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The liver is the organ most frequently injured by patients experience liver injuries concomitantly with

abdominal trauma.1 The major cause of mortality in other traumas.1 Closely associated with acute liver
patients with acute liver injuries is bleeding. Severe injury are abdominal and retroperitoneal injuries
liver injuries often lead to exsanguination, which is the (59.8%), thoracic injuries (17.6%), injuries of the
most common cause of death.2 However, 50% to 80% extremities (11.7%), cranial, and neurological injuries
of liver injuries stop bleeding spontaneously.2 As a (10%).1 Head injuries are often considered to have
result, there's been an increase in the utilization of the most severe impact on these patients. Other
nonoperative management techniques. Specific criteria injuries associated with acute liver injury include:
for conservative management of low-end liver trauma pelvic fracture, long-bone fracture, nonlong bone
have been suggested in the literature, but most fractures, scalp lacerations, and soft tissue injuries.
criteria are geared toward high-end injuries. Mortality of about 70% is cited in cases of concomitant
injury of the liver and abdomen, thorax, or brain.1
Table. The AIS
Mortality
Liver anatomy
Clinical presentation
The mortality from liver trauma decreased from 66%
during World War I to 25% during World War II and is The liver is a fragile organ prone to life-threatening
currently estimated between 20% and 40%. This injuries because of its complex vascular system and The patient with suspected blunt or known penetrating
decrease in mortality has been attributed to the large mass, which is prominent in the anterior portion liver trauma usually presents with signs and symptoms
following changes: better surgeon selection of patients of the abdomen. (See Liver anatomy and physiology of hemorrhage, peritoneal irritation, right upper
for conservative treatment, enhanced resuscitation facts.) Because of its proximity to the ribs, the right quadrant pain, and abdominal guarding. There may be
techniques in the acute phase, antibiotics, advanced lobe is more commonly injured than the left lobe. This rebound tenderness of the abdomen. In the most
surgical techniques for high-end injuries, and planned organ performs a wide variety of high-volume critical cases, the patient may present with shock,
reoperations resulting in fewer infections. biochemical reactions requiring highly specialized profound hypotension, and decreasing hemoglobin and
tissues. hematocrit. Patients with blunt liver trauma may
develop a liver abscess due to undiagnosed liver
Mortality for acute liver injuries has drastically damage.These patients will present with signs and
increased when the patient was associated with Injury evaluation symptoms of acute abdominal infections and
injuries such as head trauma. Results from one peritonitis.
selected study indicated that the mortality was 69.2%
in the presence of head trauma and 7.3% without There're several methods to classify the level of liver
head trauma.1 While other associated injuries don't injury, including scoring systems such as the Management of acute liver injury
appear to be as significant a factor in mortality as Abdominal Trauma Index (ATI), the Injury Severity
head injuries, they may produce other complications Score (ISS), the Abbreviated Injury Scale (AIS), and
the American Association for the Surgery of Trauma Management of acute liver injury is accomplished
such as hemorrhage and shock, which have a profound
(AAST) organ injury scale. The ATI was designed to through conservative methods or surgical
effect on patient survival.
stratify patients with penetrating injuries, and has management, depending on the degree of injury.
been used to classify patients with blunt trauma. Initially, the patient may require resuscitation before
Shock on admission is directly proportional to the (SeeThe ATI.) any other treatment. Prophylactic antibiotics may be
degree of injury and is an important factor that administered. Continuous monitoring of vital signs, as
impacts mortality.1 Patients in shock who were well as hemoglobin and hematocrit, are essential in the
admitted had a mortality of 58%, which was The ISS is an anatomical scoring system that provides initial period. Blood transfusions may be required if the
significantly higher than the 12% rate among patients an overall score for patients with multiple injuries. The patient has lost a significant amount of blood volume.
without this complication.2Additionally, patients who ISS was originally designed to stratify victims of blunt
were admitted in shock with an associated organ injury trauma, and is also used for victims of penetrating
trauma. To utilize this system, the scores for the three Treatment may consist of conservative or nonoperative
had a higher mortality compared with those without
most severely injured body regions are squared and measures. The surgical treatments include suturing,
shock.
added together to obtain the ISS score. (See Example resection and debridement, packing of the liver, and in
of the ISS.) the most severe cases, liver transplantation.
Mortality from acute liver injuries occurs in two
phases. Early deaths arise from hemorrhage and hypo
The AIS is an anatomical scoring system first Nonoperative management, also known as
volemic shock from either the liver or associated major
introduced in 1969. Since then, it's been revised and conservative treatment, assumes that there's no
vascular injuries. In comparison, late deaths are a
updated against survival so that it now provides a hemodynamic instability and requires strict bed rest,
result of sepsis and multiple organ dysfunction
reasonably accurate ranking of the severity of injury. close observation, serial monitoring of hemoglobin and
syndrome.2
Injuries are ranked on a scale of one to six: one is hematocrit, and periodic computed tomography (CT) of
considered minor, four is severe, and six is a the abdomen. Inclusion criteria for nonoperative
Causes of injuries nonsurvivable injury. (See The AIS.) management requires evaluation of neurologic
integrity and that excessive hepatic-related
transfusions aren't necessary. The surgeon will assess
It's more common to have penetrating trauma related the results of the CT of the abdomen and confirm
to what has become known as “the knife and gun associated intra-abdominal injuries. Most injuries
club,” a phenomenon associated with city crime. Blunt treated nonoperatively are classified as grades I to III,
trauma, on the other hand, often occurs from according to the AAST scoring system. Grade IV and V
automobile accidents or falls, and is more frequently injuries require operative intervention and are never
observed among patients in rural areas.1 treated with a conservative or nonoperative method.
(See AAST organ injury scale.)

