How to manage a trauma patient with tachycardia, hypotension, and mild right hypochondrial pain post road traffic accident (RTA) with a computed tomography (CT) scan showing a large liver laceration?

Management of Blunt Liver Trauma with Large Laceration

This patient should be admitted with close observation (Option B) in an intensive care or high-dependency unit setting with continuous hemodynamic monitoring, serial clinical examinations, and immediate access to interventional radiology and operating room. 1

Hemodynamic Assessment

This patient demonstrates relative hemodynamic stability despite concerning vital signs:

• Pulse 120 bpm (tachycardia) and BP 110/60 mmHg indicate compensated shock but not frank hemodynamic instability (typically defined as systolic BP <90 mmHg unresponsive to resuscitation) 1
• The patient is maintaining adequate blood pressure, which is the critical determinant for non-operative management (NOM) eligibility 1
• Tachycardia alone, while concerning, does not mandate immediate operative intervention if blood pressure remains stable 2

Application of WSES Classification

Based on the 2020 WSES guidelines, this patient likely falls into WSES Grade III (severe injury, AAST IV-V based on "large laceration" description, hemodynamically stable): 1

• NOM should be the treatment of choice for all hemodynamically stable patients with severe (WSES III) injuries in the absence of other internal injuries requiring surgery 1
• The CT scan has already been performed, which is the gold standard for diagnosis and treatment planning 1

Critical Requirements for Non-Operative Management

NOM is only appropriate if ALL of the following are immediately available: 1

• Intensive care unit or high-dependency environment for continuous monitoring 1
• Serial clinical examinations and hemoglobin monitoring (every 6 hours for at least 24 hours) 1
• Immediate access to interventional radiology and angioembolization 1
• Immediately available operating room and trained surgeons 1
• Blood and blood products on demand 1

Why Other Options Are Incorrect

Discharge (Option A) is absolutely contraindicated:

• Large liver lacerations carry significant risk of delayed hemorrhage and NOM failure 3
• Tachycardia and mild hypotension indicate ongoing physiologic stress requiring monitoring 2

Immediate exploration (Option C) is not indicated:

• NOM is contraindicated only in hemodynamic instability (systolic BP <90 mmHg unresponsive to resuscitation) or peritonitis 1
• This patient has neither absolute contraindication 1
• Unnecessary laparotomy increases morbidity, with non-therapeutic laparotomy rates up to 25% reported 1

Repeat CT after 6 hours (Option D) is inappropriate:

• The initial CT has already established the diagnosis 1
• Serial clinical examination and hemoglobin measurement are the cornerstones of monitoring, not repeat imaging 1, 3
• Repeat CT is only indicated if clinical deterioration occurs or if arterial blush was present on initial CT requiring angiography assessment 1

Specific Monitoring Protocol

During admission with close observation: 1

• Serial vital signs monitoring continuously in ICU/HDU setting 1
• Serial hemoglobin measurements every 6 hours for at least 24 hours 1
• Serial physical examinations to detect peritoneal signs or clinical deterioration 1, 3
• Serial liver enzyme monitoring - increasing transaminases may indicate intrahepatic ischemia or evolving complications 1, 3
• Bedside ultrasound may be used as an affordable monitoring tool 1

Indications for Conversion to Operative Management

Immediate surgical exploration is required if: 1

• Hemodynamic instability develops (systolic BP <90 mmHg despite resuscitation) 1
• Development of peritonitis on serial examination 1
• Ongoing transfusion requirements (>4 units in first 8 hours suggests NOM failure) 1
• Clinical deterioration despite resuscitation 1

Role of Angioembolization

If the initial CT showed arterial blush (contrast extravasation):

• Angiography with embolization should be considered as first-line intervention even in stable patients 1
• This can be viewed as an "extension of resuscitation" rather than a failure of NOM 1
• Angioembolization can be safely repeated if needed 1

Critical Pitfall to Avoid

The most dangerous error would be premature discharge or inadequate monitoring intensity. Large subcapsular hematomas carry inherent risk of delayed rupture, which is life-threatening and requires immediate surgical intervention if it occurs 3. The mild right hypochondrial pain and tachycardia indicate this patient requires high-acuity monitoring, not routine ward-level care.