**4. Liver trauma classification**

The American Association for the Surgery of Trauma (AAST) grading scale is widely utilized for the classification of liver injury severity (**Table 1**) [18, 19]. However, it does not take into consideration the hemodynamic status of patients and the associated injuries. Thus, the World Society of Emergency Surgery (WSES) proposed a novel classification for the proper management of hepatic injuries involving AAST grade (1994 revision), hemodynamic stability, and mechanism of injury (**Table 2**) [2, 20].

Minor (WSES grade I) and moderate (WSES grade II) liver injuries concern hemodynamically stable patients after either blunt or penetrating trauma with AAST grade I-II or III lesions, respectively. Severe hepatic injuries include


#### **Table 1.**

*The American Association for the Surgery of Trauma (AAST) liver injury scale (2018 revision).*


**Table 2.** *The World Society of Emergency Surgery (WSES) classification and management of liver trauma.*

**41**

**Figure 2.**

*Damage Control Surgery for Liver Trauma DOI: http://dx.doi.org/10.5772/intechopen.94109*

**5. Initial assessment and investigation**

theater, and blood–blood products [20, 23].

*Computed tomography scan demonstrating a severe liver injury.*

(WSES grade IV).

bleeding [20].

patients.

hemodynamically stable, AAST grade IV-VI lesions following penetrating or blunt trauma (WSES grade III) (**Figure 2**) or any hemodynamically unstable lesion

The importance of the WSES classification and management approach is highlighted by the fact that patients suffering from high-grade AAST lesions, which are hemodynamically stable, can be successfully treated non-operatively [21]. On the contrary, "minor" AAST injuries combined with hemodynamic instability must be treated operatively in order to control the intrabdominal

A liver injury should always be suspected in all patients suffering from a blunt or penetrating thoracoabdominal trauma, especially at the right site. Initial management of these patients should be based on the Advanced Trauma Life Support (ATLS) guidelines with fluid resuscitation and close monitoring being the first priorities [22]. Depending on the underlying injury mechanism, other concurrent injuries should also be evaluated and treated accordingly. The management of multi-trauma patients should take into consideration all the affected organs, and a multidisciplinary team is essential for the optimal treatment approach of these

As far as hepatic trauma is concerned, in hemodynamically unstable patients, despite adequate fluid resuscitation, an immediate operation for bleeding control is indicated, whereas in stable patients, an appropriate workup protocol using ultrasonography or computerized tomography scanning (CT) can be followed. Hemodynamic instability is characterized by the following: heart rate > 120 bpm, systolic blood pressure < 90 mmHg, low urine output, increased respiratory rate (>30 respirations/minute), signs of skin vasoconstriction and altered level of consciousness [22]. Non-operative management necessitates medical centers capable of an accurate injury severity diagnosis, intensive management of patients, and prompt access to diagnostic modalities, interventional radiology, operation

*Trauma and Emergency Surgery - The Role of Damage Control Surgery*

### *Damage Control Surgery for Liver Trauma DOI: http://dx.doi.org/10.5772/intechopen.94109*

*Trauma and Emergency Surgery - The Role of Damage Control Surgery*

**WSES** 

**AAST** 

**Mechanism of** 

**Hemodynamic** 

**CT-scan**

**First-line treatment**

**status**

**grade\***

**Injury**

**grade**

MINOR MODERATE

SEVERE

III IV *NOM: non-operative management.*

**Table 2.**

I-VI *\*American Association for the Surgery of Trauma (AAST) liver injury scale (1994 revision).*

*The World Society of Emergency Surgery (WSES) classification and management of liver trauma.*

IV-V

II

III

I

I-II

Blunt/penetrating

Blunt/penetrating

Blunt/penetrating

Blunt/penetrating

Unstable

NO

Surgery

Stable

Stable

Stable

YES + local exploration in stab

NOM + clinical/laboratory/radiological

evaluation

wounds

**40**

hemodynamically stable, AAST grade IV-VI lesions following penetrating or blunt trauma (WSES grade III) (**Figure 2**) or any hemodynamically unstable lesion (WSES grade IV).

The importance of the WSES classification and management approach is highlighted by the fact that patients suffering from high-grade AAST lesions, which are hemodynamically stable, can be successfully treated non-operatively [21]. On the contrary, "minor" AAST injuries combined with hemodynamic instability must be treated operatively in order to control the intrabdominal bleeding [20].
