Severe blunt liver injury: reappraisal of criteria for nonoperative management decision. Experience with 88 cases

AIM OF THE STUDY: To analyze the predictive value of computed tomography (CT) and initial physiologic and laboratory data findings in the immediate operative (OP) or non-operative (NOP) management of blunt liver injury (BL). METHODS: Eighty-eight BL, grade III (51), grade IV (28) and nine grade V (9), aged 26.2 years (16-75) were identified. Hemoperitoneum on CT, hemodynamic status, physiologic and laboratory data <24 hours or preoperative (transfusion, vascular filling) and follow-up >48 hours were analyzed. RESULTS: Data of 71/88 (80%) NOP and 17/88 (20%) OP patients were reviewed. A secondary laparotomy or laparoscopy was necessary in 11/71 TNO. Six OP (35%) and 1 NOP patients died. Blood units transfused were 1.33 (0-10) vs 5.9 (0-22) and vascular filling 1.45 (0.5-5.5) vs 3.6L (2-12) (P<10(-6), P<4.10(-3) respectively). NOP patients had less severe hemoperitoneum (31 vs 94%, P<10(-5)) and hemodynamic instability (8.5 vs 94%, P<10(-4)). But, there was an overlap of values of blood units transfused, amount of vascular filling and initial haemoglobin levels between NOP and OP patients and among CT grades of liver injury. No cut-off values could be determined: 33% NOP received >4 blood units and >3 L vascular filling; 30% had severe hemoperitoneum. In OP group 23.5% patients had lower values and no severe hemoperitoneum. CONCLUSION: In the management of BL, vascular filling and blood transfusion increased with the grade of CT liver injury and were globally more elevated in the operative group but did not individually correlate with hemodynamic stability and did not authorize, by themselves, to decide between operative versus non-operative management.     

Liver abscess after non-operative management of blunt liver injury

BACKGROUND: The non-operative management of blunt liver trauma can be applied in almost 80% of patients with this type of injury, with the advantages of the need for fewer blood transfusions, less intra-abdominal sepsis, and a better survival rate, than with the operative approach. However, liver abscess, as a known complication of the non-operative management of blunt liver trauma, is discussed infrequently. Therefore, we herein review our experience and describe this complication in detail. MATERIALS AND METHODS: From 1995 to 2001, 674 patients were admitted to our hospital due to blunt hepatic trauma. Among these patients, 279 underwent laparotomy and the remaining 395 patients were treated non-operatively. Twenty-two patients were identified as having liver abscess, with 16 of them belonging to the operative group, and six to the non-operative group. A retrospective review of these six patients and their characteristics, as well as pathogenesis, diagnosis, and the management of the liver abscesses, was conducted. RESULTS: These six patients were all male, with a median age of 19.5 years (range 3-24). The median injury severity score was 16.5 (range 9-25); three patients sustained grade-3 hepatic injury, and the other three were grade 4. The main diagnostic tool was abdominal computed tomography, and the abscesses took a median of 6 days (range 1-12) to form and be diagnosed. The abscesses were usually caused by infection from mixed organisms, and an abscess resulting from Clostridium infection developed within 1 day after injury. These abscesses were treated with antibiotics and drainage, and the median length of hospital stay was 26 days (range 8-44), without mortality or long-term morbidity. CONCLUSION: Liver abscess as a complication of the non-operative management of blunt hepatic trauma is a rare entity, with an incidence of 1.5% (6/395). It is usually seen in severe liver injury (grade 3 and above), but all our patients were all treated successfully, with no mortality. However, prolonged hospitalization may be required in this patient group.     

Nonoperative management of major blunt liver injury with hemoperitoneum

We evaluated the role of nonoperative therapy in 16 patients with blunt multisystem trauma, hemodynamic stability following resuscitation, and major lobar liver injury; the patients were treated with a protocol of intensive care unit observation and computed tomographic scanning to identify and follow up the hepatic lesion. Computed tomographic scans showed right-lobe or bilobar liver lacerations and/or subcapsular hematomas in all patients and associated hemoperitoneum in 8 patients. Exploration was required in 2 patients; both were found to have a hemoperitoneum and a nonbleeding liver laceration. There were no deaths. Patients with hemoperitoneum requiring transfusion had significantly greater injury severity scores and longer intensive care unit and hospital stays. The major advantage of a nonoperative approach is the opportunity to stabilize major extra-abdominal (particularly head) injuries as the first priority. Unstable hemodynamics, abdominal distension, and falling hematocrit are indications for prompt exploration. Nonoperative care of these injuries requires a strict treatment protocol.     

