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M. Chiarugi et al.
It is important to note that in hemodynamically stable children the presence of
active blush on CT is not an absolute indication for AG/AE.
AG/AE may be performed in:
1. Hemodynamically stable or rapid responder patients with moderate and severe
lesions (depending on the injured organ: i.e., spleen)
2. Patients with vascular injuries detected at CT scan (contrast blush, pseudoaneurysm, arteriovenous stula).
NOM can be considered also in selected patients with penetrating trauma. Low-
energy penetrating trauma, such as stab wound or low-energy gunshot wounds, particularly of the right upper quadrant, may benet from NOM, avoiding negative
laparotomies and their high rates of morbidity. High-energy gunshot wounds are
less likely to be successfully treated with NOM (OM is required in 90% of cases).
In penetrating trauma patients treated with NOM, serial clinical evaluations (physical examinations and laboratory testing), associated with repeated radiological
assessment, are the cornerstones and must be performed to detect any change in
clinical status.
The greatest risk of NOM is missing intra-abdominal injuries, especially in pen-
etrating trauma and mainly perforation of a hollow viscus, which can be suspected
even in stable and asymptomatic patients considering the trajectory of the bullet or
of the stab tract.
In all those patients where intra-abdominal injuries are suspected but not detected,
interval laparoscopy should be always considered as an “extension” of NOM in
order to conrm/exclude injuries requiring surgery. Interval laparoscopy is an
important tool that works as a bridge strategy to plan a step-up treatment (subsequent laparoscopy/laparotomy).
Patients with concomitant neurotrauma (i.e., spinal cord or head trauma) need
high perfusion pressure to the brain in order to avoid secondary damage (following
hypotension and hypoperfusion). Specic hemodynamic goals for these patients are:
1. Systolic blood pressure>110mmHg
2. Central perfusion pressure of 60–70mmHg in the case of moderate head or spinal cord trauma
3. Central perfusion pressure > 80 mmHg in the case of severe head or spinal
cord trauma.
For these reasons, in cases of concomitant head trauma and/or spinal cord inju-
ries with reliable clinical examination, NOM is a strategy that may be attempted if
the above hemodynamic goals are achieved and maintained without intra- abdominal
bleeding that may cause subsequent hemodynamic instability.
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10.2.3 Thromboprophylaxis, Feeding andMobilization
Unless some contraindication exists, all trauma patients should receive mechanical
prophylaxis, which has been shown to be safe, and early mobilization should be
considered in all stable patients.
Trauma patients should receive anticoagulant prophylaxis with low-molecular-
weight heparin as soon as possible, this strategy may be safe in selected patients
with solid organ injuries treated with NOM.It is recommended to start enteral feeding as soon as possible, in the absence of contraindications.
10.3 Liver Trauma
Hepatic injuries can be divided into three grades, according to the WSES classication that considers the AAST-OIS classication (Table10.1) and hemodynamic sta-
tus (Table10.2) [12]:
• minor (WSES grade I);
• moderate (WSES grade II);
• severe (WSES grade III and IV).
Table 10.1 AAST-OIS liver injury scale (1994 revision)
Injury type
Grade
I Hematoma Subcapsular, <10% surface area
Laceration Capsular tear, <1cm parenchymal depth
II Hematoma Subcapsular, 10–50% surface area: Intraparenchymal <10cm in diameter
Laceration Capsular tear 1–3 parenchymal depth, <10cm in length
III Hematoma Subcapsular, >50% surface area of ruptured subcapsular or parenchymal
Laceration >3cm parenchymal depth
IV Laceration Parenchymal disruption involving 25–75% hepatic lobe or 1–3 Couinaud’s
V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud’s
Vascular Juxtahepatic venous injuries, i.e., retrohepatic vena cava/central major
VI Vascular Hepatic avulsion
Advance one grade for multiple injuries up to grade III
AAST-OIS American Association for the Surgery of Trauma Organ Injury Scale
Injury description
hematoma; intraparenchymal hematoma >10cm or expanding
segments
segments within a single lobe
hepatic veins
Table 10.2 Liver trauma classication
WSES grade AAST grade
Minor WSES grade I I–II Stable
Moderate WSES grade II III Stable
Severe WSES grade III IV–V Stable
WSES grade IV Any Unstable
From [12] (published under the terms of the Creative Commons CC-BY license)
WSES World Society of Emergency Surgery, AAST American Association for the Surgery
