Learning Objectives Indications and Contraindications
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- Bu səhifədəki naviqasiya:
- Preoperative Preparation
- Key Steps of the Procedure
- Complications and their Treatment
- Learning Objectives Anatomy/Histology
- AAST Liver Injury Scale. From Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 20e > Chapter 16. Management of Acute Trauma Table 6.
- Operative Treatment (General Concepts)
- Nonoperative Management, including Alternative and Adjuvant Treatments
- Learning Objectives Indications and Contraindications
- Sabiston Textbook of Surgery, 20th ed. Ch. 16: Management of Acute Trauma. Table 5: AAST Spleen Injury Scale
- Intraoperative Decision Making
- AAST Grading Scale for Splenic Injuries
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Learning Objectives
Indications and Contraindications Given an injured patient who presents with blunt multisystem injury and/or an unreliable physical examination and/or a penetrating thoracoabdominal trauma, the resident can perform the Focused Assessment for the Surgery of Trauma (FAST) examination using the bedside ultrasound machine and an appropriate transducer and can compare findings to the subsequent CT scan findings or physical examination. Given a non-injured critically ill patient with the potential for a perforated viscus or intraabdominal bleeding, the resident can recognize that the absolute contraindications for performing the FAST are the signs and symptoms of pericardial tamponade or peritonitis. Operative Anatomy Given a patient with blood accumulating in the dependent regions of the abdomen, the resident can identify the structures that are isoechoic, hypoechoic, and hyperechoic based on a FAST examination. Preoperative Preparation Given a patient on whom to perform the FAST, the resident should orient the transducer for sagittal imaging; apply ultrasound transmission gel to the pericardial and abdominal areas, to the right and left upper abdominal quadrants, and to the pelvis; and adjust the "gain" so that so that the echo amplification (brightness of the image) is appropriate for the detection of blood (fluid) and that blood in the heart appears anechoic. Key Steps of the Procedure Given a patient whose pericardial and abdominal exams have been are performed and who is hemodynamically normal, the resident can perform the thoracic FAST (the extended or "e" FAST) to examine for the presence or absence of a pleural effusion (hemothorax) or pneumothorax. Complications and their Treatment Given a patient with suspected torso and extremity trauma and requiring a FAST examination, the resident can use ultrasound to augment the physical examination. Given a non-trauma patient with acute abdominal pain and requiring a FAST examination, the resident can use ultrasound to supplement the history and physical examination. Assessment of Outcomes Given a patient who is morbidly obese or who has subcutaneous emphysema, the resident can repeat the FAST after the insertion of a tube thoracostomy to improve the visualization of the pericardial area and decrease the number of false positive and negative studies. Learning Objectives Anatomy/Histology In a patient with blunt hepatic injury, identify the most commonly injured hepatic structures and explain the anatomic considerations accounting for this distribution. Most common intraabdominal organ injured in blunt trauma, second in penetrating Most of the liver is located beneath the right rib cage so injuries to the chest wall can result in hepatic injury. The liver edge extends below the rib cage – up to T12 with respiration – and can be susceptible to injury in abdominal trauma. In blunt trauma, the most common area of injury is the posterior portion of the right lobe of the liver. Physiology Describe physiologic derangements caused by severe blood loss following blunt hepatic injury and their implications for management. Extreme blood loss in all forms can lead to acidosis, cooling, and coagulopathy, leading to more blood loss. Presentation Describe signs and symptoms associated with blunt hepatic injury as well as expected changes in vital signs and laboratory values. Physical exam: chest wall injury, right flank bruising, right-sided abdominal pain. Note, a negative exam does not rule out hepatic injury. Large-volume hemorrhage is heralded by hypotension and tachycardia. A hematocrit upon arrival to the ED bay during a trauma may not reflect the degree of hemorrhage given that dilution of the remaining blood volume has not occurred. Diagnosis Explain the utility of the FAST exam for patients with blunt hepatic injury and describe its diagnostic limitations. FAST is sensitive and specific for intraabdominal free fluid, which in the setting of trauma is blood until proven otherwise. Limitations: often cannot definitively identify sources of bleeding; cannot identify retroperitoneal bleeding Staging/Grading Utilize cross-sectional imaging in order to evaluate and grade a blunt hepatic injury. AAST Liver Injury Scale. From Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 20e > Chapter 16. Management of Acute Trauma Table 6.
