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

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    Management of Spleen/Liver

    Trauma

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

    Surgeon-in-ChiefChildrens Mercy Hospital

    Kansas City, MO

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    Frequency of Pediatric Blunt

    Abdominal Injuries

    Spleen 27%

    Kidney 27%

    Liver 15%

    Pancreas 2%

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    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)

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    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).

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    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.

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    AAST Splenic Injury Scale

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

    Moore EE, Cogbill TH, Jurkovich GJ, et al

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    AAST Splenic Injury Scale

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

    occupying less than 10% of spleens surface area.

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    AAST Splenic Injury Scale

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

    less than 3 cm of parenchymal depth

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    AAST Splenic Injury Scale

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

    of parenchymal depth radiating from splenic hilum -grade III laceration

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    AAST Splenic Injury Scale

    16-yo boy injured playing hockey. Fractured spleen involving

    more than 25%, Grade IV splenic laceration

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    AAST Splenic Injury Scale

    12-yo boy pedestrian struck by MV. Fractured spleen

    with hilar devascularization. Grade V injury.

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    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.

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    Splenic Trauma

    Complications

    Pseudocysts

    Rare: 0.44%

    May become large and

    painful

    Tx: laparoscopic

    excision andmarsupialization

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    Splenic Trauma

    Immunocompetence

    Vaccination practices vary

    Adult trauma evidence supports

    immunocompetence in healed grade IV

    injuries

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    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

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    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

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    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

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    Liver Trauma

    Blunt trauma is most common

    cause of injury to liver

    High risk due to:

    Large organ, friable

    parenchyma, ligamentous

    attachments

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    AAST Liver Injury Grading

    Grade I

    Grade IV

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    Types of Injury

    Parenchymal damage/laceration

    Subcapsular hematoma/contusion

    Hepatic vascular disruptioncontrast

    extravasation

    Bile duct injury

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    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

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    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

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    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

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    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

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    72 pts

    30Liver

    44Spleen

    Liver vs spleen

    Longer recovery period

    Nine complications

    Greater use of resources

    J Pediatr Surg 43:2264-2267, 2008

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    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

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    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

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    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

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    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.

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    Solid Organ Injury

    Treatment

    > 90% of hemodynamically stable pts

    successfully managed non-operatively

    Less than 10% require transfusion

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    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 Imp