Operating Room There are few bacteria in the air of an empty theatre but every individual liberates about 10 order trazodone discount medicine assistance programs,000 organisms per minute into the air purchase trazodone 100mg with amex medications via ng tube. Therefore trusted 100 mg trazodone medications during pregnancy, to decrease airborne infections, keep the number of personnel reduced to a minimum. If there is no system to provide this, windows should be open to allow ingress of fresh outside air and escape of anesthetic gases. At regular intervals, conduct a more thorough cleaning by mopping the floor and washing the walls with detergents. Instruments All instruments and garments to be used in surgical procedures must be sterile and this is attained by sterilization. Sterilization: - is a process by which inanimate objects are made free of all microorganisms. It uses steam at a pressure of 750 0 mmHg above atmospheric pressure and temperature of 120 C for 15-30 minutes. Appropriate indicators must be used each time to show that the sterilization is accomplished. Noxythiolin:- Releases formaldehyde in contact with tissues, broad spectrum, expensive, weak and slowly bactericidal Alcohol plus chlorhexidne Alcohol plus povidon iodine useful mixtures Chlorhexidine plus cetrimide 40 Review Questions 1. Using your knowledge of the properties of the different antiseptics which one would you choose for your heath center? What is the most important measure you would take for a patient who comes to the emergency room with a contaminated wound? Types of Suture Materials Suture materials can generally be classified as absorbable and non absorbable. Catgut (natural or biologic type) Vicryl (Synthetic) Non absorbable: This is a type of suture material that remains unabsorbed by the tissue. Small bites of the subcuticular tissues on alternate sides of the wound are taken and then pulled carefully together. Introduction Successful wound management with rapid and complete healing and minimal complication depends on understanding the basic principles of assessment, bacteriology and application of the general principles of wound care. The primary goal of wound management is to aid the natural body process to produce optimal functional and cosmetic result. This requires an understanding of the basic principles of wound care and the process of healing. Failure to do this may result in delay of healing and unwanted secondary complications which may be distressing to the physician, patient and family and may lead to greater economic loss. It is caused by a transfer of any form of energy into the body which can be either to an externally visible structure like the skin or deeper structures like muscles, tendons or internal organs. There are integrated sequences of events leading to cellular proliferation and remodeling. It is characterized by vaso-constriction, clot formation and release of platelets and other substances necessary for healing and help as a bridge between the two edges. It is characterized by classical inflammatory response, vasodilatation and pouring out of fluids, migration of inflammatory cells and leukocytes and rapid epithelial growth. It is characterized by fibroblast, epithelial and endothelial proliferation, Collagen synthesis, and ground substance and blood vessel production. Equilibrium between protein synthesis and degradation occurs during this phase with cross linking of collagen bundles leading to slow and continuous increase in tissue strength of the wound to return to normal. Clinical types of healing Traditionally, wound healing can be classified into three clinical types: Healing by first, second and third intention. Healing by first intention: This is a type of healing of clean wound closed primarily to approximate the ends. Healing by Second intention: This occurs in wide, contaminated wounds, which are not primarily closed. Healing takes place by granulation tissue formation, tissue contraction and epithelialization. Healing by third intention: This occurs in wounds which are left open initially for various reasons and closed later (delayed primary closure) 48 Factors affecting healing Healing of a wound can be affected by various conditions. In the history, one has to answer the following principal questions: How the wound was caused and what caused it? General inspection and specific tests have to be done to assess the following conditions: Extent of skin loss Degree of circulation Damage to nerves, tendons, bone and other structures (deep under) the skin The degree of contamination Presence of foreign body and tissue necrosis 49 Classification of wounds Once wound is carefully assessed, it is necessary to classify into a specific type in order to plan a proper management scheme. Closed wounds: These are wound types, which have an intact epithelial surface, and skin cover not completely breeched. Example: Contusion, Bruise, Hematoma Open wounds: These are wounds caused by injury which leads to a complete breakt of the epithelial protective surface. This method classifies wounds according to the likelihood or rate of wound infection. Clean-contaminated: Minor break in technique, oropharynx entered, gastrointestinal or respiratory tracts entered without significant spillage, genitourinary or biliary tracts entered in absence of infected urine or bile. If other serious conditions exist, which endanger the patients life, the wound should be covered with sterile gauze and priorities attended to. However, the goal in all cases is to establish a good environment to assist wound healing and prevent infection. Proper