Operative Treatment (General Concepts) Identify findings on the primary and secondary survey that would require immediate operative management for a patient with blunt hepatic injury. Hemorrhagic shock on primary survey combined with intraabdominal free fluid on FAST exam should prompt emergent trauma laparotomy. FAST exam may identify blood collection in the hepatorenal recess. Secondary findings of peritonitis should also prompt emergent laparotomy. In a patient undergoing operative treatment for blunt hepatic injury, propose an initial plan for hemorrhage control as well as describe secondary and salvage maneuvers, should initial attempts fail. Operative intervention should start as all trauma laparotomies: Midline laparotomy with packing of all 4 quadrants. Allow resuscitation to occur. Remove packing from the quadrants you least expect bleeding from first. Divide triangular ligaments and falciform but be careful not to disrupt natural tamponade. Assess source of hepatic bleeding. Gentle anterior and posterior pressure can control most hepatic bleeding. Suture ligation of bleeding vessels and repair of lacerations should occur. Uncontrollable bleeding = Pringle Maneuver = clamp or vessel loop around the hepatoduodenal ligament which can stop portal and hepatic arterial flow Retrohepatic IVC injury is an extremely dangerous condition. Consider packing and reserve an IVC to right atrial shunt (Shrock) or veno-venous bypass for patients who do not respond to packing. Do not explore non-bleeding retrohepatic IVC injuries. Bleeding due to coagulopathy should prompt abdominal packing followed by ICU resuscitation. Evidence–based Practice Given a hemodynamically stable patient undergoing non-operative management (NOM) for blunt hepatic injury, state the expected failure rate of NOM as well as describe radiographic findings and patient factors that increase the likelihood of NOM failure. Treatment of choice for all hemodynamically normal patients with hepatic injury no matter grade 90% success rate Extravasation of contrast on abdominal CTA is associated with higher rates of failure. Grades IV and V injuries are associated with higher rates of failure. Nonoperative Management, including Alternative and Adjuvant Treatments Discuss the relative indications for endovascular management of blunt hepatic injury as well as common risks associated with this approach. Blush on primary CTA of the abdomen should prompt consideration of hepatic arterial embolization. Ischemic complications can occur necessitating hepatic debridement. Complications of nonoperative management are greater in patients with a greater degree of liver injury. Long-term Follow-up Describe the most common long-term complications and morbidity associated with severe blunt hepatic injury as well as their workup and management. The incidence of morbidity increases with grade of injury. Biliary tree disruption 0.5 to 21% of patients associated with RUQ pain, biloma formation, SIRS CT for diagnosis Hepatic necrosis pain and SIRS Hemobilia typically several days after injury presents as UGI bleed CT angiography and/or embolization for diagnosis and/or therapy Learning Objectives Indications and Contraindications Discuss the principles of nonoperative management of blunt liver injuries. Prior to broad adoption of nonoperative management for blunt liver injury, it was observed that many liver injuries had stopped bleeding by the time of laparotomy, whereas other injuries became hemorrhagic on mobilization of the injured liver. Approximately 85% of liver injuries can be managed successfully nonoperatively. After blunt liver injury, patients who demonstrate normal blood pressure and stable blood counts can be observed with close hemodynamic and laboratory monitoring in the absence of other indications for laparotomy. Angiography with angioembolization may be used selectively in patients with active extravasation on CT scan who remain hemodynamically normal. Penetrating liver injury is managed differently and does not qualify for a trial of nonoperative management. Identify risk factors for failure of nonoperative management of blunt liver injuries. Such risk factors include: Advanced age High-grade injury Large hemoperitoneum Pseudoaneurysm Contrast extravasation on CT scan Operative Anatomy Key anatomic structures in the operative management of liver trauma. The falciform ligament contains the ligamentum teres. It should be ligated and divided for optimizing access to the right upper quadrant. The right and left triangular ligaments provide suspension of both lobes of the liver. Taking down these structures can provide access to injured areas of the liver, but this may come at the cost of greater mobility of the organ, diminishing the effectiveness of hepatic packing. Glisson's capsule provides containment of the liver parenchyma. The IVC and hepatic veins are critical retrohepatic structures whose injury can lead to significant hemorrhage. The hepatoduodenal ligament contains the hepatic artery, portal vein, and common bile duct. Digital compression can provide effective vascular inflow control and slow hemorrhage. Preoperative Preparation Describe