Injury: the British Journal of Accident Surgery (1991) Vol. 22/No. 5
418
Death following non-operative liver trauma
management
of blunt
J. S. Bender and M. A. Levison Department
of Surgery, Detroit Receiving
Hospital and Wayne State University,
Introduction Non-operative management of select blunt liver injuries is becoming more popular (Chetham et al., 1980; Meyer et al., 1985; Famall et al., 1988; Federico et al., 1990; Hiatt et al., 1990). We report a case of sudden death from massive pulmonary embolism following apparently successful management of a right hepatic haematoma in a previously healthy young male.
Case report A lo-year-old man complained of increasing right upper quadrant
abdominal pain after a sledding accident. A chest radiograph showed a right haemopneumothorax; an abdominal computerized tomographic (CT) scan showed a fracture of the right lobe of the liver with intraparenchymal and subcapsular haematomas (Figure 1). There was no evidence of intraperitoneal blood. A chest tube was placed and he was transferred to our institution. He was haemodynamically stable throughout his evaluation. On arrival, physical examination revealed a thin but otherwise healthy individual in mild distress from pain. His pulse was 90 and his blood pressure 120/70. The only other pertinent findings were the chest tube and mild tenderness to palpation in the right upper quadrant of the abdomen. His haemoglobin was 11.9g%. He was admitted 8 h after injury; a repeat CT scan showed no enlargement of the liver haematoma.
Detroit, Michigan,
USA
A repeat CT scan 2 days later showed no change in the size or configuration of his liver injury. There was a small amount of blood in the pelvis and possible inferior vena cava (IVC) compression. Three units of blood were transfused over this period to maintain a normal haemoglobin level. Over the next 3 days, his chest tube was removed, he was started on a diet, and was transferred to a regular ward. Strict bed rest was maintained. A CT scan on the 9th day showed no change in the liver injury, but again there was suspicion of inferior vena caval compression. A large right pleural effusion was present for which a chest tube was placed; 1350 cc of serosanguineous fluid was drained. This tube was removed after 3 days when a chest radiograph was clear and there was no further drainage. No additional blood transfusions were required. He started walking 1 week later. On the morning of the 17th day, he developed acute respiratory distress with tachycardia and hypotension. His haemoglobin level was 11.7 g%, but his PO, was only 77 mmHg on a 100per cent oxygen mask He was intubated. A perfusion lung scan suggested left upper lobe and right lower lobe pulmonary emboli. A venacavogram showed no evidence of thrombus in either the IVC or the hepatic veins. The WC was 3 cm in diameter, which was thought to be too big for a KimrayGreenfield filter to be placed safely. The decision was made to start intravenous heparin therapy, but before this could be done, the patient had a cardiac arrest from which he could not be resuscitated. Post-mortem examination revealed a saddle pulmonary embolus. The origin of the embolus could not be determined.
Discussion
Figure 1. Admission capsular haematomas.
CT scan showing
0 1991 Butterworth-Heinemann 0020-1383/91/050418-02
Ltd
intrahepatic
and sub-
Non-operative therapy for blunt hepatic trauma was first suggested by Lambeth and Rubin in 1979. Since the introduction of computerized tomography, which allowed for better grading of liver injuries (Moon and Federle, 1983; Mirvis et al., 1989), this method has received increasing attention. Most authors have concluded that non-operative management is useful if certain criteria are met. These include availability of an intensive care unit for monitoring, experienced and readily available personnel, early haemodynamic stability, and good evidencethat there are no other intra-abdominal organs that need operative attention. Critics of non-operative management have mentioned the possibility of missing associated injuries of a hollow viscus as the main hazard (Bass et al., 1984). The incidence of this appears to be quite low. Pulmonary embolism (PE) is relatively uncommon among injured patients for as yet unexplained reasons. One recent
Case reports
419
study from a Leve! I trauma centre found an angiographically diagnosed incidence of PE of only 2.3 per cent (O’Malley and Ross, 1990). Of these, 25 per cent were fatal, and most occurred within the first week of hospitalization. Sudden death has not been reported in any of the previous series of non-operative management of blunt liver injury (a total of 77 patients) and hence is probably unusual. Nevertheless, its occurrence in one of the first patients in our institution to be treated in this manner has led to some grave misgivings among our staff. The finding of IVC compression on CT scan has led to speculation that this was due to the enlarged right hepatic lobe. Subsequent stasis may have predisposed that patient to thrombus formation, though there was no evidence of this on post-mortem examination. Non-operative management of blunt liver injury is still in its infancy. Before it is fully accepted, specific contraindications need to be established.
