The Liver and the Biliary Tract

The Liver and the Biliary Tract
By:Brando Cobanov, M.D.
Department of Pathology
UMDNJ-RWJMS

Hepatic Injury
* Inflammation = hepatitis
o Portal tracts, lobules
* Degeneration
o Damage from toxic or immunologic insult
o Accumulation of substances, e.g., steatosis
* Cell death
o Centrilobular, submassive, massive necrosis
* Fibrosis
o Usually irreversible
* Cirrhosis

Bile
Jaundice
* Excessive production of bilirubin
o Hemolytic anemias, ineffective erythropoiesis
* Reduced hepatic uptake
* Impaired conjugation
o Physiologic jaundice of the newborn
o Crigler-Najjar syndromes types I and II
o Gilbert syndrome
o Viral or drug-induced hepatitis, cirrhosis
* Decreased hepatocellular excretion
o Dubin-Johnson syndrome, Rotor syndrome
* Impaired bile flow

Cholestasis
* Systemic retention of not only bilirubin but also other solutes eliminated in bile, particularly bile salts and cholesterol
* Due to hepatocellular dysfunction or biliary obstruction
* Accumulation of bile pigment within the hepatic parenchyma – Kupffer cells
* Bile ductular proliferation
* Bile lakes
* Portal tract fibrosis

Hepatic Failure
Clinical Features
* Jaundice
* Hypoalbuminemia
* Hyperammonemia
* Fetor hepaticus
* Palmar erythema
* Spider angiomas
* Hypogonadism
* Gynecomastia

Complications
* Multiple organ failure
* Coagulopathy
* Hepatic encephalopathy
* Hepatorenal syndrome

Cirrhosis
* Bridging fibrous septa
* Parenchymal nodules
* Disruption of the architecture of the entire liver
* Etiologies

Portal Hypertension
* Prehepatic
* Intrahepatic
* Posthepatic

Clinical Sequelae
* Ascites
* Portosystemic venous shunts
* Splenomegaly
* Hepatic encephalopathy

Drug Induced Liver Disease
* Liver is the major drug metabolizing and detoxifying organ in the body
* Direct toxicity
* Hepatic conversion of a xenobiotic to an active toxin
* Immune mechanisms
* Table 16-6

Alcoholic Liver Disease
* Hepatic steatosis
* Alcoholic hepatitis
* Alcoholic cirrhosis
o Micronodular

Pathogenesis
* Shunting of normal substrates away from catabolism toward lipid biosynthesis
* Induction of cytochrome P-450
* Free radicals generated by microsomal ethanol oxidizing system
* Alcohol directly affects microtubular and mitochondrial function
* Acetaldehyde induces lipid peroxidation
* Neutrophil infiltration
* Immunologic attack of hepatocytes

Causes of Death
* Hepatic failure
* Massive GI hemorrhage
* Infection
* Hepatorenal syndrome
* Hepatocellular carcinoma

Nonalcoholic Fatty Liver
* Elevated serum aminotransferase levels
* Low risk for development of hepatic fibrosis or cirrhosis
* Associated with obesity, type 2 DM, hyperlipidemia
* Need to exclude other causes


Hemochromatosis
* Primary or hereditary
* Secondary
Pathogenesis
Morphology
Clinical Features
Wilson Disease
Morphology
Clinical Features
α1-Antitrypsin Deficiency
Morphology
Neonatal Hepatitis
Reye Syndrome
Morphology
Obstructive Biliary Tract Disease
Secondary Biliary Cirrhosis
Primary Biliary Cirrhosis
Primary Sclerosing Cholangitis
Circulatory Disorders
Hepatic Artery Inflow
Portal Vein Obstruction
Impaired Blood Flow Through the Liver
Hepatic Vein Thrombosis
Veno-Occlusive Disease
Hepatic Neoplasms
Benign Tumors
Focal Nodular Hyperplasia
Liver Cell Adenoma
Hepatocellular Carcinoma
Pathogenesis
Morphology
HCC
Clinical Features
Disorders of the Gallbladder
Cholelithiasis
Clinical Features
Cholecystitis
Choledocholithiasis
Cholangitis
Biliary Atresia
Gallbladder Carcinoma
Cholangiocarcinoma

The Liver and the Biliary Tract.ppt

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Trauma: Stabilization and Transport

Trauma: Stabilization and Transport
Division of Critical Care Medicine
Children’s Healthcare of Atlanta
Atlanta, Georgia

Trauma:Stabilization and Transport
Objectives
* Discuss the epidemiology of pediatric trauma
* Review the primary survey
* Identify priorities in care
* Discuss differences between adult & pediatric trauma
* Discuss pediatric trauma management
* Review the development of and
guidelines for transport

Neurosurgeon
Resuscitation Team
Surgical Specialties
Medical Specialties
Nursing
ICU
OR
Anesthesia
Orthopedic Surgeon
Trauma Surgeon
ALWAYS OPEN TRAUMA CENTER

Trauma:Initial Stabilization
Trauma:Initial Stabilization
The Golden Hour
* R. Adams Cowley, MD
* Care within 60 min.
* mortality if care given > 60 min.
"You live or die depending on where you have your accident because they take you to the nearest hospital!"