the important components of preoperative preparation for operative management of liver injuries. For emergent operative intervention for abdominal trauma, the patient should be positioned supine with the arms abducted. Large-bore intravenous access should be secured. The patient should be prepped from the knees to the chin to allow intraoperative access to the chest, femoral vessels, and neck. Equipment such as vascular instruments, Cell Saver, and an argon beam should be considered. Key Steps of the Procedure Describe the sequence of steps to obtaining initial control of hemorrhage from liver injuries. Initial exploration of the abdomen involves evacuation of hemoperitoneum. After recognizing hemorrhage from the liver, temporary hemostasis can be achieved with manual compression to reduce the liver anatomically. Packing is performed with laparotomy pads above and below the injured segments, mimicking the manual compression maneuvers that were effective and taking advantage of the hepatic parenchyma to achieve tamponade. Undue pressure toward the diaphragm or on the inferior vena cava should be avoided. If hemorrhage continues despite compression and packing, the next step is to achieve portal venous and hepatic arterial inflow control via compression (Pringle maneuver). Failure of packing and portal/hepatic arterial inflow occlusion to control hemorrhage suggests injury to the retrohepatic vena cava or hepatic veins. Total vascular isolation (portal/hepatic arterial inflow occlusion, infrarenal and intrapericardial caval control, and aortic occlusion) may be necessary to definitively treat injuries to the inferior vena cava and hepatic veins that are not controlled with packing. Describe techniques for definitive repair of liver injuries. In cases where the patient is stable, or when packing does not definitively control bleeding, it will be necessary to definitively treat the bleeding. Suture ligation may be used to control bleeding accessible within the laceration. Deep suture hepatorrhaphy should be avoided because it may cause further damage or create undue ischemia. This technique has largely been replaced by effective perihepatic packing. Omental packing may be applied selectively to occupy space within a laceration. Parenchymal resection at either initial or subsequent operations is rarely indicated. It may be necessary in the following circumstances: When packing is ineffective in controlling hemorrhage, particularly when segments of the liver are nearly avulsed At subsequent operations to remove liver tissue rendered ischemic by arterial ligation or angiographic embolization (very uncommon) Role of Damage Control Consider the principles of damage control in operative management of blunt liver injuries. The packed liver should be hemostatic prior to placement of temporary abdominal closure. Failure to control hemorrhage with the initial packing is the main early complication of perihepatic packing. For livers that have been packed effectively, angiography may be used as an adjunct if bleeding develops after the initial operation. However, this should not be a substitute for adequate packing and hemostatic maneuvers at the initial operation. Reexploration of the abdomen is indicated if a patient becomes unstable. Once the patient is resuscitated, reexploration approximately 48 hours after an initial operation is indicated for removal packing and other necessary interventions. Complications and their Treatment Discuss the management of sequelae/complications following blunt hepatic injury. Biloma (intrahepatic bile collection) may occur. CT is useful in diagnosis. Biloma or bile leak may require percutaneous drainage and/or endoscopic retrograde cholangiopancreatography (ERCP) with stenting to divert bile drainage away from the injured biliary structure. If a biloma is infected, then antibiotics should be considered. Hemobilia may be best managed with angiography and embolization to control hemorrhage into the biliary tree. Hepatic necrosis after blunt injury is common. A severe burden of liver necrosis causing feeding intolerance and uncontrolled pain may be managed by interval resection/necrosectomy. Learning Objectives Anatomy/Histology Identify the ligamentous attachments to the spleen and identify the vascular structures within. Splenophrenic ligament – avascular when no portal hypertension present Splenorenal ligament – avascular when no portal hypertension present Gastrosplenic ligament – short gastric arteries superiorly; left gastroepiploic inferior Splenorenal ligament – splenic artery and vein Identify the posterior aspect of the spleen to avoid tearing at the peritoneal reflection causing significant hemorrhage. Lies against diaphragm and left kidney but is separated by the peritoneum of the greater sac Costodiaphragmatic recess extends to the most inferior portion of a normal spleen. The peritoneum behind the stomach (lesser sac) forms part of the gastrosplenic ligament. Presentation In a patient with suspected splenic injury, rapidly assess the patient's hemodynamic status in order to determine subsequent steps in management (i.e., operative intervention vs. imaging). All trauma