The Eastern Association for the Surgery of Trauma is in the process of updating their trauma practice guidelines for liver injury. The first set of guidelines was introduced in 2003, and several advances in management have occurred since. here is a summary of the current status of the guidelines:
Level I recommendations (best quality data):
Level II recommendations (good data):
- Initial management of hemodynamically stable patients should be nonoperative
- CT of the abdomen with IV contrast is the most reliable method to assess severity of liver injury in the hemodynamically stable patient
- Unstable patients should undergo operative or endovascular management of their injury, not imaging
- Patients with peritonitis should go to the operating room
- Age, grade of injury, amount of hemoperitoneum and age are not contraindications to nonoperative management. Only hemodynamic stability matters.
- Angiography with embolization should be considered if a contrast blush is seen on CT
- Angiography with embolization may also be considered if there is evidence of ongoing blood loss without blush on CT
- Nonoperative management should only be considered if continuous monitoring and serial exams can be carried out at your hospital, and if an operating room is immediately available if needed
Level III recommendations (weak data):
- Clinical status should dictate need and frequency of followup imaging (my interpretation: only do it if the patient condition changes for the worse)
- Interventional modalities may be used to treat complications (ERCP, percutaneous drainage, laparoscopy, etc)
- If a patient transiently responds to fluid initially, try angiography with embolization while they are still stable
On Monday, I’ll present the updated guidelines for management of spleen injury.
Reference: Trauma Practice Guideline Update, 24th Annual Scientic Assembly, Eastern Association for the Surgery of Trauma, January 2011.
This preliminary EAST Practice Management Guideline was presented and discussed at the 23rd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma.
The EAST practice guideline regarding evaluation of blunt abdominal trauma was first published in 2001. It was updated by performing a new literature search spanning 1998 to 2009. A total of 33 new articles were reviewed to provide material for the revised guideline. As usual, the number of high quality references (3 Class I and 11 Class II) were outnumbered by lower quality Class III references (19).
For information on classes of data and levels of recommendations, please refer to the Primer on Evidenced Based Medicine on the EAST website.
Important: These guidelines are preliminary and may undergo further minor revision, so the final version may be slightly different than described here!
The Level I recommendations remained basically the same, with one modification (bolded below):
- FAST may be considered as the initial diagnostic modality to exclude hemoperitoneum.
- Exploratory laparotomy is indicated in hemodynamically unstable patients with a positive FAST. In hemodynamically stable patients with a positive FAST, follow-up CT scan permits nonoperative management of select injuries.
- Exploratory laparotomy is indicated for patients with a positive DPL and hemodynamic instability.
There was some interesting discussion about the continued utility of DPL. Some audience members felt that this was an outdated technique. Others pointed out that not all surgeons work in a Level I or II trauma center, and that FAST may not be available to them, so the technique remains relevant. Additionally, these guidelines may be used abroad where more advanced diagnostic testing is not as readily available, so it was recommended that the DPL language be retained.
The Level II recommendations are:
- When DPL is used, clinical decisions should be made on the basis of the presence of gross blood on initial aspiration (i.e. 10ml) or microscopic analysis of lavage effluent.
- Surveillance studies (i.e. DPL, CT scan, repeat FAST) should be considered in hemodynamically stable patients with indeterminate FAST results.
- CT scanning is recommended for the evaluation of hemodynamically stable patients with equivocal findings on physical examination, associated with neurologic injury, or multiple extra-abdominal injuries. Under these circumstances, patients with a negative CT should be admitted for observation.
- CT scanning is the diagnostic modality of choice for nonoperative management of solid visceral injuries.
- In hemodynamically stable patients, DPL and CT scanning are complementary diagnostic modalities.
- Contrast enhanced ultrasound (CEUS) is more sensitive than non-contrast ultrasound in the detection of solid organ injury. Many members of the audience were not familiar with this technique. I will comment on it in a later blog entry.
- In the patient at high risk for intra-abdominal injury (e.g. multiple orthopedic injuries, severe chest wall trauma, neurologic impairment) a CT scan should be considered in hemodynamically stable patients, even after a negative FAST.
Finally, the Level III recommendations are:
- Objective testing (i.e. FAST, DPL, CT scanning) is indicated for patients with abnormal mentation, equivocal findings on physical examination, multiple injuries, concomitant chest injury, or hematuria.
- Patients with seat belt sign should be admitted for observation and serial physical examination. The presence of intraperitoneal fluid on FAST or CT scan in a patient with seat belt sign suggests the presence of an intra-abdominal injury that may require surgery.
- CT scanning is indicated for suspected renal injuries.
- In hemodynamically stable patients with a positive DPL, a CT scan should be considered, especially in the presence of pelvic fracture or suspected injuries to the genitourinary tract, diaphragm or pancreas.
- Patients with free fluid and no solid organ injury on CT should be considered for laparotomy. Alternatively, laparoscopy or DPL may aid in diagnosis of bowel injury. Patients with no head injury and clear mentation may be followed by serial exams.