4/3/2017 1 MANAGEMENT OF SOLID ORGAN INJURIES: NON- OPERATIVE, INTERVENTIONAL AND OPERATIVE April 4, 2017 Ellen Omi, MD, FACS Trauma and Critical Care Site Program Director, Surgery Advocate Christ Medical Center Clinical Assistant Professor, Department of Surgery University of Illinois-Chicago DISCLOSURES • Gift of Hope: Consultant on Critical Care Advisory Board
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4/3/2017
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MANAGEMENT OF SOLID ORGAN INJURIES: NON-
OPERATIVE, INTERVENTIONAL AND
OPERATIVEApril 4, 2017
Ellen Omi, MD, FACS
Trauma and Critical Care
Site Program Director, Surgery
Advocate Christ Medical Center
Clinical Assistant Professor, Department of Surgery
University of Illinois-Chicago
DISCLOSURES
• Gift of Hope: Consultant on Critical Care Advisory Board
4/3/2017
2
OBJECTIVES
• To discuss the non-operative and operative management of splenic, renal
and liver injuries
• To discuss the utilization of interventional radiology in solid organ injury
and non-operative management
• To discuss cases that demonstrate the combined approach to solid organ
injury.
OBJECTIVES
• To discuss the non-operative and operative management of splenic, renal
and liver injuries
• To discuss the utilization of interventional radiology in solid organ injury
and non-operative management
• To discuss cases that demonstrate the combined approach to solid organ
injury.
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SPLENIC INJURY
• The most commonly injured solid
organ.
• Mechanisms of splenic injury
• Blunt
• Penetrating
• Management
• Nonoperative
• Operative
• Expectant
TRUTH OR MYTH
• Intentional injury of the spleen was a method of assassination.
• Giraffes were thought to have exceptional speed because they did not have a
spleen.
• The amount of spleen needed to preserve immune and filtering functions of
the spleen is about 30-50%
• Pediatric splenic capsules are thicker and the parenchyma firmer and thus
are more likely to be managed successfully nonoperatively.
• About 45% of blunt splenic injuries will require emergency surgery
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GRADES OF INJURY
• Grade I-V
• Low grade I-II
• Moderate III
• High grade IV-V
LOW GRADE
Grade I: -Subcapsular hematoma
<10% surface area-Laceration/Capsular tear
<1cm deep
ATOM, 2nd edition. 2010
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ATOM, 2nd edition. 2010
LOW GRADE
• Grade II:• Subcapsular hematoma
10-50% surface area • Intra-parenchymal
hematoma <5cm• Laceration 1-3cm without
vessel involvement
MODERATE GRADE
Grade III:
-Subcapsular hematoma >50% surface area or expanding
-Intra-parenchymal hematoma >5cm
-Ruptured hematoma-Laceration >3cm or with
trabecular vessel involvement
ATOM, 2nd edition. 2010
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HIGH GRADE
Grade IV:
Laceration of segmental
or hilar vessels causing
major
devascularization
(>25% of spleen)
ATOM, 2nd edition. 2010
HIGH GRADE
Grade V:
-Shattered spleen
-Injury of hilar vessels
with completely
devascularized spleen
ATOM, 2nd edition. 2010
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MANAGEMENT
• ABCDE
• Physicical examination
• Left upper quadrant pain
• Left lower chest wall pain
• Kehr’s sign
• Left shoulder pain
INITIAL MANAGEMENT
• Labs
• IV access
• Hemodynamic instability
• SBP <90
• HR >130
• Response to initial resuscitation
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UNSTABLE BLUNT ABDOMINAL TRAUMA
• Grade 3-5
• FAST
• Grade 3
• FAST +
• Triage to CT if initial resuscitation responsive
• Grade 4
• FAST + then to the operating room
• Selective CT scan if other suspected explanation for instability
• Grade 5
• FAST + / -
• To the operating room
EVOLUTION OF SPLENIC INJURY MANAGEMENT
• Adult
• Splenic salvage to avoid overwhelming post splenectomy sepsis (OPSI)
• Splenic salvage techniques
• Pediatrics-Best way to salvage the spleen was to not operate
• Non-operative management initiaily 30-70%
• Concern for missing intra-abdominal injuries
• Contra-indications: advanced age, fear of missing hollow viscous injury, >2U PRBC,
neurological impairment, high grade injuries)
• Non-operative management increased to 85%
• Non-operative management with angio-embolization:
• Decrease in the failure rate to 10-20%
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NONOPERATIVE MANAGEMENT EVOLUTION
• Emergence of new-generation CT scanners
• High success rate of angiographic embolization
• Better understanding of the natural history of solid organ injuries
Goffete PP, Laterre PF. Traumatic injuries: imaging and intervention in post-traumatic complications (delayed intervention) Eur Ra
MANAGEMENT DECISIONS FOR SPLENIC INJURY
• Presence and severity of hemodynamic instability
• Results of the initial workup of blunt abdominal trauma
• Availability of angiography
• Definition of failure
• Use of followup abdominal ct scanning
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OPERATIVE MANAGEMENT
• Splenectomy
• Splenic salvage
• Stable patients
• Reimplantation
• Unproven method to preserve splenic
function
INTERVENTIONAL RADIOLOGY
• How to embolize?
