Blunt Liver Trauma at Sunnybrook
Medical Centre: A 13 Year Experience

Between June 1, 1976 and June 30, 1989 The Regional Trauma Unit at Sunnybrook Medical Centre in Toronto, Ontario, Canada received 3730 patients. Of these 335 (9%) sustained a liver injury, 95% being due to blunt trauma. Open peritoneal lavage was performed on 80% of liver trauma patients (267/335), 99% being true positive.A laparotomy was performed on 97% of patients (324/335). Major surgical treatment was required in 132 patients (41%) and minor treatment in 192 patients (59%). The remaining 11 patients were treated conservatively (n = 3) or died during resuscitation (n = 8).Morbidity directly related to the liver injury was seen in 29 of 249 surviving patients (11%) although overall morbidity was 27% (67/249). Reoperation was required in 6% (14/249) with abscess or hematoma accounting for 11 of 14 operations.The overall mortality rate was 26% (86/335). Eighty two percent of patients (n = 276) had a grade I, II or III liver trauma according to Moore’s classification with a mortality of 12% (n = 32). The remaining 18% of patients (n = 59) had a grade IV or V liver trauma with a mortality of 44% (n = 26). Of the 86 deaths, head injury accounted for 48 (56% of deaths); liver hemorrhage for 17 (20%), liver sepsis for (1%) and other causes for 20 deaths (23%). Thus death due to the liver injury itself (hemorrhage and sepsis) occurred in 18 out of 335 patients (5% overall). Head injury accounted for the death of 48 out of 335 patients (14% overall).Over the past 13 years a trend has occurred at our institution whereby we are seeing less liver trauma in our population of multiply injured patients from 12% (1976–1983) down to 7% (1985–1989); with a gradual decline in overall mortality from 32% (1976–1983) to 19% (1985–1989), whereas the precentage of deaths due to head injuries and liver injury have increased.

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Absence of Stress Hyperglycemia Indicates the Most Severe Form of Blunt Liver Trauma

Diagnostics ◽

10.3390/diagnostics11091667 ◽

2021 ◽

Vol 11 (9) ◽

pp. 1667

Author(s):

Janett Kreutziger ◽

Margot Fodor ◽

Dagmar Morell-Hofert ◽

Florian Primavesi ◽

Stefan Stättner ◽

...

Keyword(s):

Blood Glucose ◽

Liver Injury ◽

Injury Severity ◽

Severe Form ◽

Liver Trauma ◽

University Hospital ◽

Hepatic Insulin Resistance ◽

Trauma Patients ◽

Stress Hyperglycemia ◽

Glucose Levels

Background: Stress hyperglycemia is common in trauma patients. Increasing injury severity and hemorrhage trigger hepatic gluconeogenesis, glycogenolysis, peripheral and hepatic insulin resistance. Consequently, we expect glucose levels to rise with injury severity in liver, kidney and spleen injuries. In contrast, we hypothesized that in the most severe form of blunt liver injury, stress hyperglycemia may be absent despite critical injury and hemorrhage. Methods: All patients with documented liver, kidney or spleen injuries, treated at a university hospital between 2000 and 2020 were charted. Demographic, laboratory, radiological, surgical and other data were analyzed. Results: A total of 772 patients were included. In liver (n = 456), spleen (n = 375) and kidney (n = 152) trauma, an increase in injury severity past moderate to severe (according to the American Association for the Surgery of Trauma, AAST III-IV) was associated with a concomitant rise in blood glucose levels independent of the affected organ. While stress-induced hyperglycemia was even more pronounced in the most severe forms (AAST V) of spleen (median 10.7 mmol/L, p < 0.0001) and kidney injuries (median 10.6 mmol/L, p = 0.004), it was absent in AAST V liver injuries, where median blood glucose level even fell (5.6 mmol/L, p < 0.0001). Conclusions: Absence of stress hyperglycemia on hospital admission could be a sign of most severe liver injury (AAST V). Blood glucose should be considered an additional diagnostic criterion for grading liver injury.

