Wednesday, November 3, 2010

Chest Examination from the back

Algorithm for treatment of renal trauma

The Liver Injury Scale (LIS) classification

The liver is the largest solid abdominal organ with a relatively fixed position, which makes it prone to injury . Damage to the liver is the most common of death after abdominal injury. The most common cause of liver injury is blunt abdominal trauma, which is secondary to motor vehicle crashes (MVC)

Hepatic injury was graded according to the Hepatic Injury Scale established by the American Association for the Surgery of Trauma (AAST).
This is a liver injury . The injury has been opened to control bleeding branches of the portal and hepatic veins as well as the hepatic arterial radicles. Several biliary ducts were ligated.

Grade and Description of injury
 Grade I : *Haematoma--->Subcapsular, non-expanding, less than 10 percent of surface area
*Laceration--->Capsular tear, non-bleeding, parenchymal depth less than 1 cm

Grade II : *Haematoma--->Subcapsular, non-expanding, 10–50 per cent of surface area or intraparenchymal, non-expanding, less than 2 cm in diameter.
*Laceration--->Capsular tear, active bleeding, parenchymal depth 1–3 cm, less than 10 cm in length.

Grade III : *Haematoma--->Subcapsular, more than 50 per cent of surface area or expanding ruptured subcapsular haematoma with active bleeding intraparenchymal haematoma larger than 2 cm.
*Laceration--->Parenchymal depth more than 3 cm.

Grade VI : *Haematoma--->Ruptured intraparenchymal haematoma with active bleeding.
*Laceration--->Parenchymal disruption of more than 25–50 percent of hepatic lobe.

Grade V : *Laceration--->Parenchymal disruption of more than 50 per cent of hepatic lobe.
*Vascular--->Juxtahepatic venous injuries.

Grade VI : *Vascular--->Hepatic avulsion.

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Penetrating Aortic Ulcer

 Ulceration of an atherosclerotic plaque which penetrates into the internal elastic lamina
· Hematoma then forms within the media of the aortic wall
· Occurs in the elderly who usually have a history of severe atherosclerosis, hypertension, and hyperlipidemia
· Similar presentation to those with a descending thoracic aortic dissection i.e. acute chest or back pain
· Plaque ulceration usually in the middle to distal third of the descending aorta
· Intramural hematoma accompanies the penetrating ulcer 80% of the time
· Associated with abdominal aortic aneurysm
· Disease progresses from intimal plaque ulceration to media hematoma formation to adventitial saccular pseudoaneurysm formation and finally rupture if there is transmural penetration
· Speculated as the cause of descending or thrombosed type dissections with all three

Imaging findings:
· Focal contrast collection projecting beyond the aortic lumen on CT
* Intramural hematoma is indistinguishable from intraluminal thrombus
Enhanced CT scan through the lower thoracic aorta demonstrates
a focal outpouching of contrast posteriorly representing a penetrating aortic ulcer

· Intimal flap is uncommon
· Intramural wall thickening or thrombus is frequently found
· On angiography, there is aortic wall thickening and the ulcerated plaque seen

· On MRI
* High signal intensity on both T1 and T2 with subacute hematoma

· Can be demonstrated by computed tomography, magnetic resonance, angiography and trans-esophageal echocardiography

· Differential diagnosis:
o Aortic dissection (has an intimal flap)
o Atheroma – has a low signal on both T1 and T2

· Surgical cases are those demonstrating hematoma expansion, impending rupture, inability to control blood pressure
· Patients routinely have co-morbid conditions that make them poor surgical candidates and are treated with transluminal placement of endovascular stent grafts

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