Nonoperative Management of Blunt Hepatic Trauma: Comparison of Level I and II Trauma Centers

Abstract

Introduction Most blunt liver injuries are treated with nonoperative management (NOM), and angiointervention (AI) has become a common adjunct. This study evaluated the use of AI, blood product utilization, pharmacological venous thromboembolic prophylaxis (VTEp), and outcomes in severe blunt liver trauma managed nonoperatively at level I versus II trauma centers. Methods American College of Surgeons Trauma Quality Improvement Program (TQIP) study (2013-2016), including adult patients with severe blunt liver injuries (AIS score>/= 3) treated with NOM, was conducted. Epidemiological and clinical characteristics, severity of liver injury (AIS), use of AI, blood product utilization, and VTEp were collected. Outcomes included survival, complications, failure of NOM, blood product utilization, and length of stay (LOS). Results Study included 2825 patients: 2230(78.9%) in level I and 595(21.1%) in level II centers. There was no difference in demographics, clinical presentation, or injury severity between centers. Angiointervention was used in 6.4% in level I and 7.2% in level II centers (P=.452). Level II centers were less likely to use LMWH for VTEp (.003). There was no difference in mortality or failure of NOM. In level II centers, there was a significantly higher 24-hour blood product utilization (PRBC P = .015 and platelets P = .002), longer ventilator days (P = .012), and longer ICU (P< .001) and hospital LOS (P = .024). The incidence of ventilator-associated pneumonia was significantly higher in level II centers (P = .003). Conclusion Utilization of AI and NOM success rates is similar in level I and II centers. However, the early blood utilization, ventilator days, and VAP complications are significantly higher in level II centers.

Solid Organ Injury Grading in the Abdomen: A Primer for Emergency Radiology

“…Liver trauma grading ranges from I to V based on severity of injury and a variety of imaging characteristics. For most liver trauma grades with hemodynamic stability, nonoperative management (NOM) is the mainstay of treatment with angiointervention/angioembolization as an indicated complement to NOM 1,5–8. Operative management is typically indicated in patients who are hemodynamically unstable or have signs of peritoneal irritation, free intraperitoneal air or fluid, or evidence of high-energy penetrating trauma on imaging (CT) 1,4–8…”

“…For most liver trauma grades with hemodynamic stability, nonoperative management (NOM) is the mainstay of treatment with angiointervention/angioembolization as an indicated complement to NOM. 1,[5][6][7][8] Operative management is typically indicated in patients who are hemodynamically unstable or have signs of peritoneal irritation, free intraperitoneal air or fluid, or evidence of high-energy penetrating trauma on imaging (CT). 1,[4][5][6][7][8] Exploratory laparoscopy may be necessary to assess injury status or other abdominal injuries; however, patients requiring surgical management may present emergently and, thus, rapid intervention is necessary due to high morbidity and mortality.…”

Evaluating associations between level of trauma care and outcomes of patients with specific severe injuries: A systematic review and meta-analysis

“…35,40,54 The majority (n = 32, 91%) were United States based, [21][22][23][25][26][27][28][29][30][32][33][34][35][36][37][38][39][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55] one study was conducted in France, 24 one in Israel, 40 and one study in Canada. 31 A total of 26 (74%) studies [22][23][24][25][26][27][29][30][31][32][34][35][36]…”

“…Of all studies, 26 studies (74%) [21][22][23][25][26][27][28][29][30][31][32][33][34][35][37][38][39][43][44][45][46][47][48][49][50][51][52] reported on HLOS comparing higher with lower level trauma centers, of which 19 studies (73%) 22,23,25,26,[30][31][32]34,35,38,39,[44][45][46][47][49][50][51][52] compared Level I with Level II trauma centers (Table 1). A total of 13 studies (50%) 22,26,28,3...…”

Liver Trauma: Management in the Emergency Setting and Medico-Legal Implications

“…Other causes include work-related accidents, sports accidents, gunshots, and blunt and penetrating wounds. The American Association for the Surgery of Trauma (AAST) graded liver trauma through the Hepatic Injury Scoring Scale [ 3 , 5 ], which recognizes VI grades of trauma, from minor lesions (which represent approximately 80–90% of hepatic lesions) to those that are fatal [ 6 ]. Other issues considered in the scoring system are computed tomography findings (imaging criteria), operative criteria based on the injured area, and pathologic criteria.…”