of Trauma
Hemodynamic status
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Liver Trauma
M. Chiarugi et al.
In the ED: E-FAST, Thoracic and Pelvic X-ray,
High flow venous vascular access
Hemodynamically Unstable
or transient responder
Other indications to
laparotomy
Repair
NO
NO
YES
YES
Positive E-FAST
(See dedicated algorithm)
Severe Lesions
Massive Transfusion
Protocol activation
Operating Room
Continue NOM
Minor Lesions
WSES I
AAST I-II
Positive blush
Early aneurysm
YES*
NO
Angioembolization
Serial
Clinical/Laboratory/Radiological
Evaluation
In case of suspected abdominal lesions
consider Interval Laparoscopy
Hemodynamically Stable
Contrast Enhanced CT-Scan
+ Local Exploration in SW #
Moderate Lesions
WSES II
AAST III
Effective
Severe Lesions
WSES II
AAST IV-V
Ineffective
Angioembolization
Consider Re-angio
Hemodynamic/Clinical Stability
No other indications to surgery
Negative
Positive
Fig. 10.1 Liver trauma management algorithm. CT computed tomography, ED emergency depart-
ment, E-FAST extended focused assessment with sonography for trauma, NOM non-operative
management, SW stab wound. #Wound exploration near the inferior costal margin should be
avoided if not strictly necessary. *Angioembolization should be always considered for adults, only
in selected patients and in selected centers for pediatrics. Reproduced from [12] published under
the terms of the Creative Commons CC-BY license
Two algorithms for the management of hepatic injuries are presented in Figs.10.1
and 10.2.
10.3.1 Specific Non-operative Management Aspects
The liver is the most commonly injured intra-abdominal solid organ and the majority of injuries do not require surgical treatment. All the aforementioned general
rules remain key points in liver trauma NOM.Only moderate (WSES II, AAST III)
and severe (WSES III, AAST IV–V) lesions may require admission to the intensive
care unit, in the case of isolated liver injury.
10.3.2 Operative Management
OM should be the treatment of choice for hemodynamically unstable and nonresponder patients (WSES IV), other than the general indications above mentioned.
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Liver trauma
Major liver bleeding
Peri-hepatic liver packing
+ Intra-operative angiography
Controlled liver bleeding
Check foe lesions to:
Portal vein
Hepatic artery
Intra-parenchymal
vessels (rarely indicated)
Repair
(Main trunk ligation discouraged)
Repair / Selective ligation
(Cholecystectomy in case of right
or Proper hep. artery ligation)
Severe Lesions - WSES IV
Exploratory laparotomy (DCS)
+ Pringle maneuver
Consider
Post-operative angiography
Ligation
Massive Transfusion Protocol activation
Minor liver bleeding
Uncontrolled liver/retro-
hepatic bleeding
Consider
vascular anomaly
Hepatic isolation
Liver mobilization
Supra-hepatic vein Retro-hepatic Cava
Trans diaphragmatic / trans thoracic and
abdominal Cava clamping and repair
Shunting techniques
(Consider REBOA-C)
Check for other lesions and fix Tr ansfer to ICU
REBOA / REBOA-C
Provide viable femoral arterial access
and high flow venous catheter(s)
Check for other bleeding source
Compression, electrocautery,
argon beam coagulation, topical
hemostatic agents, omental
packing, hepatorraphy
Check for another lesions and fix
Consider
Retro-hepatic Cava exclusion
/clamping and repair
Shunting techniques
(Consider REBOA-C)
Fig. 10.2 Hemodynamically unstable liver trauma management algorithm. DCS damage control
surgery, ICU intensive care unit, REBOA-C resuscitative endovascular balloon occlusion of the
aorta-cava. Reproduced from [12] published under the terms of the Creative Commons
CC-BY license
The primary goal during laparotomy in OM are control of the hemorrhage and of
the bile leak and initiation of damage control resuscitation as soon as possible.
If no major bleeding is present, compression alone or any other tool for hemosta-
sis control (i.e., electrocautery, bipolar devices, argon, topical hemostatic agents,
etc.) may be sufcient to stop the bleed.
In the case of major hemorrhage, several strategies can be considered:
1. Manual compression and hepatic packing.
2. Ligation of the vessels in the wound.
3. Hepatic debridement or nger fracture.
4. Balloon tamponade.
5. Temporary ligation of hepatic vessels (Pringle maneuver) in order to control the
bleeding and allow for repair.
