Non-Operative Management of Adult Blunt
Hepatic Trauma Algorithm


1. McIntyre RC Jr, Moore FA, Davis JW, Cocanour CS, West MA, Moore EE Jr. Western Trauma Association critical decisions in trauma: foreword. J Trauma. 2008;65:1005–1006.

2. Moore FA, Davis JW, Moore EE Jr, Cocanour CS, West MA, McIntyre RC Jr. Western Trauma Association (WTA) critical decisions in trauma: management of blunt splenic trauma. J Trauma. 2008;65:1007–1011.

3. Richardson JD, Franklin GA, Lukan JK, et al. Evolution in the management of hepatic trauma: a 25 year perspective. Ann Surg. 2000;232:324 –330.

4. Kashuk JL, Moore EE, Millikan JS, Moore JB. Major abdominal vascular trauma—a unified approach. J Trauma. 1982;22:672– 679.

5. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003;54:1127–1130.

6. MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma. 2003;55:39–44.

7. Meredith JW, Young JS, Bowling J, Roboussin D. Nonoperative management of blunt hepatic trauma: the exception or the rule? J Trauma. 1994;36:529 –534; discussion 534–535.

8. Croce MA, Fabian TC, Menke PG, et al. Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. The results of a prospective trial. Ann Surg. 1995;221: 744–753; discussion 753–755.

9. Pachter HL, Knudson MM, Esrig B, et al. Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma. 1996;40:31–38.

10. Malhotra AK, Fabian TC, Croce MA, et al. Blunt hepatic injury: a paradigm shift from operative to nonoperative management in the 1990’s. Ann Surg. 2000;231:804–813.

11. Velmahos GC, Toutouzas K, Radin R, et al. High success with nonoperative management of blunt hepatic trauma: the liver is a sturdy organ. Arch Surg. 2003;138:475– 480; discussion 480–481.

12. Tinkoff G, Esposito T, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008;207:646–655.

13. Eastridge BJ, Scalino J, McManus JG, et al. Hypotension begins at 110 mm Hg: redefining “hypotension” with data. J Trauma. 2007;63:291– 297; discussion 297–299.

14. Davis JW, Parks SN, Kaups KL, Gladen HE, O’Donnell-Nicol S. Admission base deficit predicts transfusion requirements and risk of complications. J Trauma. 1996;41:769 –774.

15. Cotton BA, Gunter OL, Isbell J, et al. Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization. J Trauma. 2008;64:1177–1182; discussion 1182–1183.

16. Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients. Ann Surg. 2008;248:447– 458.

17. Gonzalez EA, Moore FA, Holcomb JB, et al. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma. 2007;62:112–119.

18. Gajic O, Rana R, Winters JL, et al. Transfusion-related acute lung injury in the critically ill: prospective nested case-control study. Am J Respir Crit Care Med. 2007;176:886–891.

19. Blackbourne LH, Soffer D, McKenney M, et al. Seconary ultrasound examination increases the sensitivity of the FAST exam in blunt trauma. J Trauma. 2004;57:934 –938.

20. Duane TM, Como JJ, Bochicchio GV, Scalea TM. Reevaluating the management and outcomes of severe blunt liver injury. J Trauma. 2004;57:494 –500.

21. Davis JW, Moore FA, McIntyre RC Jr, Cocanour CS, Moore EE, West MA. Western Trauma Association critical decisions in trauma: management of pelvic fracture with hemodynamic instability. J Trauma. 2008; 65:1012–1015.

22. Fang JF, Wong YC, Lin BC, Hsu YP, Chen MF. The CT risk factors for the need of operative treatment in initially stable patients after blunt hepatic trauma. J Trauma. 2006;61:547–553; discussion 553–554.

23. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma. 1995;38:323–324.

24. Pachter HL, Hofstetter SR. The current status of nonoperative management of adult blunt hepatic injuries. Am J Surg. 1995;169: 442– 454.

25. Fang JF, Chen RJ, Wong YC, et al. Pooling of contrast material on computed tomography mandates aggressive management of blunt hepatic injury. Am J Surg. 1998;176:315–319.

26. Fang JF, Chen RJ, Wong YC, et al. Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma. J Trauma. 2000;49:1083–1088.