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Blunt Liver Trauma at Sunnybrook Medical Centre

Journal of Trauma and Acute Care Surgery ◽

10.1097/00005373-198709000-00001 ◽

1987 ◽

Vol 27 (9) ◽

pp. 965-969 ◽

Cited By ~ 5

Author(s):

SHERIF S. HANNA ◽

PETER R. GORMAN ◽

ALLAN W. HARRISON ◽

GLEN TAYLOR ◽

HENSLEY A. B. MILLER ◽

...

Keyword(s):

Liver Trauma ◽

Medical Centre ◽

Blunt Liver Trauma

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Absence of Stress Hyperglycemia Indicates the Most Severe Form of Blunt Liver Trauma (AAST V) – A Register Analysis

10.21203/rs.3.rs-361037/v1 ◽

2021 ◽

Author(s):

Janett Kreutziger ◽

Margot Fodor ◽

Dagmar Morell-Hofert ◽

Florian Primavesi ◽

Stefan Stättner ◽

...

Keyword(s):

Blood Glucose ◽

Liver Injury ◽

Injury Severity ◽

Severe Form ◽

Liver Trauma ◽

University Hospital ◽

Hepatic Insulin Resistance ◽

Trauma Patients ◽

Stress Hyperglycemia ◽

Glucose Levels

Abstract Background: Stress hyperglycemia is common in trauma patients. Increasing injury severity and hemorrhage is known to trigger hepatic gluconeogenesis and glycogenolysis and also peripheral and hepatic insulin resistance. Consequently, we expect glucose levels to rise with injury severity in liver, kidney and spleen injuries. In contrast, we hypothesized that in the most severe form of blunt liver injury, stress hyperglycemia may be absent despite critical injury and hemorrhage.Methods: All patients with documented liver, kidney or spleen injuries, treated at a single, university hospital in Austria between 2000 and 2020 were charted in a register. Besides demographic, laboratory, radiological, surgical and other data were analyzed.Results: A total of 772 patients were included. In liver (n=456), spleen (n=375) and kidney (n=152) trauma, an increasing injury severity past moderate to severe (AAST III-IV) was associated with a concomitant rise in blood glucose levels independent of the affected organ. While this stress induced hyperglycemia was even more pronounced in the most severe forms (AAST V) of spleen (median 10.7 mmol/L, p<0.0001) and kidney injuries (median 10.6 mmol/L, p=0.004), it was absent in AAST V liver injuries, where median blood glucose level even fell (5.6 mmol/L, p<0.0001). Conclusions: Absence of stress hyperglycemia is a sign of most severe liver injury (AAST V) and should prompt fundamental diagnostic and therapeutic procedures. Blood glucose should be considered as an additional diagnostic criterion in liver injury.

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A case report of blunt liver trauma in times of COVID-19 pandemic

Romanian Journal of Orthopaedic Surgery and Traumatology ◽

10.2478/rojost-2020-0014 ◽

2020 ◽

Vol 3 (2) ◽

pp. 90-94

Author(s):

Vlad Braga ◽

Iulian Slavu ◽

Adrian Tulin ◽

Bogdan Socea ◽

Lucian Alecu

Keyword(s):

Abdominal Trauma ◽

Continuous Monitoring ◽

Damage Control ◽

Liver Parenchyma ◽

Hemodynamic Instability ◽

Liver Trauma ◽

Emergency Laparotomy ◽

Trauma Patients ◽

Accidental Fall ◽

Blunt Liver Trauma

AbstractThe liver is one of the most affected organs in abdominal trauma mostly because of its considerable dimensions, the fragility of the liver parenchyma.We present the case of a 29-year-old patient who sustained an abdominal trauma after an accidental fall from a 3 m height. The patient tested positive at RT-PCR for SARS-CoV-2 at admission, without any symptoms of viral infection. The emergency CT scan revealed a blunt liver trauma with an expanding hematoma (grade III). The patient was initially hemodynamically stable but shortly after admission became unstable and required surgical treatment that initially consisted of damage control and liver packing. Reintervention was decided 36 hours later, after reevaluation unpacking and hepatorrhaphy were done. The postoperative evolution was uneventful. The case indicated the importance of continuous monitoring of the traumatic patient. In liver trauma, hemodynamic instability guarantees an emergency laparotomy. The time of operations in trauma patients with SARS-CoV-2 must be reduced to the maximum both as an objective of damage control and also to minimize the risk of contagion.

