Who needs surgeons anyway J Patel A Wale
- Slides: 10
Who needs surgeons anyway? J Patel, A Wale, J Barber, S Ameli-Renani, R Greenhalgh jaymin. patel@nhs. net Excellence in specialist and community healthcare
Clinical information § Helicopter emergency medical service (HEMS) referral by land § 37 yr old male § “Lorry driver slammed into another lorry at 40 mph” § Right sided chest pain HR 98 BP 110/65 mm. Hg
Clinical information § CT (split bolus arterial & portal venous phase) § 10 mins after arrival
Clinical information § IR called and enroute § 1 hr later – unstable § Branches of right hepatic artery successfully embolised
Clinical information § Moved onto ward § 10 days later noted to be more septic, jaundiced and breathless § Repeat split bolus CT: hepatic necrosis, larger collection in lesser sac, right pleural collection
Clinical information § US guided chest drain bile presumed diaphragmatic injury § US guided lesser sac drain purulent/faeculant content
Clinical information § ERCP: active biliary leak at the hilum of the right and left biliary ducts – successfully stented
Final Diagnosis § Grade IV liver laceration § Successfully embolised by IR in the acute setting § Grade IV extrahepatic biliary duct injury § Successfully stented by ERCP § Presumed diaphragmatic rupture § Conservative managment § Infected lesser sac biloma § Drained under ultrasound guidance
All is well that ends well. . . Discharged home and just started working again. Persistent: § Small pleural effusion § Aseptic intrahepatic biloma § Aseptic lesser sac collection
Discussion § Split bolus ‘trauma’ scans are essential in guiding appropriate management in haemodynamically unstable patients § Embolisation should be considered in isolated organ injury, despite severity § Biliary duct trauma should be suspected in high grade liver injuries § Non-invasive techniques can be used in select cases to reduce morbidity and hospital stay