Reevaluating the management and outcomes of severe blunt liver injury

Background: The purpose of this study was to identify risk factors that predict the need for operative management (OM) of severe blunt liver injury. We also sought to determine the impact of interventional angiography (Ang) in the treatment and outcomes of these patients. Methods: Patients with blunt liver injuries of grade IV or higher were retrospectively reviewed for their demographics, hemodynamics, blood product requirements, laboratory and radiologic data, hospital course, and outcomes. Results: Forty-four patients underwent OM. They had a significantly higher Injury Severity Score (ISS) and lower Glasgow Coma Scale score (p = 0.004), a lower systolic blood pressure (p = 0.002) and a higher heart rate (p = 0.02), and higher fluid and transfusion requirements (p <0.001) than those treated without OM. Their mortality rate was 66%; 59% of deaths were from uncontrolled bleeding. Initial platelet count and fluid requirements at 4 hours were independent predictors of the need for OM. Ang was performed in 48 patients. Patients who were treated without Ang required more fluids (p = 0.03) and more packed red blood cells (p = 0.02) at 4 hours. Patients requiring both OM and Ang had a higher complication rate (p = 0.02) and longer intensive care unit and hospital length of stay (p <0.001) than those who had OM alone, but mortality was the same (p = 0.1). Patients treated nonoperatively had longer intensive care unit (p = 0.006) and hospital stays (p <0.05) if they required Ang, but mortality was the same. The only survival advantage to the use of Ang was when Ang alone was compared with OM alone. Conclusion: Select high-grade injuries can be successfully managed nonoperatively. Initial platelet count and crystalloid fluid use at 4 hours predict the need for OM. Patients requiring OM are less stable and have substantial mortality but often do not die as a result of uncontrolled bleeding. Ang has a role in stable patients who do not require OM initially but does not improve outcome in patients who require OM.