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Blunt hepatic injury: A paradigm shift from operative to nonoperative management in the 1990's
McCABE AND WARREN • TRAUMA: AN ANNOTATED BIBLIOGRAPHY
ination. In patients who have extra-abdominal, usually neurosurgical or orthopedic, injuries, a vigorous assessment of the abdomen is often performed with ultrasound, computerized tomography, and/or diagnostic peritoneal lavage. The authors studied 210 patients, all of whom had a normal Glasgow Coma Score, who required surgical procedures on extra-abdominal injuries. A vigorous assessment of the abdomen using the tools previously described discovered only 3 intraperitoneal injuries, only one of which, a ruptured diaphragm, required operative intervention. They conclude that a normal physical examination is sufficient to exclude intra-abdominal injuries in patients who require extraabdominal operative intervention.
The Use of Delayed Computerized Tomography in the Evaluation of Blunt Abdominal Trauma: A Preliminary Report. Stanley AC, Vittemberger F, Napolitano LM, et al. Am Surgeon 2000;66:369-374. The CT scanner is a busy machine in all EDs. In an effort to decrease the high number of negative routine abdominal CTs that are obtained in the evaluation of blunt abdominal trauma, the trauma group at the University of Massachusetts Medical Center did a prospective trial of using serial abdominal examinations and hematocrits instead of CT for patients with admission blood pressure -> 90, Hct --> 35, GCS >- 14, and a normal abdominal examination on admission. Delayed CT was obtained in 13.5% for evaluation of a fall in Hct or change in abdominal examination; all of these were negative for injury, and all patients did well. This is a provocative article and should lead all trauma caregivers to examine their own practices, as well as the economics: which costs more, a CT or a 24 hour admission for observation?
Significance of Minimal or No Intraperitoneal Fluid Visible on CT Scan Associated with Blunt Liver and Splenic Injuries: A Multicenter Analysis. Ochner MG, Knudson MM, Pachter HL. J Trauma 2000;49:505-510. There is no question that the early discovery of intraperitoneal blood is important in the evaluation and management of the blunt trauma victim. The focused abdominal sonography for trauma (FAST) has become quite popular to show the presence of intraperitoneal blood. However, a question arises with the use of FAST, namely, are there patients who have suffered significant solid visceral injuries that do not have demonstrable intraperitoneal blood? The purpose of the present study was to determine the incidence and outcome of injuries to the liver and to the spleen which had minimal or no free intraperitoneal fluid visible on abdominal CT scan. The authors found that injuries to the liver and spleen can indeed and do occur without producing free intraperitoneal free fluid, the majority of which represent intraparenhymal hemorrhage. Patients with intraparenhymal bleeding only will be missed if ultrasound is the only diagnostic tool that is used. Of greatest import was that a certain number of the splenic injuries developed bleeding, and of the majority of these required operative intervention. The authors recommend that ultrasound not be relied on as the sole diagnostic modality in the evaluation of patients with significant possibility of intraabdominal injury; the FAST is best used as an initial screen.
Blunt Hepatic Injury: A Paradigm Shift From Operative to Nonoperative Management in the 1990's. Malhotra AK, Fabian TC, Croce MA, et al. Ann Surgery 2000;231:804-813. A paradigm shift is said to occur when the fundamental rules governing a process are changed. The authors of this paper demonstrate that such a shift has taken place in the management of hepatic trauma. They reviewed their experience over 3 time periods. Cohort 1 was a time during which the routine therapy for
445
hepatic trauma was operative. Cohort 2 showed the nonoperative management from 1993 to 1994. Cohort 3, investigated the most recent experience from 1994 to 1998 when nonoperative management was the standard of practice. In the authors' experience, 85% of patients with blunt hepatic trauma who are hemodynamically stable can be successfully managed by nonoperative therapy. The diagnostic tool which has allowed this "paradigm shift" is the use of the helical CT (computerized tomography) scan. Nonoperative management is not associated with an increased risk of infections or complications and improves overall outcome.
