Mechanisms of Abd. Trauma
Spleen, Liver – most commonly injured organs in blunt trauma
SI, LI, Liver – most commonly injured organs in penetrating trauma
Abdominal Trauma – Basic Approach
Penetrating abdominal trauma or traumatic acute abdomen --> OR
Blunt abdominal trauma with equivocal exam + HD instability --> FAST or DPL
Blunt abdominal trauma with equivocal exam + HDS --> CT or Observation
Splenic Trauma:
Historical Overview
1970s: recognition of immunologic importance
1980s: adult splenorrhaphy techniques, non-op management in peds
1990s: Non-op management in adults, splenic artery embolization
Overwhelming Post Splenectomy Infection (OPSI)
More common in Peds
0.21 incidence/1000 patient years incidence in asplenic adults
50% fatal
Associated with encapsulated organisms
- Strep pneumoniae >60%
- Hemophilus influenzae
- Neisseria meningitidis
Prevention
Trivalent vaccination decreases the risk by ~50%
For elective cases best given > 2 weeks preop
If given post op, ~ 2 weeks = optimal time for postop vaccine
Some data to support re-dose of pneumococcal vaccine at 5 years
Presentation
Fever
Upper Respiratory Infection
Rapid progression: septic shock, DIC, multi-system organ failure
Blunt Splenic Injury (BSI): Management Options
Blunt splenic injury --> operative management or non-operative management (observational vs. splenic artery embolism)
2008 Review of non-operative management:
- lack of prospective, randomized data
- much variability in practice
AAST Grading
I) Low grade
- hematoma subcapsular, <10% surface area,
- laceration capsule, <1 cm parenchymal depth
II) Low grade
- Hematoma subcapsular, 10-50% surface area, < 5cm diameter,
- laceration 1-3 cm in depth which does not involve trabecular vessel
III) High grade
- Hematoma subcapsular, >50% surface area or expanding
- Ruptured subcapsular or parenchymal hematoma
- Intraparenchymal hematoma >5cm or expanding
- Laceration >3cm depth or involving trabecular vessel
IV) High grade
- Laceration involving segmental or hilar vessels producing major
- Devascularization (>25% of spleen)
V) High grade
- Laceration, completely shattered spleen
- Vascular, hilar vascular injury which devascularizes spleen
Higher grades tend to fail NOM more
Not predictive in individual cases
Useful to standardize research
In blunt injury spleen tends to fracture along avascular plains between segmental vessels
Hemodynamic Instability Score - more helpful than grading
Grade 0: No significant hypotension (SBP < 90mmHg or serious tachycardia HR>130)
Grade 1: Hypotension or tachycardia by report but non recorded in emergency department (ED)
Grade 2: Hypotension or tachycardia responsive to initial volume loading with no ongoing fluid or pRBC requirement
Grade 3: Hypotension or tachycardia responsive to initial volume loading with modest ongoing fluid (<250 mL/hr) or pRBC requirement
Grade 4: Hypotension or tachycardia only responsive to >2L of volume loading and the need for vigorous ongoing fluid infusion (> 250 mL/h) and pRBC transfusion
Grade 5: Hypotension unresponsive to fluid and pRBC transfusion
2008 WTA Adult Blunt Splenic Injury Algorithm
After initial assessment of BAT, ATLS, Abdominal exam and monitoring response to resuscitation if stable (usually grade 0-2) to CT scan, if unstable (usually grade 3-5) to FAST
FAST positive --> OR, FAST negative --> DPA --> positive --> OR, negative --> other causes of instability?
CT with unstable splenic injury or other injuries requiring OR --> OR
CT w/ blush --> angiography to OR if failure
CT w/ splenic injury and stable --> observation
“Other” Causes of Instability
Severe Pelvic Fx (don't want to be in abdomen)
Massive HTX
Tension PTX
Cardiac Tamponade
Myocardial Contusion or MI
Air Embolism
Neurogenic Shock
Complications of Splenic Embolization
Do not take unstable patient to angio
Useful for blush in stable patients
WTA Multi-institutional experience with 140 pts:
- 16 (11%) failure to control bleeding
- 4 (3%) missed injuries
- 6 (4%) abscesses
Technique of Splenic Embolization
Main artery
Pros: Less incidence of infarction
Cons: Not as effective at preventing late pseudoaneurysm, not as effective with AV fistulas
Selective
Pros: More effective at hemostasis
Cons: Increased risk of infarction
No current consensus as to optimal approach
Emerging data to support selective embolization w/ blush
Splenic artery embolization: ?preservation of splenic function or just avoidance of surgery
Have we gone too far?
Study from J Trauma 2008
- Grade 0-2 HIS patients with blush and no other injuries
- Excluded unstable patients and peds
- Group 1 - 1st 3 months --> OR
- Group 2 - 2nd 3 months --> proximal embolization with gelfoam or coils
Increased morbidity with same mortality in SAE patients, --> maybe not a great idea, but they only used proximal embolization, not selective embolization
Observation: proximal embolization alone appears inadequate when blush is present
Appears to be a role for SAE in stable patients with higher grade injuries and a blush on CT
SAE needs to have a component of selectivity
Delayed Splenic Bleeding
ie > 48 hr
2-4% Incidence
Typically at 4-8 days but can occur weeks later
Result of pseudoaneurysm rupture
Non-operative Management: the Fresno Approach
- Patients with grade I injuries are admitted at bed rest with bathroom privileges. Their hemoglobin is checked every 6 hours for 24 hours and if stable they are discharged home with the exception of those with additional injuries requiring inpatient stay.