care should begin with the ATLS algorithm – Primary survey includes securing airway, ensuring appropriate breathing, rapid assessment of circulation (i.e., bleeding), establishing GCS, and exposure of the patient. Mechanism of injury, tachycardia, hypotension, and positive intra-abdominal blood on FAST should prompt providers to assess for hemorrhage from possible splenic compromise (among other sources). If the patient’s symptoms do not respond to resuscitation, they should proceed to the OR for immediate trauma laparotomy prior to secondary survey and imaging. However, if the patient responds to resuscitation, secondary survey should be complete and imaging considered. In patient with blunt abdominal trauma, recognize signs, symptoms, and injury patterns that may be associated with splenic injury. Hypovolemic shock – hypotension, tachycardia, +/- responsible to resuscitation Seat belt sign or flank bruising Referred abdominal pain to the left shoulder (Kehr's sign) Associated injuries that carry a high risk of concomitant splenic injury (Left rib cage, pelvic fracture, spinal injury) Diagnosis In a hemodynamically normal patient with blunt abdominal trauma, complete the primary and secondary survey, and then obtain a CT of the abdomen when appropriate. If presentation suggests intraabdominal pathology, imaging of the abdomen is appropriate. CT of the abdomen with IV contrast is the most valuable study for characterizing splenic injuries as outlined below. Look for active extravasation of intravenous contrast or the presence of a pseudoaneurysm. Active Extravasation
Given a patient with blunt abdominal trauma and shock, use FAST to check for hemoperitoneum. FAST examination can aid in the diagnosis of intraabdominal bleeding. Identification of intraabdominal fluid with ongoing shock should prompt emergent laparotomy. In a hemodynamically stable patient with a splenic injury identified on CT scan, evaluate for associated injuries, such as pancreatic or renal injury, before selecting operative or nonoperative management. Associated injuries are common and can help dictate care. If additional injuries requiring operative intervention are discovered, splenectomy versus splenic salvage procedures should be considered. Overall, up to 3% have been reported have a hollow viscous injury. Staging/Grading Grading of a splenic injury according to the American Association for the Surgery of Trauma (AAST) Injury Scale. Sabiston Textbook of Surgery, 20th ed. Ch. 16: Management of Acute Trauma. Table 5: AAST Spleen Injury Scale
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Operative Treatment (General Concepts) During an open splenectomy, be able to describe the key steps of the procedure—in particular, those involved with medial mobilization and vascular isolation. There are many approaches to splenectomy that are determined by clinician preference, need for splenectomy, and patient stability. Trauma: midline laparotomy pack all 4 quadrants, remove packing in order of area least likely to have bleeding divide lateral attachments by moving the spleen medially divide the splenocolic ligament starting at the white line of Toldt divide the short gastric arteries and gastrosplenic ligament bluntly dissect posterior to the spleen and distal pancreas to deliver the spleen into the field clamp and divide the splenic artery and vein. Given a patient with splenic injury requiring removal or repair, be able to divide the splenic ligaments safely, and achieve hemostasis. Blunt dissection of the retroperitoneal attachments and delivery of the spleen into the wound allows for quick identification and clamping of the splenic hilar vessels. Be aware of, and recognize, early and late complications following open splenectomy. Early Bleeding – usually from raw surfaces of divide ligaments. Look for hypotension, tachycardia, down trending hematocrit/hemoglobin Gastric perforation – rare from division of the short gastric arteries Late OPSI – most common fatal late complication. Heralded by an early prodromal phase of fevers, rigors, chills, diarrhea, myalgia and rapidly progresses to multisystem organ failure, DIC, death (50–70%) Thrombocytosis – more prevalent with underlying myeloproliferative disorders. Can lead to mesenteric vein thrombosis, etc. Bleeding – fewer than 1% will have delayed bleeding. Greater risk in those with greater injury severity Pancreatic fistula – pain, fever, leukocytosis Be able to determine the need for, and timing of, post-splenectomy vaccinations. Vaccinate for encapsulated organisms: N. meningitides (polysaccharide vaccine), S. pneumoniae (PPV23 not the 14 valent), H. influenza (type B conjugate) 15 days prior to elective splenectomy Within 30 days for non-elective Nonoperative Management, including Alternative and Adjuvant Treatments In a patient with a splenic injury whose CT scan of the abdomen demonstrates an arterial extravasation or a pseudoaneurysm, recommend angiographic embolization. Results are similar with central and peripheral splenic artery embolization. Both diagnostic and therapeutic intervention Patients in shock should not be considered for angiography. In a hemodynamically stable