**3. Assessment of liver trauma**

The initial resuscitation and evaluation of the patient with blunt or penetrating abdominal or thoracic trauma is similar. Most commonly, the initial resuscitation, diagnostic evaluation, and management of the trauma patient with blunt or penetrating trauma are based upon protocols from the Advanced Trauma Life Support (ATLS) guidelines, established by the American College of Surgeons Committee on Trauma (Table 1) [12].


**Table 1.** Systematic survey in ATLS

Accordingly, hemodynamically unstable trauma patients need to be transferred immediately to the operating room for emergency explore laparotomy for better life-saving evaluation and management. If the clinical setting allows, a Focused Assessment with Sonography for Trauma (FAST) exam, DPL, or CT may be performed [13].

Plain films obtained during the trauma evaluation are generally nonspecific but may demon‐ strate right-sided rib fractures, which increase the suspicion for liver injury [14].

### **3.1. History and physical examination**

of dome of right lobe of liver. Liver's ligamentous attachments to diaphragm and posterior abdominal wall act as sites of shearing forces during deceleration injury. Liver injury can also occur as a result of transmission of excessively high venous pressure to remote body sites at the time of impact. Weaker connective tissue framework, relatively large size, and incomplete maturation and more flexible ribs account for higher chance of liver injury in children compared to adults. Deceleration injuries producing shearing forces may tear hepatic lobes and often involve the inferior vena cava and hepatic veins. While a steering column injury can damage an entire lobe. In general, liver trauma may result in subcapsular/intrahepatic hematomas, lacerations, contusions, hepatic vascular injury, and bile duct injury [9, 10].

Based on the mechanism and site of blunt liver trauma, the liver injury could be classified into

The initial resuscitation and evaluation of the patient with blunt or penetrating abdominal or thoracic trauma is similar. Most commonly, the initial resuscitation, diagnostic evaluation, and management of the trauma patient with blunt or penetrating trauma are based upon protocols from the Advanced Trauma Life Support (ATLS) guidelines, established by the American

two types, type A and B as described in (Figure 1) [11].

College of Surgeons Committee on Trauma (Table 1) [12].

**3. Assessment of liver trauma**

302 Recent Advances in Liver Diseases and Surgery

Tension pneumothorax Open pneumothorax

Massive hemothorax

Massive hemothorax Cardiac tamponade

Simple pneumothorax Pulmonary contusion Tracheobronchial lesions Closed cardiac injuries Traumatic aortic rupture Traumatic diaphragm injury Lesions crossing the mediastinum

**Table 1.** Systematic survey in ATLS

**Secondary examination** (thoracic injury that endanger life)

Flail chest

Circulation

**Primary examination** Airway Breathing

Trauma generally causes irritation of diaphragm and patient complaints of pain in the right upper abdomen, right chest wall, or right shoulder. The suspicion for liver injury increases if patient gives history of trauma to the right upper quadrant, right rib cage, or right flank. Clinically, most apparent findings like abdominal pain, tenderness, and distention are seen in cases of severe abdominal hemorrhage, including hemorrhagic shock.

Even though the most common findings indicative of intra-abdominal injury are abdominal tenderness and other peritoneal signs, these findings are not sensitive or specific for liver injury. Commonly seen physical findings due to liver injury include generalized abdominal tenderness or localized tenderness on right upper quadrant or lower chest wall, presence of abdominal wall contusion or hematoma (e.g., seat belt sign), or chest wall instability due to rib fractures. Sometimes significant liver damage can occur without a wound in close proximity to site of injury. Any penetrating injury to right chest, abdomen, flank, or back increases the seriousness of injury. A negative history and normal physical examination does not reliably exclude liver injury.

Many times, physical examination findings can be unreliable due to many reasons. Such mechanisms of injury often result in other associated injuries and that can divert the physician's attention from serious life-threatening intra-abdominal pathology. The injury can be under‐ estimated due to nonspecific signs and symptoms, an altered mental state, drug and alcohol intoxication, and interpatient variability in reactions to intra-abdominal injury [1].

In about 80% of patients, other concurrent injuries can be present with blunt liver injury, which can include lower rib fractures, pelvic fracture, spinal cord injury, or combination of injuries. Such concurrent injuries can lead to rupture of vena cava, colon, diaphragm, right lung, duodenum, kidney, and extrahepatic portal structures [15].