Fame11 M. B., Spencer M. P., Thompson E. et al. (1988) Nonoperative management of blunt hepatic trauma. Surgery 104,
748. Federico J. A., Homer W. R., Clark D. E. et al. (1990) Blunt hepatic trauma: Non-operative management in adults. Arch. Str~. 125,
905. Hiatt J. R., Harrier P., Koenig B. V. et al. (1990) Non-operative management of major blunt liver injury with hemoperitoneum. Arch. Swg. 125,101. Lambeth W. and Rubin R. E. (1979) Nonoperative management of intrahepatic hemorrhage and hematoma following blunt trauma. Surg. Gynecol. Obstef. 148, 507. Meyer A. A., Crass R. A., Lim R. E. et al. (1985) Selective non-operative management of blunt liver injury using computed tomography. Arch. Surg. 120, 550. Mirvis S. E., Whitley N. O., Vainwright J. R. et al. (1989) Blunt hepatic trauma in adults: CT-based classification and correlation with prognosis and treatment. Radiology 171,27. Moon K. L. and Federle M. P. (1983) Computed tomography in hepatic trauma. AJR. 141, 309. O’Malley K. F. and Ross S. E. (1990) Pulmonary embolism in major trauma patients. 1. Trauma 30, 748.
References Bass B. L., Eichelberger M. L., Schisgall R. et al. (1984) Hazards of non-operative therapy of hepatic injury in children. 1. Trauma
Paper accepted 4 February
1991.
24,978. Chetham J. E., Smith E. I., Technell W. P. et al. (1980) Nonoperative management of subcapsular hematomas of the liver. Am. J Surg. 140,852.
Requests for reprints shot& be addressed to: Jeffrey S. Bender MD, Department of Surgery, Francis Scott Key Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224, USA.
Brachial artery rupture M. S. Davies and R. Nayak St Peter’s District General Hospital, Chertsey,
Surrey, UK
Introduction The elbow is the second most commonly dislocated joint after the shoulder (Eliason and Brown, 1937) and most often results from a fall on the outstretched hand (Apley and Solomon, 1982). Vascular complications following such injury are rare, with only 22 cases of brachial artery rupture following posterior elbow dislocation reported in the English literature since 1900 (Eliason and Brown, 1937; Grimer and Brooks, 1985; Amsallem et al., 1986; Cofer and Bums, 1988). We report a case in which brachial artery rupture occurred in the absence of confirmed dislocation of the elbow.
the lateral epicondyle (Fipre I). A diagnosis of brachial artery rupture was made and the patient was taken to theatre. Exploration of the elbow region was performed without tourniquet using a medial approach (Justis et al., 1980). A complete tear of the brachial artery and a capsular tear of the elbow joint were revealed. The deep fascia was divided down to midforearm
Case report A 29-year-old nurse came to the accident centre having fallen from a horse. On clinical examination she had a cold distal right forearm and hand, an absent radial pulse and a swelling in the anterior cubital fossa. The elbow was not clinically dislocated and there was no neurological deficit. Radiographs of the elbow showed a joint effusion, soft tissue swelling and a small avulsed fragment of bone lying adjacent to ~~ 1991 Butterworth-Heinemann OOZO-1383/91/050420-02
Ltd
Figure 1. Initial radiograph showing avulsed fragment of bone adjacent to the lateral epicondyle.