- Patients with grades II, III, IV, and V injuries are also admitted at bed rest with bathroom privileges. Their hemoglobin is checked every 6 hours for 24 hours and then every 12 hours until stable, after which time they are discharged barring additional injuries requrining hospitalization. This ensures at least a 36-hour hospital stay for splenic injuries greater than grade I
- A stable hemoglobin is defined as decline of <= 0.5 g from the previous draw. Hemograms are analyzed on a sysmex XE-2100, with a margin of error of 0.3 g/dL
- Specific discharge instructions are given. Patients with splenic injury, regardless of grade, are instructed to refrain from contact sports for 3 montths. All patients are advised to return to the hospital for any change in condition including increased abdominal pain, light-headedness, and nausea or vomiting
- Failure of NOM is defined as requiring intervention after initially being selected for observation. This may be secondary to hemodynamic instability, peritonitis, or a continued decline in hemoglobin with a transfusion requirement >2u blood
433/449 (96%) successful NOM
15 (4%) NOM Failures
- 12 (80%) within 24 hrs
- 2 (13%) 24-48 hrs
- 1 (7%) after 48 hrs - late failures usually from new developing pseudoaneurysm
No complications due to delay in operation
Routine Follow-Up CT
U Tenn Protocol = F/U CT on all @ 24-48hr
5% Latent PA rate
50% sxic
Routine F/U felt to contribute to 97% succ. NOM Rate
Helpful to repeat ct at48 hours to rule out pseudoanneurysm, a common cause of delayed bleeding
Splenectomy
Mobilize lateral attachments
Take Short Gastrics
Hilar Control
Hilar Transection/Ligation
Mop up
Check pancreas
Place drain
Eval for other injuries
Liver Trauma
Liver = most commonly injured abdominal organ
Liver Injury Grading
I)
Hematoma
- Subcapsular, <10% surface area
- Laceration Capsular tear, <1cm parenchymal depth
II)
Hematoma
- Subcapsular, 10-50% surface area; intraparenchymal, <10cm in diameter
- Laceration 1-3 cm parenchymal depth; <10 cm in length
III)
Hematoma
- Subcapsular, >50% of surface area or expanding; ruptured subcapsular or parenchymal hematoma
- Intraparenchymal hematoma >10cm or expanding
Laceration
- >3cm parenchymal depth
IV)
Laceration
- Parenchymal disruption involving 25-75% of hepatic lobe or 1-3 Couinaud's segments within a single lobe
V)
Laceration
- Parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud's segments within a single lobe
Vascular
- Juxtahepatic venous injuries (i.e. retrohepatic vena cava/central major hepatic venis
VI)
Vascular
- Hepatic avulsion
Grade IV ~ 50% mortality
Grade V ~ 80% mortality
Grade VI = fatal
Liver Trauma – Historical Perspective
Historical approach = repair
1980s – onset of non-op management
Current Approach: Multi-modal therapy
Multi-Modal Liver Injury Management
Non-Op
Angio-embolization
Packing
Packing Plus
Resection
Conservative Management
Exclusion criteria:
- Hemodynamic instability
- Peritoneal signs
- Other abdominal injuries
Majority of pts meet criteria irrespective of Grade but increased risks c IV & Vs
98% Success Rate
5% Complication rate
- Bleeding
- Biloma
- Abscess
Angioembolization in Hepatic Trauma
Addresses hepatic arterial bleeding only
- Presence of blush on CT: 60-80% bleeding on angio, 80% need OR and/or HAE
Part of Multi-modal approach
- ~70% of cases with blush still require OR
- Associated with decreased mortality (12% vs. 36%)
HAE in Hepatic Trauma: 3 Roles
1. Primary angioembolization
2. Postoperative angioembolization -- as part of a "damage control" laparotomy
3. Late embolization -- in patients exhibiting signs of hepatic hemorrhage in the perioperative period
HAE Complications
~ 40% Hepatic Necrosis - may need drainage or debridement
~ 15% GB Necrosis
HAE effect on mortality
Review of 103 Gr IV & V LAC Liver Injuries
Monitoring of patients with liver injuries
Grades I-III: telemetry unit, type and screen only, H&H every 12 hours x 48 hours, No need for follow-up CT, resumption of normal activities at 4 weeks
Grades IV-V: ICU admission 48-72 hours, type and cross 4u pRBC at all times, H&H every 8 hours for 72 hours, follow-up CT scan as needed (usually first 7 days), normal activities in 4-6 weeks, contact sports in 12 weeks
Hepatic Packing
Relies on Clot – most effective when done early
~6% survival when done in desperation
~60% survival when done as part of multi-modal care
Is a Sandwich, Not a Wrap
Can use in conjunction with HAE
Approach to RH IVC Injuries
Pack Liver & Hold Pressure --(persistent bleeding)--> Pringle Maneuver --(persistent bleeding)--> Total hepatic isolation
at any step if see improvement--> consider adjuvant angio embolization
Pringle Manuever
Create window to Left of Portal Triad to clamp
Can leave clamped for up to 45 min
Primarily effective for Arterial Bleeding
Total Hepatic Isolation
1. Pringle Maneuver
2. Infrahepatic IVC Clamping
3. Suprahepatic IVC Clamping
Intrapericardial IVC Clamping
+/- Thoracic Aortic Cross Clamping
Exception: Pandora’s Box
When bleeding up through diaphragm into chest, sew diaphragm closed, do not explore into liver