R. Adams Cowley, MD
“In the Blink of an Eye”
A-M-P-L-E History

A - Allergies
M - Medications
P - Previous history
L - Last ate
E - Events of accident

Trauma:Initial Stabilization Management of Multiple Trauma
* Primary survey
* Initial stabilization
and resuscitation
* Secondary survey
* Definitive care

Trauma:Initial Stabilization The Primary Survey
* A rapid initial assessment
* An "ABC" approach
* Resuscitation done simultaneously

Trauma:Initial Stabilization The Secondary Survey
* After the "ABCs"
* Head to toe examination

Trauma Initial Stabilization Definitive Care Phase
* Overall management
* Fracture stabilization
* Stabilization/transport
* Emergent surgery

Trauma:Initial Stabilization Pediatric Considerations
* ABCs
* Differences:
1) Size
2) Injury pattern
3) Fluids
4) Surface area
5) Psychological
6) Long term effects

Trauma:Initial Stabilization
In pediatric trauma, you don’t just have and injured child, you have an injured family
M. Eichelberger, MD
“In the Blink of an Eye”
Trauma:Initial Stabilization The Primary Survey
A - Airway and C-Spine
B - Breathing
C - Circulation (with hemorrhage control)
D - Disability
E - Exposure

Trauma:Initial Stabilization The Primary Survey
* Airway:
o Establish patency
o Beware C- Spine
o Do not:
+ Flex
+ Hyperextend
* Oxygen
o treat potential hypoxemia
o all trauma patients get O2

Trauma:Initial Stabilization Pediatric Considerations
* Craniofacial disproportion
* "Sniffing" position
* Obligate nose breathers
* Anatomy
o tongue
o larynx
o trachea

Trauma:Initial Stabilization Suspected Airway Obstruction
* Stridor
* Cyanosis
* Absence of breath sounds
* Dysphagia, snoring, gurgling
* Altered mental status
* Trauma to head, face, neck

Trauma:Initial Stabilization Cervical Spine Differences
* Flexible interspinous ligaments
* Underdeveloped neck muscles
* Poorly developed articulations
* Anterior vertebral bodies
* Flat facet joints
* Large head to BSA

Trauma:Initial Stabilization Cervical Spine
* Predisposed to serious high cervical injuries
* Assume its presence in:
o Blunt injury above clavicle
o Multisystem trauma
o Significant injury - MVA, fall
o Altered sensorium

Trauma:Initial Stabilization Cervical Spine: Radiographs
* Pseudosubluxation
* distance dens and C-1
* Growth plate fracture
* SCIWORA

Trauma:Initial Stabilization Airway Management
* Clear airway
* Jaw thrust/stabilization maneuver
* Oral/nasal airway
* Oxygenate/ventilate
* Intubation
* Cricothyroidotomy

Trauma:Initial Stabilization C-Spine Immobilization
* Backboard
* Appropriate C-collar
* Snadbags or towel
* Tape
* Torso immobilization

Trauma:Initial Stabilization Primary Survey: Breathing
* Assess via
o Exposure
o Rate/depth of respiration
o Inspection/palpation
o Quality/symmetry of breath sounds

NB: An intact airway Does Not assure adequate ventilation!!

* Oxygen
* Assisted ventilation
* Alleviate life threatening injuries

Thoracic Injury Heart, Lung, Mediastinum
* Penetrating
o Sucking, Bubbling
o Hemopneumothorax
o Tamponade
* Blunt
o Flail Chest
o Contusion (lung, heart)
o Aortic Dissection
o Tracheal Rupture
o Diaphram Rupture

Trauma:Initial Stabilization Chest Trauma
* Tension pneumothorax
* Hemothorax
* Flail chest
* Cardiac tamponade

Trauma:Initial Stabilization Chest Trauma
* Blunt injury common
* More compliant chest wall
* Sensitive to flail segment
* Mobile mediastinum
* Major vascular injury uncommon

Trauma:Initial Stabilization Tension Pneumothorax
* Air in the pleural space without exit
* Collapse of ipsilateral lung
* Compressed contralateral lung
* Mediastinal shift

Trauma:Initial Stabilization Tension Pneumothorax: Signs and Symptoms
* Respiratory distress
* Unilaterally diminished breath sounds
* Hyperresonance on affected side
* Tracheal deviation
* Distended neck veins
* Cyanosis