Evolution in the Management of Hepatic Trauma: A TwentyFive Year Experience. Richardson JD, Franklin GA, Lukan, JK, et al. Ann Surgery 2000;232:324-330. The management of hepatic trauma has undergone a dramatic evolution in the last 2 decades. Deaths resulting from hepatic trauma have decreased in the 25-year period that the authors examined. The major part of the decrease in death rate is the result of (1) a decrease in the number of patients with major venous injury requiring surgery, (2) improvements in the operative management of major venous injury, (3) improved results using packing and reoperation, and (4) improved arterial bleeding control with arteriography. The authors found that the earlier use of packing to provide hemostasis was a significant contributor to the decreased mortality from hepatic trauma. Nonsurgical management is the treatment of choice for blunt trauma patient who are hemodynamically stable.
Blunt Hepatic Injury: Minimal Intervention is the Policy of Treatment. Fang JF, Chen RJ, Lin BC, et al. J Trauma 2000; 49:722-728. This study compares the authors' methods of management of liver injuries before 1993, when the policy was operative intervention for all injuries of the liver, with the standard nonoperative management of 1996 and 1997. The authors review their nonoperative protocol and in the study showed improved outcome.
Classification and Treatment of Pooling of Contrast Material on Computed Tomographic Scan of Blunt Hepatic Trauma. Fang JF, Chin RJ, Wong YC, et al. J Trauma 2000;49:10831088. The current method of management of blunt hepatic trauma is nonoperative. Patients are carefully monitored and normally undergo computed tomographic scanning to define the severity of hepatic injury. In the past, the authors have recommended that hemodynamic status was the only reliable indicator for termination of nonoperative treatment. The purpose of this study was to further categorize CT findings and to correlate them with the character and clinical course to determine the most appropriate management of patients with blunt hepatic trauma. The authors categorized the finding of pooling of contrast material. Type 1 was extravasation of contrast material and pooling of the material in the peritoneal cavity. Type 2 consisted of computerized tomographic scans that showed simultaneous presence of hemoperitoneum and intraparenchymal contrast pooling. Type 3 showed intraperenchymal contrast pooling, but without hemoperitoneum. The authors studied 276 patients during a 42-month period of time. The presence of pooling of contrast material within the peritoneal cavity indicated active and massive bleeding. Patients with this computerized tomographic scan finding show rapid deterioration of hemodynamic status. Most of these patients require emergent surgery. The options to perform angiography versus celiotomy are available. The authors did not demonstrate that angiography was accurate or effective in controlling patient's hemorrhage. The angiography was only 67% accurate in identify-
ination. In patients who have extra-abdominal, usually neurosurgical or orthopedic, injuries, a vigorous assessment of the abdomen is often performed with ultrasound, computerized tomography, and/or diagnostic peritoneal lavage. The authors studied 210 patients, all of whom had a normal Glasgow Coma Score, who required surgical procedures on extra-abdominal injuries. A vigorous assessment of the abdomen using the tools previously described discovered only 3 intraperitoneal injuries, only one of which, a ruptured diaphragm, required operative intervention. They conclude that a normal physical examination is sufficient to exclude intra-abdominal injuries in patients who require extraabdominal operative intervention.
The Use of Delayed Computerized Tomography in the Evaluation of Blunt Abdominal Trauma: A Preliminary Report. Stanley AC, Vittemberger F, Napolitano LM, et al. Am Surgeon 2000;66:369-374. The CT scanner is a busy machine in all EDs. In an effort to decrease the high number of negative routine abdominal CTs that are obtained in the evaluation of blunt abdominal trauma, the trauma group at the University of Massachusetts Medical Center did a prospective trial of using serial abdominal examinations and hematocrits instead of CT for patients with admission blood pressure -> 90, Hct --> 35, GCS >- 14, and a normal abdominal examination on admission. Delayed CT was obtained in 13.5% for evaluation of a fall in Hct or change in abdominal examination; all of these were negative for injury, and all patients did well. This is a provocative article and should lead all trauma caregivers to examine their own practices, as well as the economics: which costs more, a CT or a 24 hour admission for observation?
