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Trauma Management 643

TABLE 23.9 Spleen injury scale 62 TABLE 23.10 Liver injury scale 62

Grade* Injury description Grade* Injury description
I Haematoma Subcapsular, <10% surface area I Haematoma Subcapsular, <10% surface area
Laceration Capsular tear, <1 cm parenchymal depth Laceration Capsular tear, <1 cm parenchymal depth
II Haematoma Subcapsular, 10–50% surface area II Haematoma Subcapsular, 10%–50% surface area
Intraparenchymal, <5 cm in diameter Intraparenchymal, <10 cm in diameter
Laceration Parenchymal depth 1–3 cm not involving a Laceration Parenchymal depth 1–3 cm, <10 cm in length
trabecular vessel
III Haematoma Subcapsular, >50% surface area or expanding
III Haematoma Subcapsular, >50% surface area or expanding; Ruptured subcapsular or parenchymal
Ruptured subcapsular or parenchymal haematoma
haematoma Laceration Parenchymal depth >3 cm
Intraparenchymal haematoma >5 cm or
expanding IV Laceration Parenchymal disruption involving 25–75% of
Laceration Parenchymal depth >3 cm or involving hepatic lobe or 1–3 Couinaud’s segments
within a single lobe
trabecular vessels
V Laceration Parenchymal disruption involving >75% of
IV Laceration Laceration involving segmental or hilar vessels hepatic lobe or >3 Couinaud’s segments
producing major devascularisation (>25% within a single lobe
of spleen)
Vascular Juxtahepatic venous injuries; i.e. retrohepatic
V Laceration Completely shattered spleen vena cava/central major hepatic veins
Vascular Hilar vascular injury that devascularises spleen VI Vascular Hepatic avulsion
*Advance one grade for multiple injuries, up to grade III.
*Advance one grade for multiple injuries, up to grade III.

incurred significant circulating blood loss. Splenic injury seatbelt injuries and abdominal blows from an assault.
is categorised in a scale consisting of five levels; this scale The liver is also at risk of secondary injury from fractured
is designed to aid classification for management and ribs. Liver injuries are graded using the six-level liver
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research purposes (see Table 23.9). injury scale (see Table 23.10). The treatment of liver inju-
ries is largely dependent on the nature of the injury or
The spleen has an immunological function that is not injuries to the liver itself, presence of concomitant inju-
well understood. After splenectomy, patients are at ries, premorbid status and overall injury severity. The
increased risk of infection and therefore require careful treatment options may also be guided by the services
education regarding lifelong risks. The role of immunisa- and expertise that your health agency can offer the
tion after splenectomy is very important, and the patient patient.
must be counselled regarding the necessity for follow-up
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on immunisations. Prior to discharge from the hospital, The overwhelming aim of the management of liver inju-
the patient should be administered the first round of ries is to preserve liver function. This is achieved by
immunisations. The current recommendation for predis- controlling haemorrhage, resting the patient and close
charge immunisations include: monitoring. Most liver injuries can be managed non-
operatively. In these cases it is imperative that the patient
l pneumococcal vaccine
l meningococcal vaccines be closely monitored for signs of haemorrhage and that
l Haemophilus influenzae type B. 69 the capacity for laparotomy is available at short notice if
required. In some cases, embolisation may be considered
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The patient will also be commenced on antibiotic pro- for arterial haemorrhage. Late complications of liver
phylaxis and should be advised to wear a medi-alert injury include infection, haematoma, bile leak and late
disk or card and consult specialist travel advice when haemorrhage.
travelling. 69
PENETRATING INJURIES
Specific Abdominal Injuries: Liver Trauma is broadly categorised according to whether the
The liver is a vital organ, with liver failure being a fatal external cause of injury was blunt or penetrating. Pene-
condition unless reversible. After the spleen, the liver is trating trauma refers to a mechanism of injury where the
the next most common solid organ injured. Any injury skin has been cut through the insertion of a foreign
to this highly vascular organ is serious and requires surgi- object. The most common examples include knife and
cal review. As the largest abdominal solid organ traversing gunshot wounds, although solid objects such as fences,
the midline, the liver is susceptible to injury from any signposts and tools can cause penetrating trauma. Pene-
external forces applied to the abdomen, for example trating trauma is significantly different from blunt trauma