Haemodynamicaly unstable patient with blunt trauma to abdomen and suspected liver injury; which of the following is the first investigation performed in the emergency room?
Ans. is 'a' i.e., FAST * The patient has gunshot injury to the right upper quadrant of abdomen, mostly damaging the liver.General: Liver trauma* The liver is the second most common organ injured in abdominal trauma.* Liver trauma can be divided into blunt and penetrating injuries.* Blunt injury produces contusion, laceration and avulsion injuries to the liver, often in association with splenic, mesenteric or renal injury.* Penetrating injuries, such as stab and gunshot wounds, are often associated with chest or pericardial involvement.* Blunt injuries are more common and have a higher mortality than penetrating injuries.Diagnosis of liver injury:* The liver is an extremely well-vascularised organ, and blood loss is therefore the major early complication of liver injuries.* Clinical suspicion of a possible liver injury is essential, as a laparotomy by an inexperienced surgeon with inadequate preparation preoperatively is doomed to failure.* All lower chest and upper abdominal stab wounds should be suspect, especially if considerable blood volume replacement has been required.* Similarly, severe crushing injuries to the lower chest or upper abdomen often combine rib fractures, haemothorax and damage to the spleen and/or liver.* Focused assessment sonography in trauma (FAST) performed in the emergency room by an experienced operator can reliably diagnose free intraperitoneal fluid.* Patients with free intraperitoneal fluid on FAST and haemodynamic instability, and patients with a penetrating wound will require a laparotomy and/or thoracotomy once active resuscitation is under way.* Owing to the opportunity for massive ongoing blood loss and the rapid development of a coagulopathy, the patient should be directly transferred to the operating theatre while blood products are obtained and volume replacement is taking place.* Patients who are haemodynamically stable should have a contrast-enhanced CT scan of the chest and abdomen as the next step.* Additional investigations that may be of value include diagnostic peritoneal lavage, which can confirm the presence of haemoperitoneum, but this is rarely performed nowadays due to inceased use of FAST and CT.Initial management:* The initial management is maintenance of airway patency, breathing and circulation (ABC) following the principles of advanced trauma life support (ATLS).* Peripheral venous access is gained with two large-bore cannulae and blood sent for crossmatch of ten units of blood, full blood count, urea and electrolytes, liver function tests, clotting screen, glucose and amylase.* Initial volume replacement should be with colloid or O-negative blood if necessary. Arterial blood gases should be obtained and the patient intubated and ventilated if the gas exchange is inadequate.* Intercostal chest drains should be inserted if associated pneumothorax or haemothorax is suspected. Once initial resuscitation has commenced, the patient should be transferred to the operating theatre, with further resuscitation performed on the operating table.* The necessity for fresh-frozen plasma and cryoprecipitate should be discussed with the blood transfusion service immediately the patient arrives, as these patients rapidly develop irreversible coagulopathies due to a lack of fibrinogen and clotting factors.* Standard coagulation profiles are inadequate to evaluate this acute loss of clotting factors, and factors should be given empirically, aided by the results of thromboelastography (TEG), if available.* A contrast CT prior to laparotomy should be considered if the patient is haemodynamically stable.
FAST
CT Scan
Diagnostic peritoneal lavage
Standing X ray Abdomen
Trauma