What is the management approach for a patient with liver trauma, graded using the liver trauma scale on CT (Computed Tomography) scan?

Management of Liver Trauma Based on CT Grading

Management of liver trauma graded on CT scan is primarily determined by hemodynamic status rather than injury grade alone, with non-operative management (NOM) being the treatment of choice for all hemodynamically stable patients regardless of severity, while hemodynamically unstable patients require immediate operative intervention. 1

Classification Framework

The WSES classification system stratifies liver injuries based on both anatomic severity and hemodynamic status:

• WSES Grade I (Minor): AAST I-II injuries, hemodynamically stable 1
• WSES Grade II (Moderate): AAST III injuries, hemodynamically stable 1
• WSES Grade III (Severe): AAST IV-V injuries, hemodynamically stable 1
• WSES Grade IV (Critical): Any AAST grade (I-VI), hemodynamically unstable 1

This classification is crucial because hemodynamic status, not injury grade, drives the initial management decision. 1

Management Algorithm by Hemodynamic Status

Hemodynamically Stable Patients

NOM should be the treatment of choice for all hemodynamically stable patients with minor (WSES I), moderate (WSES II), and severe (WSES III) injuries in the absence of other injuries requiring surgery. 1

Essential Requirements for NOM:

• CT scan with intravenous contrast must always be performed to define anatomic injury and identify associated injuries 1
• Immediate availability of trained surgeons and operating room 1
• Continuous monitoring ideally in ICU or ER setting with serial clinical examinations and laboratory testing 1
• Access to angiography/angioembolization capability 1
• Immediate access to blood and blood products 1
• System to quickly transfer patients to higher level care facilities 1

Special Consideration for Arterial Blush:

Angiography with embolization may be considered as first-line intervention in hemodynamically stable patients with arterial blush on CT scan. 1 This applies even to severe injuries, as angioembolization can prevent progression to operative management 2

Important caveat: In hemodynamically stable children, contrast blush on CT is NOT an absolute indication for angioembolization 1

Transient Responders

In patients considered transient responders with moderate (WSES II) and severe (WSES III) injuries, NOM should be considered only in selected settings with all the above requirements immediately available. 1 This represents a paradigm shift from historical practice, as even borderline patients may be candidates for NOM in well-developed trauma centers 1

Hemodynamically Unstable Patients (WSES IV)

Hemodynamically unstable and non-responder patients should undergo immediate operative management (OM). 1

Operative Principles:

• Primary surgical intention should be hemorrhage control and bile leak control with initiation of damage control resuscitation as soon as possible 1
• Major hepatic resections should be avoided initially and only considered in subsequent operations for resectional debridement of devitalized tissue by experienced surgeons 1
• Damage control techniques include manual compression, hepatic packing, Pringle maneuver, and topical hemostatic agents 2
• Angioembolization is a useful tool for persistent arterial bleeding after non-hemostatic or damage control procedures 1
• REBOA may be used as a bridge to definitive hemorrhage control procedures 1

Monitoring During NOM

Serial clinical evaluations (physical exams and laboratory testing) must be performed to detect changes in clinical status during NOM. 1 The World Society of Emergency Surgery recommends serial examinations and hemoglobin monitoring every 6 hours for at least 24 hours 3

ICU admission in isolated liver injury may be required only for moderate (WSES II) and severe (WSES III) lesions. 1

Special Populations and Situations

Concomitant Head Trauma/Spinal Cord Injuries:

NOM should be attempted with concomitant head trauma and/or spinal cord injuries with reliable clinical exam, unless the patient cannot achieve specific hemodynamic goals for neurotrauma and instability might be due to intra-abdominal bleeding. 1 This is a critical caveat, as unreliable neurologic examinations can mask peritoneal signs 2

Pediatric Patients:

NOM should be considered the optimal management approach in pediatric patients. 1 Children have higher success rates with NOM across all injury grades 1

Low-Resource Settings:

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

Management of Complications

Delayed Hemorrhage:

Delayed hemorrhage without severe hemodynamic compromise may be managed first with angiography/angioembolization. 1

Hepatic Artery Pseudoaneurysm:

Should be managed with angiography/angioembolization to prevent rupture. 1

Bilomas:

Symptomatic or infected bilomas should be managed with percutaneous drainage. 1 Combination of percutaneous drainage and endoscopic techniques (ERCP with stenting) may be considered for post-traumatic biliary complications not suitable for percutaneous management alone 1

Intrahepatic Abscesses:

May be successfully treated with percutaneous drainage. 1

Common Pitfalls to Avoid

Critical pitfall: Do not base the decision for operative versus non-operative management solely on CT injury grade. 1 Recent data shows that 85-90% of blunt liver injuries can be managed non-operatively regardless of grade in hemodynamically stable patients 4

Second pitfall: Do not attempt NOM in facilities lacking the complete infrastructure outlined above. 1 The failure rate of NOM for grade III-V injuries can be as high as 46.7%, with 50% mortality in failed grade IV-V cases 5

Third pitfall: Do not perform major hepatic resections during initial damage control surgery. 1 These should be reserved for subsequent operations if needed 1

Thromboprophylaxis

Mechanical prophylaxis is safe and should be considered in all patients with no absolute contraindication. 1 LMWH-based prophylaxis should be started as soon as possible following trauma and may be safe in selected patients with liver injuries. 1