Injury to the liver is more common in children due to


the flexibility of their ribs, which allows more force to The main objectives in the operative management of
be directed to the liver. In addition, the connective liver trauma are to control the bleeding and bile leak,
tissue in children isn't as fully developed as in adults, remove devitalized tissue, and control infection in
which also increases the risk for liver injury. patients with associated visceral injury as well as to
establish adequate drainage of the abdomen.
Table. Example of the ISS Hemostasis may be achieved with the use of
According to Yaman et al., 56% to 76% of hepatic electrocautery, sponge gel, primary suturing, hepatic
injuries are caused by blunt trauma.1 The most resection, or perihepatic packing. Utilization of any of
frequent cause of this type of abdominal injury is In a hemodynamically unstable patient with severe these techniques requires the surgeon's careful
related to motor vehicle, occupational, or sporting blunt abdominal trauma, the delayed indication for evaluation, and imaging results and physical findings
accidents. Other causes of blunt trauma include emergency laparotomy can be life-threatening. The will help determine the most appropriate treatment.
automobile-pedestrian accidents, falls from heights, need for blood transfusion correlates with the
mountain bikes, and urban violence excluding knives prognosis in patients with multiple injuries, including
or guns. blunt liver trauma.1 Table. AAST organ injury scale

Penetrating injuries include stab wounds caused by Types of procedures


sharp objects such as knives, gunshot wounds, and
shrapnel. Rib fractures that penetrate the liver are also
included in this group. Treatment of acute liver injury has come full cycle
from aggressive surgical management to extremely
conservative management. Surgeons originally packed
Associated injuries the liver to create a tamponade effect. Perihepatic
packing was often left in for 1 to 2 weeks, with
excessive complications. Many patients succumbed to
Less than 50% of liver injuries occur without any other overwhelming infections. Infection rates and
associated injuries, indicating that the major ity of
associated morbidity were high.4 Surgeons eventually Anatomic resection, which was widely performed control, physiological monitoring, and psychological
became reluctant to utilize this therapy and during the 1960s, was criticized because of its high support in the preinduction phase. Nurses can help
nonoperative treatment of acute liver injuries became mortality. Most reports during the last decade have not allay fears by providing the family with a patient
more prevalent. supported an anatomic resection.3 update, including information about the progress of
the surgical procedure and the condition of the patient.

