Liver trauma
Blunt or penetrating liver injury, adult or child. Traumatic cardiac arrest: use the traumatic arrest pathway.
All Pathways
Hepatobiliary SurgeryEmergency
Liver Trauma Management (WSES 2020, AAST 2018)
Liver Trauma Management (WSES 2020, AAST 2018): Liver trauma → Primary survey and resuscitation (<C>ABCDE) → Check now: anticoagulant, brain injury, chi...
Pathway Overview
19 steps
Algorithm Steps
19 total
01Start 02Action Primary survey and resuscitation (<C>ABCDE)
Trauma team leads. Call the surgeon early.
- Control external haemorrhage first, then ABCDE
- 2 large-bore IV or IO lines; crossmatch, FBC, coagulation, blood gas with lactate and base excess
- E-FAST: abdominal free fluid, pneumothorax, pericardial fluid
- Keep warm; limit crystalloid; give blood early if shocked
- Pregnant: call obstetrics; over 20 weeks displace the uterus to the left; Rh D negative over 12 weeks: Rh D immunoglobulin, dose by FMH test
- Penetrating wound: IV antibiotic prophylaxis and tetanus cover per local protocol
- No surgeon, IR or ICU on site: call the retrieval service now for transfer to a major trauma centre
03Warning Check now: anticoagulant, brain injury, child
These change the next steps. Do not delay resuscitation.
- Anticoagulant and bleeding: reverse now (warfarin: 4F-PCC + IV vitamin K; dabigatran: idarucizumab; Xa inhibitor: PCC, or andexanet alfa where available)
- Brain or spinal cord injury: no permissive hypotension; keep MAP at least 80 mmHg if GCS 8 or less
- Child under 16: call the paediatric trauma team; hypotension is SBP below 70 + (2 x age in years) mmHg at 1-10 years, below 90 mmHg over 10 years
04Decision Unstable or transient responder? (WSES)
Yes: damage control and theatre. No: CT. Unstable if any line below. Beta-blockers and old age can hide tachycardia: use base excess and transfusion need.
- SBP below 90 mmHg with shock signs (cool, clammy, slow capillary refill, confused, breathless)
- SBP 90 mmHg or more but needs fluid boluses, transfusion or vasopressors
- Admission base excess below -5 mmol/L
- More than 4 units of red cells in the first 8 h
- Transient responder (improves, then deteriorates): treat as unstable. CT or angioembolisation only if theatre, IR and ICU are ready now
- If Yes
- Unstable
05Warning Unstable: damage control resuscitation
No CT. Go to theatre or hybrid suite now.
- Activate the massive transfusion protocol: red cells, plasma and platelets in a balanced ratio; check ionised calcium and correct it
- Tranexamic acid, only within 3 h of injury: adult and child 12 years or over 1 g IV over 10 min, then 1 g IV over 8 h; child under 12: 15 mg/kg (max 1 g) IV over 10 min, then 2 mg/kg/h for 8 h
- Target SBP 80-90 mmHg until bleeding is controlled (not with brain or spinal cord injury); prevent hypothermia
06Decision Unstable: E-FAST shows abdominal free fluid?
Yes: laparotomy now. No: look for another bleeding source.
- If Yes
- E-FAST positive
07Action Laparotomy: control bleeding and bile leak
For unstable patients, peritonitis, other surgical injury or failed NOM. Use damage control if physiology is poor.
- Major bleeding: manual compression and perihepatic packing
- Pringle manoeuvre for inflow control
- Arterial bleeding after packing, or AAST IV-V: early angiography and embolisation
- Bleeding from behind the liver (retrohepatic IVC or hepatic veins): pack; direct repair only by experienced surgeons
- Minor bleeding: diathermy, haemostatic agents, suture or omental patch
- No major liver resection at the first operation
- Portal vein: repair; avoid main branch ligation
- Right or common hepatic artery ligated: remove the gallbladder
- REBOA only as a bridge in centres with expertise
- Temporary abdominal closure if a second look is needed or compartment syndrome risk is high; then ICU
08Action Complications after NOM or surgery
Repeat CT for pain, fever, jaundice, falling Hb or rising inflammatory markers.