6. Repair of hepatic vessels (i.e., hepatic artery or portal vein injuries).
7. Hepatic artery ligation or selective ligation (concomitant cholecystectomy if the
right hepatic artery has been ligated, to avoid gallbladder necrosis).
8. In the event of suspected injuries to the retrohepatic cava or hepatic vein: tamponade with hepatic packing, direct repair, lobar resection.
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Complete vascular exclusion or other techniques, such as atriocaval shunt, are
generally poorly tolerated.
Major hepatic resections should be avoided at rst and only considered in subse-
quent operations. In selected patients with large areas of devitalized liver tissue,
resectional debridement done by experienced surgeons may be considered a strategy.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used
as a temporary bleeding control maneuver and as a bridge to other more denitive
procedures of hemorrhage control in hemodynamically unstable patients.
Indications for postoperative AG/AE are:
1. Persistent arterial bleeding despite emergency laparotomy and hemostasis
attempt.
2. After initial operative hemostasis, in stable or stabilized patients with contrast
blush at completion CT scan.
M. Chiarugi et al.
10.3.3 Complications
The most frequent complications after liver trauma are:
• vascular complications: rebleeding or secondary hemorrhage (i.e., subcaspular
hematoma), pseudoaneurysm (PSA), arteriovenous stula;
• biliary complications: bile leak, biloma, biliary peritonitis, biliary stula and
hemobilia);
• hepatic necrosis and abscess;
• abdominal compartment syndrome.
Delayed hemorrhage without severe hemodynamic compromise may be man-
aged at rst with AG/AE, and this should also be considered in hepatic artery PSA,
in order to prevent rupture.
Percutaneous drainage is a viable treatment strategy in cases of symptomatic or
infected bilomas as well as intrahepatic abscesses.
Post-traumatic biliary complications not suitable for percutaneous management
alone can be managed with a combination of percutaneous drainage and endoscopic
techniques. A post-traumatic biliary stula may be treated with laparoscopic lavage/
drainage or endoscopic stenting as a rst approach; if there is any other concomitant
indication for surgery, laparotomy should be considered.
10.4 Splenic Trauma
Splenic injuries can be divided into three grades according to the WSES classication that considers the AAST-OIS classication (Table10.3) and hemodynamic sta-
tus (Table10.4) [10]:
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Table 10.3 AAST-OIS spleen injury scale (1994 revision)
Injury type
Grade
I Hematoma Subcapsular, <10% surface area
Laceration Capsular tear, <1cm parenchymal depth
II Hematoma Subcapsular, 10–50% surface area; intraparenchymal, <5cm in diameter
Laceration Capsular tear, 1–3cm parenchymal depth that does not involve a trabecular
III Hematoma Subcapsular, >50% surface area or expanding; ruptured subcapsular or
Laceration >3cm parenchymal depth or involving trabecular vessels
IV Laceration Laceration involving segmental or hilar vessels producing major
V Laceration Completely shattered spleen
Vascular Hilar vascular injury which devascularizes spleen
Advance one grade for multiple injuries up to grade III
AAST-OIS American Association for the Surgery of Trauma Organ Injury Scale
Table 10.4 Spleen trauma classication
Minor WSES grade I I–II Stable
Moderate WSES grade II III Stable
Severe WSES grade IV Any Unstable
From [10] (published under the terms of the Creative Commons CC-BY license)
WSES World Society of Emergency Surgery, AAST American Association for the Surgery
of Trauma
Injury description
vessel
parenchymal hematoma; intraparenchymal hematoma, >5cm or expanding
devascularization (>25% of spleen)
WSES grade AAST grade
WSES grade III IV–V Stable
Hemodynamic status
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• minor (WSES grade I);
• moderate (WSES grade II and III);
• severe (WSES grade IV).
An algorithm for the management of splenic injuries is presented in Fig.10.3.
10.4.1 Specific Diagnostic Procedures andNon-operative
Management Aspects
The spleen is the second most commonly injured abdominal solid organ and NOM
is successful in around 80% of patients.
Doppler ultrasound (US) and contrast-enhanced US are useful to evaluate splenic
vascularization, to better dene some vascular anomalies (i.e., PSA) and during the
follow-up.
Injury grade on CT scan, extent of free uid and presence of a PSA are not pre-
dictive factors of NOM failure. Conversely, age>55years old, high Injury Severity
Score (ISS) and moderate to severe splenic injuries seem to be prognostic factors for
failure.
