Liver Trauma Management (WSES/AAST 2020)

Algorithm Steps

1. ▶

   Start

   Liver Trauma

   Blunt or penetrating injury

   1. ●

      Action

      Primary Survey (ATLS)

      Immediate assessment

      • Airway, Breathing, Circulation
      • Assess hemodynamic status
      • FAST exam if available
      • Identify life-threatening injuries
      • IV access, type and crossmatch
      1. ◆

         Decision

         Hemodynamic Status?

         Key decision point

         • STABLE: SBP >90, HR <100, responds to fluids
         • UNSTABLE: Persistent hypotension despite resuscitation
         1. ⚠

            Warning

            Hemodynamically Unstable

            Immediate intervention required

            • Massive transfusion protocol
            • FAST positive → OR
            • FAST negative → Consider other sources
            • No time for CT
            1. ●

               Action

               Emergency Laparotomy

               Damage control surgery

               • DAMAGE CONTROL PRINCIPLES:
               • - Packing (most effective)
               • - Direct pressure
               • - Pringle maneuver (hepatic pedicle clamp)
               • - Hepatorrhaphy for lacerations
               • - Resection only if required
               • - Temporary abdominal closure
               • Return to OR in 24-48h when stable
               1. ●

                  Action

                  Delayed Complications

                  Monitor and manage

                  • BILOMA: Percutaneous drainage + ERCP
                  • HEMOBILIA: Angioembolization
                  • HEPATIC NECROSIS: Debridement if infected
                  • ABSCESS: Percutaneous drainage
                  • ACS (Abdominal Compartment): Decompression
                  1. ✓

                     Outcome

                     Outcomes

                     Prognosis

                     • NOM success: >90%
                     • Grade I-III: Excellent prognosis
                     • Grade IV-V: Higher morbidity
                     • Grade VI: Often fatal
                     • Overall mortality depends on associated injuries
         2. ●

            Action

            Hemodynamically Stable

            CT scan for grading

            • CT abdomen/pelvis WITH IV contrast
            • Arterial and portal venous phases
            • Grade injury by AAST scale
            • Look for: Active extravasation, pseudoaneurysm
            1. ●

               Action

               AAST Liver Injury Scale

               CT-based grading

               • GRADE I: Subcapsular hematoma <10%, laceration <1cm
               • GRADE II: Hematoma 10-50%, laceration 1-3cm
               • GRADE III: Hematoma >50% or ruptured, laceration >3cm
               • GRADE IV: Parenchymal disruption 25-75% of lobe
               • GRADE V: Parenchymal disruption >75%, juxtahepatic venous injury
               • GRADE VI: Hepatic avulsion (often non-survivable)
               1. ◆

                  Decision

                  Active Extravasation on CT?

                  Blush or pseudoaneurysm

                  1. ●

                     Action

                     Angioembolization

                     For active arterial bleeding

                     • Hepatic angiography
                     • Selective embolization of bleeding vessel
                     • Can repeat if needed
                     • Adjunct to NOM
                     • Success rate: 80-90%
                     • Monitor for hepatic necrosis
                     1. ●

                        Action

                        Non-Operative Management (NOM)

                        For stable patients without extravasation

                        • CRITERIA FOR NOM:
                        • - Hemodynamically stable
                        • - No peritonitis
                        • - No other indications for laparotomy
                        • MONITORING:
                        • - ICU for Grade III-V
                        • - Serial H&H q6h x 24h
                        • - Bed rest initially
                        • - Repeat imaging for worsening
                        • SUCCESS RATE: >90%
                        1. ◆

                           Decision

                           NOM Failure Signs?

                           Indication for intervention

                           • Hemodynamic instability
                           • Falling H&H despite transfusion
                           • Peritonitis
                           • Increasing abdominal pain
                           1. ●

                              Action

                              Discharge Planning

                              Activity restrictions

                              • Grade I-II: 2 weeks rest
                              • Grade III: 4-6 weeks rest
                              • Grade IV-V: 3 months rest
                              • No contact sports until healed
                              • Follow-up imaging controversial
                              • Return if: Fever, increasing pain, hemodynamic symptoms