wound care includes the following measures: Adequate hemostasis locally to stop bleeding. It provides a reliable drainage and opportunity for repeated inspection and debridement as necessary. There is no specific management needed except local compress and analgesics if pain is severe. Management: - It usually gets absorbed spontaneously and should be left - Local compress to alleviate pain - Aseptic evacuation or aspiration only if very large (expanding) or over a cosmetic area or leading to compression of vital structures. Management: - Cleanse using scrubbing brushes - Use antiseptic or lean tap water and soap - Analgesic Punctures These may be compound wounds which involve deeper structures. Management: - Careful inspection - Adequate cleansing - Closure, if feasible, under appropriate anesthesia - Proper wound debridement if needed - Appropriate antibiotic prophylaxis - Tetanus Prophylaxis - Analgesics as needed Crush and avulsion wounds These are compound complicated wounds. They are usually associated with systemic involvement and have more extensive damage than may appear. Management: - Correct associated life threatening conditions - Proper wound debridement - Early skin cover if possible or late graft, wound left open if contaminated - Appropriate antibiotics - Tetanus Prophylaxis - Analgesics as needed Missile injuries These are type of wounds which are compound and complicated. They usually present with severe life threatening conditions and should be carefully managed. Human bites These are relatively rare but more heavily contaminated than those of most animalss due to polymicrobial nature including anaerobic organisms as a normal oral flora. To avoid this complication the animal must be kept for observation for at least 10 days.

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If in doubt buy trazodone 100mg without a prescription medications errors, try antibiotics for a few If there is a firm lump on the gum effective 100 mg trazodone symptoms 5-6 weeks pregnant, it is probably a days purchase trazodone canada symptoms ruptured ovarian cyst, and see if they become smaller. It may be with little further benefit from multi-dose regimes, or more one of a wide range of obscure, rare, fibro-osseous lesions. Pyogenic granulomas are common inside the mouth, and can also occur on the The range of possible oral pathology is large; some of the tongue. If a patient is pregnant, leave the lesion and do more important lesions are tumours. This is commonly associated with repetitive irritating trauma, particularly If there is a irregular ulcer of the gums, cheek or the that from an ill-fitting denture. Send tissue for histology and arrange deep radiotherapy, or radical If there is a papilloma (wart) inside the mouth (31-13E) surgery. If necessary, excise the Bolivia, Brazil and Peru, and is transmitted by the sandfly oral lesion. Itchy papules arise at the mucocutaneous junction of the If there is an expanding tumour of the mandible, lips and nose, and ulcerate. This is a particular form of retention cyst, arising from the inferior aspect of the tongue, and caused by blockage of the submandibular duct. More likely, it is a pleomorphic adenoma (mixed salivary tumour) in an ectopic site. D, Poor speech is almost invariably due to hearing deficiency secondarily infected nasopalatine cyst. These cysts may arise from the mucous glands anywhere inside the mouth, including the tongue, If a patient cannot close the mouth because the facial but are most common inside the lower lips. If there is no If it does not, under ketamine, grasp it with toothed lagophthalmos (lid-lag: 28. Trauma is dealt with in volume 2 is merely stiff, exercising it should not be too difficult. If only the skin, subcutaneous tissues, and muscles are involved in a contracture, you should be able to release them. Structurally, can be due to: contractures are the result of shortening of the soft tissues (a) Mild or dense adhesions. This can happen as the result of: (c) Destructive changes, as the result of past infection. Any muscle which can lift its part of a limb against gravity, must have a power of at least 3. If a joint is to remain useful, it must young children In an older patient tremors, rigidity owing move regularly through its full range. Anything which to Parkinsonism or a patient pretending disability can prevents it from doing this eventually causes a contracture. The soft tissues surrounding a disused joint become shorter, and less elastic, and its muscles waste and will not Try non-operative methods first. The two important principles in prevention are: (4) You can apply serial corrective casts. Manipulation and (1),Most importantly, to keep all joints moving whenever casts can often be usefully combined. The result will severe contractures in both the joint again, and replace the cast with another one, in elbows, which were perfectly normal on admission. Contractures like these happen quite unnoticed, and a joint may bleed, or a contracture split and ultimately when you do notice them, it may be too late. You can also introduce an angle in a cast, by putting in a wedge, and combine it with manipulation by applying a ratchet. Polio contractures are easier to release than the contractures which follow burns, because there is less scar tissue, and no skin loss. In the anatomical position all joints are at 0, so record the movement there is from this position, and state whether they are active or passive. For example, the range of movement for a normal hip could be: flexion 0/120, that is from 0 to 120. You can test all other muscle A patient with