Trauma:Initial Stabilization Tension Pneumothorax: Treatment
* Needle decompression
o 2nd intercostal space mid-clavicular line
* Chest tube
o 4-5th intercostal space mid-axillary line

Trauma:Initial Stabilization Hemothorax: Signs and Symptoms
* breath sounds on affected side
* Dullness to percussion
* Hypovolemia
* Flat vs distended neck veins

Trauma:Initial Stabilization Hemothorax: Treatment
* Fluids/blood
* Decompression
* Chest tube
* Autotransfusion

Trauma:Initial Stabilization Flail Chest
* Boney discontinuity of the chest wall
* Major problem = underlying injury
* Signs and symptoms
o respiratory distress
o paradoxical chest wall movement
o severe chest pain

Trauma:Initial Stabilization Flail Chest:Treatment
* Oxygen
* Stabilize segment
* Re-expand lung
* + intubation
* Give fluids cautiously

Trauma: Initial Stabilization abdominal trauma
* Following the head and extremities, the abdomen is the third most commonly injured anatomic region in children
* significant morbidity and may have a mortality rate as high as 8.5%
* abdomen is the most common site of initially unrecognized fatal injury in traumatized children

Trauma: Initial Stabilization abdominal trauma
* Why more prone to abdominal injury
o child has thinner musculature
o ribs are more flexible in the child
o solid organs are comparatively larger in the child
o fat content and more elastic attachments leading to increased mobility
o bladder is more exposed to a direct impact to the lower abdomen

Intraperitoneal Hemorrhage Management
o Immediate surgical exploration
o Non-operative protocols
+ successful in more than 95% of blunt abdominal trauma in appropriately selected cases

Intraperitoneal Hemorrhage
Immediate Surgical Exploration
o Abdominal distention + “shock”
o Transfusion requirement > 40 cc/kg
o Peritonitis
o Pneumoperitoneum
o Bladder rupture

Intraperitoneal Hemorrhage
CT Scan
o Hemodynamically stable
o Unreliable exam
o Immediate non-abdominal surgery
o Specific Indicators
Hematuria (any)
SGOT 200, SGPT > 100
Hyperamylasemia

Intraperitoneal Hemorrhage
* FAST
o standard part of the initial evaluation of bluntly injured abdomens in adults
o rapid assessment of the peritoneal cavity and can detect free fluid

Intraperitoneal Hemorrhage
o Pediatrics role of FAST is still up for debate
+ Detailed information regarding the grade of organ injury is not provided by the FAST
+ operator-dependent and lacks specificity
+ FAST examination produces a significant number of false-negative results

Intraperitoneal Hemorrhage
Diagnostic Peritoneal Lavage
Trauma:Initial Stabilization Circulation
Trauma:Initial Stabilization Frequent Reassessment of Vital Signs
What Are Normal Pediatric Vital Signs?
Trauma:Initial Stabilization Pediatric Vital Signs
Trauma:Initial Stabilization Circulation: Vital Signs
Trauma:Initial Stabilization Circulation: Shock
Trauma:Initial Stabilization Circulation: Fluid Therapy
Trauma:Initial Stabilization Circulation: Fluid Therapy
Trauma:Initial Stabilization Circulation: Blood Replacement
Trauma:Initial Stabilization Circulation:Pediatric Considerations
Trauma:Initial Stabilization Disability
Trauma:Initial Stabilization Disability: Children's Glasgow Coma Scale
Trauma:Initial Stabilization Pediatric Trauma Score
Airway Normal Oral or nasal Intubated, tracheostomy
Trauma:Initial Stabilization Expose: Pediatric Considerations
Trauma:Initial Stabilization Cathertization
Trauma:Initial Stabilization Definitive Care
Questions ??
References
Trauma: Stabilization and Transport .ppt

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Acute Mental Status Changes in the Intensive Care Unit

Acute Mental Status Changes in the Intensive Care Unit
By:Danagra Georgia Ikossi, MD
Stanford General Surgery Resident


* Brief review of Delirium, Seizures and Stroke
* “ICU Psychosis”
o How do you know if they’re confused? (J. Am. Ger. Soc. 2005)
o Why do they become delirious? (Critical Care 2001)
o Does delirium portend a poor outcome? (JAMA 2004)
o Geriatrics: Delirium plus dementia, what to do? (J. Am. Ger. Soc. 2005)


Disorders of Mentation
* Abnormalities of mental function
* Levels of Conciousness

Etiology of depressed level of consciousness
In non head injured patients
o SMASHED
o Substrate deficiencies (glucose, thiamine)
o Meningoencephalitis or Mental illness (malingering, psychogenic coma)
o Alcohol or Accident (CVA)
o Seizures
o Hyper-capnia, -glycemia, -thyroid, -thermia OR Hypo-xia, -tension, -thyroid, -thermia
o Electrolyte abnormalities (hyperNa, hypoNa, hyperCa) and Encephalopathies
o Drugs

