2. Case 1: Blunt trauma
● 29 year old female
● Driver of a car, wearing seatbelt
● Collision heavy vehicle
● Airbags activated
● Managed as per ATLS protocols
● GCS 15 /15, haemodynamically stable
● RUQ pain, left wrist fracture-dislocation
3. Radiology
● Bi-malleolar left ankle fracture
● Ultrasound abdomen: free fluid, splenic
contusion
● CT abdomen
– oblique tear through right lobe of the liver
– right adrenal gland contusion
– blood in peritoneum
4. Management
● Transferred to ICU with IV fluids & blood
● Ankle dislocation reduced, back slab applied
● Laparotomy: full assessment performed
– Large volume of intraperitoneal blood
– 2 liver lacerations
– Small haematoma at splenic hilum
– Small contusion of tail of pancreas
– No active bleeding
● Surgicel to splenic hilum and liver lacerations
● Washout performed and drains placed
6. Case 2: Penetrating trauma
● 24 year old male
● Stab wounds
– Three in upper abdomen
– Left side of neck
7. Clinical findings
● GCS 13/15, haemodynamically stable
● 3cm wound over the right zygoma
● 1.5cm wound zone 2 left side of the neck
● Abdomen: 1.5cm wound over the right and left
upper quadrants breaching rectus sheath and
muscles
● Managed as per ATLS protocol
● IV Fluids, Catheterized
● Hb = 13.5
8. Management
● Chest x-ray normal
● Ultrasound abdomen: No free fluid
● Admitted to ICU pre laparotomy
● Became haemodynamically unstable with increasing
abdo pain
● Responded to IV fluids and blood transfusion
9. Emergency laparotomy findings
● Haemoperitoneum
● Wound in the right upper quadrant obliquely traversed
both lobes of liver, through the 1st
part of duodenum
into pancreas
● Bleeding from D1 and pancreas
● Haemostasis achieved
● Duodenum repaired with interrupted PDS
● Wash out performed, drain placed
10. Management
● Neck wound: fascia breached but no vascular
injuries, closed in layers
● Managed with NG tube, antibiotics and parenteral
nutrition
● Developed bile leak, conservatively managed
● Small pelvic collections were managed with
antibiotics
● Discharged on 31st
post-operative day
11. Background
● Largest solid abdominal organ, fixed position
● Liver injury is the most common cause of death after
abdominal trauma
● Blunt injury due to road traffic accidents most
common
● 80% adults, 97% children have successful
conservative management
● Liver injured more easily in children
13. Liver anatomy
● Cantile described main divisions along axis
from gallbladder fossa to the IVC
● This divides the liver into equal halves
● Couinaud divided the liver into 8 segments.
14. Liver segments
• Divided vertically
by the 3 main
hepatic veins and
transversely by the
right and left portal
branches.
15. Types of liver injuries
● Haematoma: subcapsular or intrahepatic
● Laceration
● Contusion
● Hepatic vascular disruption
● Bile duct injury
● 86% of injuries have stopped bleeding at time of surgical
exploration
● Transfusion requirements are reduced with conservative
management
16. Management
● Initial resuscitation as per ATLS protocol
● It is important to note the mechanism of injury
● Clinical picture may vary from mild RUQ pain
through to peritonism to haemorrhagic shock
● Stable patients undergo CT imaging
● Unstable patients require resuscitation and
laparotomy
17. CT Scans
● Accurate in localizing the site of liver injury
and any associated injuries
● Used to monitor healing
● CT criteria for staging liver trauma uses
AAST liver injury scale
● Grades 1-6
18. Classification
● I- Subcapsular hematoma<1cm or superficial laceration<1cm
deep
● II- Parenchymal laceration 1-3cm deep or subcapsular
hematoma1-3 cm thick
● III- Parenchymal laceration >3cm deep and subcapsular
hematoma >3cm diameter
● IV- Parenchymal/supcapsular hematoma >10cm in diameter,
lobar destruction or devasularization
● V- Global destruction or devascularization of the liver
● VI- Hepatic avulsion
19. Example of a grade 3 injury
Subcapsular hematoma
Parenchymal hematoma
and laceration
20. Angiography
● May be useful in
localizing the site of
haemorrhage in stable
patients
● Transcatheter
embolization of
bleeding sites
21. Treatment
● Conservative
– Blunt liver trauma,
– Haemodynamically stable
– No other injuries requiring surgery
● Surgical
– Penetrating injuries
– Haemodynamically unstable
– Other injuries requiring surgery
22. Surgical management
● Full laparotomy
● Pringles manoeuvre to occlude the portal
triad
● Packing of the liver
● Treat other intra-abdominal injuries as
appropriate
23. Learning points!
● Liver injuries frequently are associated with
multiple other injuries
● Most liver injuries can be managed
conservatively
● Essential Skills: Laparotomy, Pringles,
Ligament mobilisation and liver packing
● As with all trauma, the ATLS protocol is the
foundation of treatment