• Main splenic artery
• Reduces bleeding, but does not
prevent late pseudoaneurysm
rupture and will not likely treat
AVF.
• Distal selective
• Stop bloodflow causing infarction
and abscess
• Combination
• IR suite
• Monitoring in the same standards
of an ICU
• Therapeutic embolization
• Aneurysm
• Arteriovenous fistula
• Extravasation
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VASCULAR BLUSH
• Hemodynamically stable (Grade 3-5)
• Angiography
• OR if angiography not immediately
available
• Hemodynamically unstable (non-
responder)
• OR
• Aggressive angiography
• Highest rates of non-operative
management (80%)
• High rate of complications
• Labor intensive
RISK OF FAILURE OF NONOPERATIVEMANAGEMENT
• Advanced age
• Large hemoperitoneum
• Higher Injury Severity Score
• Brain Injury
• Subcapsular Hematoma
Scalafini SJ, et al. Non-operative salvage of computed tomography diagnosed splenic injuries: utilization of angiography from triage and embolization for hemostasis. Lopez JM, et al. Subcapsular hematoma in blunt splenic injury: A significant predictor of failure of nonoperative management. J Trauma, 2015
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10 DOGS IN 1975
• Artifical splenic trauma
• Embolization of the splenic artery
• 7 survived for 2 months
• Arteries were patent
• Parenchyma smaller, but trauma could
not be identified
• Chuang VP, Reuter SR. Selective arterial embolization for the
control of traumatic splenic bleeding. Invest Radiol 1975 Jan-Feb;
10(1):18-24.
• Diagnostic peritoneal lavage was the most reliable method of identifying
intraperitoneal injuries.
• Cannot determine who can be treated nonoperatively based on the DPL
• CT was found to be reliable alternative to DPL but not practical to replace all
DPL
• CT allowed for the nonoperative management of blunt abdominal trauma-No
longer mandatory exploration
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• Splenic injury on CT 1981-1993
• Urgent angiography in those that did not require immediate operation
• Selective embolization with extravasation of contrast.
• Exravasation into the peritoneum-main splenic arterial branch embolization
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• Coil embolization was the best methods of occlusion of the proximal splenic
artery
• Did not result in splenic infarction
• Blood flow returned to normal in a few weeks
• Pitressin was temporary and unpredictable
• Gelfoam embolized to the distal collateral circulation and caused infarction
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39 WOMAN YEAR OLD HIGH SPEED ROLLOVER
• History of ETOH abuse and cirrhosis
• Primary Survey
• ABC intact, GCS 15
• Secondary Survey
• Contusion forehead
• C-spine tenderness
• Left upper quadrant pain
• Seatbelt sign across the chest and abdomen
DIAGNOSIS
• Grade 2 splenic laceration with blush
• Mild hemoperitoneum
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PLAN
• IR for angiography
• Findings
• Superselective splenic artery catheterization and subsequent arteriogram.
• Coil embolization of the branches of the splenic artery feeding the inferior
spleen
• Coil embolization of the mid portion of the splenic artery.
• Discharged home HD #7
• Return to the clinic HD #14 with abdominal pain
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INTRAOPERATIVE FINDINGS
• Laparoscopic splenectomy.
• Pathology: Benign splenic tissue with hemorrhage, ischemia and necrosis.
