title: Is the Grading of Liver Injuries a Useful Clinical Tool in the Initial Management of Blunt Trauma Patients?
abstract: BACKGROUND
  Computed tomography (CT) has become the preferred method for evaluation of the abdomen for victims of blunt trauma. Grading of liver injuries, primarily by CT, has been advocated as a measure of severity and, by implication, the likelihood for intervention or complications. We have sought to determine if grading of liver injuries, as a clinical tool, affects immediate or extended management of patients.
  
  
  METHODS
  We have retrospectively reviewed all patients sustaining blunt liver injuries as diagnosed by CT over a five-year period at a Level I trauma center to determine if grading of injury influenced management. The AAST organ scaling system was utilized (major grade 4-5, minor grade 1-3), as well as the ISS, AIS, mortality, morbidity, and treatment. There were 133 patients available for review. The patients were grouped into major (n = 20) and minor (n = 113) liver injuries and operative (n = 12) and nonoperative (n = 121) management.
  
  
  RESULTS
  Major liver injuries had a higher ISS (39 + 13 vs. 27 + 15, p = 0.001) and were more likely to require operative intervention (5/20 vs. 7/113, p = 0.02). Mortality in this group was not different (major vs. minor), and there were no differences in the incidence of complications. Twelve patients (9%) required operation, all for hemodynamic instability, all within 24 h, and 11/12 within 6 h. At operation 8/12 patients had other sources of bleeding beside the liver injury, and 7/12 had minor hepatic injuries. The operative patients had higher ISS and AIS scores (head/neck, chest, abdomen, extremities) than those managed nonoperatively. More patients died in the operative group (6/12 vs. 8/121, p = 0.0003). There were more pulmonary (6/12 vs. 16/121, p = 0.005), cardiovascular (6/12 vs. 19/121, p = 0.01), and infectious (5/12 vs. 20/121, p = 0.049) complications in the operative group. There were 14 deaths overall; 13/14 were due to traumatic brain injury, and 8/14 required urgent operation for hemorrhage.
  
  
  CONCLUSIONS
  In conclusion, grading of liver injuries does not seem to influence immediate management. Physiologic behavior dictated management and need for operative intervention, as well as prognosis. However, both major hepatic injuries and need for early operation reflected overall severity and the possibility of associated injuries.
authors.affiliation: Department of Surgery, Conemaugh Memorial Medical Center, 1086 Franklin Street, Johnstown, PA, 15905, USA. thelling@conemaugh.org.
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Helling
authors.forename: Michael R
authors.initials: MR
authors.lastname: Ward
authors.affiliation: Department of Surgery, Conemaugh Memorial Medical Center, Johnstown, PA, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Balon
keywords: Blunt trauma; Hepatic injuries; Liver trauma; Trauma
references.citation: J Trauma. 1996 Jan;40(1):31-8
references.pmid: 8576995
references.citation: Ann Surg. 1995 Jun;221(6):744-53; discussion 753-5
references.pmid: 7794078
references.citation: Radiology. 1989 Apr;171(1):27-32
references.pmid: 2928537
references.citation: Ann Surg. 1954 May;139(5):690-719
references.pmid: 13159120
references.citation: Ann Surg. 1986 Oct;204(4):438-45
references.pmid: 3767479
references.citation: J Trauma. 1995 Mar;38(3):323-4
references.pmid: 7897707
references.citation: Arch Surg. 2003 May;138(5):475-80; discussion 480-1
references.pmid: 12742948
references.citation: J Trauma. 2003 Dec;55(6):1077-81; discussion 1081-2
references.pmid: 14676654
references.citation: J Trauma. 2004 Sep;57(3):494-500
references.pmid: 15454793
references.citation: J Trauma. 2006 Sep;61(3):547-53; discussion 553-4
references.pmid: 16966985
references.citation: J Am Coll Surg. 2005 May;200(5):648-69
references.pmid: 15848355
references.citation: J Trauma. 2007 Jul;63(1):44-9
references.pmid: 17622867
references.citation: Radiology. 1996 Oct;201(1):215-20
references.pmid: 8816546
references.citation: J Am Coll Surg. 2008 Apr;206(4):685-93
references.pmid: 18387475
references.citation: J Trauma. 2006 Sep;61(3):541-4; discussion 545-6
references.pmid: 16966984
references.citation: J Trauma. 1998 Aug;45(2):360-4; discussion 365
references.pmid: 9715196
references.citation: J Trauma. 1994 Oct;37(4):616-21
references.pmid: 7932893