a flexion contracture might have: flexion 30/110, groups in the same way. You may not have physiotherapists, but this is something Grade 3 movement is just possible against gravity. A contracture of one joint can (4);Early movements in bone and joint injuries, as with affect movement in another, so take this into account. This will correct any (5) Early drainage of pus, as with septic arthritis of the hip, lumbar lordosis, which may disguise as much as 60 of which readily causes a flexion contracture (7. Extend and abduct the hip, because a (6) Early grafting of wounds and burns over joints. If you are assessing a flexion deformity of the knee, Practice several of these preventive measures at the same do so with the hip in both neutral and the flexed positions. Assess backward, or lateral subluxation of the tibia on the femur as mild, moderate, or severe. In polio, start to assess the power of the muscles (32-1) Assess external rotation of the tibia on the femur with the as soon as tenderness allows, usually about 3wks after the knee extended as much as possible. Assess the degree of recovery regularly, whether an immobile stiff straight knee may be more of a you will then be able to judge how far full recovery is hindrance in a rural setting than a fixed flexed knee. The joints must be stretched in the direction opposite to that in which a contracture might form, Ankle. Fit a calliper (32-13), as soon as the tender this will help in deciding management. In the acute stage, leave this on for in the ankle joint, it will be the same whether the knee is most of the day and the night. Look for: deformity part is more medial than it should be and valgus (32-11A) of the joint surfaces, evidence of active disease, where the distal part is more lateral. The need for treatment usually means that prevention has If there is an equinus deformity, support the ankle, failed. If possible, encourage active movements, or alternatively passive movements (done by someone else). Most useful are assisted active movements: (1);Support the limb while the patient gently moves it himself. Press firmly for at least 5mins in a direction opposite to that of the contracture. Before you begin, remember that a bone which has not been moving is osteoporotic and breaks easily. To prevent this, reduce the leverage that you can exert, by holding the bones close to the contracted joint (32-2). Press the upper of the thigh backwards, to pressure close to a joint, or you may break a bone or displace the bring the leg down on the table in slight abduction. For an equinus deformity of the ankle (E), grasp it near Laying the patient prone is a very useful nursing procedure the ankle, and dorsiflex it.

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High fat diet-induced obesity modies the methylation pattern of leptin promoter in rats purchase generic trazodone from india medications quizlet. Human leptin tissue distribution cheap 100 mg trazodone with mastercard treatment modality definition, but not weight loss-dependent change in expression cheap trazodone 100mg free shipping medicine identification, is associated with methylation of its promoter. Evolution in health and medicine Sackler colloquium: Stochastic epigenetic vari- ation as a driving force of development, evolutionary adaptation, and disease. Paternally induced transgenerational envi- ronmental reprogramming of metabolic gene expression in mammals. Chronic high-fat diet in fathers programs beta-cell dysfunction in female rat offspring. Personalized epigenomic signatures that are stable over time and covary with body mass index. Increased expression of inammation- related genes in cultured preadipocytes/stromal vascular cells from obese compared with non-obese Pima Indians. Potential etiologic and functional implications of genome-wide association loci for human diseases and traits. Epigenetic epidemiology of common complex disease: prospects for prediction, prevention, and treatment. Association of lipidome remodeling in the adipocyte membrane with acquired obesity in humans. Chromatin and heritability: how epigenetic studies can complement genetic approaches. Tet Proteins Can Convert 5-Methylcytosine to 5-Formylcytosine and 5-Carboxylcytosine. Maternal genistein alters coat color and protects Avy mouse offspring from obesity by modifying the fetal epigenome. Obesity in childhood is of particular concern, with recent estimates that as many as 10% of school-aged children are either overweight or obese, although the prevalence is higher in economically developed regions [3]. A recent statement released by the World Watch Institute revealed that for the rst time in human history the number of overweight people rivals the number of underweight [4]. Epigenetics in Human Disease They found that while the worlds underfed population has declined slightly since 1980 to 1. In the developing world, obesity is also increasingly becoming as signicant a problem as underfeeding. The number of overweight people in China has risen from less than 10% to over 15% in a period of 3 years. In Brazil and Colombia the numbers of overweight indi- viduals are comparable to those seen in a number of European countries, at around 40% of adults. Even in sub-Saharan Africa, a region home to the largest proportion of the worlds hungry, an increase in obesity has been observed. The large and increasing numbers of overweight and obese people presents a huge clinical and public health burden. There are also costs to society and the economy more broadly e for example, sickness absence reduces productivity. The number of overweight