This guideline was developed by the Western Trauma Association (westerntrauma.org)
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.
Updated 8-17-17
Updated 8-17-17
