Clinical Challenges in Trauma Surgery: Penetrating Liver Trauma

Behind The Knife: The Surgery Podcast

Science, Health & Fitness, Medicine, Education

4.8 • 1.4K Ratings

🗓️ 7 February 2022

⏱️ 39 minutes

🔗️ Recording | iTunes | RSS

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Summary

In this episode, our team discusses the management of penetrating liver trauma both before, during, and after surgery. Listen in for helpful tips such as how to perform an intraoperative air cholangiogram, creating an occlusion catheter from a red rubber and a Penrose, and much more!

Hosts:
Elliott R. Haut, MD, PhD, a senior, nationally recognized name in trauma and acute care surgery at Johns Hopkins University. Dr. Haut is a past president of The Eastern Association for the Surgery of Trauma (EAST).

Marcie Feinman, MD, MEHP, the current program director of General Surgery Residency at Sinai Hospital of Baltimore and editorial board member of SCORE. She received her Masters in Education in the Health Professions from Johns Hopkins.

David Sigmon, MD, MMEd, a PGY-6 resident at the University of Illinois at Chicago who plans on going into trauma surgery. He did two years of research in surgical education at the University of Pennsylvania where he also received his Master’s in Medical Education.

LITERATURE
1. Murphy PB, de Moya M, Karam B, et al. Optimal timing of venous thromboembolic chemoprophylaxis initiation following blunt solid organ injury: meta-analysis and systematic review. Eur J Trauma Emerg Surg. Published online September 18, 2021. https://pubmed.ncbi.nlm.nih.gov/34537859/

2. Kozar RA, Crandall M, Shanmuganathan K, et al. Organ injury scaling 2018 update: Spleen, liver, and kidney. J Trauma Acute Care Surg. 2018;85(6):1119-1122.
https://pubmed.ncbi.nlm.nih.gov/30462622/

3. Kodadek LM, Efron DT, Haut ER. Intrahepatic balloon tamponade for penetrating liver injury: rarely needed but highly effective. World J Surg. 2019;43(2):486-489.
https://pubmed.ncbi.nlm.nih.gov/30280221/

4. EAST Practice Management Guidelines: Selective Nonoperative Management of Hepatic Injury, Blunt
https://www.east.org/education-career-development/practice-management-guidelines/details/hepatic-injury-blunt-selective-nonoperative-management-of

5. WEST Nonoperative Management of Adult Blunt Hepatic Trauma Algorithm
https://www.westerntrauma.org/wp-content/uploads/2020/08/Non-Operative-Management-of-Adult-Blunt-Hepatic-Trauma-Algorithm_FINAL.svg

6. THE JOURNAL OF TRAUMA AND ACUTE CARE SURGERY 3-MINUTE EXPERT CONSULT VIDEO: “BALLOON TAMPONADE FOR PENETRATING LIVER TRAUMA.
https://journals.lww.com/jtrauma/Pages/videogallery.aspx?videoId=13

7. Coccolini F, Coimbra R, Ordonez C, et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg. 2020;15:24.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7106618/

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Transcript

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0:00.0	Behind the Night, the surgery podcast, relevant and engaging content designed to help you dominate the day.
0:13.0	Welcome back to Behind the Night, Trauma Edition. This is our team's third podcast, and we are excited to continue to share our expertise and trauma with you.
0:29.0	My name is Marcy Feyman, and I am a trauma and acute care surgeon in Baltimore, Maryland, as well as the general surgery residency program director at Sinai Hospital.
0:37.0	I am joined as always by Dr. David Sigmund, PGY4 at the University of Illinois, Chicago, and Education Guru, as well as Dr. Elliott Hout, trauma surgeon extraordinaire from Johns Hopkins and past president of the Eastern Association for the surgery of trauma.
0:52.0	Together, we will be your hosts in this episode as we discuss best practices in liver trauma. David, why don't you give us a case to start us off.
1:01.0	Alright, thank you as always for that great intro, Marcy. We're going to start with our case here. So you get a code yellow and activation in your trauma bay, and they tell you that it's a 23 year old gentleman.
1:11.0	On arrival, he's able to tell you that he has no past medical history, no past surgical history. On your primary survey, you find a right up or quadrant gunshot wound, and that's really the only injury you find or other problem that you find on your primary survey.
1:24.0	The patient's stable at this time, and a secondary survey fails to find anything else.
1:30.0	An X-ray confirms there's no retained bullet just a through and through right up or quadrant gunshot wound.
1:36.0	The emergency resident who's on your team for this particular rotation is wondering if you should grab the ultrasound scanner for a fast. What do you think about that, Elliott?
1:45.0	I love the idea of fast in this patient. It's actually probably even more important than that X-ray that I heard about.
1:53.0	The benefit of the fastest it's going to tell you, you know, is there blood in the paracardium or in the admin or I would do an e-fast extended fast to look at the lungs as well for human and orthorex.
2:05.0	The real important reason I think the fastest helpful is it helps you calculate this ABC score.
2:10.0	The ABC score is a four point score that looks at and helps us predict two needs massive transfusion protocol.
2:18.0	If you get to two points or more, that patient is going to likely be needing massive transfusion.
2:24.0	This patient has one point for penetrating trauma, a positive fast would give him a second point, even if he doesn't have a significantly elevated heart rate or low blood pressure.
2:36.0	Okay, so now I'm interested to hear what the fastest, but David, I've got a couple questions for you.
2:42.0	The question for you that the general one is who's going to CAT scan.
2:47.0	Once we get this diagnosis or once we get this patient decided upon once we get the fast.
2:54.0	Okay, you've told me he's stable. Say his fastest negative. Can he go to CAT scan? Are we going to benefit there?
3:00.0	I think then absolutely if he's stable with a negative fast with this type of injury, the next thing to do would be to take into the CAT scanner and see what type of injury you're dealing with.
3:10.0	Okay, so what if we modify it a little bit? He's that same hemodynamic stability, but his fastest positive in the right up or quadrant there's blood.
	...

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