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Sun Jan 11 14:37:30 GMT 2009

Two weeks post op patient presents with a sudden drop in his hemoglobin and a 
repeat CT abdomen is essentially negative. 

i think angio not ct is warranted for bleeding when hemorrhage recurs after hepatic embolization. 

sal

-----Original Message-----
From: michael parra <michaelwparra at yahoo.com>
To: trauma-list at trauma.org
Sent: Sun, 11 Jan 2009 12:59 am
Subject: Delayed Hepatic Rupture

30 yo male status post motor vehicle crash who arrived complaining of abdominal 
pain / hemodinamically stable. CT abdomen revealed a Grade IV liver laceration 
extending threw segments 7 & 8 with active extravasation of contrast, and 
moderate amount of hemoperitoneum. Taken immediately to angio where?a distal 
right?hepatic artery branch was successfully embolized. Next morning patient 
presents with an elevated WBC / worsening acidosis and increase abdominal 
tenderness for which patient is taken to the operating room for exploratory 
laparotomy to rule out any other?missed injury. During laparotomy no other 
injuries found, abdominal washout is performed and hepatorraphy with several 
interrupted zero chromic liver mattress sutures.
Two weeks post op patient presents with a sudden drop in his hemoglobin and a 
repeat CT abdomen is essentially negative. 
Four weeks post op patient presents with an abrupt episode of cardiac arrest 
following a melenotic stool. A rapid EGD is performed during CPR protocol to 
rule out a hepato-biliary or upper GI source. EGD was negative. FAST was 
negative. An acute abdominal compartment syndrome developed as a consequence of 
the aggressive IVF and blood product resuscitation during CPR. The abdomen was 
opened at the bedside in the TICU, and no hemoperitoneum was noted. CPR is 
continued and a significant and distinct cyanosis of the shoulders/neck /and 
head developed all of a sudden. A presumptive diagnosis of an acute superior 
vena cava syndrome is considered for which bilateral chest tubes are placed. Lt 
chest tube resulted no air or blood. Right chest tube decompressed a massive 
hemothorax of greater than 2 liters. An immediate right antero-lateral 
thoracotomy was performed with packing of the right chest and the patient was 
transferred from the TICU to the OR with
 ongoing CPR.
In the OR both chest and abdominal incisions were united and the diaphragm was 
transected following the ligament of Teres down to the suprahepatic vena cava. 
Complete liver isolation was 
performed by placing vessel loops on the 
hepatoduodenal ligament (Pringle), the suprahepatic inferior vena cava and the 
suprarenal subhepatic vena cava.The liver is encased with a plastic bag ( 
"Seattle Bag") and then packed. All vascular controls were released and liver 
bleeding was controlled. Both the abdomen an the chest are left open and a poor 
mans VAC were placed on each cavity.Patient was taken back to the TICU for 
rewarming and correction of coagulapathy.Patient stabilizes overnight and is 
taken to the angio suite the next morning to?coil any possible?intrahepatic 
pseudo aneurysm, any persistent intrahepatic arterial?bleeding 
and?possibly?prophylactic embolization of?the right hepatic artery in 
preparation for?planned surgical resection. Angiogram
 revealed a blush?of the right medial hepatic artery?that was then?successfully 
embolized. 48 hours later patient was taken back for packing removal and a 
subtotal right hepatectomy/cholecystectomy. Patient eventually undergoes 
thoracotomy and abdominal wall closure with alloderm. Patient recovers and is 
transferred to a rehab facility.
?
?
Michael W. Parra, MD 
Trauma Research Director
Broward General Medical Center
Fort Lauderdale, Fl

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Delayed Hepatic Rupture