Date: Fri, 26 Jul 1996 19:59:58 +0100
From: "Dr. Karim Brohi"
Organization: Trauma.Org
Subject: Nonoperative management of hepatic trauma
Reply-To: trauma-list@ftech.net
I'd just like an idea of list members opinions on some aspects
of non-operative management of liver trauma. Top of the list
of criteria for non-operative management is haemodynamic stability.
No paper I have read actually defines haemodynamic instability.
So is it :
A. Patient cardiovascularly normal on arrival
B. Patient cardiovascularly normal after initial crystalloid bolus
C. Patient cardiovascularly stable after bolus of crystalloid
and some blood (how much?)
D. A gut feeling that you'll be able to keep this person alive
through CT. - ie requiring fluids constantly but
not dramatically exsanguinating
E. None of the above!
Secondly, by virtue of our trauma system, patients with isolated
intra-abdominal injuries are taken to the nearest teaching hospital.
Patients with multiple injuries (especially neuro) are brought back
to us by helicopter (excluding our catchment area of course).
As such they often arrive anaesthetised & ventilated (head injuries).
Can you non-operatively manage safely someone who is unconcious?
How do you exclude the enteric injury (or can you?)
If so what imaging/laboratory support would you require serially.
We have many patients whose abdomens would meet non-operative
criteria if they were awake.
'No more than 2 hepatic related transfusions' is also quoted. How do
you know, in the multiple injured patient, which of your transfusions
was hepatic???!!
Dr. Karim Brohi BSc FRCS
Trauma & Critical Care Unit, Royal London Hospital
Mailto:karim@trauma.org
http://www.trauma.org/
(Must be a subscriber)
To subscribe :
Send an email message to
majordomo@ftech.net with
subscribe trauma-list
as the first line in the body of the message.
To unsubscribe :
Send an email message to
majordomo@ftech.net with
unsubscribe trauma-list
as the first line in the body of the message.
Discussion
Date: Fri, 26 Jul 1996 16:37:39 -0400
From: "Lisa S. Dresner" <71211.2533@compuserve.com>
Subject: Re: Nonoperative management of hepatic trauma
Reply-To: trauma-list@ftech.net
We manage hemodynamically stable patients with blunt liver trauma (and
splenic trauma) with non operative techniques. We define hemodynamically
stable as ones who respond to initial resuscitation with 1-2 liters of
crystalloid with normalized pulse rate, etc.While some of these patients
do require blood transfusions during their hospital stay, as long as they
do not appear to have evidence of ongoing blood loss (persistant
metabolic acidosis, ongoing volume requirments, etc) we observe them. In
the early days we did a lot of angiography on a those with greater than
grade 2-3 on CT or with concommittent splenic injury but found that only
those liver injuries with evidence of ongoing blood loss every required
any intervention.
Lisa Dresner, MD
Kings County Hospital Center/SUNY Brooklyn
Brooklyn, New York
Date: Fri, 26 Jul 1996 19:26:23 -0500
From: "Dr. Jay Smith"
Subject: Nonoperative management of hepatic trauma -Reply
Reply-To: trauma-list@ftech.net
We use a pulse < 120, bp >90, base deficit <3 as criteria for "stability".
Of course, stable implies stability over several measurements: 120--120
is stable but so is 60--60. The actual state of perfusion must be
addressed as with the base deficit.
We will also use 2 liters of replacement crystalloids to stabilize. We use
lberal amounts of CT scans to determine the severity of injury and will
even watch grade 4 liver injuries nonoperatively if stable. The grade 4
injury of the right lobe extending from the juxtahilar area to the costal
margin often has a bleeding vessel off the right hepatic artery and
coursing posteriorly and laterally that is embolizable via angiography.
Embolization will leave an area of posttraumatic cyst, but these seem to
be benign.
Consciousness does not affect our decision because we follow these
patients with blood counts and CT scans as needed.
From: Critical Care
Subject: RE: Nonoperative management of hepatic trauma
Reply Date: Sat, 27 Jul 96 13:01:00 PDT
Reply-To: trauma-list@ftech.net
There are many hepatic injuries which are able to be treated non-operatively
(or operatively) with little consequence as to final outcome. This is
probably the majority of injuries seen on CT. Before CT was used so
liberally these were found at lap after positive DPL and were either ignored
or had minor haemostatic procedures. Many of these patients have
lifethreatening injuries in other body regions - usually the head. In my own
view whether or when these patients have surgery is of little consequence -
the worst that happens is that they end up with an impressive abdominal scar
and a tiny increased risk of adhesive obstruction in the distant future.
Conversely there are some patients who are clearly exsanguinating (eg
"hypotensive and unchanged despite 2 litres rapid colloid infusion") and the
luxury of selective non-operative management is not available. How long you
wait before taking these patients to the OR will probably be of great
importance in the overall number salvaged. If you wait till they have
dilutional coagulopathy, hypothermia, acidosis and intra-abdominal
hypertension you have waited too long and when you get in you are not sure
which bit to put in the bucket and which bit to try and keep. It is
important to bite the bullet early and take these patients to the OR fast.
