Liver Trauma
Blunt or penetrating injury
All Pathways
Hepatobiliary SurgeryEmergency
Liver Trauma Management (WSES/AAST 2020)
Liver Trauma Management (WSES/AAST 2020): Liver Trauma → Primary Survey (ATLS) → Hemodynamic Status? → Hemodynamically Unstable → Emergency Laparotomy.
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Primary Survey (ATLS)
Immediate assessment
- Airway, Breathing, Circulation
- Assess hemodynamic status
- FAST exam if available
- Identify life-threatening injuries
- IV access, type and crossmatch
03Decision Hemodynamic Status?
Key decision point
- STABLE: SBP >90, HR <100, responds to fluids
- UNSTABLE: Persistent hypotension despite resuscitation
04Warning Hemodynamically Unstable
Immediate intervention required
- Massive transfusion protocol
- FAST positive → OR
- FAST negative → Consider other sources
- No time for CT
05Action Emergency Laparotomy
Damage control surgery
- DAMAGE CONTROL PRINCIPLES:
- - Packing (most effective)
- - Direct pressure
- - Pringle maneuver (hepatic pedicle clamp)
- - Hepatorrhaphy for lacerations
- - Resection only if required
- - Temporary abdominal closure
- Return to OR in 24-48h when stable
06Action Delayed Complications
Monitor and manage
- BILOMA: Percutaneous drainage + ERCP
- HEMOBILIA: Angioembolization
- HEPATIC NECROSIS: Debridement if infected
- ABSCESS: Percutaneous drainage
- ACS (Abdominal Compartment): Decompression
07Outcome Outcomes
Prognosis
- NOM success: >90%
- Grade I-III: Excellent prognosis
- Grade IV-V: Higher morbidity
- Grade VI: Often fatal
- Overall mortality depends on associated injuries
08Action Hemodynamically Stable
CT scan for grading
- CT abdomen/pelvis WITH IV contrast
- Arterial and portal venous phases
- Grade injury by AAST scale
- Look for: Active extravasation, pseudoaneurysm
09Action AAST Liver Injury Scale
CT-based grading
- GRADE I: Subcapsular hematoma <10%, laceration <1cm
- GRADE II: Hematoma 10-50%, laceration 1-3cm
- GRADE III: Hematoma >50% or ruptured, laceration >3cm
- GRADE IV: Parenchymal disruption 25-75% of lobe
- GRADE V: Parenchymal disruption >75%, juxtahepatic venous injury
- GRADE VI: Hepatic avulsion (often non-survivable)
10Decision Active Extravasation on CT?
Blush or pseudoaneurysm
11Action Angioembolization
For active arterial bleeding
- Hepatic angiography
- Selective embolization of bleeding vessel
- Can repeat if needed
- Adjunct to NOM
- Success rate: 80-90%
- Monitor for hepatic necrosis
12Action Non-Operative Management (NOM)
For stable patients without extravasation
- CRITERIA FOR NOM:
- - Hemodynamically stable
- - No peritonitis
- - No other indications for laparotomy
- MONITORING:
- - ICU for Grade III-V
- - Serial H&H q6h x 24h
- - Bed rest initially
- - Repeat imaging for worsening
- SUCCESS RATE: >90%
13Decision NOM Failure Signs?
Indication for intervention
- Hemodynamic instability
- Falling H&H despite transfusion
- Peritonitis
- Increasing abdominal pain
- Path rejoins step 05Shared downstream outcome
- Path rejoins step 06Shared downstream outcome
14Action Discharge Planning
Activity restrictions
- Grade I-II: 2 weeks rest
- Grade III: 4-6 weeks rest
- Grade IV-V: 3 months rest
- No contact sports until healed
- Follow-up imaging controversial
- Return if: Fever, increasing pain, hemodynamic symptoms
- Path rejoins step 07Shared downstream outcome
- Path rejoins step 12Shared downstream outcome
Guideline Source
WSES/AAST Guidelines for Management of Liver Trauma
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- CT grading may underestimate injury
- Delayed complications (biloma, hemobilia) possible
- Requires experienced trauma center
- Associated injuries affect management
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Liver Trauma Management (WSES/AAST 2020)?
The Liver Trauma Management (WSES/AAST 2020) is a emergency clinical algorithm for Hepatobiliary Surgery. It provides a structured decision tree to guide clinical decision-making, based on WSES/AAST Guidelines for Management of Liver Trauma.
What guideline is the Liver Trauma Management (WSES/AAST 2020) based on?
This algorithm is based on WSES/AAST Guidelines for Management of Liver Trauma (DOI: 10.1186/s13017-020-00302-3).
What are the limitations of the Liver Trauma Management (WSES/AAST 2020)?
Known limitations include: CT grading may underestimate injury; Delayed complications (biloma, hemobilia) possible; Requires experienced trauma center; Associated injuries affect management. Individual patient factors may require deviation from these recommendations.
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