Eye Opening
Spontaneous
To Speech
To Pain
Verbal Oriented
Inappropriate
Incomprehensible
Abnormal Extension
Abnormal Flexion
Withdraws
Localizes
Obeys Commands
Motor
Glascow Coma Scale: GCS
“T” denotes intubation
Predictive value of GCS
* Septic Encephalopahthy
Delirium
DSM-IV Diagnosis of Delirium
A. Reduced ability to maintain and shift attention to external stimuli
B. Disorganized thinking, as indicated by rambling, irrelevant, or incoherent speech
C. At least two of the following:

1. Reduced level of consciousness
2. Perceptual disturbances: misinterpretations, illusions, or hallucinations
3. Disturbance of sleep–wake cycle with insomnia or daytime sleepiness
4. Increased or decreased psychomotor activity
5. Disorientation to time, place, or person
6. Memory impairment

D. Abrupt onset of symptoms (hours to days), with daily fluctuation

E. Either one of the following:
1. Evidence from history, physical examination, or laboratory tests of specific organic etiologic factor(s)
2. Exclusion of non-organic mental disorders when no etiologic organic factor can be identified

Delirium
* Hypoactive delirium:
* Dementia and Delerium:
* Management
THIS IS MUCH MORE THAN WE USE
Important to differentiate Delirium from DTs
* Delirium Tremens
Cocaine Related Delirium
Who becomes delirious?

Delirium, Dementia or Both?
* Delirium is a risk factor for increased ICU and Hospital length of stay
* In the geriatric population, becomes difficult to differentiate between underlying dementia and delirium
* Group at Brown did a prospective study of 118 patients in ICU
* Baseline dementia diagnosis given by family on Blessed Dementia Scale
* Delirium diagnosed by CAM and CAM-ICU scales
CAM ICU SCORE
Overall CAM ICU Score:
Delirium and mortality
Perspective on ICU Psychosis
AACM and SCCM Guidelines
Seizures
* Second most common neurologic complication in ICU
* Movements
* Generalized Seizures
* Partial Seizures
* Status Epilepticus
New Onset Seizures
* Drug intoxication
(amphetamies, cocaine, phenocyclidine, cipro, imipenam, lidocaine, PCN, theophylline, TCA)
* Drug withdrawal (EtOH, BZO, Barbiturates, Opiates)
* Infection (Meningoencephalitis, abscess)
* Ischemia (focal or diffuse)
* Space occupying lesion (tumors or bleeds)
* Metabolic derrangement
(hepatic encephalopathy, uremia, hypo-glycemia, -natremia, -calcemia)

* Evaluation:
o Examination looking for lateralizing signs
o Review of medications
o Imaging (CT)
o Procedural diagnostics (LP, labs, blood cultures)
* Management:
o BZO
o Valium 0.2mg/kg IV stops 80% of seizures within 5 min, effect lasts 30 min
o Ativan 0.1mg/kg is as effective and lasts 12-24hrs
o Dilantin 20mg/kg following valium, aim for 20mg/l therapeutic serum level

Stroke
* Acute neurologic disorder
* Nontraumatic brain injury, vascular origin
* Focal findings (not global)
* Persists for more than 24 hours
* 80% ischemic, 20% of which are embolic
o Most thrombi are mural, LA, LV, DVT with PFO
* TIA: transient ischemic attack, focal deficits resolve in less than 24 hours (ischemia rather than infarction)
* Minor Stroke = RIND (reversible ischemic neurologic deficit) resolves within 3 weeks of event
* Major Stroke = deficits persist for more than 3 weeks
* Evaluation: common things you’ll see at the bedside
o Full neuro exam, looking for focal deficits
o Seixures in 10% of cases, focal and within first 24 hours
o Fever in 50% of strokes (not with TIA) – look for other sources
o Coma and LOC are not common – more likely hemorrhage, massive infarct with edema, brainstem infarction, seizure (absence) or postictal state
o Aphasia – Left MCA distribution
o Weakness in contralateral limbs (can also have other metabolic causes)

Diagnostic Studies
* Time is brain
* Coags, Chemistries: hypoglycemia, hyponatremia, ARF
* ECG: Afib?
* CT head: 70% sensitivity for infarct, 90% for hemorrhage - critical to distinguish btwn these
* Better if after 24 hours for infarct
* MRI: more sensitive esp for brainstem and cerebellar strokes
Diagnostics and Treatment
* ICP: monitoring not recommended routinely
o Elevate HOB 30 degrees
o Do not use measures that will decrease CBF
o minimize suctioning (HTN)
o Do not hyperventilate (reduces CBF)
o Steroids not recommended
o Hyperosmolar therapy can be used if edema is severe (Mannitol, HTS)

Acute Mental Status Changes in the Intensive Care Unit.ppt

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