128
s
I
(
)
Moderate
T
*
e
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M. Chiarugi et al.
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ADULT PATIENTS
Contrast Enhanced CT-Scan
+ Local Exploration in SW #
Minor Lesions
Minor Lesion
WSES I
WSES
(AAST I-II)
AAST I-II
NOM*
NOM
Consider Angio if positive
Consider Angio if positiv
blush or early aneurysm
blush or early aneurys
Pre-emptive Agioembolization
Moderate Lesions
NO
N
Serial Clinical/Laboratory/
Radiological Evaluation
Consider Re-Angio if indicated
Hemodynamically Stable
WSES II
WSE
(AAST III)
(AAS
or early aneurysm
Angiography
Positive blush
Moderate Lesions
(AAST VI-V)
YES
Hemodynamic/Clinical Stability
Absence of other indications to
WSES III
Ineffective
Angioembolization
Effective
Angioembolization
laparotomy
Spleen Trauma
Bowel Evisceration-Impalement-Peritonitis
other indications for laparotomy
In the E D : E-FAST, Thoracic and Pelvic X-ray,
Hemodynamically Unstable
or transient responders @
Positive E-FAST
Severe Lesions
WSES IV
(AAST I-V)
Laparotomy
+ Splenectomy/
Splenic salvage
NO
YES
Continue NOM *
Fig. 10.3 Spleen trauma management algorithm for adult patients. CT computed tomography, ED
emergency department, E-FAST extended focused assessment with sonography for trauma, NOM
non-operative management, GSW gunshot wound, SW stab wound. * NOM should only be
attempted in centers capable of a precise diagnosis of the severity of spleen injuries and capable of
intensive management (close clinical observation and hemodynamic monitoring in a high dependency/intensive care environment, including serial clinical examination and laboratory assay, with
immediate access to diagnostics, interventional radiology, and surgery and immediately available
access to blood and blood products) or alternatively in the presence of a rapid centralization system
in those patients amenable to be transferred. @ Hemodynamic instability is considered the condition in which the patient has an admission systolic blood pressure <90mmHg with evidence of
skin vasoconstriction (cool, clammy, decreased capillary rell), altered level of consciousness and/
or shortness of breath, or >90mmHg but requiring bolus infusions/transfusions and/or vasopressor
drugs and/or admission base excess >−5mmol/L and/or shock index >1 and/or transfusion requirement of at least 4–6 units of packed red blood cells within the rst 24 h; moreover, transient
responder patients (those showing an initial response to adequate uid resuscitation, and then signs
of ongoing loss and perfusion decits) and more in general those responding to therapy but not
amenable to sufcient stabilization to undergo interventional radiology treatments. # Wound
exploration near the inferior costal margin should be avoided if not strictly necessary because of
the high risk of damaging the intercostal vessels. Reproduced from [10] published under the terms
of the Creative Commons CC-BY license
The following conditions are not absolute contraindications for NOM but require
intensive monitoring and a higher index of suspicion (for NOM failure):
1. Age>55years old.
2. Large hemoperitoneum.
3. Hypotension before resuscitation.
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4. Glasgow Coma Scale <12.
5. Low hematocrit level at admission.
6. Blush at CT scan.
7. Anticoagulant drugs.
8. HIV disease, drug addition, cirrhosis.
9. Associated abdominal injuries and need for blood transfusion.
Other than the general indications (mentioned above), proximal or combined
AG/AE can also be considered in hemodynamically stable patients with:
1. WSES grade II lesions without blush but with risk factors for NOM failure (not
routinely recommended but to be considered).
2. An absent blush at AG but previously seen at CT scan (not routinely recommended but to be considered).
3. WSES grade III lesions, regardless of the presence of CT blush
(recommended).
4. Multiple splenic vascular abnormalities or in the presence of a severe lesion
(recommended).
In performing proximal AE for splenic vascular injuries, it is important to always
evaluate and conrm a permissive pancreatic vascular anatomy. Usually, coils
should be preferred to temporary agents.
There is no current agreement in the literature regarding whether proximal or
distal embolization should be used in the event of a single vascular injury (contrast
blush, pseudoaneurysm, and arteriovenous stula) in minor and moderate injuries.
In WSES II–III splenic injuries and concomitant neurological trauma, a NOM
strategy should be considered with caution and only in centers with rapidly available operating room and/or AG/AE; otherwise, splenectomy has been shown to be
a safe strategy that helps prevent secondary damage due to hypoperfusion.