Selective nonoperative management of blunt liver injury using computed tomography

Computed tomographic (CT) scans are used to evaluate victims of blunt trauma for abdominal injury when reasons for immediate laparotomy are not present. Twenty-four patients whose CT scans showed liver injuries that were small parenchymal lacerations or intrahepatic hematomas were managed without laparotomy. Intra-abdominal blood was absent or estimated to be less than 250 mL in volume. None of the patients were in shock; six patients required transfusions, none for acute abdominal bleeding. None of these patients subsequently required laparotomy or showed hepatobiliary problems at a follow-up examination less than one year later. Five follow-up scans showed varying degrees of resolution. Two patients died of severe head injury, but the liver injury did not contribute to the cause of death. Other patients with more severe blunt liver injury who were treated nonoperatively developed significant complications that required delayed surgery. It seems that patients with limited liver injury diagnosed by CT scan and selected by strictly applied criteria can be managed safely without laparotomy in a setting where rapid evaluation and treatment of any potential complication is available.     

Diagnosis and management of bile leaks after blunt liver injury

BACKGROUND: Nonoperative management (NOM) of blunt liver injuries (BLIs) is common, but little data exist on the management of complications related to NOM. Furthermore, bile leaks are emerging as frequent complications of NOM. The goal of this study was to determine which BLI patients are at greatest risk for bile leaks and how to manage this complication. METHODS: Patients treated with NOM, including angiographic embolization (AE) and observation, were compared with those undergoing operation (OR). Mortality, hospital length of stay, liver-related complications, and severity of liver injury were compared among the groups. RESULTS: Two hundred eighty-one patients sustained a BLI from 1997 through 2004. The Injury Severity Score and age of the groups were similar. The mortality rate of the OR patients was higher (P = .02). All bile leaks occurred in patients with a liver Abbreviated Injury Score (AIS) of > or = 4. For survivors of more than 4 days, 71% of OR, 50% of AE, and 17% of observed patients developed bile leaks. For the OR and AE groups, HIDA scanning detected all leaks, leading to earlier drainage procedures. Detection of a bile leak in NOM patients before 5 days of hospitalization led to shorter HLOS, P = .02. No patient with a negative HIDA scan developed a subsequent bile leak. CONCLUSIONS: NOM of BLIs is associated with lower mortality, but significant complications. Bile leaks are more common in patients with higher liver AIS, and in this study presented in only those with liver AIS > or = 4. HIDA scanning successfully diagnosed all patients with bile leaks and led to less invasive drainage procedures over time and shorter HLOS.     

成人钝性肝损伤的非手术治疗

目的：评价成人钝性肝损伤非手术治疗的效果。
方法：回顾性分析近6年间非手术治疗96例成人钝性肝损伤患者的临床资料。其中肝外伤I级者51例（53.1%）,Ⅱ级30例（31.3%）,Ⅲ级12例（12.5%）,Ⅳ级3例（3.1%）。诊断包括病史、超声检查,腹腔穿刺及CT检查。入院后监测生命体征,并给予对症支持治疗。
结果：非手术治疗成功87例,成功率90.6%,中转手术治疗9例。共发生并发症15例,包括右侧胸腔积液12例,肝周脓肿3例,经对症处理后均痊愈。
结论：对钝性肝损伤施行非手术治疗是可行的;严格选择适应证、注意监测血流动力学、超声及CT等辅助检查,是提高成功率的关键。

     

