What is the initial management for a patient with a Grade 2 liver injury?

Management of Grade 2 Liver Injury

Non-operative management (NOM) is the treatment of choice for Grade 2 liver injuries in hemodynamically stable patients, with CT scan confirmation, serial clinical monitoring, and readiness for intervention if needed. 1

Initial Assessment and Diagnostic Approach

• Obtain CT scan with intravenous contrast in all hemodynamically stable patients being considered for NOM—this is the gold standard for defining anatomic injury and identifying associated injuries 1, 2
• E-FAST is useful for rapid detection of intra-abdominal free fluid during initial evaluation 1, 2
• Hemodynamic status determines the entire management pathway 2

Classification Context

Grade 2 liver injury corresponds to:

• WSES Grade II: AAST Grade III injury in a hemodynamically stable patient 1
• This is classified as a moderate hepatic injury 1

Non-Operative Management Protocol

For hemodynamically stable patients (the vast majority of Grade 2 injuries):

• NOM should be the primary treatment approach regardless of injury grade, provided no other internal injuries require surgery 1
• ICU admission may be required for moderate injuries to ensure continuous monitoring 1
• Serial clinical evaluations (physical exams and laboratory testing) must be performed to detect any change in clinical status 1
• Serial hemoglobin measurements are cornerstone monitoring tools 3

Angiography Considerations

• Angiography with embolization (AG/AE) may be considered as first-line intervention if arterial blush is present on CT scan, even in hemodynamically stable patients 1
• This can prevent progression to hemodynamic instability 2

Resource Requirements for NOM

Critical caveat: NOM of moderate injuries should only be attempted when the following are immediately available 1:

• Trained surgeons and operating room
• Continuous monitoring in ICU or ER setting
• Access to angiography and angioembolization
• Blood and blood products
• System for rapid transfer to higher level of care if needed

Operative Management Indications

Proceed directly to surgery if 1:

• Hemodynamic instability develops (BP <90 mmHg, HR >120 bpm, altered consciousness)
• Peritonitis is present
• Other internal injuries require surgical intervention
• NOM fails (clinical deterioration, ongoing bleeding)

Supportive Care During NOM

• Mechanical thromboprophylaxis should be started in all patients without absolute contraindications 1
• LMWH-based prophylaxis should be initiated as soon as possible and is safe in selected patients with liver injury treated with NOM 1
• Early mobilization should be achieved once the patient is stable 1
• Enteral feeding should be started as soon as possible in the absence of contraindications 1

Special Considerations

Concomitant Head or Spinal Cord Injury

• NOM can still be attempted if clinical exam remains reliable, unless hemodynamic instability prevents achieving specific neurotrauma goals (SBP >110 mmHg or CPP 60-70 mmHg) 1, 2

Liver Hematomas

• Avoid external abdominal compression that could increase intra-abdominal pressure or mask clinical deterioration 3
• Serial clinical evaluation remains essential to detect delayed rupture 3

Common Pitfalls to Avoid

• Do not attempt NOM in resource-limited settings without immediate access to OR, angiography, and ICU monitoring—this significantly increases failure rates 1
• Do not ignore arterial blush on CT scan—this warrants consideration of prophylactic angioembolization even in stable patients 1
• Do not apply external compression devices in patients with liver hematomas, as this can mask deterioration or increase rupture risk 3
• Do not delay surgical intervention if hemodynamic instability develops—mortality increases significantly with delayed recognition of NOM failure 1