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Golf Related Head Injuries in Children: The Little Tigers

Scottish Medical Journal ◽

10.1177/003693309804300504 ◽

1998 ◽

Vol 43 (5) ◽

pp. 139-140 ◽

Cited By ~ 9

Author(s):

A.C. McGuffie ◽

M.O. Fitzpatrick ◽

D. Hall

Keyword(s):

Emergency Department ◽

Head Injury ◽

Emergency Departments ◽

Head Injuries ◽

Western Society ◽

Accident And Emergency ◽

Head Injured ◽

Accident And Emergency Department ◽

Injured Patients

Head injury is a major cause of morbidity in Western society and sport related incidents account for approximately 11% of all head injured patients attending Accident and Emergency Departments. 1 Golf was shown to be one of the sports most commonly associated with head injury requiring referral to a regional neurosurgical centre.2 Previous studies have demonstrated that it is predominantly children who sustain golf related head injuries which present either to an accident and emergency department3 or a regional neurosurgical centre.2 This study examines the number and pattern of golf related head injuries in children presenting to an accident and emergency department or requiring admission to the regional neurosurgical centre, over a three month period.

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Failure to Rescue in Geriatric Trauma: The Impact of Any Complication Increases with Age and Injury Severity in Elderly Trauma Patients

The American Surgeon ◽

10.1177/00031348211054072 ◽

2021 ◽

pp. 000313482110540

Author(s):

David P. Stonko ◽

Eric W. Etchill ◽

Katherine A. Giuliano ◽

Sandra R. DiBrito ◽

Daniel Eisenson ◽

...

Keyword(s):

Geriatric Patients ◽

Injury Severity ◽

Data Bank ◽

Geriatric Trauma ◽

Trauma Patients ◽

Failure To Rescue ◽

Elderly Trauma Patients ◽

Injured Patients ◽

The Impact ◽

Overall Mortality

Introduction The interaction of increasing age, Injury Severity Score (ISS), and complications is not well described in geriatric trauma patients. We hypothesized that failure to rescue rate from any complication worsens with age and injury severity. Methods The National Trauma Data Bank (NTDB) was queried for injured patients aged 65 years or older from January 1, 2013 through December 31, 2016. Demographics and injury characteristics were used to compare groups. Mortality rates were calculated across subgroups of age and ISS, and captured with heatmaps. Multivariable logistic regression was performed to identify independent predictors of mortality. Results 614,496 geriatric trauma patients were included; 151,880 (24.7%) experienced a complication. Those with complications tended to be older, female, non-white, have non-blunt mechanism, higher ISS, and hypotension on arrival. Overall mortality was highest (19%) in the oldest (≥86 years old) and most severely injured (ISS ≥ 25) patients, with constant age increasing across each ISS group was associated with a 157% increase in overall mortality ( P < .001, 95% CI: 148-167%). Holding ISS stable, increasing age group was associated with a 48% increase in overall mortality ( P < .001, 95% CI: 44-52%). After controlling for standard demographic variables at presentation, the existence of any complication was an independent predictor of overall mortality in geriatric patients (OR: 2.3; 95% CI: 2.2-2.4). Conclusions Any complication was an independent risk factor for mortality, and scaled with increasing age and ISS in geriatric patients. Differences in failure to rescue between populations may reflect critical differences in physiologic vulnerability that could represent targets for interventions.

