An observation-first strategy for liver injuries with “blush” on computed tomography is safe and effective

Abstract

This important Western Trauma multicenter study found minimal benefit from embolization of liver injuries following the finding of blush on CT. Embolization carried a higher rate of complications with more drain placements and longer LOS.

Adult blunt hepatic injury: A Western Trauma Association critical decisions algorithm

“…Recent literature suggests that the use of angioembolization in severe hepatic injuries is associated with decreased mortality, especially for patients who also undergo an exploratory laparotomy 14 . Complications after angioembolization are not insignificant, and there is still no consensus on whether all injuries with a “contrast blush” (free extravasation of contrast suggesting active hemorrhage) need immediate angiographic embolization 4,13 . Most experts agree that angioembolization is indicated for hepatic trauma as an adjunct to nonoperative management in hemodynamically stable patients with evidence of ongoing hemorrhage 1,13,15 .…”

“…14 Complications after angioembolization are not insignificant, and there is still no consensus on whether all injuries with a "contrast blush" (free extravasation of contrast suggesting active hemorrhage) need immediate angiographic embolization. 4,13 Most experts agree that angioembolization is indicated for hepatic trauma as an adjunct to nonoperative management in hemodynamically stable patients with evidence of ongoing hemorrhage. 1,13,15 Patients with highgrade liver injuries should be admitted to the ICU for continued observation.…”

“…The WTA Algorithms Committee's last published guidelines were on the nonoperative management of adult blunt hepatic trauma in 2009 2 and operative management in 2011 3 . With emphasis on selective operative and nonoperative management of blunt hepatic injuries, recent literature has sought to reexamine the outcomes of nonoperative interventions and improve techniques and adjuncts for operative management 4 . The intent of this article is to provide an updated WTA practice management guideline for the diagnosis and management of adult blunt hepatic injuries, with additional guidance on the subsequent inpatient management decisions such as admission location, initiation of diet and ambulation, and other common issues.…”

Blunt abdominal trauma: watch and wait

“…The risk of clinically relevant biliary complications after NOM in high-grade liver trauma without AE is reported to be low or absent. The development of delayed PSAs is the most significant complication, which can be primarily managed through repeated AE for lesions larger than 1 cm [15 ▪▪ ,26].…”

“…This evidence is supported by a recent systematic review, which reported lower complication rates in NOM without AE. However, it should be noted that the available studies have high heterogeneity and a small number of recruited patients [15 ▪▪ ].…”