Reevaluating the management and outcomes of severe blunt liver injury

BACKGROUND: The purpose of this study was to identify risk factors that predict the need for operative management (OM) of severe blunt liver injury. We also sought to determine the impact of interventional angiography (Ang) in the treatment and outcomes of these patients. METHODS: Patients with blunt liver injuries of grade IV or higher were retrospectively reviewed for their demographics, hemodynamics, blood product requirements, laboratory and radiologic data, hospital course, and outcomes. RESULTS: Forty-four patients underwent OM. They had a significantly higher Injury Severity Score (ISS) and lower Glasgow Coma Scale score (p = 0.004), a lower systolic blood pressure (p = 0.002) and a higher heart rate (p = 0.02), and higher fluid and transfusion requirements (p < 0.001) than those treated without OM. Their mortality rate was 66%; 59% of deaths were from uncontrolled bleeding. Initial platelet count and fluid requirements at 4 hours were independent predictors of the need for OM. Ang was performed in 48 patients. Patients who were treated without Ang required more fluids (p = 0.03) and more packed red blood cells (p = 0.02) at 4 hours. Patients requiring both OM and Ang had a higher complication rate (p = 0.02) and longer intensive care unit and hospital length of stay (p < 0.001) than those who had OM alone, but mortality was the same (p = 0.1). Patients treated nonoperatively had longer intensive care unit (p = 0.006) and hospital stays (p < 0.05) if they required Ang, but mortality was the same. The only survival advantage to the use of Ang was when Ang alone was compared with OM alone. CONCLUSION: Select high-grade injuries can be successfully managed nonoperatively. Initial platelet count and crystalloid fluid use at 4 hours predict the need for OM. Patients requiring OM are less stable and have substantial mortality but often do not die as a result of uncontrolled bleeding. Ang has a role in stable patients who do not require OM initially but does not improve outcome in patients who require OM.     

Design and injury assessment criteria for blunt ballistic impacts

BACKGROUND: Less-lethal technologies are used in situations where lethal force is not warranted; however, a variety of injuries have been reported. Design and injury criteria are needed to assess the safety of these munitions. METHODS: Injury data from ballistic impacts of cadavers were analyzed to validate design and injury criteria. Logistic regression analysis determined the predictive ability of the blunt criterion (BC) for munition design and the viscous criterion (VC) for injury risk assessment. Differences in risk for men and women were determined. RESULTS: For a 50% risk of Abbreviated Injury Scale 2 or 3 thoracic injury, BC = 0.37 (chi = 17.71, p = 0.001) and VCmax = 0.8 m/s (chi = 11.28, p = 0.001). The 5th percentile female subject has a 36% lower tolerance to ballistic energy than the 50the percentile male subject. CONCLUSION: The BC can be used in the development of kinetic energy munitions and the VC for testing impact injury risk. These criteria provide much needed tools for the development and progression of less-lethal munitions.     

Pediatric blunt liver injury and coagulopathy managed with packs and a silo: case report

Packing the abdomen can be lifesaving when severe hepatic trauma is complicated by refractory hypothermia, coagulopathy, and continuing hemorrhage requiring large-volume transfusion. This report describes the successful use of abdominal packs and a modified silo in a child following blunt liver injury.     

钝性脾损伤非手术治疗探讨

目的 探讨钝性脾损伤非手术治疗的监测和治疗方法.方法 回顾分析2005年9月至2008年4月连续收治的95例钝性脾损伤患者中行非手术治疗的82例(86.3%)患者的临床资料.其中75例应用经皮腹腔穿刺置管引流、监测腹腔出血,38例行非术中自体血回输.全部病例随访3周～8个月.结果 82例非手术治疗全部成功,其中Ⅲ～Ⅳ级钝性脾损伤34例、55岁以上者6例、损伤严重度评分≥16分者14例.37例腹腔出血量500 ml,引流腹腔血量30～2400 ml.38例回输自体血量共23 300 ml,平均613 ml.随访除脾介入术后并发脾假性囊肿1例外,无延迟出血、腹腔感染等并发症发生.结论 大多数血流动力学稳定的钝性脾损伤可通过非手术治疗治愈.运用经皮腹腔穿刺置管引流回收并监测腹腔出血及非术中自体血回输技术,可明显提高钝性脾损伤的非手术治疗率和成功率.     

闭合性胰腺合并十二指肠联合损伤的急诊处置

目的 研究胰腺十二指肠复合伤的急诊处置方法。方法 回顾性分析本院1998年1月～2007年4月严重闭合性腹部损伤行手术探查者117例,研究其中胰腺十二指肠联合伤5例的处置经过。结果 胰腺十二指肠联合伤占本组腹部闭合性损伤的4．3％,5例均抢救成功,1例并发十二指肠漏保守治疗。2例胰腺断裂患者经不同处置,结果均良好。结论 及早手术探查修复损伤、有效的引流是抢救成功的关键;胰腺污染血在一定条件下是可以利用的。     

Hepatic haematoma following blunt injury: non-operative management

Four patients with multiple injuries including suspected closed hepatic injury are described, all of whom needed resuscitation in the Intensive Care Unit. All 4 had local signs suggesting hepatic injuries, but no evidence of generalized intraperitoneal bleeding.They were carefully monitored clinically, and the suspected diagnosis of hepatic haematoma was confirmed by ultrasound scanning and follow-up with repeated scans until complete resolution occurred. All made a satisfactory recovery and are well and asymptomatic, except for one patient who has residual orthopaedic disabilities.     

