A 28-year-old woman is brought to the emergency department following a stab wound to the right upper quadrant. Examination reveals right-sided tenderness and mild peritoneal signs. CT scan with IV contrast shows a Grade III hepatic laceration with active extravasation. Regarding hepatic injury management, all of the following statements are correct EXCEPT:

Explanation

## Hepatic Injury Management in Blunt and Penetrating Trauma **Key Point:** The modern approach to hepatic trauma prioritizes non-operative management (NOM) in haemodynamically stable patients, even with higher-grade injuries, reserving surgery for those with uncontrolled bleeding or peritoneal signs suggesting other organ injury. ### Correct Answer Analysis **Option 2 (INCORRECT — the answer):** The statement claims that minor hepatic injuries (Grade I–II) with stable vital signs require "routine operative exploration and primary repair." This is **false**. Grade I–II injuries in stable patients are managed **non-operatively** with bed rest, serial clinical examination, and imaging surveillance. Operative intervention is reserved for haemodynamic instability, peritoneal signs, or higher-grade injuries with active bleeding [cite:ATLS 10th Edition]. **Option 0 (CORRECT):** Hepatic artery embolization (HAE) is highly effective in Grade III–IV injuries in haemodynamically stable patients, with success rates >90%. It preserves liver parenchyma and avoids the morbidity of hepatic resection. **Option 1 (CORRECT):** Perihepatic packing (also called "damage control hepatic surgery") is a critical technique in the unstable, coagulopathic patient. The liver is packed with laparotomy pads, the abdomen is left open or loosely closed, and the patient is taken to ICU for resuscitation. Re-exploration occurs after 24–48 hours when coagulopathy is corrected. **Option 3 (CORRECT):** The "lethal triad" (or "triad of death") comprises hypothermia, coagulopathy, and acidosis. Aggressive correction of these three factors is essential to break the cycle of uncontrolled bleeding and death. Permissive hypotension (target SBP 90 mmHg) is used until haemorrhage is controlled, but once bleeding is stopped, aggressive rewarming and correction of coagulopathy (fresh frozen plasma, platelets, cryoprecipitate, tranexamic acid) are mandatory. ### Hepatic Injury Grading & Management Algorithm ```mermaid flowchart TD A[Hepatic injury on imaging]:::outcome --> B{Haemodynamically stable?}:::decision B -->|Yes| C[Grade assessment]:::action C --> D{Grade I-II?}:::decision D -->|Yes| E[Non-operative management<br/>Bed rest, serial exam, repeat imaging]:::action D -->|No| F{Grade III-IV?}:::decision F -->|Yes| G[Consider HAE if stable<br/>for angiography]:::action G --> H{Bleeding controlled?}:::decision H -->|Yes| I[Continue NOM or ICU monitoring]:::action H -->|No| J[Operative intervention<br/>Hepatic resection or packing]:::urgent B -->|No, unstable| K{Other injuries<br/>requiring laparotomy?}:::decision K -->|Yes| L[Laparotomy + damage control]:::urgent K -->|No| M[Resuscitate, consider HAE<br/>if bleeding source]:::action L --> N[Perihepatic packing if<br/>uncontrolled bleeding]:::action N --> O[Correct coagulopathy<br/>& hypothermia in ICU]:::action O --> P[Re-explore in 24-48 hrs]:::action ``` **High-Yield:** The shift from mandatory operative repair to NOM + HAE has dramatically improved outcomes in hepatic trauma. Even Grade IV injuries can be managed non-operatively if the patient is haemodynamically stable and there are no other indications for laparotomy [cite:ATLS 10th Edition]. **Mnemonic: LETHAL TRIAD** — **L**ow temperature (hypothermia), **E**xcessive bleeding (coagulopathy), **T**issue damage (acidosis). Prevent by: Early transfusion, permissive hypotension until haemorrhage control, aggressive rewarming, and correction of coagulopathy. **Clinical Pearl:** A Grade III hepatic laceration with active extravasation in a haemodynamically stable patient is an ideal candidate for HAE. The patient avoids splenectomy, avoids hepatic resection, and preserves liver synthetic function.