The current trend is for surgeons to evaluate the A study by Strong et al. showed that an aggressive
patient with more specific criteria to guide the anatomic hepatic resection for trauma was associated Postoperative care
treatment. In general, hemodynamically unstable with low mortality and low liver-related morbidity rates
patients with either blunt or penetrating trauma should when performed by experienced surgeons.6 Therefore,
undergo emergency laparotomy. its role in the management of severe hepatic trauma The postoperative phase of patient care may vary
should be reevaluated further.3 In general, there's depending on the type and severity of hepatic injury.
little research on aggressive emergency hepatic Nursing care may focus on replacing blood and blood
Perihepatic packing for liver trauma resection in the literature, suggesting a need for future products, monitoring coagulation studies, stabilizing
studies. vital signs, and pain management. In addition to the
management of the acute liver injury, nurses may
A 1999 report by Caruso et al.4 discouraged the use of provide unique care to other systems affected by
perihepatic packing due to increased frequency and Partial resection surgically removes the devascularized trauma such as head injuries and bone fractures.
severity of complications related to this technique. liver peripheral to the injured section or fracture line. Rapid access to lab results such as arterial and venous
However, recent improvements in outcomes related to It completes the resection, which has occurred during blood gas analysis, electrolytes, glucose, and ionized
a better understanding of the anatomy and physiology the traumatic injury. Removal of a partially detached calcium are essential for good patient management.
of the liver, improved anesthetics and postoperative portion leaves just one surface that requires repair,
care, and advances in operative techniques related to which is completed with a suture ligation of the
liver transplantation, have established this technique structure. Most liver resections require clamping of the Reoperation
as the treatment of choice. hepatic pedicle, called the Pringle maneuver, to avoid
excessive blood loss. Resectional debridement is
The reoperation rate for hepatic injury is
limited to removal of nonviable liver tissue adjacent to
Perihepatic packing is a common surgical procedure to approximately 19% for various complications and
the injured site.
control hemorrhage in traumatic or spontaneous patient treatment. Surgical removal of packs,
hepatic rupture. By placing packs around the liver, the additional procedures to promote hemostasis,
surgeon is able to induce tamponade and foster Although there're other surgical therapies for liver peritonitis, intra-abdominal abscess formation,
hemostasis. Additional surgical intervention is required trauma, little research has been conducted on these intestinal obstruction, and hematoma formation are
within the following days to unpack the liver. techniques to support their efficacy. Patients with some of the possible conditions that would require a
Perihepatic packing itself may cause serious acute liver trauma may undergo laparoscopic surgical evaluation. It's not unusual for reexploration
complications, such as hypotension and decreased hepatectomy for low-grade blunt hepatic trauma. In after hepatic resection to be performed for repair of
cardiac output, abdominal compartment syndrome addition, minimally invasive surgery for hepatic splenic laceration or splenectomy, minor perforations
(ACS), and multiple organ failure because of ischemia resection should increase as the method of choice for of the small intestine, and intra-abdominal abscess.
of the spleen and retroperitoneal organs. Other blunt trauma. Minimally invasive surgical procedures
important complications related to perihepatic packing are increasingly being used for nonanatomic resection
are thrombotic formation in the abdominal vessels, Morbidity
to remove ischemic parts of the liver.
deep vein thrombosis of the legs, and pulmonary
embolism. Perihepatic packing in patients with liver
Significant factors that influence the patient's outcome
trauma may lead to ACS and to venous thrombosis of Preoperative considerations
include: the mechanism of injury, delay before
the lower part of the body.5 In addition, packing might
surgery, shock on admission, grade of injury, presence
lead to elevated intra-abdominal pressure causing
Immediate treatment for liver injury includes physical of an associated injury, age of the patient, injury
cardiopulmonary dysfunction.
exam, abdominal ultrasound, and in some cases, severity, or operative blood loss.
diagnostic peritoneal lavage. During the physical
Failure to relieve ACS can result in multisystem organ exam, it's important to gain hemodynamic stability
