Blunt Hepatic Trauma
VBMC TRAUMA CARE SERVICES GUIDELINE
Blunt Hepatic Trauma
Non-operative management of Blunt Hepatic Injury (EAST PMG)
Level 1
· Patients who are
hemodynamically unstable or who have diffuse peritonitis after blunt abdominal
trauma should be taken urgently for laparotomy.
Level 2
A routine laparotomy is
not indicated in the hemodynamically stable patient without peritonitis
presenting with an isolated blunt hepatic injury.
·
In the hemodynamically stable blunt
abdominal trauma patient without peritonitis, an abdominal CT scan with
intravenous contrast should be performed to identify and assess the severity of
injury to the liver.
·
Angiography with embolization may be
considered as a first-line intervention for a patient who is a transient
responder to resuscitation as an adjunct to potential operative intervention.
·
The severity of hepatic injury (as
suggested by CT grade or degree of hemoperitoneum), neurologic status, age of
more than 55 years, and/or the presence of associated injuries are not absolute
contraindications to a trial of nonoperative management in a hemodynamically
stable patient.
·
Angiography with embolization should
be considered in a hemodynamically stable patient with evidence of active
extravasation (a contrast blush) on abdominal CT scan.
·
Nonoperative management of hepatic
injuries should only be considered in an environment that provides capabilities
for monitoring, serial clinical evaluations, and an operating room available
for urgent laparotomy.
Level 3
·
After hepatic injury, clinical factors
such as a persistent systemic inflammatory response, increasing persistent
abdominal pain, jaundice, or an otherwise unexplained drop in hemoglobin should
prompt reevaluation by CT scan.
·
Interventional modalities including
endoscopic retrograde cholangiopancreatography, angiography, laparoscopy, or
percutaneous drainage may be required to manage complications (bile leak,
biloma, bile peritonitis, hepatic abscess, bilious ascites, and hemobilia) that
arise as a result of nonoperative management of blunt hepatic injury.
·
Pharmacologic prophylaxis to prevent
venous thromboembolism can be used for patients with isolated blunt hepatic
injuries without increasing the failure rate of nonoperative management,
although the optimal timing of safe initiation has not been determined.
Blunt hepatic injury, selective
nonoperative management of, EAST. J Trauma 2012. 73(5): S288-S293.