children is increasing so rapidly that there is an urgent need to identify risk factors for obesity in order to prevent further increases and to identify possible intervention strategies. Apart from the likelihood that these children will remain overweight throughout adolescence and their entire adult life, the consequences of childhood obesity are now beginning to be fully understood. Being overweight has a negative effect on the psycho- logical wellbeing of the child and studies have shown that overweight children have a lower health-related quality of life [7], as well as poorer educational and social outcomes as compared to children of normal weight [8]. Direct health consequences of being an overweight child 298 include an increased risk of type 2 diabetes, which is now being seen in adolescents due to the pediatric obesity epidemic [9]. Studies have also linked being overweight in childhood with increased risk of impaired glucose tolerance and cardiovascular disease in later life [10]. Although it is well established that the risk of an individual developing obesity is dependent upon the interaction between their genotype and lifestyle factors such as an energy-rich diet and sedentary behavior, it is becoming clear that these are not the sole causes of the obesity epidemic. Whilst there is a genetic component related to the ways that genes can favor fat accumulation in a given environment (Table 15. The Dutch Hunger Winter provides an example of how the timing of nutritional constraint during pregnancy is important in determining the future risk of disease. Small babies who were born at term and undergo early catch-up growth, characterized by a greater accumulation of fat mass relative to lean body mass, have a particularly increased risk of becoming obese in later life compared to those born at higher birth weights [14]. Early catch-up growth in infants born preterm and who were fed formula milk is also associated with an increased cardio-metabolic risk in later life [15], including obesity. A number of studies have shown a greater incidence of obesity in adults who were formula-fed as opposed to breast-fed during infancy. Dorner and Plagemann [17] have reported that children of obese women are themselves more likely to become overweight and develop insulin resistance in later life. Gestational weight gain irrespective of prepregnancy weight is positively associated with greater childhood adiposity [18] and even moderate weight gain between successive pregnancies has been shown to result in 302 an increase in large-for-gestational-age births [19]. However, maternal weight loss through bariatric surgery prevents transmission of obesity to children compared with the offspring of mothers who did not undergo the surgery and remained obese [20]. These data suggest that even within a relatively normal dietary range, modest alterations can affect the development of the fetus [21]. However, it is possible that these correlations may not be due to an intrauterine effect but result from shared socioeconomic lifestyle factors between the mother and offspring or the transmission of genetic factors. However, these studies were all relatively small and may have lacked sufcient power. The thrifty phenotype hypothesis proposes that reduced fetal growth is associated with a number of chronic conditions in later life [25]. These conditions include coronary heart disease, stroke, diabetes, and hypertension. This increased susceptibility is proposed to result from adaptations made by the fetus in utero due to its limited supply of nutrients. The hypothesis is that poor nutrient supply in utero results in fetal adaptations such that the infant will be prepared for survival in an environment in which resources are likely to be limited, resulting in a thrifty phenotype. Those with a thrifty phenotype who actually develop in an afuent environment may be more prone to metabolic disorders, such as obesity and type 2 diabetes, whereas those who have received a good nutrient supply in utero will be adapted to good conditions and therefore better able to cope with rich diets. This idea is now widely accepted and is a source of concern for societies such as those in the developing world where rapid socioeconomic improvement is underway resulting in a transition from sparse to adequate or good nutrition [26]. Animal models have been useful in understanding the effects on adult phenotypes resulting from perturbations in the developmental environment. The induction during early life of persistent changes to the phenotype of the offspring by perturbations in maternal diet implies stable alteration of gene transcription which, in turn, results in the altered activities of metabolic pathways and homeostatic control processes. Initially using a candidate gene approach many groups reported long-term changes in the expression of key metabolic genes in response to variations in maternal diet. More recently genome-wide approaches have been used to determine which genes are altered in response to diet. This change in a relatively small subset of genes suggests that these may represent an orchestrated response to the nutritional challenge and be part of an adaptive response [46]. The alterations in offspring metabolism and physiology induced by maternal protein restric- tion are dependent upon the timing of the nutritional challenge. Animal studies have also shown a clear interaction between the pre- and postnatal environ- ments [48,49], with variations in the diet fed after weaning exacerbating the effects of maternal undernutrition on the phenotype of the offspring.

