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Lacerated Livers

Lacerated Livers. Dr Richard Downey. The patients. 3 patients BIBA @ 7am Single vehicle RTA Head on collision with side of house Speed unknown, DFB cut patients from car Multidisciplinary care from arrival- ED team with referrals to General, Neuro and Orthopaedic surgeons. The Driver.

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Lacerated Livers

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  1. Lacerated Livers Dr Richard Downey

  2. The patients • 3 patients • BIBA @ 7am • Single vehicle RTA • Head on collision with side of house • Speed unknown, DFB cut patients from car • Multidisciplinary care from arrival- ED team with referrals to General, Neuro and Orthopaedic surgeons

  3. The Driver • RC, 52 yr old male • Unrestrained-Steering wheel broken • Injuries • Traumatic SAH (no intervention) • Suspected tension pneumothorax • Flail chest and haemo-pneumothorax • T1 facet joint # • L2, L3, L4 TP # • Left foot Lis Franc # (ORIF) • Pancreatic collection

  4. JC • 33 yr old male • Front seat passenger-restrained • A-Airway patent • B-Air entry bilaterally, Chest drain inserted • C- BP 86/55, HR 79, IV access • D- No focal neurology • E- No thoracic wall tenderness • Trauma series Xrays, IV fluids, IV abx, Analgesia

  5. RC • CT C spine • NAD • CT Thorax • Right 7th and 8th rib #’s, chest drain in situ • Left 1st and 2nd rib #’s • CT Abdomen • Segment 8 of liver laceration extending deeply to lie close to IVC, no vascular injury • Fluid around GB and into pelvis (blood) • Undisplaced # of right acetabulum

  6. RC • Hepatobiliary team consulted • Conservative management, close monitoring of vitals and haematology/biochemistry markers • HB stable @> 12.5 • CT 1/52 post injury • Liver lac with residual fluid filled cleft in segment 8 of the liver. Appearances have improved, less peri hepatic fluid than on previous study

  7. MM • 21 yr old female • Back seat passenger-unrestrained • A-Airway patent • B-Air entry bilaterally, Chest drain inserted • C-BP 92/39, HR 116, IV access • D-Deformed shortened right lower limb • E- Teeth loss • Trauma series Xrays, IV fluids, IV abx, Analgesia

  8. MS • CT C spine • # Right mandible • Mildly displaced • CT Brain • NAD • CT Thorax • # left 5th and 6th ribs • Small to moderate pneumothorax • Plain film left Upper limb • Non displaced humeral head # (Neer 2)

  9. MM • CT Abdomen • Segment 5 of liver-3cm irregular hypodensity consistent with grade 2-3 liver laceration • Right kidney contusion • Pericholecystic fluid, fluid within hepatorenal pouch of Morrison and a small amount of right perinephric fluid • Spleen, pancreas, adrenals, left kidney-NAD • No extravasation of contrast on delayed scan • Undisplaced # of right acetabulum and left inferior pubic ramus

  10. Treatment • Conservative management of liver laceration • Monitoring of vital signs and bloods • IM nailing right femur • Conservative management of renal contusion, catheterised • Physio and immobilisation of shoulder #

  11. Anatomy of the Liver

  12. Liver Segments • Classical anatomical descriptions based on hepatic vasculature • Couinaud divided the liver into 4 sectors and 8 segments • Divided by 3 vertical and oblique planes defined by 3 main hepatic veins and a transvers plane through right and left portal branches

  13. Hepatic Trauma • Liver is largest solid abdominal organ with a relatively fixed position • Second most commonly injured organ in abdominal trauma after spleen • Most common cause of death after abdominal injury • Mechanism of injury-blunt abdominal trauma, particularly decelerating injuries in RTAs • Associated with rib #’s, pneumothorax, kidney and adrenal injuries

  14. Type of injuries • Subscapular haematoma • Laceration • Intrahepatic haematoma • Contusion • Right lobe > Left lobe • Left lobe injuries associated with injury to duodenum,pancreas and transverse colon • 45% of all liver injuries have splenic injury

  15. Criteria for Trauma Team • MECHANISM OF INJURY • Penetrating wound to head, neck or chest • Ejection of a patient from vehicle • A fall greater than 6m • Burns involving the head and neck • PHYSIOLOGY • Systolic blood pressure less than 90mmhg • Glasgow Coma Scale less than or equal to 8 • Trauma patients requiring intubation • EMERGENCY DEPARTMENT • Senior ED doctor discretion

  16. Discussion THANK YOU!

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