01Approach to the Critical Patient/attcp53

Immediate priorities

›Initial stabilization

›Airway compromise

›Altered mental status with loss of protective reflexes

›Severe facial trauma or massive emesis

›Breathing failure

›Hypoxemia with respiratory distress

›Concomitant thoracic injury requiring immediate intervention

›Circulatory collapse

›Hypotension with suspected intraabdominal hemorrhage

›Persistent tachycardia despite initial fluid and blood resuscitation

›Hemorrhage control pathway selection

›Unstable patient with positive FAST

›Stable patient for contrast CT abdomen and pelvis

›Hemodynamic targets

›Permissive hypotension for uncontrolled hemorrhage without traumatic brain injury

›Systolic blood pressure target 80 to 90 mmHg until hemostasis

›Avoid in pregnancy

›Normotension targets when traumatic brain injury suspected

›Systolic blood pressure at least 100 mmHg age 50 to 69

›Systolic blood pressure at least 110 mmHg age 15 to 49 or over 70

›Temperature management

›Core temperature at least 36 C

›Active warming for hypothermia

›Monitoring and access

›Vascular access

›Two large bore peripheral IVs

›Intraosseous access if IV delay

02History/hx46

Mechanism and bleeding risk

›Injury context

›Mechanism of injury

›Blunt trauma

›Motor vehicle collision

›Fall from height

›Crush injury

›Penetrating trauma

›Stab wound upper abdomen or right thoracoabdominal region

›Gunshot wound transabdominal trajectory

›Timing

›Time since injury

›Prehospital hypotension episodes

›Prehospital interventions

›Tourniquet use for concomitant extremity bleeding

›Prehospital transfusion

›Bleeding modifiers

›Anticoagulant and antiplatelet exposure

›Direct oral anticoagulants

›Warfarin

›Aspirin

›P2Y12 inhibitors

›Liver disease risk

›Cirrhosis history

›Alcohol use disorder

›Hemophilia or bleeding diathesis

›Known inherited bleeding disorder

›Prior excessive bleeding with procedures

03Physical Exam/exam38

Primary survey focused findings

›Immediate exam priorities

›Vital signs trend

›Tachycardia

›Hypotension

›Perfusion markers

›Cool clammy skin

›Delayed capillary refill

›Mental status

›Agitation from hypoperfusion

›Somnolence from shock

›External hemorrhage search

›Bleeding sources

›Scalp laceration

›Long bone deformity with bleeding

›Pelvic instability concern

Abdominal and thoracoabdominal exam

›Abdominal exam

›Tenderness

›Right upper quadrant tenderness

›Generalized tenderness

›Peritoneal signs

›Guarding

›Rebound tenderness

›Distension

›Progressive abdominal distension

›Tympany suggesting hollow viscus injury

›Thorax and ribs

04Differential Diagnosis/ddx28

Life threats in similar presentations

›Major hemorrhage causes

›Hepatic laceration and intraperitoneal hemorrhage (ICD10 S36.11)

›SNOMED liver laceration

›AAST liver injury spectrum

›Splenic laceration (ICD10 S36.03)

›Left upper quadrant pain predominance

›Mesenteric injury with hemorrhage (ICD10 S36.89)

›Seatbelt sign association

›Retroperitoneal hemorrhage

›Pelvic fracture bleeding

›Renal injury bleeding

›Abdominal catastrophe mimics

›Hollow viscus perforation (ICD10 S36.5)