Many will die regardless.
Finally and most importantly there are a group (a small group) who have what
are often anatomically devastating injuries seen on CT who have a early
moderate or even major bleed (>10 unit) and then have a period of stability
and in whom operative disturbance would very likely be the difference
between life and death. ("If we disturb that clot given that the disruption
goes right down to the porta he will probably bleed out"). It is important
to recognise this group and make vigourous effort to manage them
non-operatively if possible - even if this means quite a substantial period
of intensive care and repeated cautious transfusion. They are not the same
as the patients who are bleeding to death in front of your eyes and should
be distinguished from them by an experienced surgeon (if not an intensivist
!). This message brought to you by an intensivist who (almost) never stays
the hand of any surgeon prepared to cut anything.
IMHO focussing discussion on "what set of numbers makes a patient considered
stable or unstable" is a necessary but not sufficient part of the issue. We
should also discuss the cognitive stuff too. Comments ?
Stephen Streat FRACP
Intensivist
Department of Critical Care Medicine
Auckland Hospital, Auckland, New Zealand V +64 9 307 2892
F +64 9 307 4927
dccm@ahsl.co.nz
Date: Sat, 27 Jul 1996 22:04:06 +0800
From: Sue Taylor
Subject: RE: Nonoperative management of hepatic trauma
Reply-To: trauma-list@ftech.net
At 4:01 AM +0800 7/28/96, Critical Care wrote:
>IMHO focussing discussion on "what set of numbers makes a patient considered
>stable or unstable" is a necessary but not sufficient part of the issue. We
>should also discuss the cognitive stuff too. Comments ?
>
>Stephen Streat FRACP
>Intensivist
>Department of Critical Care Medicine
>Auckland Hospital, Auckland, New Zealand
Yes, absolutely, and thank you for your stimulating dissertation. But I
haven't seen the discussion which gives us those "Magic Numbers" yet.
Admittedly, the rules are made for breaking, and that is what the cognitive
stuff is for, but some of us don't know the rules, yet...
Surgical-Trainee-to-be.
Sue Taylor.
Surgical Registrar, SCGH
Perth, Western Australia.
sue @highway1.com.au
Date: Sat, 27 Jul 1996 20:44:19 +0300
From: "Aviel Roy-Shapira, M.D."
Subject: Re: Nonoperative management of hepatic trauma
Reply-To: trauma-list@ftech.net
At 19:59 26-07-96 +0100, Dr. Karim Brohi wrote:
Karim raises some interesting points. I too would like to see the results of
this survey.
>A. Patient cardiovascularly normal on arrival
>B. Patient cardiovascularly normal after initial crystalloid bolus
I consider either A or B as signs of cardiovascular stability.
>C. Patient cardiovascularly stable after bolus of crystalloid
> and some blood (how much?)
>D. A gut feeling that you'll be able to keep this person alive
> through CT. - ie requiring fluids constantly but
> not dramatically exsanguinating
>E. None of the above!
>
>Secondly, by virtue of our trauma system, patients with isolated
>intra-abdominal injuries are taken to the nearest teaching hospital.
>Patients with multiple injuries (especially neuro) are brought back
>to us by helicopter (excluding our catchment area of course).
>As such they often arrive anaesthetised & ventilated (head injuries).
>
>Can you non-operatively manage safely someone who is unconcious?
>How do you exclude the enteric injury (or can you?)
These two questions are clearly related. If the only concern were bleeding,
head injury would not exclude non-op management, since the hemodynamic
effects of head traua and bleeding are in different directions. The problem
is that the signs of enteric injury on CT are subtle, and it is difficult to
judge whether the fluid seen on CT is blood or enteric contents, or a
mixture of the too.
My tendency is therefore to explore these patients. However, it is a matter
of judgement. If the CT shows no fluid, except around the liver, with grade
I injury, and the patient is CV normal (not the same as stable, as Karim
points out), I think that non-op management is justified.
Avi
>
Aviel Roy-Shapira, M.D. email:avir@bgumail.bgu.ac.il
Ben-Gurion University, Beer Sheva, Israel
Dept of Surgery A and the Critical Care Unit,
Soroka University Hospital. POBox, 151 Beer Sheva, Israel
Phone:972-7-6403390, 972-52-703902. Fax:972-7-6403260
Date: Sat, 27 Jul 1996 10:57:40 -0400
From: "Eric Frykberg M.D."