• 1980-1990s
• Failure rate 31-48% of non-operative splenic management
• The vascular blush was seen in 67% of patients who failed nonoperative
management
Shackford SR, Molin M. Management of splenic injuries. Surg Clin North Am. 1990Godley CD, et al. Nonoperative management of blunt splenic injuries in adults: age over 55 year a powerful indicator for failure. J Am Coll SuSchurr MJ, et al. Management of blunt splenic trauma: computed tomographic contrast blush predicts failure of nonoperative management. J
Search...
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• 1993-1997
• 4.5 year interval ending in June
1997
• Hemodynamically stable and no
immediate need for operation
• CT scan of the abdomen within an
hour of presentation
• Followup CT 48-72 hours after
presentation
• Blush
• Well-circumscribed, intraparenchymal
collection of contrastthat is hyperdense
with respect to the surrounding splenic
parenchyma
• Arteriography
• Confirm the pseudoaneurysm
• Selective embolization
• No main splenic artery embolization
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• 524 patients
• 180 (34%) underwent urgent
exploration
• 344 stable patients
• CT scan
• 61 % non-operative management in
this study.
PSEUDOANEURYSM
• 31 pseudoaneurysms
• Initial CT: 8
• Followup CT: 23
• Angiography
• Mean time: 4 days
• 30 underwent angiography
• 23 managed nonoperatively
• 20 pseudoaneurysm confirmed on
angiogram
• 3 without pseudoaneurysm
• 7 patients OR
• Unable to be embolized
• OR for exploration
Davis, et al. 1998
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FAILURE ON NONOPERATIVE MANAGEMENT AND NO PSEUDOANEURYSM
• Number of patients: 15
• 7 clinical evidence of hemorrhage
• 6 Worsening appearance on CT
• 1 delay in diagnosis pancreatic
injury
• 1 splenic infacrction
Davis, et al. 1998
• Retrospective chart review
• 126 patients
• Angiography at admission
• 68% negative
• 32% embolization
• 8% laparotomy
• 92% salvage rate
J Trauma, 2001
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NONOPERATIVE MANAGEMENT IS AS EFFECTIVE AS IMMEDIATE SPLENECTOMY FOR
ADULT PATIENTS WITH HIGH-GRADE BLUNT SPLENIC INJURY
• American College of Surgeons Trauma Quality Improvement Program (TQIP)
• Non-operative and Immediate Splenectomy Patients were matched (n=1516)
• Median duration of mechanical ventilation
• Infectious Complications
• 12.8% had embolization
• 11% embolized failed
• 21.4 not embolized failed
Scarborough JE, et al. Nonoperative management is as effective as immediate splenectomy for adult patients with high-grade blunt spJ Am Col Surg, August 2016
**
**
• National Trauma Databank
• 18 years or older with high grade
blunt splenic injury
• Level 1-2 trauma centers
• Manage over 20 patients in one year
Annals of Surgery, March 201
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• 53689 patients Grade 3 or higher
• Patients treated in an angio center
• Higher ISS
• More commonly had Grade IV
• Lower admission Motor GCS scores
• More commonly Level 1 centers
• More commonly university
affiliated
• Tended to be larger hospitals
**
**
**
**
**
**Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March 2017
• 5.7% rate of angiography in 2008 to 14.1% in 2014
Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March 2017
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• Splenectomy rates are the same at angio centers
• Spenectomy rates decreased in non-angiocenters in combined and grade 3
and 4Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March 2017
• Reduction only in the splenectomy rate in Grade III injuries in non-angio
centers
Splenectomy within 6h of admission
Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March 2017
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• Reduction in the rate of late splenectomy in all groups except the Grade IV splenic injuries in the non-angio centers
Angio-Reduction 5.4% to 4.1%
Non-angioReduction 6.0% to 3.3%
Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March 2017
• No differences in mortality over time
• Late splenectomy overall associated with increased mortality in Grade III
and IVDolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March 2017
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CONCLUSIONS
• Angiography is not the only factor driving the decreased rate of late
splenectomy
• Increase in total hospital costs with angiography
• Role of angiography in Blunt Splenic Injury needs to be further defined
Dolejs SC, et al. Overall splenectomy rates stable despite increasing usage of angiography in the management of high-grade blunt splenic injury. Annals of Surgery March 2017
No difference in splenic embolization and observation
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No difference in splenic embolization and observation
No difference in splenic embolization and observation
No difference in the mortality in the two groups
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No difference in the mortality in the two groups
Significant variation among Level 1 trauma centers. Higher ratesof embolization have higher splenic salvage.
