What is the management for Non-Operative Management (NOM) of a class III traumatic injury?

Non-Operative Management of Class III Traumatic Injury

Non-operative management (NOM) of class III traumatic injuries should only be considered in hemodynamically stable or stabilized patients, in centers with around-the-clock intensive monitoring capabilities, immediately available endoscopy and interventional radiology suite, operating room, and only in the absence of other abdominal injuries requiring surgery. 1

Hemodynamic Status Assessment

• Hemodynamic stability is the key determining factor for NOM eligibility in traumatic injuries 1
• Hemodynamically unstable (WSES class IV) patients should never be considered for NOM 1
• Patients with peritonitis, bowel evisceration, or impalement should undergo immediate operative intervention 1

NOM Protocol for Class III Injuries

Initial Management

• Serial abdominal examinations must be performed to detect changes in clinical status 1
• Bowel rest and nasogastric tube decompression should be initiated 1
• Parenteral nutrition may be required if obstruction persists beyond 7 days 1
• CT scan with intravenous contrast should always be performed in patients being considered for NOM 1

Monitoring Requirements

• Intensive care unit admission is required for class III injuries 1
• Continuous clinical monitoring and serial hemoglobin testing must be available 1
• Around-the-clock availability of trained surgeons, CT scanning, angiography, operating room, and blood products is essential 1

Specific Management by Injury Type

Duodenal Injuries

• Duodenal hematomas should be considered for operative management if obstruction has not resolved within 14 days 1
• Percutaneous drainage of duodenal hematomas is a viable alternative to surgery 1
• NOM of duodenal hematomas is generally successful in both adults and children with failure rates between 5-10.3% 1

Pancreatic Injuries

• Location of the injury largely determines optimal treatment for class III pancreatic injuries 1
• Injuries distal to the superior mesenteric vein should be managed operatively as this is associated with improved recovery times and reduced morbidity 1
• Isolated proximal class III injuries may be considered for NOM 1
• NOM success rate in adults with class III pancreatic injuries is approximately 30% 1
• Endoscopic and percutaneous interventions such as ERCP with pancreatic stent and/or sphincterotomy or percutaneous aspiration and drain placement have success rates of 68-94% 1

Extrahepatic Biliary Tree Injuries

• Fluid collections should be drained percutaneously 1
• ERCP with stent placement should be attempted to address ductal lacerations 1
• Limited data exists on NOM of extrahepatic biliary tree injuries, but small case series have demonstrated success in both adult and pediatric patients 1

Liver Injuries

• NOM should be attempted in class III liver injuries in hemodynamically stable patients 1
• Angiography/angioembolization may be considered as a first-line intervention in hemodynamically stable patients with arterial blush on CT scan 1
• Intrahepatic abscesses should be treated with percutaneous drainage 2
• Delayed hemorrhage without severe hemodynamic compromise may be managed with angiography/angioembolization 2

Complications Management

• Pancreatic fistulae and pseudocysts can be addressed with image-guided percutaneous drain placement, endoscopic stenting, internal drainage, and endoscopic cyst-gastrostomy or cyst-jejunostomy 1
• Pseudocyst rate is higher among NOM patients, with 65-74% of cases also managed non-operatively 1
• Patients with progressive symptoms or worsening findings on repeat imaging should be considered failures of NOM 1
• For post-traumatic biliary complications not suitable for percutaneous management alone, a combination of percutaneous drainage and endoscopic techniques may be considered 2

Special Considerations

• NOM should be attempted in patients with concomitant head trauma and/or spinal cord injuries with reliable clinical exam, unless the patient cannot achieve specific hemodynamic goals for the neurotrauma 1
• In low-resource settings, NOM could be considered in patients with hemodynamic stability without evidence of associated injuries, with negative serial physical examinations and negative imaging and blood tests 1
• In selected cases where an intra-abdominal injury is suspected in the days after the initial trauma, interval laparoscopic exploration may be considered as an extension of NOM 1

Pitfalls and Caveats

• NOM failure rates are higher in adults compared to pediatric patients 1
• Concerns exist regarding increased rates of pancreatic duct stricture with endoscopic interventions 1
• The presence of other abdominal organ injuries requiring surgery is a contraindication to NOM 1
• Attempting NOM in class III injuries requires the ability to diagnose all associated injuries and provide intensive management 1