Subject: Nonoperative management of hepatic trauma
Reply-To: trauma-list@ftech.net
We also watch hepatic injuries nonoperatively based solely on
hemodynamic stability, meaning no evidence of ongoing blood loss
regardless of how much crystalloid or blood is required to
replete the initial loss, just as Dr. Dresner described. Since
this management based solely on the patient's clinical condition
clearly works, what the liver looks like on CT is irrelevant, a
point much of the country (the world?) has yet to realize, much
to the delight of our radiology departments. Beyond one initial
CT to document that it is the liver that is injured, any further
studies while the patient remains unchanged are superfluous. The
liver injury grading system should not be used to make treatment
decisions, since it is the patient's condition that alone
determines the necessary course. If a stable patient has a Grade
4 or 5 injury, we will observe, and if a Grade 1 injury is
unstable we will operate. Even the practice of ordering a 2nd CT
to document "healing" before discharge of a stable patient has
been shown unnecessary (not surprisingly) in a paper by David
Ciraulo and Len Jacobs presented at EAST in Jan. 1996, abstract
in Dec 1995 issue of Journal of Trauma. I am also unaware of any
data in which decompensation requiring surgery in an initially
stable patient being observed has any correlation with the grade
of liver injury, even though that appears to be the presumption
behind the practice of multiple CT's described by Dr. Smith.
Even if such a correlation exists, however, the patient, and not
the CT, will still dictate the treatment, and we should still
treat patients, and not shadows on a piece of celluloid.
I wholly agree with Dr. Streat's comments on nonoperative
observation of liver injuries, but caution him that virtually all
the surgeons participating in this net ARE "intensivists", and
may not understand the distinction implied in his statement.
Eric Frykberg, M.D.
Jacksonville, Fl
From: KMATTOX@aol.com
Date: Sat, 27 Jul 1996 21:24:20 -0400
Subject: Re: Nonoperative management of hepatic tr
Reply-To: trauma-list@ftech.net
A word of caution. A STRONG word of caution. Be careful. The data we
generate in the large teaching hospitals with many house staff, monitors and
other assistive systems is totally different from the lone surgeon in a
15,000 population community with a 25 bed hospital. If a single major
complication occurs, including hepatitis C following blood transfusions, his
gonads in that community are worthless. In that environment, the most
"conservative" approach may be to operate and the aggressive approach is to
watch.
k
Date: Sun, 28 Jul 1996 11:31:05 +0100
From: "Dr. Karim Brohi"
To: trauma-list@ftech.net
Subject: Re: Nonoperative management of hepatic trauma
Reply-To: trauma-list@ftech.net
Dr. Mattox
I don't think anyone is suggesting that these patients are managed
nonoperatively outside a setting where there is adequate supervision
in terms of monitoring, nursing and medical staff and radiology
backup.
I'm interested to hear in the criteria you use for 'haemodynamically
stable' and also how (if at all) you apply nonoperative management to
the unconscious patient, being one of the leading proponents of this
technique.
Dr. Karim Brohi BSc FRCS
Trauma & Critical Care Unit, Royal London Hospital
Mailto:karim@trauma.org
http://www.trauma.org/
From: SHERIDAN@HELIX.MGH.HARVARD.EDU
Date: Sun, 28 Jul 1996 12:44:36 -0500 (EST)
Subject: Re: Nonoperative management of hepatic trauma
Reply-To: trauma-list@ftech.net
amen to Eric Frykberg's comments on
nonoperative management of liver injuries
Rob Sheridan
Boston, MA
Date: Mon, 29 Jul 1996 18:50:00 +1200 (NZST)
From: dave adams
Subject: Re: Nonoperative management of hepatic trauma
Reply-To: trauma-list@ftech.net
Karim
In this context our idea of stable is haemodynamically stable after initial
fluid challenge of 1,500 to 2,000ml of crystalloid or colloid and only
requiring maintenance fluids thereafter.
CT is not as sensitive for bleeding, for gut injury, and probably for
pancreatic injury as DPL, so we do a DPL first as a screening measure. Then
if we are going to be conservative we do CT to further document what it is
that we are sitting on. ie DPL tells us whether there is an injury, but not
what it is. We get about 6 significant liver injuries per year, and haven't
had to operate on one for three years. Haven't had any complication of this
approach.
Cheers
Dave
>
Dave Adams FRACS
General & Vascular Surgeon
Middlemore Hospital
Auckland, NEW ZEALAND
email dcrad@ihug.co.nz
Ph ++64 21 986614
Date: Mon, 29 Jul 1996 08:16:09 -0500
From: "Dr. Jay Smith"
Subject: Nonoperative management of hepatic trauma
Reply-To: trauma-list@ftech.net
Actually, we do not use liberal amounts of CT scans, but use the CT
scanner liberally. Most patients only get 2 scans at most. We have been
doing a study to document the development of cysts after embolization.
>>> Dr. Jay Smith 07/26/96 07:26pm >>>
We use a pulse < 120, bp >90, base deficit <3 as criteria for "stability".
Of course, stable implies stability over several measurements: 120--120
is stable but so is 60--60. The actual state of perfusion must be
addressed as with the base deficit.
We will also use 2 liters of replacement crystalloids to stabilize. We use
lberal amounts of CT scans to determine the severity of injury and will
even watch grade 4 liver injuries nonoperatively if stable. The grade 4
injury of the right lobe extending from the juxtahilar area to the costal
margin often has a bleeding vessel off the right hepatic artery and
coursing posteriorly and laterally that is embolizable via angiography.
Embolization will leave an area of posttraumatic cyst, but these seem to
be benign.
Consciousness does not affect our decision because we follow these
patients with blood counts and CT scans as needed.