27. Hagiwara A, Murata A, Matsuda T, Matsuda H, Shimazaki S. The efficacy and limitations of transarterial embolization for severe hepatic injury. J Trauma. 2002;52:1091–1096.

28. Kozar RA, Moore JB, Niles SE, et al. Complications of nonoperative management of high-grade blunt hepatic injuries. J Trauma. 2005;59: 1066–1071.

29. Wahl WL, Ahrns KS, Brandt MM, Franklin GA, Taheri PA. The need for early angiographic embolization in blunt liver injuries. J Trauma. 2002;52:1097–1101.

30. Mohr AM, Lavery RF, Barone A, et al. Angioembolization for liver injuries: low mortality, high morbidity. J Trauma. 2003;55:1077– 1082.

31. Asensio JA, Demetriades D, Chalwan S, et al. Approach to the management of complex hepatic injuries. J Trauma. 2000;48:66–69.

32. Asensio JA, Rolda´n G, Petrone P, et al. Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angioembolization helps. J Trauma. 2003;54:647– 654.

33. Ciraulo D, Luk S, Palter M, et al. Selective hepatic arterial embolization of grade IV and V blunt hepatic injuries: an extension of resuscitation in the nonoperative management of traumatic hepatic injuries. J Trauma. 1998;45:353–359.

34. Hagiwara A, Murata A, Matsuda T, Matsuda H, Shimazaki S. The usefulness of transcatheter arterial embolization for patients with blunt polytrauma showing transient response to fluid resuscitation. J Trauma. 2004;57:271–276; discussion 276–277.

35. Carillo E, Spain D, Wohltmann D, et al. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma. 1999;46:619–622; discussion 622–624.

36. Kozar RA, Moore FA, Cothren CC, et al. Risk factors for hepatic morbidity following nonoperative management. Arch Surg. 2006;141: 451–458; discussion 458–459.

37. Christmas AB, Wilson AK, Manning B, et al. Selective management of blunt hepatic injuries including nonoperative management is a safe and effective strategy. Surgery. 2005;138:606–610; discussion 610–611.

38. Lee SK, Carrillo EH. Advances and changes in the management of liver injuries. Amer Surg. 2007;73:201–206.

39. Cuft RF, Cogbill TH, Lambert PJ. Nonoperative management of blunt liver trauma: the value of follow up abdominal computed tomographic scans. Amer Surg. 2000;66:332–336.

40. Howdieshell TR, Purvis J, Bates WB, Teeslink CR. Biloma and biliary fistula following hepatorraphy for liver trauma: incidence, natural history, and management. Am Surg. 1995;61:165–168.

41. Sugimoto K, Asari Y, Sakaguchi T, Owada T, Maekawa K. Endoscopic retrograde cholangiography in the nonsurgical management of blunt liver injury. J Trauma. 1993;35:192–199.

42. Cogbill TH, Moore EE, Jurkovich GJ, Feliciano DV, Morris JA, Mucha P. Severe hepatic trauma: a multi-center experience with 1,335 injuries. J Trauma. 1988;28:1433–1438.

43. Carillo EH, Reed DN, Gordon L, Spain DA, Richardson JD. Delayed laparoscopy facilitates the management of biliary peritonitis in patients with complex liver injuries. Surg Endosc. 2001;15:319 –322.

44. Franklin GA, Richardson JD, Brown AL, et al. Prevention of bile peritonitis by laparoscopic evacuation and lavage after nonoperative treatment of liver injuries. Am Surg. 2007;73:611–616; discussion 616–617.

45. Letoublin C, Chen Y, Arvieux C, et al. Delayed celiotomy or laparoscopy as part of the nonoperative management of blunt hepatic trauma. World J Surg. 2008;32:1189 –1193.

46. Marks JM, Ponsky JL, Shillingstad RB, Singh J. Biliary stenting is more effective than sphincterotomy in the resolution of biliary leaks. Surg Endosc. 1998;12:327–330.

47. Polanco P, Leon S, Pineda J, et al. Hepatic resection in the management of complex injury to the liver. J Trauma. 2008;65:1264 –1269; discussion 1269–1270.