dxy

We continue our discussion of polytrauma today.

While crossing a busy street, a 48-year old pedestrian is struck by a car. She is unconscious at the scene, intubated, and C-spine immobilized and boarded. She is air evacuated to a level I trauma center. Upon arrival, she remains unresponsive with a dilated left pupil and stable vital signs. On physical exam, she has multiple facial abrasions, periorbital ecchymosis, symmetrical breath sounds, and a slightly distended abdomen. Her Glasgow coma scale is 7. A lateral C-spine is unremarkable. CXR reveals the endotracheal tube to be in good position with no chest pathology. AP pelvis reveals sacroiliac disruption and a left acetabular fracture. She undergoes an emergent Head and Abdominal/pelvic CT scan. Her Head CT reveals a left subdural hematoma and a grade IV liver injury. She is taken emergently to the operating room for subdural evacuation.

1.  How would you mange her liver injury?

今天我们继续讨论多发性损伤。

48岁女性在通过拥挤的街道时被汽车撞倒。当时意识丧失，气管插管，颈椎固定，位于硬板床上。被空运到Ⅰ级创伤中心。到达之后，发现患者左侧瞳孔散大，对光反射消失，生命体征平稳。体格检查发现，患者面部多处擦伤，眼眶周围瘀血，呼吸节律正常，腹部轻度膨隆。Glasgow昏迷等级评分7分，颈椎侧面不显著。胸部X片显示导管位置正确，没有胸部病理学改变。骨盆AP显示骶髂分离并且左侧髋臼骨折。进行了急诊头部、腹部/骨盆CT扫描。头颅CT显示左侧硬脑膜下血肿和IV级的肝脏损伤。紧急送往手术室行急诊硬膜下血肿清除手术。

您该如何处理该患者的肝脏损伤？

参考答案：

在过去四十年，肝脏损伤的治疗发展迅速。我们已从主要依靠手术治疗的时代过渡到主要依靠非手术治疗的时代。手术主要用于血管造影术和其他介入性放射治疗有辅助作用的选择性临床情况。这种治疗上的发展主要因为两个原因。首先，Ctde 广泛使用使得肝脏损伤准确定位成为可能。其次，非治疗性剖腹手术及其死亡率使外科医生对既往常规进行的剖腹探查术的必要性提出了质疑。

整体死亡率取决于肝损伤及伴随损伤的严重程度，范围为6-15%。死亡率主要与钝性损伤的机制有关，与刀刺伤或火器伤相比，钝性损伤死亡率更高。肝脏解剖与发病率和死亡率高有很大的相关性。肝脏有两套供血系统，即肝总动脉和门静脉。肝下下腔静脉和很短的桥静脉使得肝下损伤死亡率非常高。

为比较肝脏损伤患者不同治疗措施的有效性，常用下表的对肝损伤进行分级：

非手术治疗用于血流动力学稳定且没有内脏损伤的患者。试图实施非手术治疗的决定主要取决于CT的最初发现。一旦确定非手术治疗，必须积极地观察患者，连续检查及HCT检测非常重要。输血超过4u的大多数患者将需要采取其他的治疗措施。这些治疗措施包括通过血管造影术行选择性动脉栓塞术或手术探查。

How would you mange her liver injury?

Over the past four decades, management of hepatic injuries has evolved. We have moved from an era of strictly operative management to an era of primarily non-operative management. Operation is reserved for selected clinical situations with an adjunctive role for angiography and other interventional radiology approaches. Much of this evolution in management has occurred secondary to two factors. First, the widespread availability of CT has made it possible to accurately define the anatomy of the injury. Secondly, non-therapeutic laparotomies and mortality from operative intervention made surgeons question the need for mandatory explorations.

Depending on the severity of the hepatic injury and concomitant injuries, overall mortality varies from 6 to 15%. Mortality depends on the mechanism of injury with blunt trauma carrying the highest mortality when compared to stab or gunshot wounds. Hepatic anatomy contributes to the high morbidity and mortality. The liver has a rich dual blood supply from the common hepatic artery and portal vein. The retro-hepatic inferior vena cava and short bridging veins contribute to the extremely high mortality of retro-hepatic injuries.

To compare the efficacy of management strategies of patients with liver injuries, a liver injury scale has been devised as depicted below

Non-operative management is reserved for hemodynamically stable patients without evidence of visceral injury. The decision to attempt no-operative management hinges on the initial CT findings. Once the decision is made to actively observe the patient, serial exams and serial hematocrits are essential. Most patients who need more than 4 units of transfused blood will need additional interventions. These interventions include selective arterial embolization via angiography or operative exploration.

References:

1.  Moore EE, Shackford SR, Pachter HL, et al. Organ injury scaling: spleen, liver, kidney. J Trauma 1989;29:1664.
2.  Management of Trauma: Pitfalls and Practice, 2nd edition. Edited by Wilson RF & Walt AJ. Williams & Wilkins, 1996.


编辑：ache