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Cause of decline in head-injury mortality rate in San Diego County, California

Journal of Neurosurgery ◽

10.3171/jns.1985.62.4.0528 ◽

1985 ◽

Vol 62 (4) ◽

pp. 528-531 ◽

Cited By ~ 71

Author(s):

Melville R. Klauber ◽

Lawrence F. Marshall ◽

Belinda M. Toole ◽

Sharen L. Knowlton ◽

Sharon A. Bowers

Keyword(s):

Head Injury ◽

San Diego ◽

Head Injuries ◽

Mortality Rates ◽

San Diego County ◽

Content Type ◽

Severity Of Injury ◽

Prehospital Emergency ◽

Injured Patients ◽

Number Of Individuals

✓ Even with an increasing population, there were 100 fewer deaths due to head injury in San Diego County, California, in 1982 compared to 1980. During the 5 years from 1976 to 1980 there was nearly a constant death rate from head injuries, followed in the next 2 years by a decline of 24%. The number of deaths at the scene of injury declined 28%, and the number of individuals listed as dead on arrival at the hospital declined 68%. Mortality rates in the emergency room increased slightly and later death rates declined slightly. Mortality rates of hospitalized patients, adjusted for severity of injury, did not vary materially by year. This decline in deaths due to head injury followed a marked improvement in the county's emergency ground and prehospital air evacuation services. The data strongly suggest that advanced prehospital emergency medical services can substantially reduce mortality rates in head-injured patients. The authors postulate that some patients who ordinarily “would die now talk” because of early airway and circulatory management by highly trained paramedical personnel and airborne trauma specialists. Despite a search for other factors that might explain these observations, no satisfactory alternatives could be identified.

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Prophylactic Inferior Vena Cava Filters

The American Surgeon ◽

10.1177/0003134820950297 ◽

2020 ◽

pp. 000313482095029

Author(s):

Adel Elkbuli ◽

John D. Ehrhardt ◽

Kyle Kinslow ◽

Mark McKenney

Keyword(s):

Inferior Vena Cava ◽

Hospital Mortality ◽

Inferior Vena ◽

Head Injuries ◽

Vena Cava ◽

Trauma Patients ◽

Severely Injured ◽

Icu Length Of Stay ◽

Vena Cava Filters ◽

Injured Patients

Background Patients with major trauma and contraindications to anticoagulation are often considered candidates for a prophylactic inferior vena cava filter (IVCF). Prophylactic IVCFs are controversial in trauma and backed by varying levels of evidence. This study aims to analyze outcomes in severely injured patients who receive IVCFs. Methods A retrospective review of trauma patients aged ≥ 16 years with ISS ≥ 15 admitted to our level 1 trauma center from years 2013 through 2018. Patients were divided into 2 groups: prophylactic IVCF versus VTE chemoprophylaxis. The analysis evaluated demographics, stratified by ISS (15-24, 25-34, ≥35), and subgrouped those with AIS-Head ≥3. Adjusted outcome measures included DVT, PE, mortality, and ICU length-of-stay (ICU-LOS). Results The study sample included 413 patients with prophylactic IVCFs and 2487 on VTE chemoprophylaxis. IVCF placement was associated with higher severity injuries: ISS 28 versus 25 and lower GCS 10.0 versus 11.8, TBI prevalence 83% versus 68% ( P < .001). Patients with IVCFs had increased ICU-LOS (23.2 days vs 12.2 days), DVT (14.8% vs 4.3%), and PE (5.8% vs 1.6%) for patients with ISS <35 ( P < .001). ISS ≥35 was not associated with intergroup DVT or PE rate differences ( P = .81 and .43). No intergroup mortality differences were observed, including after ISS stratification. Among patients with AIS-Head ≥3, prophylactic IVCF was associated with lower in-hospital mortality (8.4% vs 15.7%, P = .001). Conclusions Prophylactic IVCF placement was associated with higher rates of DVT and nonfatal PE, and prolonged ICU-LOS. Prophylactic IVCF placement was not associated with increased in-hospital mortality for severely injured trauma patients. Among patients with concomitant critical head injuries (AIS-Head ≥3), prophylactic IVCF placement was associated with lower in-hospital mortality than VTE chemoprophylaxis.

