7 Liver - Spleen Trauma.ppt

8/10/2019 7 Liver - Spleen Trauma.ppt

1/34

Management of Spleen/Liver

Trauma

George W. Holcomb, III, M.D., MBA

Surgeon-in-ChiefChildrens Mercy Hospital

Kansas City, MO


2/34


3/34

Frequency of Pediatric Blunt

Abdominal Injuries

Spleen 27%

Kidney 27%

Liver 15%

Pancreas 2%


4/34

Splenic Trauma

Diagnosis:

Plain abdominal film

Unreliable andnonspecific

Triad of radiographic

findings in acute

splenic rupture

Left diaphragmatic

elevation

Left lower lobe

atelectasis

Left pleural effusion Radiograph demonstrates a left pleuraleffusion, left basilar atelectasis, and

inferomedial displacement of the

splenic flexure (arrow)


5/34

Splenic Trauma

Diagnosis: FAST

Focused AbdominalSonography for Trauma

Bedside study for unstablepatient

15% false-negative

May miss up to 25% of liver

and spleen injuries Compared to CT only 63%

sensitive for detecting freefluid

Fluid in the subphrenic space and

splenorenal recess can be detected.

The image shown demonstrates blood

(arrow) between the spleen (S) and

diaphragm (D).


6/34

Splenic Trauma

Diagnosis:

CT with IV contrast

Noninvasive, highlyaccurate, easily

identifies and

quantifies extent of

injury, for stable

patient only

A: Hemoperitoneum with a liver

laceration (arrow) and a

shattered spleen is seen.


7/34

AAST Splenic Injury Scale

*Advance one grade for multiple injuries, up to grade III

Moore EE, Cogbill TH, Jurkovich GJ, et al


8/34


17-yo boy injured on an ATV. Grade I injury with subcapsular fluid

occupying less than 10% of spleens surface area.


9/34


17-yo girl injured in an MVC. Grade II injury with laceration involving

less than 3 cm of parenchymal depth


10/34


18-yo boy injured playing football. Lacerations involving more than 3 cm

of parenchymal depth radiating from splenic hilum -grade III laceration


11/34


16-yo boy injured playing hockey. Fractured spleen involving

more than 25%, Grade IV splenic laceration


12/34


12-yo boy pedestrian struck by MV. Fractured spleen

with hilar devascularization. Grade V injury.


13/34

Splenic Trauma

Complications

Pseudoaneurysms

Often asymptomatic and

resolve over time If treatment required,

angiographicembolization may beused

Also occur in livertrauma

A. Splenic pseudoaneurysm(arrowheads) after nonoperativetreatment of blunt splenic injury.

B. Successful angiographicembolization The microcatheterused to deploy the coils is markedby the arrowheads and the emboliccoils are marked by the arrows.


14/34

Splenic Trauma

Complications

Pseudocysts

Rare: 0.44%

May become large and

painful

Tx: laparoscopic

excision andmarsupialization


15/34

Splenic Trauma

Immunocompetence

Vaccination practices vary

Adult trauma evidence supports

immunocompetence in healed grade IV

injuries


16/34

Splenic Trauma

If splenectomy is indicated

Pt requires vaccinations prior to discharge

Streptococcus pneumoniae

Pneumovax 23

Haemophilus influenzae type B

Hib vaccine

Neisseria meningitidis

Quadravalent meningococcal/diphtheriaconjugate

Prophylactic antibiotics controversial

Most centers use penicillin


17/34

Splenic Trauma

Treatment

Nonoperative failure rate 2%

Risks for increased nonoperative failure rate

Bicycle-related injury mechanism

More than one solid organ injury Peaks at 4 hrs, declines at 36hrs after admission


18/34

Contrast Blush - Spleen

216 Pts7 yrs

26 PtsContrast blush on CT scan Lower HgB

More likely to need op (22% vs 4%)

Not a definite indication for operation, but indicates subset of pts who

have active bleeding and may need transfusion and/or operation

Blunt Splenic Injury


19/34

Liver Trauma

Blunt trauma is most common

cause of injury to liver

High risk due to:

Large organ, friable

parenchyma, ligamentous

attachments


20/34


21/34

AAST Liver Injury Grading

Grade I

Grade IV


22/34

Types of Injury

Parenchymal damage/laceration

Subcapsular hematoma/contusion

Hepatic vascular disruptioncontrast

extravasation

Bile duct injury


23/34

Diagnosis

Physical exam tachycardia, hypotention,

peritoneal irritation

FAST better for unstable patients

not stable enough for CT1

CT w contrast

determine grade and look foractive extravasation

1Coley et al. J Trauma 2000


24/34

Contrast Blush - Liver

105 ptsblunt liver injury6 yrs

75 ptsGrade IIIV

22 ptsContrast blush transfusion req.

