Decision Making by CT Grading in Blunt Hepatic Injury Patient

BACKGROUND: Because of increased number of traffic and industrial accidents, the incidence of blunt abdominal injury patients has increased. Recently, abdominal computed tomographic(CT) scans have been widely used in emergency departments for initial diagnostic workups on patients with blunt hepatic injuries. The purpose of this study is to analyze the correlation between abdominal CT scans and the clinical outcomes and to recommend a direction for the management of blunt hepatic injury. METHODS: A retrospective review was conducted of 66 patients with blunt hepatic injuries who underwent abdominal CT scans and were treated at the Department of Emergency Medicine of Dankook University Hospital during the period from January 1998 to December 2000. Statistical analysis was performed using the chi-square(x2) test, Spearman correlation test, Cochran-Mantel-Haenszel chi-square(x2) test and Fisher's exact test; a value of p<0.05 was considered significant. RESULTS: Based on CT scans, we graded the liver injuries by using the system of the Organ Injury Scaling Committee of American Association for the Surgery of Trauma. Grade II injuries(28 cases, 42.4%) were the most common in this study. Most patients with injuries above grade III were managed surgically, and CT grades correlated well with operative treatment and initial fluid resuscitation. Initial shock status correlated with the CT grade, but did not correlate with operative management. For nonoperative management, as the CT grade increased, the amount of blood transfusion also increased. Increasing liver enzyme did not correlate with CT grade. The mortality rate was 9.1%, and the most common cause of death were hypovolemic shock due to massive bleeding. CONCLUSION: Non-operative management is the first choice of treatment in low grade blunt hepatic injury(CT grade I, II, and III). For cases above grade IV hepatic injury, the key points of operative management were the hepatic injury itself and it's complication.

The Study of Operative Indications of Blunt Hepatic Trauma

PURPOSE: Nonoperative management is currently considered a treatment modality in 50 to 80% of patients with blunt liver injury. Nevertheless 10 to 50% of patients need operative management, and the criteria for operative management have not established. The purpose of this study is to find criteria for operative management of patients with blunt liver injury. METHODS: The records of 117 patients who experienced blunt hepatic injury from January 1992 to April 1999 were reviewed retrospectively with respect to hemodynamic stability, transfusion requirement, injury severity score, liver injury grade, amount of blood in the peritoneal cavity, and pooling of contrast material on computerized tomography (CT). RESULTS: Among the 117 patients, 29 patients (25%) were treated operatively (Group 1) and 88 patients (75%) were treated nonoperatively (Group 2). The initial systolic blood pressure in Group 1 was significantly lower than that of Group 2 (74.4+/-30.3 mmHg vs 107.1+/-27.2 mmHg, p<0.001). The amounts of transfusion for hemodynamic stability were 2.1 units in Group 1 and 0.4 units in Group 2 (p<0.001). The injury Severity score of Group 1 was significantly higher than that of Group 2 (20.8 +/- 11.0 vs 10.7+/-6.8, p=0.03). The mean injury grade was 3.7+/-0.1 for Group 1 and 2.4+/-1.0 for Group 2, which was a statistically significant difference was seen (p<0.001). The amount of hemoperitoneum in Group 1 was significantly higher than that of Group 2 (p<0.001). The pooling of contrast material on CT was detected in 3 cases in Group 1. CONCLUSION: We can establish the following criteria for operative management: operative management is necessary for hemodynamic instability during resusci tation, positive peritoneal irritation signs, and presence of pooling of contrast material on CT. In cases above grade IV, above 500 mL of hemoperitoneum on CT, or above 2 units of blood transfusion during resuscitation, close observation in an intensive care unit is necessary. If abnormality develops during observation, prompt operative management is mandatory.