›Delayed peritonitis

›Acute traumatic pancreatitis

›Epigastric pain

›Right hemothorax

›Chest findings more prominent than abdominal

Hepatobiliary complications after injury

›Delayed complications

›Bile leak and biloma

›Rising bilirubin

›Persistent abdominal pain and fever

›Hepatic artery pseudoaneurysm

›Delayed hemorrhage

›Gastrointestinal bleeding via hemobilia

›Hepatic abscess

05Laboratory Tests/lt46

Initial hemorrhage and perfusion assessment

›Resuscitation labs

›Complete blood count for bleeding concern

›Hemoglobin trend interpretation

›Early normal hemoglobin does not exclude hemorrhage

›Serial values with hemodynamics more informative

›Platelet count for massive transfusion planning

›Venous or arterial blood gas for perfusion

›Lactate mmol/L

›Elevated lactate suggests hypoperfusion

›Serial lactate clearance target

›Base deficit

›Worsening suggests ongoing shock

›PaCO2 mmHg for ventilation adequacy if arterial sample

›Type and screen or crossmatch

›Emergency release uncrossmatched blood trigger

›Rh negative blood strategy for females of childbearing potential

›Coagulation evaluation

›INR and PT

›Warfarin effect assessment

›Baseline coagulopathy identification

›aPTT

›Heparin effect assessment

›Fibrinogen

›Low fibrinogen in trauma induced coagulopathy

›Cryoprecipitate trigger based on local protocol

›Viscoelastic testing if available

›TEG or ROTEM guided hemostatic therapy

06Diagnostic Tests/dt79

Scoring Systems

›Decision and severity tools

›AAST liver injury grading

›Grade I

›Subcapsular hematoma less than 10 percent surface area

›Capsular tear less than 1 cm depth

›Grade II

›Subcapsular hematoma 10 to 50 percent surface area

›Intraparenchymal hematoma less than 10 cm diameter

›Laceration 1 to 3 cm depth and less than 10 cm length

›Grade III

›Subcapsular hematoma over 50 percent surface area or expanding

›Ruptured subcapsular or parenchymal hematoma

›Intraparenchymal hematoma over 10 cm or expanding

›Laceration over 3 cm depth

›Grade IV

›Parenchymal disruption 25 to 75 percent of a hepatic lobe

›One to three Couinaud segments within one lobe

›Grade V

›Parenchymal disruption over 75 percent of a hepatic lobe

›More than three Couinaud segments within one lobe

›Juxtahepatic venous injury

›Grade VI

›Hepatic avulsion

›Shock index

›Over 0.9 associated with higher hemorrhage risk

›Useful for trending during resuscitation

›ABC score for massive transfusion prediction

07Disposition/dispo26

Level of care and monitoring

›Admission criteria

›Any hepatic laceration on imaging

›Observation with serial exams and vital signs

›Hemoglobin trend monitoring

›High risk features

›AAST grade III to VI injury

›Active contrast extravasation

›Large hemoperitoneum

›Transfusion requirement

›ICU criteria

›Persistent hemodynamic instability

›Ongoing transfusion requirement

›High grade injury with high intervention risk

›Transfer criteria

›Need for angioembolization not available

›Need for hepatobiliary surgery capabilities

›Massive transfusion resources limited

Discharge selection when appropriate

›Discharge eligibility

›Minor injury with stable vitals and exam

›Grade I injury in select systems

›No transfusion requirement

›Reliable follow up and return precautions

›Clear access to emergency services

›Support at home

›Activity restriction plan

›Avoid contact sports until cleared

08Treatment/t99

Hemorrhage control and resuscitation

›Damage control resuscitation

›Balanced blood product strategy

›Massive transfusion protocol

›RBC plasma platelet balanced ratio per local protocol

›Early plasma and platelet administration

›Minimize crystalloid

›Calcium replacement during transfusion

›If ionized calcium low then calcium chloride IV per protocol

›Repeat ionized calcium mmol/L trending

›Temperature management

›Blood warmer use

›Active external warming

›Tranexamic acid

›If within 3 hours of injury and significant bleeding risk then initiate

›1 g IV over 10 minutes

›Then 1 g IV over 8 hours

›Avoid if isolated traumatic brain injury without systemic bleeding per local protocol