Pediatric blunt vertebral artery injury: case report and treatment plan

Aggressive screening for blunt cerebrovascular injuries in patients with trauma has led to the identification and successful treatment of these injuries. We report the case of an 8-year-old boy who sustained a vertebral artery injury after a motor vehicle collision. Computed tomography angiogram showed an 8-mm thrombosed segment of the vertebral artery. The patient was initially anticoagulated with a heparin drip and transitioned over to treatment with enoxaparin sodium (Lovenox). With few reports in the literature of blunt cerebrovascular injuries in the pediatric population, a review of the appropriate screening parameters, treatment plans, and follow-up is helpful for the practicing physician.     

Pediatric aortoiliac injury following blunt abdominal trauma: A case report

IntroductionThe most common mechanism of aortic injury involves motor vehicle collisions resulting in aortic disruptions, occurring almost exclusively in the chest. Injury to the abdominal aorta following blunt trauma is nearly twenty times less likely to occur than the thoracic aorta. Because of the low incidence, there are few reports regarding the presentation and repair of these particular injuries, especially in the pediatric population.Presentation of caseWe present a case of a 7-year-old boy involved in a high speed motor vehicle accident with an abdominal aorta transection at the aortic bifurcation extending into the left iliac artery. The injury was repaired using bovine pericardium with the adventitia and intima of the vessel approximated over the bovine bridge.DiscussionPrimary repair of thoracic aortic injury has been thoroughly described in the literature with good outcomes yet, abdominal aortic repair remains ambiguous. Few techniques and materials have been described with even less data surrounding the long-term outcomes.ConclusionBovine pericardium is a strong and stable acellular collagenous material with the potential to accelerate endothelialization and tissue regeneration. This remains an interesting field of research as stenosis and pseudo-coarction data have yet to be determined.     

Non-operative management of blunt liver injuries

Over a 10-year period 281 patients with liver injuries following blunt abdominal trauma were seen at Westmead Hospital. A decision to treat the liver injury without an operation was made in 55 (20 per cent) of the 281 patients. Two of these 55 patients required a subsequent laparotomy, one for continued bleeding and one for a bile leak. No patient died from a missed intra-abdominal or retroperitoneal injury or from concealed haemorrhage. These patients were compared with 181 patients with liver injuries who were operated on. The two groups of patients could be distinguished in terms of their clinical status on arrival at the hospital, the magnitude of their injury and the sequelae of the injury. Non-operative management proved a safe alternative to an operation in appropriate patients, but a laparotomy to exclude unsuspected intra-abdominal injuries is associated with little significant morbidity and offers some reassurance in managing patients with multiple injuries.     

Risk factors for liver abscess formation in patients with blunt hepatic injury after non-operative management

Purpose

To identify risk factors for liver abscess formation in patients with blunt hepatic injury who underwent non-operative management (NOM).

Methods

From January 2004 to October 2008, retrospective data were collected from a single level I trauma center. Clinical data, hospital course, and outcome were all extracted from patient medical records for further analysis.

Results

A total of 358 patients were enrolled for analysis. There were 13 patients with liver abscess after blunt hepatic injury. Patients with abscess had a significant increase in glutamic oxaloacetic transaminase (GOT, p = 0.006) and glutamic pyruvic transaminase (GPT, p < 0.0001), and a decrease in arterial blood pH (p = 0.023) compared to patients without abscess in the univariate analyses. In addition, high-grade hepatic injury and transarterial embolization (TAE, p < 0.001) were also risk factors for liver abscess formation. Five factors (GOT, GPT, pH level in the arterial blood sample, TAE, and high-grade hepatic injury) were included in the multivariate analysis. TAE, high-grade hepatic injury, and GPT level were statistically significant. The odds ratios of TAE and high-grade hepatic injury were 15.41 and 16.08, respectively. A receiver operating characteristic (ROC) analysis was used for GPT, and it suggested cutoff values of 372.5 U/L. A prediction model based on the ROC analysis had 100 % sensitivity and 86.7 % specificity to predict liver abscess formation in patients with two of the three independent risk factors.

Conclusions

TAE, high-grade hepatic injury, and a high GPT level are independent risk factors for liver abscess formation.     