- Hepatic artery pseudoaneurysm, even without symptoms: angioembolisation
- Haemobilia (melaena or haematemesis after liver injury): angioembolisation
- Biloma: most resolve; drain if enlarging, symptomatic or infected; add ERCP and stent if needed
- Bile peritonitis: laparoscopic lavage and drainage plus ERCP stent, or laparotomy
- Liver abscess: percutaneous drainage
- Infected or devitalised liver: surgical debridement
- Abdominal compartment syndrome: decompression
09Action Discharge and return to activity
Discharge on clinical status, not on injury grade.
- Ready: normal vital signs, eating, pain controlled, Hb stable
- No routine follow-up imaging; image only for symptoms
- Adult AAST III-V: normal physical activity usually after 3-4 months
- Child: restrict activity for (injury grade + 2) weeks
- On anticoagulant: restart as soon as bleeding risk allows; agree timing with the surgeon
- Do not stay alone for long periods in the first weeks
- Return now if: more pain, lightheaded, nausea, vomiting, fever, jaundice, or blood in vomit or stool
10End End of pathway
Follow up with the treating surgical team.
If No- E-FAST negative
11Action Unstable, E-FAST negative: find the bleeding source
Look at chest, pelvis, long bones, external loss and retroperitoneum.
- Chest X-ray and lung E-FAST; pelvic X-ray and pelvic binder
- Repeat E-FAST: it can miss clotted blood
- Abdomen still suspected: go to the laparotomy step
- Other source: treat it with the matching trauma pathway
- Path rejoins step 10Shared downstream outcome
If No- Stable
12Action Stable: CT abdomen and pelvis with IV contrast
Needed before any non-operative management (NOM).
- Arterial and portal venous phases; delayed phase if bleeding is suspected
- Look for active extravasation, pseudoaneurysm and signs of bowel injury
- Contrast allergy or kidney impairment: do not delay CT in major trauma
- Child: E-FAST often misses injury; use CT when injury is suspected
13Action Grade the injury (AAST 2018, WSES class)
Use the highest grade; advance one grade for multiple injuries, up to grade III. WSES I = AAST I-II, II = AAST III, III = AAST IV-V (all stable); WSES IV = any grade, unstable.
- Grade I: subcapsular haematoma <10% of surface; laceration <1 cm deep
- Grade II: subcapsular haematoma 10-50%; intraparenchymal haematoma <10 cm; laceration 1-3 cm deep and up to 10 cm long
- Grade III: subcapsular haematoma >50% or ruptured; intraparenchymal haematoma >10 cm; laceration >3 cm deep; vascular injury or active bleeding contained in the liver
- Grade IV: disruption of 25-75% of a lobe; active bleeding into the peritoneum
- Grade V: disruption of >75% of a lobe; juxtahepatic venous injury (retrohepatic IVC, central hepatic veins)
14Decision Stable: peritonitis or other reason for laparotomy?
Yes: go to the laparotomy step. No: check CT for arterial blush. Includes CT signs of bowel injury and high-energy gunshot wounds.
- Peritonitis
- CT: free air, free fluid without solid-organ injury, bowel wall thickening, missile track near bowel with haematoma
- High-energy gunshot wound: laparotomy in most patients
- Stab wound, stable, no peritonitis: NOM possible in a capable centre with serial examination
- If Yes
- Laparotomy needed
- Path rejoins step 07Shared downstream outcome
If No- No indication
15Decision Stable: arterial blush or pseudoaneurysm on CT?
Yes: angioembolisation, then NOM. No: go to the NOM step. Children: blush alone is not an indication.
- If Yes
- Blush
16Action Stable with blush: angiography and embolisation
Adults: first-line. Child: only with signs of ongoing bleeding, in a paediatric centre.