418
Death following non-operative liver trauma
management
of blunt
J. S. Bender and M. A. Levison Department
of Surgery, Detroit Receiving
Hospital and Wayne State University,
Introduction Non-operative management of select blunt liver injuries is becoming more popular (Chetham et al., 1980; Meyer et al., 1985; Famall et al., 1988; Federico et al., 1990; Hiatt et al., 1990). We report a case of sudden death from massive pulmonary embolism following apparently successful management of a right hepatic haematoma in a previously healthy young male.
Case report A lo-year-old man complained of increasing right upper quadrant
abdominal pain after a sledding accident. A chest radiograph showed a right haemopneumothorax; an abdominal computerized tomographic (CT) scan showed a fracture of the right lobe of the liver with intraparenchymal and subcapsular haematomas (Figure 1). There was no evidence of intraperitoneal blood. A chest tube was placed and he was transferred to our institution. He was haemodynamically stable throughout his evaluation. On arrival, physical examination revealed a thin but otherwise healthy individual in mild distress from pain. His pulse was 90 and his blood pressure 120/70. The only other pertinent findings were the chest tube and mild tenderness to palpation in the right upper quadrant of the abdomen. His haemoglobin was 11.9g%. He was admitted 8 h after injury; a repeat CT scan showed no enlargement of the liver haematoma.
Detroit, Michigan,
USA
A repeat CT scan 2 days later showed no change in the size or configuration of his liver injury. There was a small amount of blood in the pelvis and possible inferior vena cava (IVC) compression. Three units of blood were transfused over this period to maintain a normal haemoglobin level. Over the next 3 days, his chest tube was removed, he was started on a diet, and was transferred to a regular ward. Strict bed rest was maintained. A CT scan on the 9th day showed no change in the liver injury, but again there was suspicion of inferior vena caval compression. A large right pleural effusion was present for which a chest tube was placed; 1350 cc of serosanguineous fluid was drained. This tube was removed after 3 days when a chest radiograph was clear and there was no further drainage. No additional blood transfusions were required. He started walking 1 week later. On the morning of the 17th day, he developed acute respiratory distress with tachycardia and hypotension. His haemoglobin level was 11.7 g%, but his PO, was only 77 mmHg on a 100per cent oxygen mask He was intubated. A perfusion lung scan suggested left upper lobe and right lower lobe pulmonary emboli. A venacavogram showed no evidence of thrombus in either the IVC or the hepatic veins. The WC was 3 cm in diameter, which was thought to be too big for a KimrayGreenfield filter to be placed safely. The decision was made to start intravenous heparin therapy, but before this could be done, the patient had a cardiac arrest from which he could not be resuscitated. Post-mortem examination revealed a saddle pulmonary embolus. The origin of the embolus could not be determined.
Discussion
Figure 1. Admission capsular haematomas.
CT scan showing
0 1991 Butterworth-Heinemann 0020-1383/91/050418-02
Ltd
intrahepatic
and sub-
Non-operative therapy for blunt hepatic trauma was first suggested by Lambeth and Rubin in 1979. Since the introduction of computerized tomography, which allowed for better grading of liver injuries (Moon and Federle, 1983; Mirvis et al., 1989), this method has received increasing attention. Most authors have concluded that non-operative management is useful if certain criteria are met. These include availability of an intensive care unit for monitoring, experienced and readily available personnel, early haemodynamic stability, and good evidencethat there are no other intra-abdominal organs that need operative attention. Critics of non-operative management have mentioned the possibility of missing associated injuries of a hollow viscus as the main hazard (Bass et al., 1984). The incidence of this appears to be quite low. Pulmonary embolism (PE) is relatively uncommon among injured patients for as yet unexplained reasons. One recent
Case reports
419
study from a Leve! I trauma centre found an angiographically diagnosed incidence of PE of only 2.3 per cent (O’Malley and Ross, 1990). Of these, 25 per cent were fatal, and most occurred within the first week of hospitalization. Sudden death has not been reported in any of the previous series of non-operative management of blunt liver injury (a total of 77 patients) and hence is probably unusual. Nevertheless, its occurrence in one of the first patients in our institution to be treated in this manner has led to some grave misgivings among our staff. The finding of IVC compression on CT scan has led to speculation that this was due to the enlarged right hepatic lobe. Subsequent stasis may have predisposed that patient to thrombus formation, though there was no evidence of this on post-mortem examination. Non-operative management of blunt liver injury is still in its infancy. Before it is fully accepted, specific contraindications need to be established.