›Coagulopathy management

›Viscoelastic guided therapy if available

›Fibrinogen replacement if low

›Cryoprecipitate dosing per local protocol

›Recheck fibrinogen

›Platelet transfusion for thrombocytopenia in active bleeding

›Target platelet count per local protocol

›Repeat CBC trend

›Warfarin reversal if applicable

›Four factor PCC

›Weight based dosing per INR and institutional guideline

›Repeat INR

›Vitamin K IV

›5 to 10 mg IV

›Repeat INR monitoring

Nonoperative management pathway

›Observation based management

›Hemodynamic stability requirements

›No ongoing hypotension from hemorrhage

›No escalating transfusion requirement

›Monitoring elements

›Serial abdominal exams

›Serial hemoglobin based on stability

›Repeat imaging triggers

›New abdominal pain

›Drop in hemoglobin with instability

›Angioembolization indications

›CT active contrast extravasation

›Pseudoaneurysm

›Ongoing transfusion requirement with stable enough physiology

›Venous thromboembolism prophylaxis timing

›Mechanical prophylaxis early

›Pharmacologic prophylaxis when bleeding stabilized per trauma protocol

Operative management pathway

›Indications for laparotomy

›Hemodynamic instability with positive FAST not responsive to resuscitation

›Peritonitis suggesting hollow viscus injury

›Penetrating injury with hemodynamic instability

›Damage control surgery concepts

›Perihepatic packing

›Temporary tamponade

›Planned re exploration

›Pringle maneuver

›Temporary inflow occlusion

›Persistent bleeding suggests hepatic venous or retrohepatic source

›Adjuncts

›Topical hemostatic agents

›Temporary abdominal closure

Analgesia and supportive care

›Pain control strategy

›Opioid analgesia

›Fentanyl IV

›25 to 50 mcg IV

›Repeat every 5 to 10 minutes as needed

›Monitoring for respiratory depression

›Hydromorphone IV

›0.2 to 0.5 mg IV

›Repeat every 10 to 15 minutes as needed

›Dose reduction in elderly

›Non opioid adjuncts

›Acetaminophen

›Avoid high total daily dosing in liver disease

›Consider reduced maximum per institutional policy

›Regional anesthesia consideration

›Rib fracture pain blocks if concomitant chest trauma

›Anticoagulation status awareness

›Nausea management

›Ondansetron IV

›4 mg IV

›Repeat dosing per nausea severity

›QT prolongation risk awareness

Infection prophylaxis and antibiotics

›Penetrating abdominal trauma coverage

›Broad spectrum antibiotics for hollow viscus contamination concern

›Ceftriaxone IV

›2 g IV daily

›Add metronidazole if anaerobic coverage needed

›500 mg IV every 8 hours

›Piperacillin tazobactam IV alternative

›4.5 g IV every 6 hours

›Renal dosing adjustment

›De escalation based on findings

›Biliary complication management

›Suspected cholangitis or infected biloma

›Broad spectrum antibiotics with biliary penetration

›Source control planning with drainage

09Special Populations/sp33

Pregnancy

›Pregnancy specific considerations

›Maternal resuscitation priority

›Left uterine displacement after mid pregnancy

›Higher blood volume masking early shock

›Imaging balance

›FAST as initial adjunct

›CT when maternal benefit outweighs fetal risk

›Rh immunoglobulin

›Rh negative patient with abdominal trauma

›Dose per gestational age and local obstetric protocol

›Obstetric consultation triggers

›Viable gestation with trauma

›Uterine tenderness or vaginal bleeding

Geriatric

›Older adult considerations

›Atypical shock presentation

›Less tachycardia

›Baseline hypertension masking hypotension severity

›Medication effects

›Anticoagulant prevalence higher

›Beta blocker blunting response

›Lower physiologic reserve

›Earlier ICU consideration

›Aggressive warming and balanced resuscitation

Pediatrics

›Pediatric considerations

›Higher success of nonoperative management

10Background/b34

Epidemiology

›Trauma epidemiology

›Liver as common solid organ injured in abdominal trauma

›Frequent in blunt trauma with right lower rib injury

›Frequent in penetrating right upper quadrant injury

›Mortality drivers

›Exsanguination early phase

›Associated injuries and traumatic brain injury

Pathophysiology

›Injury mechanisms

›Parenchymal disruption

›Capsular tear and bleeding from hepatic parenchyma

›Segmental arterial and venous injury

›Vascular injury patterns

›Hepatic arterial branch injury

›Contrast extravasation

›Pseudoaneurysm formation

›Juxtahepatic venous injury

›Retrohepatic vena cava involvement

›High mortality and operative complexity

›Biliary injury patterns

›Bile duct disruption causing leak

›Biloma formation and infection risk

Therapeutic Considerations

›Management principles

›Nonoperative management

›Preferred for hemodynamically stable blunt injury in equipped centers

›Requires monitoring and rapid access to intervention

11Patient Discharge Instructions/pdi27

Copy discharge instructions

›Home care and activity

›Activity restriction

›Avoid heavy lifting and contact sports until trauma follow up

›Gradual return to activity based on symptom resolution and clinician clearance

›Pain control plan

›Use prescribed analgesics as directed

›Avoid alcohol while taking opioids

›Return to emergency criteria

›Bleeding and shock symptoms

›Fainting or near fainting

›New severe weakness or confusion

›Fast heartbeat with lightheadedness

›Worsening abdominal symptoms

›Increasing abdominal pain

›New abdominal distension

›Repeated vomiting

›Infection and biliary complication symptoms

›Fever

›New jaundice

›Dark urine or pale stools

›Worsening right upper quadrant pain

›Gastrointestinal bleeding symptoms

›Vomiting blood

›Black tarry stools

›Follow up

›Trauma clinic follow up timing per local protocol

›Imaging follow up if recommended for high grade injuries or vascular lesions

12References/r17

Clinical guidelines and evidence sources

›Trauma and hepatobiliary guidance sources

›WSES guidelines on liver trauma

›Nonoperative management in stable patients

›Angioembolization for arterial blush

›EAST practice management guidelines for blunt hepatic injury

›CT based grading and monitoring

›Selective use of angiography

›AAST organ injury scale for liver

›Standardized grading I to VI

›Prognosis and intervention correlation

›Resuscitation and transfusion guidance sources

›Trauma massive transfusion and damage control resuscitation recommendations

›Balanced component therapy strategy

›Hypothermia acidosis coagulopathy prevention

›CRASH 2 trial for tranexamic acid in trauma

›Benefit when given within 3 hours of injury

›Time to treatment effect gradient

Evidence & Review

Evidence & Review