (Morrison’s pouch) Diaphragm, liver, and kidney

11. FAST: Step 3. LUQ view LUQ view Sagittal view in the midaxillary line 8 th, 9 th rib space Splenorenal fossa Diaphragm, liver, and kidney

12. FAST: Step 4. Suprapubic view Suprapubic view A transverse view suspected damage to the pelvic region especially with blunt trauma optimally obtained prior to placement of a Foley catheter

14. Abdominal CT (with IV contrast) American Association for the Surgery of Trauma (AAST) classification system

15. AAST classification system: Liver Low-grade injuries (Grade I, II, III): Grade I −Hematoma: Subcapsular <10% surface area. − Laceration: capsular tear <1 cm parenchymal depth

16. AAST classification system: Liver Low-grade injuries (Grade I, II, III): Grade II: −Hematoma: subcapsular 10 to 50 % surface area −Intraparenchymal <10 cm in diameter −Laceration: capsular tear 1 to 3 cm parenchymal depth, <10 cm in length

17. AAST classification system: Liver Low-grade injuries (Grade I, II, III): Grade III −Hematoma: subcapsular >50% of surface area or ruptured subcapsular or parenchymal hematoma −Intraparenchymal hematoma >10 cm or expanding −Laceration >3 cm in depth

18. AAST classification system: Liver High-grade injuries (Grade IV, V) Grade IV −Laceration: parenchymal disruption involving 25 to 75% of a hepatic lobe or 1 to 3 Couinaud segments

19. AAST classification system: Liver High-grade injuries (Grade IV, V): Grade V: −Laceration: Parenchymal disruption involving >75% of hepatic lobe >3 couinaud’s segments within a single lobe −Vascular Juxtahepatic venous injuries; ie, retrohepatic vena Grade VI: Cava/central hepatic vein Hepatic avulsion “bear claw injury”

21. AAST classification system: Spleen

23. AAST classification system: Pancreas

24. Hepatic Trauma in Adults

25. Introduction The most frequently injured abdominal organ Minor (most common): − Non-operative management which consists of observation − Arteriography and embolization *May heal spontaneously Severe (about 14%): − Initially present with hemodynamic instability − Fail nonoperative management *Operative intervention Reference: Tinkoff, Glen, et al. "American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank." Journal of the American College of Surgeons 207.5 (2008): 646-655.

26. Mechanism of injury: Location of Liver *2 to 3 cm below the right rib margin, descends to as low as T12 with deep inspiration *high as the level of T4 (nipple) with expiration

27. Mechanism of injury Most common cause: Motor vehicle collision Other: − Injuries to the chest wall − Abdominal penetrating injuries *Factors determine the Severity of penetrating liver injury: Trajectory of the missile or implement (injuries can range from simple parenchymal to major vascular laceration)

28. Trauma evaluation: History and physical examination History of trauma: − Right upper quadrant − Right rib cage − Right flank Pain in: − RUQ or chest wall − Right shoulder (due to diaphragmatic irritation) *Other common findings indicative of intraabdominal injury: Abdominal tenderness and peritoneal signs

29. Trauma evaluation: History and physical examination Wall contusion or hematoma (eg, Seat belt sign) RUQ or generalized abdominal tenderness Right lower chest wall: − Tenderness − Contusion − Instability due to rib fractures

30. Seat-belt sign Sign in motor vehicle accident victims with abdominal injuries Indicative of an increased risk of intestinal injury Order of Injury frequency: −Hepatic −Intestinal −Splenic −Retroperitoneal injuries Wotherspoon, Sonya, Kevin Chu, and Anthony FT Brown. "Abdominal injury and the seat‐belt sign." Emergency Medicine 13.1 (2001): 61-65.

31. Contraindications to non-operative management Hemodynamic instability after initial resuscitation Other indication for abdominal surgery (eg, peritonitis) Gunshot injury (relative contraindication if extrahepatic injury is suspected). Absence of an appropriate clinical environment to provide monitoring, serial clinical evaluation, or availability of facilities and personnel for hepatic embolization or urgent abdominal exploration should the need arise.

32. Morbidity & Mortality Complications Complications following the management of liver injuries: Biliary tree disruption: − Formation of biloma − Persistent bile leak − May leads to Ascitis/abscess Hepatic necrosis − Related to angioembolization

33. Morbidity & Mortality Mortality: Low-grade (I, II, III): − rare High-grade injuries (IV, V, VI): − ranges from 10 to 42 %

34. Trauma evaluation: History and physical examination Other injuries are present in about 80 percent of patients with hepatic injury − Chest injury (most common) − Spleen (most commonly injured intraabdominal organ) − Other injuries associated with a blunt mechanism: lower rib fractures, pelvic fracture, and spinal cord injury

38. Thanks for your attention