patient with a splenic injury demonstrated on CT scan, admit the patient for nonoperative management and monitor the patient’s vital signs, perform serial physical examinations, and order intermittent laboratory studies, including hemoglobin and/or hematocrit as appropriate. Most patients are no longer bleeding at presentation and thus do not require splenectomy. Any sign of ongoing bleeding and/or shock usually indicates failure of nonoperative management. In a patient with a splenic injury who is undergoing nonoperative management, recognize the presence of ongoing hemorrhage and determine an appropriate treatment plan for either operative exploration or angiographic embolization. Patients with greater bleeding risk (pseudoaneurysm, blush) often can be managed with angioembolization. Any sign of shock should prompt emergent operation and possible repair or splenectomy. Be able to identify patients at higher risk for failure of nonoperative management based on hemodynamics, imaging findings, and injury severity scores. 6–15% failure rate depending on the degree of injury Patients with abnormal coagulation status or preexisting splenic disease are more likely to fail nonoperative management Although patients >55 years are more likely to have nonoperative treatment failure; greater than 80% will still be successful. Grade IV and V injuries have up to a 33% and 75% risk of nonoperative treatment failure with 92% of these occurring by 9 days post injury. Assessment of Outcomes Given a patient who has received successful nonoperative management of a splenic injury, recommend an appropriate period of time, based on the grade of the injury, before allowing the patient to return to full activity. 3 months for vigorous activity but data is lacking for sound guidance. 80% of patients will have splenic healing by 2 months (excluding grades IV-V). Given a patient with imaging findings of a splenic pseudoaneurysm, arteriovenous fistula, or high-grade injury, be able to discuss the role of repeat CT imaging and angioembolization. EAST trauma guidelines do not recommend routine follow-up imaging after non-operative management. Up to 15% of patients will develop a pseudoaneurysm, half of which spontaneously thrombose.
‘sdsds Learning Objectives Indications and Contraindications Describe the workup of a patient with abdominal trauma for splenic injury. Determine the need for operative intervention, emergent or delayed, versus nonoperative management. Advanced Trauma Life Support (ATLS) is a commonly used guideline for evaluation of injured patients. In hemodynamically unstable blunt trauma patients with a positive (identification of intra-abdominal fluid) FAST (focused assessment with sonography for trauma), splenic injury is commonly identified during emergent exploratory laparotomy. In hemodynamically stable patients, computed tomography (CT) imaging with intravenous contrast is used to evaluate for spleen and other solid organ injuries. Nonoperative management is a viable strategy in hemodynamically stable patients without other indications for surgical intervention. Nonoperative management may include the use of angiography with embolization for vascular abnormalities associated with the splenic injury (splenic pseudoaneurysm or blush). Operative Anatomy Given a patient requiring splenectomy, describe the anatomic location of the spleen and associated anatomic structures, including the splenic vasculature and ligamentous attachments. The spleen is located in the left costodiaphragmatic recess. Multiple peritoneal reflections (splenophrenic, gastrosplenic, splenorenal, and splenocolic ligaments) support the organ. Short gastric arteries (located off the gastroepiploic and left gastric arteries) are located in the gastrosplenic ligament. The splenic artery and vein are located in the splenorenal ligament. The tail of the pancreas commonly abuts the hilum of the spleen. Preoperative Preparation Given a patient who presents for operative intervention, be able to independently prepare the patient for emergent surgery. A midline celiotomy is commonly used in emergent surgery for ease of exploration and intervention of the whole abdominal cavity for unstable abdominal trauma. Key Steps of the Procedure Describe the critical steps for resection of the spleen in a patient undergoing operative intervention. The superior and lateral attachments are generally taken first. This can also be extended inferiorly to divide the attachments to the colon. Both of these can be done bluntly. Then the spleen is lifted out of its bed using blunt dissection (in similar manner to the Kocher maneuver for the duodenum) to bring the spleen medially into the wound. One's fingers should be between the tail of the pancreas and the anterior surface of the left kidney. The short gastric arteries are divided with care to ensure the gastric wall is not injured. The splenic artery and vein are then identified and ligated. Care should be taken to avoid injury to the pancreatic tail, which is commonly at the splenic hilum or near it. A drain should be placed if concern for pancreatic injury is present. Intraoperative Decision Making Identify