Page 1646 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 120: Torso Trauma 1165

Resection of Devitalized Tissue in Liver Trauma: Formal hepatic lobec- there is a suggestion of associated injury or there is an acute splenic
tomy is seldom necessary for trauma. Resection usually is confined to injury in an adult who is severely compromised hemodynamically, sple-
removal of frankly nonviable tissue. The area for resectional débride- nectomy is advised.
ment usually is well demarcated by the nature of the liver laceration At laparotomy, the aim should be to control hemorrhage, with splenic
itself. Manual compression is maintained on the liver while the resec- salvage if possible. In order to assess the splenic injury adequately,
tion is conducted to control hemorrhage. Intermittent packing and complete mobilization and delivery of the spleen into the wound are
compression of the liver are required to allow volume resuscitation of necessary. Superficial subcapsular tears of the spleen may be treated by
the patient during the procedure. initial packing for approximately 15 minutes. Failure to control the hem-
orrhage by this means will necessitate such techniques as the application
Drainage: The lacerated liver continues to drain bile, blood, and tissue of microfibrillar collagen or fine sutures. Identifiable bleeding points are
fluid for a considerable period postoperatively. Accumulation of this coagulated as well as suture ligated, particularly when bleeding points
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fluid in the peritoneal cavity is prevented by appropriately function- occur near the hilum of the spleen. Ligation of the short gastric vessels in
ing peritoneal drains. T-tube drainage of the common bile duct is certain instances also will arrest splenic hemorrhage. In some instances,
not required unless there is a central ductal injury requiring surgical a lacerated portion of the spleen may be excised, with suturing of the
repair or unless the common bile duct is enlarged because of previous remainder of the spleen with large chromic sutures with Teflon pledgets
pathology. for securing the sutures. When multiple lacerations are evident, control
During the postoperative period, these patients frequently run a of the hemorrhage has been reported by placing the spleen in a net of
febrile course, which makes it difficult to determine whether or not Dexon mesh, which can be tightened to produce compression and con-
there is underlying sepsis. Therefore, antibiotics frequently are admin- trol of hemorrhage. If control of hemorrhage by a combination of these
istered in the immediate perioperative period. With major hepatic techniques is impossible, then splenectomy should be conducted. Also,
resection, glucose infusions are required to treat hypoglycemia, and if the patient remains unstable from other major injuries and bleeding
hypoalbuminemia needs to be treated temporarily with plasma and from the spleen is a major problem, splenectomy should be conducted
albumin infusions until the nutritional status of the patient is improved. most expeditiously to decrease the operating time and improve the
Coagulation defects are treated with fresh frozen plasma, vitamin K patient’s chances of survival. At present, most patients with splenic
supplements, and platelets when indicated. Most of these patients also injury who come to laparotomy undergo splenectomy because they
develop some degree of jaundice, which usually is transient but may last have usually failed conservative nonoperative management or have life-
from several days to several weeks. Because many of the signs indicated threatening associated injuries.
earlier are common in uncomplicated liver injuries, the presence of sep- Postsplenectomy patients are very prone to septic complications,
tic complications may go unnoticed. Frequent radiologic investigation particularly from infections associated with the encapsulated pneu-
and monitoring of the WBC count are necessary, and baseline estimate mococcus, Haemophilus influenzae, and Neisseria meningitidis. Prior
of these parameters would allow one to determine whether the patient to discharge from the unit, these patients should be vaccinated against
is progressing satisfactorily or not. A patient whose bilirubin level and these organisms. Patients also should be warned that any infective
WBC count are decreasing but who suddenly shows an increase in process is cause for seeking medical attention because of the increased
serum bilirubin level or has a spike in temperature should be investi- risk of overwhelming sepsis in splenectomized patients. One of the
gated carefully for a source of sepsis in the abdomen. Another compli- areas of concern in monitoring patients after splenectomy in the ICU
cation that may arise in hepatic injury is hemobilia, which may present is the frequent occurrence of leukocytosis and thrombocytosis. This
with upper gastrointestinal hemorrhage, as evidenced by hematemesis situation makes monitoring for intra-abdominal sepsis difficult, and
or blood-stained nasogastric drainage. This lesion requires immediate one has to follow the WBC count until it plateaus. A deviation or a
investigation in the form of hepatic angiography and CT or ultrasound sudden increase from a plateau high WBC count could be consid-
examination. Once the source of the intrahepatic hemorrhage is iden- ered evidence of occult sepsis. In patients who are in the ICU for
tified, hepatic artery embolization or balloon tamponade is a viable prolonged periods with platelet counts above 10 /µL, consideration
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option for controlling the hemobilia before formal hepatic resection is should be given to prophylactic anticoagulation to prevent throm-
considered. botic complications.
■ SPLEEN INJURIES ■ INJURIES TO THE EXTRAHEPATIC BILIARY TRACT

Injuries to the spleen should be suspected in patients who present with These injuries are relatively infrequent. Common bile duct injuries
left upper quadrant pain, especially in the presence of left lower rib often involve the other structures in the porta hepatis, with frequently
fractures. There may be associated shoulder tip pain on the left side. associated injury to the liver, duodenum, or other structures in the
A frequent mode of presentation, however, is a patient with signs of abdomen. Vascular injuries isolated to the porta hepatis are relatively
massive intraperitoneal hemorrhage requiring immediate laparotomy rare and carry a very high mortality rate. If a porta hepatis injury is
for hemorrhagic shock. In situations where the signs are equivocal, suspected, the Pringle maneuver would allow better identification of
ultrasound examination may be helpful. CT of the abdomen in an oth- the injury. Vascular injuries take priority over duct injuries because of
erwise stable patient also will identify splenic injury. Most patients who the immediate threat to survival posed by massive hemorrhage. If the
are able to maintain adequate hemodynamics with minimal require- portal vein is the source of the hemorrhage, then attempts should be
ments for blood transfusions, particularly children, can be treated made to repair this by lateral venorrhaphy, resection, and anastomo-
conservatively without the need for laparotomy. Such patients should be sis or interposition grafting. Portal systemic shunting usually results
monitored very closely in the ICU setting for signs of continued blood in severe encephalopathy in previously healthy patients with normal
loss and requirement for continued fluid infusions. Although imaging hepatic flow and should be avoided if possible. Common hepatic artery
techniques have been attempted to identify splenic injury patients that injury should be repaired where possible; otherwise, ligation may be
will require surgical intervention, the most important determinant of performed as a last resort. 7
the need for surgical intervention remains the hemodynamic status of Common bile duct injuries that involve less than 50% of the cir-
the patient and the requirement for continued fluid infusion. Where cumference of the duct should be treated by débridement and primary
the patient’s condition allows, angiography can identify bleeding vessels closure with a stent (a ureteric stent or T-tube) exiting away from the
that may be embolized to control bleeding from the traumatized spleen. anastomosis. If more than 50% of the circumference of the bile duct is
Currently, nearly all children and 50% to 80% of adults with blunt involved, then there is an over 50% rate of late stricture that diminishes
hepatic or splenic injuries are treated without laparotomy. Whenever to about 5% if a biliary enteric anastomosis is performed.
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