Liver Trauma: Presentation, Management, and Anaesthetic Considerations

Epidemiology and Mechanism

Diagnosis and Grading

• FAST (Focused Assessment with Sonography for Trauma) identifies free intraperitoneal fluid at the bedside.
• Haemodynamically unstable patients with penetrating injury go straight to laparotomy/thoracotomy while resuscitation and blood products are mobilised.
• Haemodynamically stable patients get contrast-enhanced CT chest/abdomen (dual arterial/portal-venous phase) to grade injury and detect pseudoaneurysm or AV fistula.
• The AAST liver injury scale (revised 2018) grades I (subcapsular haematoma <10% surface area, capsular tear <1 cm) through to VI (hepatic avulsion) - Bailey and Love's Short Practice of Surgery, 28th ed.

Surgical Management

• Rooftop or midline incision with xiphisternal extension for exposure.
• Perihepatic packing against the diaphragmatic contour is the first-line technique - effective for most injuries, but overzealous packing risks pressure necrosis or abdominal compartment syndrome.
• Pringle manoeuvre (occlusion of the hepatoduodenal ligament - hepatic artery and portal vein) if packing fails to control bleeding; warm ischaemia tolerated up to ~45 minutes.
• Suture ligation, hepatotomy, resectional debridement; anatomical resection and venovenous bypass reserved for tertiary centres with major hepatic vein/IVC injury.
• Packs are removed at 48-72 hours once coagulopathy, temperature, and acidosis are corrected.
• Major complications: recurrent haemorrhage, sepsis, bile leak, and (long-term) biliary stricture or hepatic abscess.

1. Phase 1 - recognition, rapid-sequence induction, rewarming, transfer to theatre.
2. Phase 2 - abbreviated laparotomy: control bleeding/contamination, pack, temporary closure.
3. Phase 3 - ICU resuscitation to normalise physiology.
4. Phase 4 - planned re-look and definitive repair, sometimes over multiple trips.

Anaesthetic Considerations

• Assume full stomach and aspiration risk in all trauma patients - rapid-sequence induction with cricoid pressure.
• Presume cervical spine injury until cleared; use manual in-line stabilisation for laryngoscopy.
• Choose induction agents that preserve haemodynamic stability - ketamine or etomidate are preferred over propofol in hypovolaemic patients; reduce doses in shock.
• Avoid nitrous oxide (bowel distension, risk of pneumothorax expansion if occult).

• Large-bore IV access (x2) plus consideration of rapid infusion devices; arterial line for continuous BP and blood gas/coagulation monitoring; central access often needed for vasopressors and CVP trends.
• Continuous core temperature monitoring - hypothermia worsens coagulopathy and bleeding, so warm all fluids/blood and use forced-air warming; keep the theatre warm.

• Up to 25% of trauma patients have trauma-induced coagulopathy (TIC) before resuscitation even begins.
• Give red cells, FFP, and platelets in a balanced 1:1:1 ratio (massive transfusion protocol) rather than large-volume crystalloid, which dilutes clotting factors and worsens acidosis - Morgan and Mikhail's Clinical Anesthesiology, 7e.
• Tranexamic acid within 3 hours of injury improves survival in bleeding trauma patients (CRASH-2 trial data).
• Permissive hypotension (target systolic ~80-90 mmHg or a palpable radial pulse, in patients without head injury) until surgical haemorrhage control is achieved, to avoid "popping the clot."
• Correct the lethal triad aggressively: hypothermia, coagulopathy, and metabolic acidosis potentiate each other and drive mortality.
• Monitor for TACO (transfusion-associated circulatory overload) as the main risk of DCR; TRALI risk is reduced by male/never-pregnant plasma donors.

• Anticipate abrupt haemodynamic swings during Pringle manoeuvre (portal vein/hepatic artery occlusion) and IVC clamping - sudden preload drop and hypotension; communicate closely with the surgical team about clamp/unclamp timing.
• Watch for air embolism or reperfusion hypotension/hyperkalaemia on unclamping, especially after prolonged warm ischaemia.
• Elevated intra-abdominal pressure from packing can cause abdominal compartment syndrome - monitor ventilatory pressures, oxygenation, and urine output; consider intra-abdominal pressure measurement.
• Ventilation: expect reduced compliance from packing/distension; use lung-protective settings and be alert to tension pneumothorax if chest trauma coexists.
• Renal protection: maintain perfusion pressure, avoid nephrotoxins, monitor urine output closely given risk of hypoperfusion and rhabdomyolysis/haemoglobinuria.

• Continue rewarming, correction of coagulopathy/acidosis, and ventilatory support.
• Plan for return to theatre (Phase 4) for pack removal and definitive repair once physiology normalises (usually 24-72 hours).
• Antibiotic cover is advisable given contamination risk and necrotic tissue.

Key sources

• Liver trauma pathophysiology, grading, and surgical technique - Bailey and Love's Short Practice of Surgery, 28th ed.
• Damage control surgery phases - Bailey and Love's Short Practice of Surgery, 28th ed.
• Trauma anaesthesia, damage control resuscitation, massive transfusion, tranexamic acid - Morgan and Mikhail's Clinical Anesthesiology, 7e.
• Permissive hypotension and DCR components - Mulholland and Greenfield's Surgery, 7e.
• Recent evidence: Güsgen et al. 2025 systematic review/guideline update on surgical management of abdominal trauma (PMID: 40237811); Duncan et al. 2023 meta-analysis on hepatic pseudoaneurysm risk after liver trauma (PMID: 36690777) - both consistent with the damage-control approach above.