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10.4.2 Operative Management
OM should be the treatment of choice for hemodynamically unstable and nonresponder patients (WSES IV), other than the general indications mentioned above.
Stable patients with moderate and severe lesions should undergo OM in centers
where intensive monitoring cannot be performed and/or when AG/AE is not rapidly
available.
Splenectomy should be performed when NOM with AG/AE has failed and:
• the patient remains hemodynamically unstable or
• shows a signicant drop in hematocrit levels or
• continuous transfusions are required.
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During OM, salvage of at least a part of the spleen is debated and cannot be
suggested.
Laparoscopic splenectomy in the early trauma scenario in bleeding patients is
described but cannot be recommended.
M. Chiarugi et al.
10.4.3 Follow-Up inNon-operative Management
In the rst 48–72h of follow-up in moderate and severe lesions, clinical and laboratory observation associated with bed rest is essential.
During hospitalization, the CT scan should be repeated in the case of:
• patients with moderate and severe lesions;
• decreasing hematocrit;
• presence of vascular anomalies;
• underlying splenic pathology or coagulopathy;
• neurologically impaired patients.
CT follow-up is recommended also after discharge in the presence of underlying
splenic pathology or coagulopathy and in neurologically impaired patients.
Activity restriction may be suggested for 4–6weeks in minor injuries and up to
2–4months in moderate and severe injuries.
10.4.4 Infection Prophylaxis inAsplenic
andHyposplenic Patients
After splenectomy or AG/AE, patients should receive immunization against encapsulated bacteria (Streptococcus pneumoniae, Haemophilus inuenzae, and Neisseria
meningitidis). Vaccination programs should be started 14days after splenectomy or
spleen total vascular exclusion. In patients discharged before 15days after splenectomy or AE, where the risk of missing vaccination is deemed high, the best choice
is to vaccinate before discharge.
Malaria prophylaxis is strongly recommended for travelers, immunization
against seasonal u is recommended for patients over 6months of age, and antibiotic therapy should be strongly considered in the event of any sudden onset of unexplained fever, malaise, chills or other constitutional symptoms, especially when
medical review is not readily accessible.
10.5 Kidney Trauma
Kidney injuries can be divided into three grades according to the WSES classication that considers the AAST-OIS classication (Table10.5) and hemodynamic sta-
tus (Table10.6) [13]:
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Table 10.5 AAST-OIS kidney injury scale
Injury type
Grade
I Contusion Microscopic or gross hematuria; urologic studies normal
Hematoma Subcapsular, nonexpanding without parenchymal laceration
II Hematoma Nonexpanding perirenal hematoma conrmed to renal retroperitoneum
Laceration <1.0cm parenchymal depth of renal cortex without urinary extravasation
III Laceration <1.0cm parenchymal depth of renal cortex without collecting system
IV Laceration Parenchymal laceration extending through renal cortex, medulla, and
Vascular Main renal artery or vein injury with contained hemorrhage
V Laceration Completely shattered kidney
Vascular Avulsion of renal hilum which devascularizes kidney
Advance one grade for multiple injuries up to grade III
AAST-OIS American Association for the Surgery of Trauma Organ Injury Scale
Table 10.6 Kidney trauma classication
WSES
grade AAST grade
Minor WSES
Moderate WSES
Severe WSES
From [
WSES World Society of Emergency Surgery, AAST American Association for the Surgery
of Trauma
grade I
grade II
grade III
WSES
grade IV
13] (published under the terms of the Creative Commons CC-BY license)
Injury description
rupture or urinary extravasation
collecting system
I–II Stable
III or segmental vascular injuries Stable
IV–V or any grade parenchymal lesion with main
vessels dissection/occlusion
Any Unstable
Hemodynamic
status
Stable
131
• minor (WSES grade I);
• moderate (WSES grade II);
• severe (WSES grade III and IV).
An algorithm for the management of kidney injuries is presented in Fig.10.4.
10.5.1 Specific Diagnostic Procedures
Blunt trauma, and especially high-velocity deceleration mechanism, is the most frequent cause of kidney injuries. This same mechanism is also responsible for a very
rare type of lesion, namely isolated renal artery transection or divulsion.
Micro- and macrohematuria are often highly suggestive of kidney damage (being
present in around 85–90% of cases) but do not predict the grade and the severity of
the injury itself.
E-FAST has low sensitivity and specicity in diagnosing kidney lesions, the kid-
ney being a retroperitoneal organ.
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