Morbidity rates associated with liver injury vary
failure and death. Urgent decompression is the therapy with a modest volume of I.V. fluids or with blood and
significantly depending on the mechanism of injury
of choice, and this action is accomplished by removing blood products. This requires insertion of large-bore
and can range from 5% to 24%.2 Minor complications
the packing. A major complication of this process is I.V.s in the upper extremities, the right internal
from acute liver injury include atelectasis and
uncontrollable bleeding, which can be life-threatening. jugular vein, and the subclavian vein to allow sufficient
pneumonia; urinary infection; wound infection; and
fluid or blood product replacement with the aid of two
neurological deficits. Major complications include
rapid infusion systems.
Perihepatic packing is accomplished using gauze biliary fistula, abscesses, pancreatic fistula, acute
laparotomy sponges to pack the liver. Packs should be respiratory distress syndrome, multisystem organ
removed when the patient is stable, which is generally Abdominal CT scan is usually obtained to focus on the failure, transfusion-related acute lung injury (TRALI),
24 to 72 hours after injury. Stability is determined as grade of hepatic injury, the presence and quality of peritonitis, and sepsis.
normothermic, correction of acidosis, resolution of any hemoperitoneum, or any active bleeding. Monitoring
coagulopathy, and a surgeon's evaluation and should include ECG, BP via an arterial line, central
Liver transplantation for severe liver injury with
recommendation for removal of the packing. The venous pressure, end-tidal carbon dioxide, pulse
massive tissue destruction has been described as a
timeframe for pack removal hasn't been proven in oximetry, and core temperature. It's imperative that
salvage therapy.7 Although surgical techniques used
research and may vary between institutions. all preoperative consents and preparations are
for liver transplantation have improved the outcomes
expedited.
for liver injured patients, the liver may be so damaged
Timing of pack removal affects the rate of rebleeding that the only treatment choice is a transplant.
and the incidence of postoperative liver-related Intraoperative considerations However, transplantation in unstable abdominal
complications such as biloma, bile leak, and intra- trauma patients should be avoided due to high
abdominal abscess. Biloma is the intra-abdominal mortality. OR
collection of bile, which requires percutaneous or The intraoperative phase is characterized by the type
operative drainage. A bile leak occurs when a bile of procedure employed to create homeostasis of the
injured liver. The most frequently used techniques The ATI
fistula is created, which may require surgical
intervention if it persists for 10 days or more. An intra- include manual compression, perihepatic packing, the
abdominal abscess is indicated by a positive culture of Pringle maneuver, anatomic resection, nonanatomic
The ATI consists of the following categories:
hepatic fluid. These complications usually require resection, resectional debridement, and in the most
operative intervention. severe cases, liver transplantation.
* none

Anatomic resection Warm ischemia can increase the damage to the


already existing acute liver injury and ischemic * nonbleeding
damage, which affects other organs. To prevent
An anatomic resection is the removal of any of the damage to the liver, the surgeon may use a perfusion
eight defined segments of the liver. Anatomic resection solution. This solution differs from cardioplegia, which * peripheral bleeding
of an acute liver injury has two primary goals: to is used for preservation of the heart during cardiac
eradicate the source of the bleeding or to remove the surgery. Cardiac cardioplegia has a high-potassium
site of necrosis. This procedure is performed using level, which is a potent cardiac depressant and * central or minor debridement
conventional anatomic planes of the liver and is requires cross-clamping of the aorta to prevent cardiac
different from nonanatomic resection, which is done by arrest if leaked into the patient's circulation. Perfusion
a partial resection or a resectional debridement of the solution administered to the patient with acute liver * major debridement or hepatic artery ligation
liver. One feature of the anatomic resection is that it trauma doesn't have this concentration of potassium
leaves a smooth surface on the liver with a low and therefore doesn't have similar complications. * lobectomy
propensity for septic complications.

Nursing responsibilities during the intraopertive phase * lobectomy with caval repair or extensive bilobar
may involve environmental safety issues, asepsis debridement.

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