Operative Management of Adult Blunt Hepatic Trauma

Annotation for Point B

The first step in the management of patients with major hepatic hemorrhage is manual compression. During this time, the surgeon compresses the injured parenchyma between two hands to allow clotting to occur. The patient should undergo intraoperative resuscitation with blood component therapy according to institutional guidelines. Activation of a massive transfusion protocol should be strongly considered as early activation has been shown to reduce mortality.23 In addition, prevention and correction of hypothermia and acidosis should be instituted. Patients receiving massive transfusion are also at risk for hypocalcemia, which results from binding of calcium by citrate found in stored blood. With rapid infusion of blood or with impaired hepatic function, hypocalcemia secondary to citrate toxicity can occur.24 Finally, a rapid and systematic abdominal exploration should be performed to identify sources of nonhepatic hemorrhage and areas of contamination. Perihepatic packing will control bleeding in most patients when done correctly and expeditiously.25 Laparotomy pads are placed around the liver to both compress the injury and to assist in hemostasis. Some surgeons advocate mobilization of the liver for optimal placement of packs, although this does have the potential to increase bleeding if not done correctly. Importantly, definitive management of the liver injury is not performed at the initial surgery, rather packing is left in place, a temporary abdominal closure is performed, and the patient is transported to the intensive care unit (ICU) for resuscitation. Although most applicable for penetrating trauma with deep tracts into the liver parenchyma, balloon tamponade using a Penrose or Foley catheter can be a useful adjunct to control exsanguinating hemorrhage in patients not responding to packing alone.26