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CARDIOVASCULAR ANESTHESIA

Transesophageal Echocardiographic Diagnosis of a Liver Laceration Accompanied by Hemodynamic Instability

From the Department of Anesthesiology, Medical College of Ohio, Toledo, Ohio

Address correspondence and reprint requests to James P. Hofmann, MD, Assistant Professor, Department of Anesthesiology, Medical College of Ohio, 3000 Arlington, Toledo, OH 43614–2598. Address email to Jhofmann{at}mco.edu

	Abstract

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Transesophageal echocardiography (TEE) is a useful adjunct in the evaluation of trauma patients, particularly in the area of aortic injury and cardiac tamponade. Little has been written on the use of this modality in the evaluation of extra-cardiac injury. We present a case of a trauma patient in whom TEE was used to evaluate hemodynamic instability; during the course of the examination a previously undiagnosed liver laceration was identified.

We report the diagnosis of a liver laceration in a trauma patient by novel use of the transesophageal echocardiographic imaging modality.

	Introduction

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Transesophageal echocardiography (TEE) is extremely helpful in diagnosing pericardial, intracardiac, and aortic lesions after abdominothoracic trauma (1). It also has been used to diagnose and quantify traumatic hemomediastinum (2,3). We report a case of blunt abdominal trauma with hemodynamic instability accompanied by a hepatic laceration identified by intraoperative TEE despite a preoperative abdominal computerized tomography (CT) scan reported to be negative.

	Case Report

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A 76-yr-old 66-kg unrestrained female driver in a motor vehicle accident arrived at our Trauma Center via Life Flight. She was alert and oriented (Glasgow Coma Scale score of 15), breathing spontaneously, with two large bore IV catheters, and wearing a hard cervical collar. The flight crew reported that the patient had suffered a short period of loss of consciousness at the scene.

The primary survey revealed bilateral, open, compound ankle fractures, fracture dislocation of the manubrium and left clavicle, and a closed supracondylar fracture of the right elbow (abdominal examination was negative). She was hemodynamically stable with an SpO₂ of 100% while breathing room air. The secondary survey was negative. Her medical history was significant for hypertension and a right total knee arthroplasty. CT scans of the abdomen, pelvis, and head were performed. The initial abdominal/pelvic CT scan (with contrast) indicated only a right renal cyst and a right pleural effusion. The CT scan of the head was negative. Reexamination of the patient revealed a significant discrepancy in arterial blood pressure between the upper extremities, which required an emergent angiogram that identified dissection and compression of the left subclavian artery. After successful angioplasty and stent placement in the artery, a Greenfield filter was placed in the inferior vena cava. The patient was admitted to the orthopedic ward where she subsequently became hypoxemic, tachypneic, and hypotensive, requiring endotracheal intubation and resuscitation with crystalloid solutions and packed red blood cells. An arterial catheter and right subclavian catheter were placed. The patient regained hemodynamic stability with IV fluids. A diagnostic evaluation for pulmonary embolus was negative.

She was taken to surgery to repair the open ankle fractures. Preinduction arterial blood pressure was 145/65 mm Hg with a heart rate of 90 bpm. Anesthesia was induced with IV etomidate and fentanyl and was maintained with isoflurane in oxygen, additional fentanyl, and rocuronium. Fifteen minutes after surgical incision the patient had progressive hemodynamic decompensation. A systolic blood pressure of 90 mm Hg was maintained with IV crystalloids, packed red blood cells, and vasopressors. There was no hemorrhage from the open fracture sites, and no substantial hematomas were evident at the injury sites. The central venous pressure tracings revealed low to normal pressures.

TEE evaluation was performed and demonstrated global hypokinesis with mildly decreased left ventricular systolic function, mild left ventricular hypertrophy, and underfilling of the left ventricle. The aorta had no evidence of dissection. Thus the differential diagnoses included myocardial contusion and myocardial infarction as well as hypovolemia; cardiac enzymes were drawn, and fluid resuscitation was continued.

TEE examination of peripheral structures revealed bilateral pleural effusions. From the transgastric position a hemispheric anechoic area of approximately 3 cm was evident between the liver and the diaphragm. An echo density consistent with thrombus bordered the area, which separated the diaphragm from the liver, maintaining the profile of each (Fig. 1). This finding was thought to be consistent with a hemoperitoneum produced by an adjacent liver laceration, and the diagnosis of a possible liver laceration was reported to the surgeon.