SPLENIC ANATOMY AND FUNCTION
• White pulp
• B-cell follicles
• Marginal Zone
• Macrophages
• Memory B-cells
• Red Pulp
• Erythrocyte filtering
• Measure of Immune function
• Immune response upon vaccination
or by evaluation of B-cell subsets .
• Erythrocyte filtering
• Radionucleotide tests (scintigraphy)
• Clearance of labelled erythrocytes
• Count of Howell Jolly bodies
• Count of pitted red blood cells
Schimmer JAG, et al. Splenic function after angioembolization for splenic trauma in children and adults: Asystemic review. In
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SPLENIC COMPLICATIONS
• Reported up to 8%
• Vascular Complications (70% occur within 2 weeks of injury)
• Delayed rupture
• Pseudoaneurysm
• Arteriovenous Fistula
• Pseudocyst
• Abscess
Goffete PP, Laterre PF. Traumatic injuries: imaging and intervention in post-traumatic complications (delayed intervention) Eur Ra
LATE COMPLICATIONS
• >48 hours from injury-5-8% incidence
• Splenic abscess
• Pseudoaneurysm
• Hemorrhage
• Most require splenectomy
Cocanour, CS, et al. Delayed complications of nonoperative management of blunt adult spenic trauma, Arch Black JJ, et al. Subcapsular hematoma as a predictor of delayed splenic rupture. Am Surg, 1992.
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OVERWHELMING POST-SPLENECTOMY SEPSIS(OPSS)
• Encapsulated organisms
• Pnemococcus
• Meningiococcus
• Hemophilus Influenza
• 2-5 per 1000 Asplenic patients
• 70% mortality
• All but one study demonstrate no
compromise of immune function
with splenic artery embolization.
• No reports of OPSS in the literature
after splenic artery embolization
Schimmer JAG, et al. Splenic function after angioembolization for splenic trauma in children and adults: Asystemic review. In
EMBOLIZATION OF THE SPLEEN AND IMMUNE FUNCTION
• Clearance of opsonized autologous red blood cells in normal controls and in
patient who underwent splenic artery ligation
• No significant difference
• The spleen undergoes hypertrophy and as much as 80% can be removed
• Short gastrics are adequate to protect against pneumococcal challenge
• Scintigraphy-reticulo-endothelial system remains viable.
Schwalke, et al. Splenic artery ligation for splenic salvage: Clinical experience and immune function. JTrauma, 1991Greco and Alvarez. Regeneration of the spleen after etopic implantation and partial splenectomy. Surg,1980
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EAST PRACTICE GUIDELINES
• Level 1
• Peritonitis or hemodynamic instability should go for urgent laparotomy
• Level 2
• Routine laparotomy not necessary with isolate splenic in jury
• Grade of injury, age >55, neurologic status, and associated injuries do not
exclude non-operative management
• Consider angiography in grade III or greater, presence of a blush, moderate
hemoperitoneum, or evidence of ongoing bleeding.
• Nonoperative management should only be considered in an environment that
allows.
EAST.org, 2012
EAST PRACTICE GUIDELINES
• Level 3
• Consider followup imaging with clinical changes
• Contrast blush is not an absolute indication for angiographic intervention
• Angiography can be used as an adjunct to non-operative management in high
risk patients
• Venous thromboembolism can be used for patients with isolated blunt splenic
injuries without increasing failure of nonoperative rate
EAST.org, 2012
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THE LIVER
INITIAL EVALUATION
• ABCDE
• Hemodynamically stable
• Associated abdominal injuries
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GRADES OF LIVER INJURY
trauma.org, 2017
APPROACH
• Operative
• Packing
• Hemostatic agents
• Suturing
• Total Hepatic Isolation
• Does surgery lead to further
bleeding and unnecessary
interventions and complications??
• Nonoperative 82-100% success
• Angiographic intervention
• ERCP (Endoscopic Retrograde
Cholangiopancreatography)
• Percutaneous drainage
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SPLENIC AND LIVER BLUSH
• Patients with no blush on
angiography were more than twice
as likely to rebleed compared with
those with angiographic evidence of
blush.
