Rosen & Barkin's 5-Minute Emergency Medicine Consult (335 page)

BASICS

• The size and location of the liver places it at significant risk for injury:
  
  • The liver is the solid organ most frequently injured in penetrating trauma.
    
  • The liver is the 2nd most commonly injured in blunt abdominal trauma, 2nd to the spleen.
    
  • Highly susceptible to blunt injuries, by direct blow or deceleration forces
    
• Mechanism of injury and description of forces are important factors in evaluating patients for possible hepatic injury:
  
  • Blunt trauma:
    
    • Obtain information about the forces and direction (horizontal or vertical) of any deceleration or compressive forces.
      
  • Penetrating trauma:
    
    • Type and caliber of the weapon
      
    • Distance from the weapon
      
    • Variety and length of knife or impaling object
      
• Hepatic injuries are graded by severity, ranging from subcapsular hematoma and lacerations to severe hepatic fragmentation.
  
• Associated conditions include rib fractures and injuries to the spleen, diaphragm, kidney, lung, gallbladder, pancreas, and blood vessels.
  
• Overall mortality of hepatic injury is reported at 8–10%.
  
• More often nonoperative management is becoming more common in isolated blunt hepatic trauma.
  

Poorly developed musculature and relatively smaller anteroposterior diameter increase the vulnerability of liver to compressive forces in children.

Trauma:

• Blunt mechanism:
  
  • Deceleration
    
  • Acceleration
    
  • Compression
    
• Penetrating mechanism:
  
  • Stab wound
    
  • Gunshot wound
    
  • Impaled object
    

DIAGNOSIS

Physical exam and history can be variable.

History of trauma usually available from patient or pre-hospital providers

• Neither sensitive nor specific for hepatic injury
  
• Systemic signs related to acute blood loss:
  
  • May present with dizziness and weakness
    
  • Signs of shock including tachycardia and hypotension
    
• Local signs:
  
  • Right upper quadrant tenderness
    
  • Guarding
    
  • Abdominal distention
    
  • Rigidity
    
  • Rebound
    
  • Tenderness
    
  • Contusions/abrasions
    
  • Penetrating wounds to the right chest, flank, or abdomen
    

• Physical exam is unreliable.
  
• Objective evaluation includes imaging of the abdomen or surgical exploration.
  

• No hematologic lab studies are specific for diagnosis of injury to the liver.
  
• Obtain baseline hemoglobin level.
  
• Liver function tests are not helpful in the acute setting.
  
• Consider type and cross if active hemorrhage is suspected.
  

• Consider imaging based on mechanism and physical exam.
  
• Plain abdominal radiographs:
  
  • Little value
    
• Bedside US:
  
  • Screening tool for both blunt and penetrating abdominal trauma
    
  • Procedure of choice in unstable patient
    
  • May identify intra-abdominal fluid in the hepatorenal (Morison) pouch or parenchymal injuries
    
  • Suggests intra-abdominal hemorrhage in patient with blunt, multiple-organ trauma
    
• CT scan with IV contrast:
  
  • Best depicts extent of hepatic injury and injuries to adjacent organs
    
  • Requires patient to be hemodynamically stable
    
  • Extravasation of IV contrast during arterial phase of CT injection indicative of vascular or high-grade liver injury requiring surgical intervention
    

• Diagnostic peritoneal lavage (DPL):
  
  • Rarely performed; usually done in conjunction with trauma surgeon
    
  • Sensitive for presence of hemoperitoneum
    
  • Nonspecific for source of bleeding
    
  • Surgery and exploratory laparotomy if positive
    
  • Operative management may be necessary for unstable patients and those with high-grade lesions.
    
• Lower-grade injuries have been increasingly managed successfully without surgery.
  

• Other causes of intraperitoneal injury
  
• Retroperitoneal injury
  
• Thoracic injury
  
• Diaphragmatic injury
  
• Splenic injury
  
• Vascular injury
  

TREATMENT

• Obtain details of mechanism of injury.
  
• Initiate large-bore IV access:
  
  • Hemorrhage may be rapid and life-threatening.
    
• Moist saline dressings over penetrating wounds or evisceration
  
• Direct pressure to control active bleeding
  
• Full spinal immobilization except in isolated penetrating trauma
  

ABCs:

• Control airway as needed; may have associated injuries including head injury.
  
• Supplemental oxygen, cardiac monitor, pulse oximetry
  
• Adequate IV access, including central line, intraosseous line, and cut down as dictated by the patient’s status
  
• Fluid resuscitation, initially with 2 L of crystalloid (normal saline or Ringer lactate), followed by blood products such as packed red blood cells. Consider fresh frozen plasma (FFP) as needed.
  

• Immediate laparotomy may be appropriate in the acutely injured patient with the following conditions:
  
  • Hemodynamic instability
    
  • Gunshot wounds to the anterior abdomen
    
  • Frank signs of intraperitoneal hemorrhage
    
  • Indications based on diagnostic procedures, such as DPL
    
  • Failure of nonoperative management
    
• Stab wounds can be managed by local wound exploration followed by US or DPL when intraperitoneal penetration is not demonstrated or equivocal.
  
• Consider nonoperative management for the following patients:
  
  • Hemodynamically stable with normal mental status
    
  • No evidence of other intra-abdominal injury
    
  • Isolated low-grade (1–3) hepatic injury confirmed by imaging study
    
  • Transfusion requirements ≤2 U of packed red blood cells
    
• High-grade liver injuries (4 and 5) have less successful nonoperative rates.
  
• Diet: Nothing per mouth (NPO)
  
• Activity: Strict bedrest
  
• Special therapy:
  
  • Angiography with embolization: Selective use in patients with persistent bleeding may decrease the need for operative management and blood transfusions
    
  • Factor VIIa and prothrombin complex have been used as an adjunct in nonoperative management to control significant bleeding.
    

• Crystalloid IV fluids: NS or lactated Ringer
  
• Packed red blood cells
  
• FFP
  
• Recombinant factor VIIa: 15–30 μg/kg IV bolus every 4–6 hr until hemostasis is achieved
  
• Prothrombin complex concentrate (PCC): 50 U/kg IV
  

FOLLOW-UP

• All patients with hepatic injury require hospitalization for definitive laparotomy or close hemodynamic observation with serial exams or CT scans, as well as hematocrit measurements.
  
• ICU admission is often indicated in the 1st 48 hr after injury.
  

Patients with proven or suspected hepatic injuries should not be discharged.

Report all gunshot and stab wounds to appropriate local authorities.

Follow-up US, physical exam, and hematocrits are crucial in noting changes in initially benign presentations.

• Obtain early surgical consultation in unstable patients.
  
• Failing to obtain appropriate and adequate imaging studies is a pitfall.
  
• Do not rely on negative US to rule out hepatic injury.
  
• Failing to adequately resuscitate with IV fluids and blood products is a pitfall.
  
• If hepatic injury is confirmed, ensure no trauma to surrounding organ systems.
  
• Check for pregnancy in women.
  

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