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

Keric, Natasha; Shatz, David V.; Schellenberg, Morgan; de Moya, Marc; Moore, Laura J.; Brown, Carlos V.R.; Hartwell, Jennifer L.; Inaba, Kenji; Ley, Eric J.; Peck, Kimberly A.; Fox, Charles J.; Rosen, Nelson G.; Weinberg, Jordan A.; Coimbra, Raul; Kozar, Rosemary; Martin, Matthew J.

doi:10.1097/ta.0000000000004141

Cited by 3 publications

(1 citation statement)

References 32 publications

(142 reference statements)

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“…Odds of VTE were even higher when VTEp was started beyond 24 hours, suggesting that VTE mitigation from early VTEp initiation may be most impactful when VTEp is started within the first day of admission. These findings align with published recommendations from major trauma societies about VTEp initiation after blunt splenic and liver injury 21,22 …”

Section: Discussionsupporting

confidence: 87%

When Is It Safe to Start VTE Prophylaxis after Blunt Solid Organ Injury? A Prospective AAST Multi-Institutional Trial

Schellenberg,

Owattanapanich,

Emigh

et al. 2023

J Trauma Acute Care Surg

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Background The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests VTEp ≤48 h is safe and effective. This study was undertaken to validate this clinical practice. Methods Blunt trauma patients presenting to 19 participating trauma centers in North America were screened over a one-year study period beginning between August 1 and October 1, 2021. Inclusions were age > 15 years; ≥1 liver, spleen, or kidney injury; and initial nonoperative management (NOM). Exclusions were transfers, ED death, pregnancy, and concomitant bleeding disorder/anticoagulation/antiplatelet medication. A priori power calculation stipulated the need for 1,158 patients. Time of VTEp initiation defined study groups: Early (≤48 h of admission) vs. Late (>48 h). Bivariate and multivariable analyses compared outcomes. Results In total, 1,173 patients satisfied study criteria with 571 (49%) liver, 557 (47%) spleen, and 277 (24%) kidney injuries. Median patient age was 34 [25-49] years and 67% (n = 780) were male. Median ISS was 22 [14-29] with AIS Abdomen 3 [2-3] and median AAST grade of solid organ injury 2 [2-3]. Early VTEp patients (n = 838, 74%) had significantly lower rates of VTE (n = 28, 3% vs. n = 21, 7%, p = 0.008); comparable rates of NOM failure (n = 21, 3% vs. n = 12, 4%, p = 0.228); and lower rates of post-VTEp blood transfusion (n = 145, 17% vs. n = 71, 23%, p = 0.024) when compared to Late VTEp patients (n = 301, 26%). Late VTEp was independently associated with VTE (OR 2.251, p = 0.046). Conclusion Early initiation of VTE chemoprophylaxis was associated with significantly reduced rates of VTE with no increase in bleeding complications. VTEp initiation ≤48 hours is therefore safe and effective and should be the standard of care for patients with blunt solid organ injury. Level of Evidence II, Therapeutic and Care Management

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Section: Discussionsupporting

confidence: 87%

When Is It Safe to Start VTE Prophylaxis after Blunt Solid Organ Injury? A Prospective AAST Multi-Institutional Trial

Schellenberg,

Owattanapanich,

Emigh

et al. 2023

J Trauma Acute Care Surg

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Main versus segmental hepatic artery angioembolization in patients with traumatic liver injuries: A Western Trauma Association multicenter study

Nguyen,

Nahmias,

Aryan

et al. 2024

Surgery

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Observation-first versus angioembolization-first approach in stable patients with blunt liver trauma: A WTA multicenter study

Nguyen,

Nahmias,

Aryan

et al. 2024

J Trauma Acute Care Surg

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BACKGROUND Prior studies evaluating observation versus angioembolization (AE) for blunt liver injuries (BLT) with contrast extravasation (CE) on computed tomography imaging have yielded inconsistent conclusions, primarily due to limitations in single-center and/or retrospective study design. Therefore, this multicenter study aims to compare an observation versus AE-first approach for BLT, hypothesizing decreased liver-related complications (LRCs) with observation. METHODS We conducted a post hoc analysis of a multicenter, prospective observational study (2019–2021) across 23 centers. Adult patients with BLT + CE undergoing observation or AE within 8 hours of arrival were included. The primary outcome was LRCs, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. A multivariable logistic regression analysis was used to evaluate risk factors associated with LRCs. RESULTS From 128 patients presenting with BLT + CE on imaging, 71 (55.5%) underwent observation-first and 57 (45.5%) AE-first management. Both groups were comparable in age, vitals, mechanism of injury, and shock index (all p > 0.05), however the AE group had increased frequency of American Association for the Surgery of Trauma Grade IV injuries (51.0% vs. 22.0%, p = 0.002). The AE cohort demonstrated increased rates of in-hospital LRCs (36.8% vs. 12.7%, p = 0.038), emergency department representation (25.0% vs. 10.0%, p = 0.025), and hospital readmission for LRCs (12.3% vs. 1.4%, p = 0.012). However, the two cohorts had similar mortality rates (5.7% vs. 5.3%, p = 0.912). After adjusting for age, ISS, and grade of liver injury, an AE-first approach had a similar associated risk of LRCs compared with observation-first management (odds ratio, 1.949; 95% confidence interval, 0.673–5.643; p = 0.219). CONCLUSION Patients with blunt liver injury and CE undergoing an observation-first approach were associated with a similar adjusted risk of LRCs and rate of mortality compared with AE-first approach. Overall, this calls for reevaluation of the role of routine AE in blunt liver trauma patients with CE. Future prospective randomized trials are needed to confirm these findings. LEVEL OF EVIDENCE Therapeutic/Care Management, Level IV.

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

Cited by 3 publications

References 32 publications

When Is It Safe to Start VTE Prophylaxis after Blunt Solid Organ Injury? A Prospective AAST Multi-Institutional Trial

When Is It Safe to Start VTE Prophylaxis after Blunt Solid Organ Injury? A Prospective AAST Multi-Institutional Trial

Main versus segmental hepatic artery angioembolization in patients with traumatic liver injuries: A Western Trauma Association multicenter study

Observation-first versus angioembolization-first approach in stable patients with blunt liver trauma: A WTA multicenter study

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