Significance of Minimal or No Intraperitoneal Fluid Visible on CT Scan Associated with Blunt Liver and Splenic Injuries: A Multicenter Analysis. Ochner MG, Knudson MM, Pachter HL. J Trauma 2000;49:505-510. There is no question that the early discovery of intraperitoneal blood is important in the evaluation and management of the blunt trauma victim. The focused abdominal sonography for trauma (FAST) has become quite popular to show the presence of intraperitoneal blood. However, a question arises with the use of FAST, namely, are there patients who have suffered significant solid visceral injuries that do not have demonstrable intraperitoneal blood? The purpose of the present study was to determine the incidence and outcome of injuries to the liver and to the spleen which had minimal or no free intraperitoneal fluid visible on abdominal CT scan. The authors found that injuries to the liver and spleen can indeed and do occur without producing free intraperitoneal free fluid, the majority of which represent intraparenhymal hemorrhage. Patients with intraparenhymal bleeding only will be missed if ultrasound is the only diagnostic tool that is used. Of greatest import was that a certain number of the splenic injuries developed bleeding, and of the majority of these required operative intervention. The authors recommend that ultrasound not be relied on as the sole diagnostic modality in the evaluation of patients with significant possibility of intraabdominal injury; the FAST is best used as an initial screen.
Blunt Hepatic Injury: A Paradigm Shift From Operative to Nonoperative Management in the 1990's. Malhotra AK, Fabian TC, Croce MA, et al. Ann Surgery 2000;231:804-813. A paradigm shift is said to occur when the fundamental rules governing a process are changed. The authors of this paper demonstrate that such a shift has taken place in the management of hepatic trauma. They reviewed their experience over 3 time periods. Cohort 1 was a time during which the routine therapy for
445
hepatic trauma was operative. Cohort 2 showed the nonoperative management from 1993 to 1994. Cohort 3, investigated the most recent experience from 1994 to 1998 when nonoperative management was the standard of practice. In the authors' experience, 85% of patients with blunt hepatic trauma who are hemodynamically stable can be successfully managed by nonoperative therapy. The diagnostic tool which has allowed this "paradigm shift" is the use of the helical CT (computerized tomography) scan. Nonoperative management is not associated with an increased risk of infections or complications and improves overall outcome.
Evolution in the Management of Hepatic Trauma: A TwentyFive Year Experience. Richardson JD, Franklin GA, Lukan, JK, et al. Ann Surgery 2000;232:324-330. The management of hepatic trauma has undergone a dramatic evolution in the last 2 decades. Deaths resulting from hepatic trauma have decreased in the 25-year period that the authors examined. The major part of the decrease in death rate is the result of (1) a decrease in the number of patients with major venous injury requiring surgery, (2) improvements in the operative management of major venous injury, (3) improved results using packing and reoperation, and (4) improved arterial bleeding control with arteriography. The authors found that the earlier use of packing to provide hemostasis was a significant contributor to the decreased mortality from hepatic trauma. Nonsurgical management is the treatment of choice for blunt trauma patient who are hemodynamically stable.
Blunt Hepatic Injury: Minimal Intervention is the Policy of Treatment. Fang JF, Chen RJ, Lin BC, et al. J Trauma 2000; 49:722-728. This study compares the authors' methods of management of liver injuries before 1993, when the policy was operative intervention for all injuries of the liver, with the standard nonoperative management of 1996 and 1997. The authors review their nonoperative protocol and in the study showed improved outcome.
Classification and Treatment of Pooling of Contrast Material on Computed Tomographic Scan of Blunt Hepatic Trauma. Fang JF, Chin RJ, Wong YC, et al. J Trauma 2000;49:10831088. The current method of management of blunt hepatic trauma is nonoperative. Patients are carefully monitored and normally undergo computed tomographic scanning to define the severity of hepatic injury. In the past, the authors have recommended that hemodynamic status was the only reliable indicator for termination of nonoperative treatment. The purpose of this study was to further categorize CT findings and to correlate them with the character and clinical course to determine the most appropriate management of patients with blunt hepatic trauma. The authors categorized the finding of pooling of contrast material. Type 1 was extravasation of contrast material and pooling of the material in the peritoneal cavity. Type 2 consisted of computerized tomographic scans that showed simultaneous presence of hemoperitoneum and intraparenchymal contrast pooling. Type 3 showed intraperenchymal contrast pooling, but without hemoperitoneum. The authors studied 276 patients during a 42-month period of time. The presence of pooling of contrast material within the peritoneal cavity indicated active and massive bleeding. Patients with this computerized tomographic scan finding show rapid deterioration of hemodynamic status. Most of these patients require emergent surgery. The options to perform angiography versus celiotomy are available. The authors did not demonstrate that angiography was accurate or effective in controlling patient's hemorrhage. The angiography was only 67% accurate in identify-