mortality (23% vs 4%)

ISS also

Mortality may be related to the other injuries


25/34

Indication for Intervention

Operate for continued blood loss withhypotension, tachycardia, decreased urineoutput, decreasing Hg unresponsive to IVF andpRBC

Operative rates

3-11% for multiple injuries

0-3% for isolated liver injury

Angioembolizationnot used as commonly asin adults


26/34

Bile Duct Injury

With nonoperative management, 4% risk of

persistent bile leak

HIDA with delayed images if bile duct injurysuspected

ERCP with decompression and stentingcan

be diagnostic and therapeutic


27/34

72 pts

30Liver

44Spleen

Liver vs spleen

Longer recovery period

Nine complications

Greater use of resources

J Pediatr Surg 43:2264-2267, 2008


28/34

APSA Guidelines

CT GRADE I II III IV

Days in ICU None None None 1 day

Hospital stay 2 days 3 days 4 days 5 days

Predischarge

imaging

None None None None

Postdischarge

imaging

None None None None

Activity

restrictions

3 weeks 4 weeks 5 weeks 6 weeks

From Stylianos S, and APSA Trauma Committee: Evidence-based guidelines for resource

utilization in children with isolated spleen or liver injury.

APSA guidelines for hemodynamically stable children with isolated

spleen or liver injury

J Pediatr Surg 35:164-169, 2000


29/34

Prospective study all pts with BSLI

No exclusions Bedrest : Grade III inj 1 night

Grade IIIV inj2 nights

J Pediatr Surg 46:173-177, 2011


30/34

Prospective Study - BSLI

131 pts (spleen only 72, liver only 55

1 splenectomy (Grade V inj)

Transfusions24 (18 due to BSLI)

Mean injury grade2.6

Mean bed rest1.6 days

Need for bed rest limiting factor in duration of

hospital in 86 pts (66%)

J Pediatr Surg 46:173-177, 2011


31/34

Prospective StudyBSLI

An abbreviated protocol of 1 night for Grade I

II injuries and 2 nights for Grade III or higher in

hemodynamically stable pts is safe and

significantly decreases hospitalization c/w

previous APSA recommendations.


32/34

Solid Organ Injury

Treatment

> 90% of hemodynamically stable pts

successfully managed non-operatively

Less than 10% require transfusion


33/34

References Coley BD, Mutabagani KH, Martin LC, Zumberge N, Cooney DR, Caniano DA, Besner GE,

Groner JI, Shiels WE 2nd. Focused abdominal sonography for trauma (FAST) in children with

blunt abdominal trauma. J Trauma. 2000 May;48(5):902-6.

Holcomb GW III, Murphy JP. Ashcrafts Pediatric Surgery. 5thed. Philadelphia, PA:

Saunders An Imprint of Elsevier, 2010.

Lynn KN, Werder GM, Callaghan RM, Sullivan AN, Jafri ZH, Bloom DA. Pediatric blunt

splenic trauma: a comprehensive review. Pediatr Radiol (2009) 39:904-916.

Moore EE, Cogbill TH, Jurkovich GJ, et al: Organ injury scaling: Spleen and liver (1994

revision). J Trauma 38:323-324, 1995

Sabiston DC II, Townsend CM III. Sabiston Textbook of Surgery. 18thed. Philadelphia, PA:

Saunders An Imprint of Elsevier, 2007.

Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen

or liver injury. The APSA Trauma Committee. J Pediatr Surg. 2000 Feb;35(2):164-7.

Tataria M, Nance ML, Holmes JH 4th, Miller CC 3rd, Mattix KD, Brown RL, Mooney DP,

Scherer LR 3rd, Grooner JI, Scaife ER, Spain DA, Brundage SI. Pediatric blunt abdominal

injury: age is irrelevant and delayed operation is not detrimental. J Trauma 2007

Sep;63(3):608-14.


34/34

QUESTIONS

www.cmhmis.com

www.cmhclinicaltrials.com
http://www.cmhcenterforminimallyinvasivesurgery.com/http://www.centerforprospectiveclinicaltrials.com/http://www.centerforprospectiveclinicaltrials.com/http://www.cmhcenterforminimallyinvasivesurgery.com/

Documents

7 Liver - Spleen Trauma.ppt