- Selective embolisation of the bleeding artery
- Can be repeated if needed
- Continue NOM afterwards
- Deteriorates during or after: laparotomy
- Watch for liver necrosis, abscess and bile leak
17Action Stable, no surgical indication: non-operative management
Standard for stable AAST I-V (WSES I-III). Needs theatre, IR, blood and ICU available 24 h; otherwise transfer.
- ICU or HDU for AAST III-V; ward for AAST I-II
- Serial examination and haemoglobin every 6 h for at least 24 h
- Head or spinal injury: NOM only if examination is reliable and neuro BP targets are met
- Mechanical VTE prophylaxis now; start LMWH as soon as bleeding risk allows (delay over 72 h raises VTE risk)
- Early mobilisation; strict bed rest is not needed
- Enteral feeding early; oral intake after 24-48 h if possible
- Repeat CT only for clinical change
- Child: ICU only if vital signs stay abnormal after resuscitation; transfuse if Hb below 70 g/L or ongoing bleeding
18Decision Signs of NOM failure or complication?
Yes: escalate (next step). No: go to the discharge step. Check at every review.
- Haemodynamic instability
- Falling haemoglobin or ongoing transfusion need
- Peritonitis
- More pain, fever, jaundice, melaena or haematemesis
- If Yes
- Failure
19Action NOM failure: act on haemodynamics
Unstable or peritonitis: laparotomy now (go to the laparotomy step). Stable: repeat CT.
- Stable rebleed or pseudoaneurysm: angioembolisation
- Then manage complications (next step)
- Path rejoins step 08Shared downstream outcome
If No- Stable course
- Path rejoins step 09Shared downstream outcome
If No- No blush
- Path rejoins step 17Shared downstream outcome
Guideline Source
Coccolini F et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020;15:24
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- NOM and angioembolisation are safe only where theatre, IR, blood and ICU are available 24 h; otherwise transfer early.
- Children differ: SBP limit, angioembolisation, transfusion threshold and activity advice; involve a paediatric trauma team.
- CT can underestimate injury; delayed bleeding, pseudoaneurysm, bile leak and abscess occur, mostly after AAST IV-V.
- Associated injuries (brain, chest, pelvis, bowel) often decide management.
Contraindicated Populations
Traumatic cardiac arrest: use the traumatic cardiac arrest pathwaySpontaneous (non-traumatic) liver haemorrhage, for example HELLP syndrome or tumour rupture
Applicable Regions
AUUSEUGlobal
AU: Call the state retrieval service early when theatre, IR or ICU are not on site. Use the local massive transfusion protocol. Australia has moved from Prothrombinex-VF (3-factor) to 4F-PCC (Beriplex) for warfarin reversal; andexanet alfa is not on the ARTG, so use PCC for Xa inhibitors. Follow local reversal guidance.
Global: WSES 2020 liver trauma guideline with the AAST 2018 liver injury scale; resuscitation per the European trauma bleeding guideline 2023.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Liver Trauma Management (WSES 2020, AAST 2018)?
The Liver Trauma Management (WSES 2020, AAST 2018) is a emergency clinical algorithm for Hepatobiliary Surgery. It provides a structured decision tree to guide clinical decision-making, based on Coccolini F et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020;15:24.
What guideline is the Liver Trauma Management (WSES 2020, AAST 2018) based on?
This algorithm is based on Coccolini F et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020;15:24 (DOI: 10.1186/s13017-020-00302-7).
What are the limitations of the Liver Trauma Management (WSES 2020, AAST 2018)?
Known limitations include: NOM and angioembolisation are safe only where theatre, IR, blood and ICU are available 24 h; otherwise transfer early.; Children differ: SBP limit, angioembolisation, transfusion threshold and activity advice; involve a paediatric trauma team.; CT can underestimate injury; delayed bleeding, pseudoaneurysm, bile leak and abscess occur, mostly after AAST IV-V.; Associated injuries (brain, chest, pelvis, bowel) often decide management.. Individual patient factors may require deviation from these recommendations.
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