Nonoperative management of blunt renal injury: a need for further study

Background

Blunt renal injury in children is usually managed without an operation. However, there are no published guidelines for nonoperative management. Therefore, we conducted a retrospective review to examine the natural history of these injuries and to identify potential recommendations for management.

Methods

A retrospective analysis of our most recent 12-year experience with blunt renal injury was performed.

Results

One hundred eleven trauma patients were identified as having a renal injury. Mean age was 10.8 ± 4.4 years with a weight of 43.1 ± 20.8 kg and 65% of the patients were males.In patients with an isolated renal injury (n = 65), the mean length of bed rest was 3.8 ± 1.9 days, resulting in a mean length of hospitalization of 3.8 ± 3.1 days. There were no transfusions, and the only operation for renal trauma was a nephrectomy in a patient with existing end-stage obstructive nephropathy of that kidney.There were 15 patients discharged with persistent hematuria, none of which had long-term sequelae.

Conclusion

Our data suggest the risk of significant injury from blunt renal trauma is low, and clearance of hematuria is not likely an important parameter such that bed rest with serial blood and urine monitoring may not be justified. There is clearly a role for the prospective application of a more liberal management protocol.     

Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children

Objective(s)

The current management of blunt spleen/liver injury in children requires a number of days of bed rest equal to the grade of injury plus 1. This protocol is used even when there is no clinical indication of ongoing bleeding. To establish a prospective protocol with an abbreviated period of bed rest, we conducted a retrospective review of our blunt spleen and liver trauma experience to examine the safety of such an attenuated protocol.

Methods

A retrospective analysis of our most recent 10-year experience (January 1996 to December 2005) with blunt spleen or liver injury was performed. Patient demographics, vital signs, hemoglobin levels, need for transfusion, operations, and outcomes were measured. An abbreviated protocol using 1 night of bed rest for grades 1 and 2 injuries and 2 nights of bed rest for higher grades was designed. This protocol was then applied to our patient population to assess its safety. Data are expressed as mean ± SD.

Results

During the study period, 243 patients were admitted with blunt spleen and/or liver injury. The mean patient age was 9.0 ± 4.6 years, and the mean weight was 35.3 ± 19.3 kg. Sixty-three percent were male. The spleen was injured in 148 (61.2%) patients and the liver in 121 (50.0%), and 26 (10.6%) had both. The mean grade was 2.0 ± 1.1, for which the mean bed rest was 3.5 ± 1.1 days. This resulted in 5.6 ± 6.5 days of hospitalization. There were 9 patients who died, 7 with severe brain injury and 2 with massive liver hemorrhage on presentation. No patient required an operation or transfusion after 2 nights of observation who did not have clinically obvious signs of ongoing blood loss. Implementation of the abbreviated protocol would have affected 65.8% of our patients and would have saved a mean of 2.0 ± 1.5 hospital days per patient.

Conclusions

According to our data, an abbreviated trauma protocol with overnight bed rest for grades 1 and 2 injuries and 2 nights for higher grades could be safely used. This protocol would immensely improve current resource use. Based on these retrospectively collected data, we have initiated a prospective consecutive controlled series to assess the safety of such an attenuated protocol.     

Prospective evaluation of criteria for the nonoperative management of blunt splenic trauma

Recent reports have shown an increased mortality associated with the nonoperative management of blunt splenic injury. We have prospectively applied criteria developed from our previous 15-year experience for the nonoperative management (NOM) of blunt splenic injury. These criteria consist of 1) hemodynamic stability on admission or after initial resuscitation with up to two liters of crystalloid infusion, 2) no physical findings or any associated injuries necessitating laparotomy, and 3) a transfusion requirement attributable to the splenic injury of 2 units or less. From 1994 through 2000 a total of 99 patients presented with blunt splenic injury. Thirty-one patients (31%) underwent splenectomy secondary to hemodynamic instability. During the observation period eight of the 68 patients (12%) who initially met criteria for NOM developed hemodynamic instability and underwent splenectomy. All NOM failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the NOM (Group I) or in the group failing NOM (Group II), and no associated morbidities from the splenic injury were seen in either group. No significant differences were seen between Groups I and II in terms of age, gender, mechanism of injury, Injury Severity Score, admitting systolic blood pressure, admitting hemoglobin, transfusion requirements, intensive care unit length of stay, or total hospital length of stay (all P > 0.200). We conclude that established criteria for intervention and careful observation in an intensive care setting for at least 72 hours will minimize morbidity or mortality associated with blunt splenic injury in adults.