Crushed Liver... Ride It Out

Motor Vehicle Crash (Pickup Truck vs. Telephone Pole)

This accident happened in the Fall of 1983. At the time of impact, the restrained teenage female driver’s upper torso moved forward and hit the steering wheel. The transformer crashed through the roof, hit her in the mid back, and crushed her liver. She was in shock at the scene from blood loss. EMTs extricated her from the pickup and transported her to Emanuel.

She arrived in the Trauma Operating Room with a barely palpable blood pressure and a distended abdomen. The trauma anesthesiologist intubated her, while we did an exploratory laparotomy as other trauma team members inserted large bore IV catheters and started massive transfusions.

 On opening her abdomen, large amounts of dark blood flowed out the incision. Her liver had large cracks in the hepatic capsule of both the right and left lobes of the liver. Large gauze packs were placed under her liver and around the spleen to temporarily slow the bleeding until we had a chance to assess her injuries. The spleen was uninjured, as were the kidneys. There was little other choice but to reinforce the packs with more packs and compress the liver fragments together. We left her abdominal incision open and created a silo to avoid abdominal compartment syndrome. 

We planned to change the packs every 4 days to see if the liver could recover and “knit” together with time. Her blood pressure stabilized. Her kidney function declined, and we started hemodialysis once the blood urea nitrogen exceeded 80 mg/dl (normal 6-24 mg/dl). Her liver failed as her hepatic enzymes and total bilirubin exceeded 30 mg/dl (normal 1.5).

She became septic. As her jaundice and renal failure progressed, her serial abdominal Cat Scans without contrast showed no normal liver anatomy. Questions arose whether she had a survivable liver injury. A biopsy of her liver revealed “ghost” cells. Another question arose whether she was a candidate for a live transplant? Oregon and Seattle had yet to do a successful adult liver transplant by 1983.

We called Tom Starzl, the pioneer of liver transplant in the USA, and asked his opinion. He said, “Wait it out and she will recover.” And we did and she made a full recovery, got married, and had two kids. This patient displayed the amazing ability of the liver to regenerate, something that few organs can do.

Medical Clarifications:
1. The liver gets 25% of the cardiac output for a patient at rest.
2. The spleen is the organ that makes the most antibodies.

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