Blunt Hepatic Injury
CT-confirmed liver injury
All Pathways
Trauma SurgeryManagement
Blunt Hepatic Injury Management
Blunt Hepatic Injury Management: Blunt Hepatic Injury → AAST Injury Grade → Hemodynamic Status? → Unstable → Laparotomy → Perihepatic Packing.
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action AAST Injury Grade
Grade on CT findings
- Grade I: Subcapsular hematoma <10%, laceration <1cm deep
- Grade II: Subcapsular 10-50%, laceration 1-3cm deep
- Grade III: Subcapsular >50%, laceration >3cm deep
- Grade IV: Parenchymal disruption 25-75% of lobe, active bleeding
- Grade V: Parenchymal disruption >75%, juxtahepatic venous injury
- Grade VI: Hepatic avulsion (usually fatal)
03Decision Hemodynamic Status?
Response to resuscitation
04Warning Unstable → Laparotomy
Operative management
- Damage control surgery
- Perihepatic packing
- Pringle maneuver (clamp hepatoduodenal ligament)
- Avoid complex liver resections initially
- Pack and return in 24-48h
05Action Perihepatic Packing
Damage control technique
- Mobilize liver by dividing ligaments
- Pack between liver and diaphragm
- Pack between liver and RUQ
- Avoid packing INTO laceration
- Temporary abdominal closure
- Return to OR in 24-48h for pack removal
06Outcome Hepatic Injury Managed
Recovery and follow-up
07Decision Stable: NOM Candidate?
Assess for non-operative management
- NOM Criteria:
- • Hemodynamically stable
- • No peritonitis
- • No hollow viscus injury
- • Blood products available
- • ICU monitoring capability
08Decision Contrast Blush on CT?
Active extravasation
09Action Angioembolization
For active arterial bleeding
- Contrast blush on CT
- Pseudoaneurysm
- Selective embolization preferred
- May need repeat angiography
- Monitor for hepatic necrosis
10Decision NOM Successful?
Monitor for failure or complications
- Failure: ongoing transfusion, hemodynamic instability
- Complications to monitor:
- • Biloma / bile leak
- • Hepatic abscess
- • Delayed hemorrhage
11Action Bile Leak / Biloma
Delayed complication
- Suspect if RUQ pain, fever, elevated bilirubin
- CT with contrast
- ERCP + stent for ductal injury
- Percutaneous drainage for biloma
- Rarely requires operative intervention
- Path rejoins step 06Shared downstream outcome
12Action Discharge Planning
NOM success
- Activity restrictions (grade-dependent):
- Low grade: 3-4 weeks
- High grade: 6-8 weeks
- Avoid contact sports
- Return precautions for RUQ pain, fever
- Follow-up imaging if high-grade
- Path rejoins step 06Shared downstream outcome
- Path rejoins step 04Shared downstream outcome
13Action Observation
ICU monitoring
- Serial abdominal exams
- Serial hematocrits q4-6h
- Bed rest, NPO initially
- Low-dose DVT prophylaxis when stable
- Repeat imaging if deteriorates
- Path rejoins step 10Shared downstream outcome
Guideline Source
WTA Critical Decisions: Adult Blunt Hepatic Injury
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- High-grade injuries challenging for NOM
- Bile leak may present delayed
- Requires ICU monitoring capability
- IR availability for angioembolization
Applicable Regions
USEUGlobal
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Blunt Hepatic Injury Management?
The Blunt Hepatic Injury Management is a management clinical algorithm for Trauma Surgery. It provides a structured decision tree to guide clinical decision-making, based on WTA Critical Decisions: Adult Blunt Hepatic Injury.
What guideline is the Blunt Hepatic Injury Management based on?
This algorithm is based on WTA Critical Decisions: Adult Blunt Hepatic Injury (DOI: WTA Algorithm).
What are the limitations of the Blunt Hepatic Injury Management?
Known limitations include: High-grade injuries challenging for NOM; Bile leak may present delayed; Requires ICU monitoring capability; IR availability for angioembolization. Individual patient factors may require deviation from these recommendations.
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