View larger version (109K): [in this window] [in a new window]   Figure 1. Transgastric transesophageal echocardiography image of the liver and diaphragm demonstrating hemoperitoneum (the hypoechoic area in the center of the image marked by the unlabeled arrow) with adjoining thrombus produced by a liver laceration (confirmed by computed tomography scan).

Two negative diagnostic peritoneal lavages were performed several hours apart in the surgical ICU and the patient remained hemodynamically stable. The cardiac enzymes were negative for myocardial infarction. The patient was discharged 1 mo later with resolution of the hepatic laceration.

	Discussion

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Serious complications of blunt abdominal trauma include hemoperitoneum and solid organ lacerations. Liver laceration is the most common abdominal injury resulting in death and most often occurs in patients with multiple injuries that have delayed or missed diagnoses (4–6). Sonographic assessment has gained acceptance as the most cost-effective, accurate evaluation of patients with potential thoracoabdominal injury. In addition to the Focused Assessment with Sonography for Trauma (FAST) technique (a handheld screening tool for detection of free fluid in the abdomen after blunt trauma), TEE has emerged as a new and important application of sonography in trauma care (7,8). TEE has been independently validated against angiography and has been established as more sensitive than CT scanning for the identification of traumatic aortic injuries (9,10).

Abdominal examination by TEE is limited and is affected by factors such as patient size, body habitus, gastric contents, and preexisting intraabdominal pathology. These limitations exclude TEE as a primary diagnostic modality for upper abdominal injury; however, it may be an important adjunct. Its portability and relative safety allow expeditious use of TEE in many settings, and it is widely accepted for evaluation of trauma to the thoracic aorta, cardiac dysfunction after multisystem trauma, estimation of volume loading status, and visualization of pericardial fluid and blood (11). A complete examination of all cardiovascular structures should be performed each time TEE is used and an explanation of all abnormalities sought.

Patients with traumatic, life-threatening injuries may arrive for surgery without diagnostic studies such as CT scans or angiograms. Thus TEE may provide a first diagnosis of additional injury. Fluids, such as blood or ascites, commonly collect between the liver and the diaphragm and may be easily identified in the transgastric view by TEE. Probe rotation while in this position allows a large portion of the liver parenchyma to be visualized. Unexplained fluid seen in the abdominal cavity of a trauma patient may portend hemorrhage.

Intraabdominal injuries not accompanied by hemoperitoneum may not be identifiable with an initial FAST examination or CT scan. The ease and rapidity of TEE application and the important information it delivers warrant its use in any trauma patient developing new onset hemodynamic instability. Esophageal intubation with a TEE probe is not without risk and could exacerbate facial, esophageal, or gastrointestinal injuries. Unfortunately, quantification of this risk is not possible with currently available data. This requires a careful evaluation of possible risks and benefits in each individual case. Evaluation of hemodynamic instability in trauma that may be related to cardiac dysfunction or aortic injury merits TEE evaluation. Routine placement of a TEE probe for upper abdominal evaluation in trauma cannot be recommended at this time, but if the probe has been placed in a trauma patient for cardiac or aortic examination, the examiner should garner available information on other injuries.

The advantages of TEE in trauma patients are evident. Its liberal use offers a marked increase in diagnostic potential while decreasing the number of undiagnosed life-threatening injuries. In this report we demonstrate that diagnosis of a liver laceration and hemoperitoneum by TEE is possible. There remains a need for further evaluation of the benefits of TEE in upper abdominal injury, specifically the diaphragm/liver interface. Validation of TEE against angiography for acute traumatic aortic injury is apparent and its diagnostic value in peritoneal and solid organ injury needs to be addressed. A prospective trial of TEE evaluation in patients with suspected traumatic hepatic injuries would be of great value in clarifying its role in this venue.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Hofmann, J. P. Articles by Papadimos, T. J. Search for Related Content PubMed PubMed Citation Articles by Hofmann, J. P. Articles by Papadimos, T. J. Related Collections Blood Monitoring (Cardiac) Monitoring (Non-cardiac)