intraoperative and physiologic findings that would determine if operative splenic salvage, including splenorrhaphy and partial splenectomy, is appropriate. Splenorrhaphy and partial splenectomy, while commonly discussed, are not generally practiced in the emergent setting. They are more often used when an incidental splenic injury with mild bleeding is identified when exploring patient for other injuries. Intervention may involve topical agents (procoagulants), cautery, hemostatic wrap and packing. Complications and Their Treatment Review the presentation of early and late postsplenectomy complications of operative and nonoperative management strategies in patients with splenic injuries. Operative complications include injury to associated organs (gastric wall, pancreatic tail, colon), pancreatic leak, and abscess formation. Nonoperative complications include delayed splenic rupture, splenic abscess formation (with embolization of trunk of splenic artery), and splenic infarction. Splenic function postembolization is not known. Postsplenectomy thrombocytosis and leukocytosis are common findings. The thrombocytosis can lead to thrombosis when associated with myeloproliferative disorder. Overwhelming postsplenectomy sepsis is a rare but high mortality/morbidity condition. Describe the guidelines for overwhelming postsplenectomy infection (OPSI) prophylaxis, including antibiotics and vaccination. OPSI generally occurs years after splenectomy. (See Learning Objective 8b for more information.) Streptococcus pneumoniae is the most common organism (50%-90% of cases). Other common organisms include Haemophilus influenzae and Neisseria meningitidis. Vaccinations for these agents are recommended within 14 days from splenectomy for H influenzae and N meningitidis and immediately for pneumococcal disease. Antibiotic therapy is controversial at the present time and is more commonly used in children. Assessment of Outcomes In the nonoperative management of splenic injuries, understand the importance of monitoring, serial clinical evaluations, and laboratory studies. Discuss the need for repeated radiographic imaging, specifically angiography. Nonoperative treatment of splenic injuries often involves periods of serial examinations, laboratory monitoring, bed rest, and bowel rest. This varies between institutions and grade of injury. Repeat imaging also varies among institutions. It ranges from mandatory repeat CT imaging to identify splenic vascular abnormalities (pseudoaneurysms) in higher-grade splenic injuries to repeat imaging based on clinical factors. Indications for angiography with embolization are currently debated among trauma surgeons. Vascular abnormalities (pseudoaneurysm, blush) are commonly accepted indications for use of angiography. High-grade (IV and V) injuries are also commonly evaluated and treated empirically in many centers with angioembolization. Long-term Follow-up Discuss outpatient follow-up of patients who have undergone operative and nonoperative management of splenic injuries. Understand the importance of reevaluation of patient prior to clearance for participation in contact sports. The majority of nonoperative failures occur in the first 72 hours postinjury. Additional significant failure can occur up to 1 month postinjury. Therefore, patients must understand the signs of bleeding and the importance of returning to the hospital if concerns develop after nonoperative treatment. Return to contact sports is a controversial topic in trauma, especially concerning reimaging of injuries prior to return to such activities, and it varies depending on location and grade of injury. Describe the presentation and management of late complications of splenectomy, specifically mesenteric vein thrombosis and OPSI. Thrombosis of vessels associated with postsplenectomy thrombocytosis generally occurs with associated myeloproliferative disorders. It is most often treated when the platelet level exceeds 1,000,000/µL and is generally treated with aspirin. The presentation of OPSI is often insidious in nature, with a prodromal state similar to an upper respiratory infection, with rapid physiologic decline in hours. OPSI has a high mortality rate (50%-70%), with survivors often having associate comorbidities. AAST Grading Scale for Splenic Injuries Grade I Hematoma: Subcapsular with <10% surface area Laceration: Capsular tear with <1 cm parenchymal depth
Multiple grade I injuries is graded as grade II Grade II Hematoma: Subcapsular with 10% to 50% surface area or intraparenchymal with <5 cm in diameter Laceration: Capsular tear with 1 to 3 cm parenchymal depth that does not involve a trabecular vessel
Multiple injuries with greatest being grade II upgraded to grade III Grade III Hematoma: Subcapsular with >50% surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma ≥5 cm or expanding Laceration: >3 cm parenchymal depth or involving trabecular vessels Grade IV Laceration: Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) Grade V Hematoma: Completely shattered spleen Laceration: Hilar vascular injury devascularizes spleen Yüklə 4,08 Mb. Dostları ilə paylaş:
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