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The management of trauma victims with head injury: a study by the national confidential enquiry into patient outcome and death

Annals of The Royal College of Surgeons of England ◽

10.1308/003588413x13511609956813 ◽

2013 ◽

Vol 95 (2) ◽

pp. 101-106

Author(s):

NCE Smith ◽

GP Findlay ◽

D Weyman ◽

H Freeth

Keyword(s):

Patient Outcome ◽

Head Injury ◽

Injury Severity ◽

Head Injuries ◽

Good Practice ◽

High Volume ◽

Level Of Care ◽

Trauma Patients ◽

Confidential Enquiry ◽

Number Of Patients

Introduction In 2006 the National Confidential Enquiry into Patient Outcome and Death undertook a large prospective study of trauma care, which revealed several findings pertaining to the management of head injuries in a sample of 493 patients. Methods Case note data were collected for all trauma patients admitted to all hospitals accepting emergencies in England, Wales, Northern Ireland and the Channel Islands over a three-month period. Severely injured patients with an injury severity score (ISS) of ≥16 were included in the study. The case notes for these patients were peer reviewed by a multidisciplinary group of clinicians, who rated the overall level of care the patient received. Results Of the 795 patients who met the inclusion criteria for the study, 493 were admitted with a head injury. Room for improvement in the level of care was found in a substantial number of patients (265/493). Good practice was found to be highest in high volume centres. The overall head injury management was found to be satisfactory in 84% of cases (319/381). Conclusions This study has shown that care for trauma patients with head injury is frequently rated as less than good and suggests potential long-term remedies for the problem, including a reconfiguration of trauma services and better provision of neurocritical care facilities.

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Head Injury in Very Young Children: Mechanisms, Injury Types, and Ophthalmologic Findings in 100 Hospitalized Patients Younger Than 2 Years of Age

PEDIATRICS ◽

10.1542/peds.90.2.179 ◽

1992 ◽

Vol 90 (2) ◽

pp. 179-185 ◽

Cited By ~ 1

Author(s):

A. C. Duhaime ◽

A. J. Alario ◽

W. J. Lewander ◽

L. Schut ◽

L. N. Sutton ◽

...

Keyword(s):

Head Injury ◽

Young Children ◽

Motor Vehicle ◽

Head Injuries ◽

Older Children ◽

Retinal Hemorrhages ◽

Injury Type ◽

Vehicle Accidents ◽

Very Young Children ◽

Injured Patients

Head injury in the youngest age group is distinct from that occurring in older children or adults because of differences in mechanisms, injury thresholds, and the frequency with which the question of child abuse is encountered. To analyze some of these characteristics in very young children, the authors prospectively studied 100 consecutively admitted head-injured patients 24 months of age or younger who were drawn from three institutions. Mechanism of injury, injury type, and associated injuries were recorded. All patients underwent ophthalmologic examination to document the presence of retinal hemorrhages. An algorithm incorporating injury type, best history, and associated findings was used to classify each injury as inflicted or accidental. The results confirmed that most head injuries in children younger than 2 years of age occurred from falls, and while different fall heights were associated with different injury types, most household falls were neurologically benign. Using strict criteria, 24% of injuries were presumed inflicted, and an additional 32% were suspicious for abuse, neglect, or social or family problems. Intradural hemorrhage was much more likely to occur from motor vehicle accidents and inflicted injury than from any other mechanism, with the latter being the most common cause of mortality. Retinal hemorrhages were seen in serious accidental head injury but were most commonly encountered in inflicted injury. The presence of more serious injuries associated with particular mechanisms may be related to a predominance of rotational rather than translational forces acting on the head.

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