Hence order trazodone with paypal medicine identifier pill identification, first step in redo is confirm diagnosis with 24 hour urinary Ca++ (if normal no disease) purchase trazodone 100mg overnight delivery symptoms 9 days before period. There is significant vertical overlap buy 100 mg trazodone free shipping symptoms for strep throat, such that superior glands can actually be below inferior glands, and vice versa. For most other pancreatic islet tumors, except gastrinomas, surgery is also indicated; however, there is no consensus over tumor criteria for the latter operations. Parathyroidectomy should be the same as in other disorders with multiple parathyroid tumors. Accuracy increased by Amended ratio = insulin (uU/ml)/ [glucose (mg/dl) 30] > 0. Low dose dexamethasone suppression will suppress causes of hypercortisolism such as obesity and excess ethanol ingestion, but not others (confirms dx) 3. High dose dexamethasone suppression will suppress pituitary adenoma, but not ectopic sources (locates cause) 4. Ann Surg 1994, 219:416] Under normal conditions, body produces 30 mg hydrocortisone equivalent (solucortef)/day Under extreme stress up to 300 mg/day Prednisone is 4:1 (to solucortef) SoluMedrol is 5:1 Decadron is 25:1 Normal adrenal secretion is 25 30 mg cortisol/24h Appropriate stress test: 250 mcg cosyntropin 1. Aortic arch and thoracic portions of its Thymoma Superior) branches (brachiocephalic, left common Germ cell tumor carotid, left subclavian) Lymphoma 2. Vagus nerves, left recurrent laryngeal Parathyroid adenoma nerve, phrenic nerves Lipoma 4. Reduced antegrade intrauterine blood flow, which causes underdevelopment of the aortic arch 2. Extension of the ductal tissue into the thoracic aorta which, when it constricts, causes coarctation of the aorta The most common clinical manifestation is a difference in systolic pressure between the upper and lower extremities (diastolic pressures are usually similar), manifested by: 1. If patient is hemodynamically unstable as a result of dysrhythmia proceed directly to cardioversion (300 J) 2. If patient has a wide complex tachycardia proceed directly to cardioversion (300 J) 3. Rate control was not inferior to rhythm control for the prevention of death and morbidity from cardiovascular causes and may be appropriate therapy in patients with recurrence of persistent Afib after electrical cardioversion. Management of Afib with rhythmcontrol offers no survival advantage over the ratecontrol strategy. Hence, both rate and rhythm controlled patients need anticoagulation as their stroke rate is 1% per year. Asymptomatic: bruits (+ bruit 30 50% have significant stenosis; + significant stenosis 20 50% bruit; Bruit are actually a significant predictor of cardiac disease) 2. The incidence of stroke was decreased in all subgroups but was largest in patients who experienced major ipsilateral stroke with an 81% risk reduction. Overall, 26% of patients with highgrade (70 99%) stenosis sustained a stroke within 18 months with medical management vs. Early mortality was greater in the surgery group, but total mortality was greater in the surveillance group at 8 years. Although advances in graft design have greatly expanded the population of patients who would be considered candidates for endograft placement, there are certain anatomic limitations that place the patient at high risk for a type I endoleak (a lack of, or suboptimal fixation in, the proximal or distal attachment site). Critical information that the vascular surgeon/interventionalist needs to know prior to embarking on an endograft placement procedure includes: 1. Is there a sufficient length of neck ( 15 mm) of normal aorta above the aneurysm? Endotension (controversial): said to occur when there is intrasac pressure without evidence of endoleak. Ankle systolic pressure < 50 mmHg (with or without tissue loss/gangrene) Exercise Test positive if > 20% fall in ankle systolic pressure requiring > 3 min to recover Arterial Flow is triphasic: 1. Pain is most common over metatarsal heads, not toes (usually occur at pressure points). Leukocytes are thought to play an important role in the pathophysiology because they have been found to be sequestered in the ankle region of patients with elevated venous pressures, especially in the dependent position. Can dilate and stent (especially if older and/or malnourished) Hopkins