Fame11 M. B., Spencer M. P., Thompson E. et al. (1988) Nonoperative management of blunt hepatic trauma. Surgery 104,
748. Federico J. A., Homer W. R., Clark D. E. et al. (1990) Blunt hepatic trauma: Non-operative management in adults. Arch. Str~. 125,
905. Hiatt J. R., Harrier P., Koenig B. V. et al. (1990) Non-operative management of major blunt liver injury with hemoperitoneum. Arch. Swg. 125,101. Lambeth W. and Rubin R. E. (1979) Nonoperative management of intrahepatic hemorrhage and hematoma following blunt trauma. Surg. Gynecol. Obstef. 148, 507. Meyer A. A., Crass R. A., Lim R. E. et al. (1985) Selective non-operative management of blunt liver injury using computed tomography. Arch. Surg. 120, 550. Mirvis S. E., Whitley N. O., Vainwright J. R. et al. (1989) Blunt hepatic trauma in adults: CT-based classification and correlation with prognosis and treatment. Radiology 171,27. Moon K. L. and Federle M. P. (1983) Computed tomography in hepatic trauma. AJR. 141, 309. O’Malley K. F. and Ross S. E. (1990) Pulmonary embolism in major trauma patients. 1. Trauma 30, 748.
References Bass B. L., Eichelberger M. L., Schisgall R. et al. (1984) Hazards of non-operative therapy of hepatic injury in children. 1. Trauma
Paper accepted 4 February
1991.
24,978. Chetham J. E., Smith E. I., Technell W. P. et al. (1980) Nonoperative management of subcapsular hematomas of the liver. Am. J Surg. 140,852.
Requests for reprints shot& be addressed to: Jeffrey S. Bender MD, Department of Surgery, Francis Scott Key Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224, USA.
Brachial artery rupture M. S. Davies and R. Nayak St Peter’s District General Hospital, Chertsey,
Surrey, UK
Introduction The elbow is the second most commonly dislocated joint after the shoulder (Eliason and Brown, 1937) and most often results from a fall on the outstretched hand (Apley and Solomon, 1982). Vascular complications following such injury are rare, with only 22 cases of brachial artery rupture following posterior elbow dislocation reported in the English literature since 1900 (Eliason and Brown, 1937; Grimer and Brooks, 1985; Amsallem et al., 1986; Cofer and Bums, 1988). We report a case in which brachial artery rupture occurred in the absence of confirmed dislocation of the elbow.
the lateral epicondyle (Fipre I). A diagnosis of brachial artery rupture was made and the patient was taken to theatre. Exploration of the elbow region was performed without tourniquet using a medial approach (Justis et al., 1980). A complete tear of the brachial artery and a capsular tear of the elbow joint were revealed. The deep fascia was divided down to midforearm
Case report A 29-year-old nurse came to the accident centre having fallen from a horse. On clinical examination she had a cold distal right forearm and hand, an absent radial pulse and a swelling in the anterior cubital fossa. The elbow was not clinically dislocated and there was no neurological deficit. Radiographs of the elbow showed a joint effusion, soft tissue swelling and a small avulsed fragment of bone lying adjacent to ~~ 1991 Butterworth-Heinemann OOZO-1383/91/050420-02
Ltd
Figure 1. Initial radiograph showing avulsed fragment of bone adjacent to the lateral epicondyle.