• SPLEEN:
• 25% vs 10%, P < .05
• LIVER
• 32% vs 11%, P = .046
Alarhayem, et al. “Blush at first sight” : Significance of computed tomographic and angiographic discrepancy in patient with blunt abdominal trauma. Am J Surgery, 2015
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CONSIDERATIONS
• No consistent correlation between the grade and failure on nonoperative
management
• Hemodynamic status is more important
• Limitation of persistent bleeding or delayed bleeding with early angiography
• Poletti, et al. 2000
• CT grade III or higher
• Evidence of arterial injury (blush)
• Evidence of hepatic venous injury
FAILURES OF NONOPERATIVEMANAGEMENT OF THE LIVER
• Hemodynamic instability is the cause of 75% of failures
• Delayed hemorrhage incidence is 2.8-3.5%
• Most common complication
• Most common cause of death
• Complication rate increases with the grade of injury
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COMPLICATIONS LIVER
• 50-60% of patients with grade IV or V liver or splenic lacerations require some type of interventional treatment
• Vascular
• Delayed hemorrhage (2.4-5%)
• Vascular abnormalities 1-2%• Pseudoaneurysm
• Arterivenous fistula
• Hemobilia (<1%)
• Liver and Biliary complications
• Bilhemia
• Bile leaks (biliary fistula and biloma)
• Bile peritonitis
• Biliary Stricture
• Sepsis
Goffete PP, Laterre PF. Traumatic injuries: imaging and intervention in post-traumatic complications (delayed intervention) Eur R
30 YEAR OLD IN A MOTOR VEHICLE COLLISION
• Airway-Patent and breathing spontaneously
• Breathing-Saturation 100%, Breath sounds equal, crepitus left anterior chest
wall
• Circulation-Intact. BP 130s, HR 90
• GCS 3
• Intubated for airway protection
• Left chest wall does not expand well and is smaller in volume than the right
• Desaturation
• Hypotension
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• Chest tube placement
• 900mL out
• Stabilized.
• Saturations improved
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SECONDARY
• Left abdominal wall abrasion
• Left chest wall with crepitus.
• No rectal tone
• No extremity deformities
• FAST negative
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TO THE OPERATING ROOM
• Pre-op diagnosis
• Left diaphragmatic rupture
• Free fluid/blood in the pelvis
• Hypoperfused left hepatic lobe
• Post-op diagnosis
• Left diaphragmatic rupture
• Grade 2 liver laceration stellate
• Grade 1 pancreatic hematoma
• Doppler signal in the porta hepatis,
and palpable pulse
• Normal gallbladder
THE NEXT DAY
• Hypotensive
• Acidotic
• Increased airway pressures
• Compartment syndrome
• Intestinal ischemia?
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OPERATING ROOM
• Re-opened
• Compartment syndrome
• Gangrenous gallbladder
• Mottled liver at the gallbladder bed
COURSE
• Hospitalized for 1.5 months
• Acute kidney Injury
• Acute respiratory failure
• Portal Hepatic Duplex
• Good flow in the heparic and portal
vessels
• Limited study
• CT Abdomen and Pelvis 10 days
later
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10 DAYS LATER
2.5 MONTHS LATER
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FINDINGS
• Proper hepatic artery occlusion and
pseudoaneurysm
• Replaced left hepatic artery whic
h
cross collateralizes to the right l
obe of the liver
• Ischemic dilation of biliary ducts in
the right lobe of the liver
1.5 YEARS LATER
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EAST PRACTICE GUIDELINES
• Level 1
• Patients who are hemodynamically unstable or who have diffuse peritonitis after blunt trauma should be taken urgently for laparotomy
• Level 2
• A routine laparotomy in hemodynamically stable patients with liver injury is not indicated
• Angiography may be considered first line intervention in the transient responder to resuscitation as and adjunct to possible operative intervention
• Grade of injury, age >55, neurologic status, and associated injuries do not exclude non-operative management
• Angiographic embolization should be considered in the hemodynamically stable patient with evidence of extravasation on CT scan
• Nonoperative management should only be considered in an environment that allows.
EAST.org, 2012
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EAST PRACTICE GUIDELINES
• Level 3
• Consider followup imaging with clinical changes
• Interventional modalities including ERCP, angiography, laparoscopy, and
drainage percutaneously may be required to manage complications
• Venous thromboembolism can be used for patients with isolated blunt splenic
injuries without increasing failure of nonoperative rate