General Surgery Manual 53 Urology 1. Seen with sudden deceleration with laponly seatbelts; usually L1 or L2; > 50% chance of underlying hollow viscous injury (small bowel is most common) [www. Underlying pathology/etiology Cervical: neck pain (especially with flexion), crepitus, right pleural effusion Spontaneous: usually distal left Hopkins General Surgery Manual 60 Nonoperative Criteria (i. H2O Following bowel resection Ca++/Mg++ soap form cations to complex with oxalate in colon oxalate absorption (worsened by Vit C consumption). Venous blood from extensive retroperitoneal mets drains into paravertebral veins 3. Intussusception (in adults): up to 90% result from underlying pathology (most often a tumor; about half are benign). Ileum (excluding Meckels) *If arises in periampullary region must protect during surgery For Meckels resect asymptomatic patient if: 1. In adults fecalith; in children lymphoid hyperplasia Continued secretion of mucus leads to pressure (up to 126 cmH2O within 14 hours) gangrene & perforation The area of the appendix with the poorest blood supply is midportion of antimesenteric side, hence location of most frequent gangrene and perforation Presentation of Appendicitis: Classically, abdominal pain begins in periumbilical region (somatic pain from appendiceal distention) then localizes to site of appendix (e. Transsphincteric* Unacceptable rates of perineal fistula, not preferred *Transsphincteric leads to unacceptably high rates of fecal incontinence, not preferred Transanal excision is reserved for tumors less than 8 cm anterior and 10 cm posterior from the anal verge, not involving sphincters (also less than 4 cm in diameter and occupying less than 40% of rectal circumference) Preoperative staging is important: patients with evidence of transmural (e. Anatomy: Full thickness defect of abdominal wall to the right of the umbilical cord; umbilical cord has a normal insertion Herniation of bowel loops (uncommonly liver): organs are not covered by a membrane Meconium stained amniotic fluid common, and may be secondary to intestinal irritation Associated anomalies (5 10%): Not associated with chromosomal abnormalities. Ileal/jejunal atresia is most common associated defect; cardiac anomalies are rare Outcomes: Mortality ranges from 7 25%; if liver herniates mortality increases to 50%: Management: Vaginal delivery at term, at tertiary care facility. Primary closure is obtainable in 90% of cases; silo placement and staged reduction necessary in the remaining 10% Omphalocele Incidence: 1:5000 to 1:6000 (and decreasing) Embryology: Improper migration and fusion of lateral embryonic folds. Failure of lateral folds to fuse results in isolated omphalocele; failure of cephalic folds results in defects seen in Pentalogy of Cantrell. Anatomy: Herniation of the intraabdominal contents into the base of the umbilical cord. Associated Anomalies (40 60%): Can be seen with chromosomal abnormalities (including trisomy 18, trisomy 13). Also seen as part of Pentalogy of Cantrell and BeckwithWeidemann syndrome (see below). Ectopic cordis Outcome: overall mortality 40 80% (varies depending on presence of associated anomalies; cardiac abnormalities determine mortality to a large extent) Management: Cardiac echo and karyotype indicated, as well as search for other anomalies. C/S delivery controversial: important to diagnose potential anomalies that are incompatible with life. C/S for large lesions or lesions containing large portions of the liver seems prudent. Omphalocele Gastroschisis midline defect defect to right of umbilical cord has a peritoneal sac no sac covered abdominal contents within few associated abnormalities umbilical cord 10% associated atresias 60% cardiac abnormalities immediate intervention required pulmonary hypoplasia (closure can be delayed, but repair can be delayed intervention must be immediate; Silo vs. Types: Macrocystic: > 5 mm cyst Microcystic: < 5 mm cyst or solid; poorer prognosis, more likely to be complicated by hydrops. Result of hepatic disease no splenectomy of total body platelets are stored in spleen Delayed Splenic Rupture: A subcapsular hematoma may rupture at a later time after blunt trauma up to 2 weeks later. Left hepatic artery arises in part or completely from left gastric artery (23%) 2. Both right and left hepatic ducts (if not be concerned about duct transaction) 2.