Liver trauma
Key points
Algorithm for suspected liver injury in trauma call
If stable - CT and non-operative management (NOM)
If unstable - Initial resuscitation - if no response - laparotomy
If response - CT
Still ongoing bleeding - discuss with Interventional radiology (IR)
Then embolise or laparotomy
If no ongoing bleeding - NOM always discuss scan pre-emptively with IR and see if feasible - and check out of hours cover
Most frequent complication: 1. Bleeding 2. Bile leak
Hepatic artery pseudoaneurysms - should embolise as less likely to resolve
Liver Injury Scale (2018 Revision) American Association of Surgery of Trauma (AAST)
Grade I (Abbreviated Injury Score (AIS) Severity 2):
Subcapsular haematoma <10% of surface area
Parenchymal laceration <1 cm depth
Capsular tear
Grade II (AIS Severity 2):
Subcapsular haematoma 10-50% of surface area
Intraparenchymal haematoma <10 cm in diameter
Laceration 1-3 cm depth and ≤10 cm length
Grade III (AIS Severity 3):
Subcapsular haematoma >50% of surface area or expanding
Ruptured subcapsular or parenchymal haematoma
Intraparenchymal haematoma >10 cm
Laceration >3 cm depth
Any injury with liver vascular injury or active bleeding contained within liver parenchyma
Grade IV (AIS Severity 4):
Parenchymal disruption involving 25-75% of a hepatic lobe
Active bleeding extending beyond the liver parenchyma into the peritoneum
Grade V (AIS Severity 5):
Parenchymal disruption >75% of a hepatic lobe
Juxtahepatic venous injury, including retrohepatic vena cava and central major hepatic veins
Standard scenario
Abdominal trauma
Concern is solid or hollow viscus injury
Ensure patient has had full primary and secondary survey as per ATLS/APLS guidelines and is being resuscitated appropriately
History:
Timing and mechanism of injury
Co-morbidities (AMPLE history)
Examination:
Respiratory and Haemodynamic status
Thoracic and abdominal signs
Other injuries
If haemodynamic compromise - transfuse 10ml/kg, give tranexamic acid
Good response - CT
Partial response - second transfusion 10ml/kg
If active bleeding (blush) on CT, discuss with radiologist for suitability of embolisation
If no active bleeding and patient stable - NOM
No response or deterioration - activate major haemorrhage protocol, transfuse RBC, Cryo, Platelets 1:1:1
Book and consent for trauma laparotomy
Trauma laparotomy:
Warm theatre
Arms out for access
Prep nipples to knees before patient paralysed
Knife to skin as soon as paralysed
Midline laparotomy
4 quadrant packing starting with area bleeding
Wait until patient stabilised
Remove packs starting with areas not bleeding
Operative management of liver trauma:
Can occlude portal vein and artery temporarily (Pringle manoeuvre)
Fully mobilise liver and manually compress to stop bleeding
Can wrap in mesh
Floseal
Packing above and below
Damage control surgery - leave VAC dressing (e.g. AbThera)
Steps for placing AbThera
Cut protective layer to size - through middle of foam squares - then pinch off the half that is left
Can cut between to make more round
Place inside abdomen
Put foam on top
Put on Abthera clear sticky drape
Cut hole in drape, place suction pad over
References
Kozar RA, Crandall M, Shanmuganathan K, Zarzaur BL, Coburn M, Cribari C, Kaups K, Schuster K, Tominaga GT; AAST Patient Assessment Committee. Organ injury scaling 2018 update: Spleen, liver, and kidney. J Trauma Acute Care Surg. 2018 Dec;85(6):1119-1122. doi: 10.1097/TA.0000000000002058. Erratum in: J Trauma Acute Care Surg. 2019 Aug;87(2):512. doi: 10.1097/TA.0000000000002419. PMID: 30462622.
Choi, Pamela, et al. "Liver and Spleen Trauma." Pediatric Surgery NaT, American Pediatric Surgical Association, 2022. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829086/all/Liver_and_Spleen_Trauma.