A 34-year-old woman is admitted to the trauma unit following a crush injury to the abdomen sustained when a heavy metal shelf collapsed on her during a warehouse accident. On examination, she is alert, blood pressure 110/70 mmHg, heart rate 102/min. The abdomen is tender diffusely with guarding over the right lower quadrant. FAST is negative. CT scan with IV contrast shows a Grade III liver laceration in the right lobe with a small amount of free fluid in the pelvis, and a Grade II renal laceration on the right with a small perinephric hematoma. Urine dipstick shows 2+ blood. Over the next 6 hours, her haemodynamic parameters remain stable, urine output is maintained at 0.5 mL/kg/hr, and repeat abdominal examination shows no peritonitis. What is the most appropriate management?

Explanation

## Non-Operative Management of Blunt Abdominal Trauma **Key Point:** Haemodynamically stable patients with blunt liver and renal injuries can be managed non-operatively with close monitoring, regardless of injury grade, provided there is no peritonitis or ongoing hemorrhage. ### Criteria for Non-Operative Management | Criterion | This Patient | Status | | --- | --- | --- | | Haemodynamic stability | BP 110/70, HR 102 | ✓ Stable | | Peritonitis | Absent on serial exam | ✓ Absent | | Ongoing hemorrhage | No signs | ✓ Controlled | | Urine output | 0.5 mL/kg/hr | ✓ Adequate | | FAST | Negative | ✓ No free fluid | | Conscious level | Alert, GCS 15 | ✓ Normal | **High-Yield:** **Haemodynamic stability is the primary determinant of operative vs. non-operative management**, not injury grade. Grade III liver and Grade II renal injuries can both be managed conservatively in stable patients. ### Non-Operative Management Protocol 1. **Admission to ICU or high-dependency unit** for continuous monitoring 2. **Strict bed rest** until haemodynamically stable for 48–72 hours 3. **Serial abdominal examinations** every 2–4 hours initially to detect peritonitis or deterioration 4. **Maintain adequate analgesia** without masking peritoneal signs 5. **Serial hemoglobin checks** to detect ongoing bleeding 6. **Follow-up CT imaging** at 4–6 weeks to document healing (not acutely unless clinical deterioration) **Clinical Pearl:** The presence of hematuria in renal injury does not mandate intervention; it indicates the injury but does not change management strategy if the patient is stable. ### Liver Injury Grading Context Grade III liver laceration involves parenchymal disruption but does not mandate surgery in stable patients. Success rate of non-operative management for blunt liver injury is >90% in haemodynamically stable patients. **Mnemonic:** **STABLE = OBSERVE** — Haemodynamic stability with no peritonitis or ongoing hemorrhage = non-operative management with close monitoring. [cite:ATLS 10th Edition Ch 8]