Management of Traumatic Solid Organ Injury Liver Spleen

Management of Traumatic Solid Organ Injury: Liver, Spleen, and Pancreas Catherine Martin Frederick, ACNP, CCRN September 14, 2015

Trauma Care – Initial Assessment and Resuscitation • • • Airway with cervical spine precautions Breathing Circulation Disability Exposure

Abdominal Assessment • Vital Signs and Physical Exam • Investigational Studies – FAST – DPL – CT Abdomen/Pelvis

Diagnostic Peritoneal Lavage • First described in 1965 • Rapid • Accurate, predictive value greater than 90% • Able to detect minimal blood • High sensitivity, low specificity • Useful in unstable patient, gross blood predictive in intra-abdominal hemorrhage

CT Scan • Gold standard • Not for use in hemodynamically unstable patient • Must be done with IV contrast to be sensitive for solid organ injury • Determines source and amount of bleeding • Reveals associated injuries: pancreas, genitourinary, orthopedic • Poor for hollow viscous injury

Focused Assessment with Sonography in Trauma (FAST) • • First used in 1996 Rapid Sensitive (86 -99%) Can detect as little as 100 m. L fluid Cost effective Useful in unstable patient Views – Pericardiac – Perihepatic – Perisplenic – Peripelvic

Liver

Abdominal Trauma – Examples of CT Findings

Grade I Liver Injury: Laceration(s) less than 1 cm deep Subcapsular hematoma less than 1 cm diameter (Right lateral aspect)

Grade II Liver Injury: Laceration(s) 1 -3 cm deep Subcapsular or central hematoma 1 -3 cm diameter

Grade III Liver Injury: Laceration(s) 3 -10 cm deep Subcapsular or central hematoma 3 -10 cm diameter

Grade IV Liver Injury: Laceration(s) greater than 10 cm deep Subcapsular or central hematoma greater than 10 cm diameter Lobar maceration or devascularization

Grade V Liver Injury: Bilobar tissue maceration or devascularization

Management • Operative (Higher grade injuries, hemodynamically unstable, failed non-operative management) – Diagnostic laparoscopy – Laparotomy – May require open abdomen technique, packing of liver injury with hemostatic agents/absorbent material – Lobar resection • Non-Operative (Lower grade injuries I, III) – Serial hemoglobin/abdominal exam/LFTs – Bedrest until stable Hgb – Hydration – Bowel rest – Transfusion – Cautious use of pharmacologic prophylaxis *Adjunctive use of angioembolization * Patients over age 60 less successful

Bile Duct Injury • With non-operative management-4% incidence of continued bile leak. Increased 10 fold in Grade IV and V injuries. • HIDA scan with delayed imaging if bile duct injury suspected. • ERCP with decompression and stenting may be both diagnostic and therapeutic. • May require operative washout for delayed bile leak and peritonitis.

Spleen

Grade I Splenic Injury: Laceration(s) less than 1 cm deep Subcapsular hematoma less than 1 cm diameter

Grade II Splenic Injury: Laceration(s) 1 -3 cm deep Subcapsular or central hematoma 1 -3 cm diameter

Grade III Splenic Injury: Laceration(s) 3 -10 cm deep Subcapsular or central hematoma 3 -10 cm diameter

Grade IV Splenic Injury: Laceration(s) greater than 10 cm deep Subcapsular or central hematoma greater than 10 cm diameter; hilar disruption (Blue is hilar disruption, red is active extravasation or “contrast blush”)

Grade V Splenic Injury: “Shattered Spleen” – Splenic tissue maceration or devascularization

Management • Operative (Higher grade injuries, hemodynamically unstable, failed non-operative management) – Diagnostic laparoscopy – Laparotomy – Splenectomy * Post-splenectomy patients must receive vaccines • Non-Operative (Lower grade injuries I, III) – Serial hemoglobin/abdominal exam – Bedrest until stable Hgb – Hydration – Bowel rest – Transfusion – Cautious use of pharmacologic prophylaxis *Adjunctive use of angioembolization (painful) * Patients over age 60 less successful

Post-Splenectomy Vaccination Recommendations Streptococcus pneumoniae �� Polyvalent pneumococcal vaccine (Pneumovax 23) o Haemophilus influenzae type B �� Haemophilus influenzae b vaccine (Hib. TITER) o Neisseria meningitidis �� Age 16 -55: Meningococcal (groups A, C, Y, W-135) polysaccharide diphtheria toxoid conjugate vaccine (Menactra) �� Age >55: Meningococcal polysaccharide vaccine (Menomune-A/C/Y/W 135) *Administered in the deltoid or lateral thigh region. †Contact the manufacturer for the latest recommendations prior to revaccination. Vaccine Dose Route Revaccination Polyvalent pneumococcal 0. 5 m. L SC* Every 6 years Quadravalent meningococcal/diphtheria conjugate 0. 5 m. L IM upper deltoid Every 3 -5 years† Quadravalent meningococcal polysaccharide 0. 5 m. L SC* Every 3 -5 years Haemophilus b conjugate 0. 5 m. L IM* None

Pancreas

AAST Classification of Pancreatic Trauma • Grade I: Minor contusion without ductal injury • Grade II: Major contusion without ductal injury or tissue loss • Grade III: Distal transection or pancreatic parenchymal injury with ductal injury • Grade IV: Proximal transection or pancreatic parenchymal injury involving the ampulla • Grade V: Massive disruption of the pancreatic head

Grade IV Pancreatic Injury

Management • Operative – Laparotomy – Partial or total pancreatectomy depends on location/grade of injury – Distal pancreatectomy typically also requires splenectomy – Pancreatic head injuries may necessitate Whipple procedure • Nonoperative if hemodynamically stable with no evidence of pancreatic ductal injury – Serial Hgb/LFTs/pancreatic enzymes/abdominal exam – Hydration – Bowel rest – may need parenteral nutrition – Monitoring for pseudocyst formation (may happen several months later)