Quick reference algorithm

Hepatic Injury Management

Patients with blunt hepatic injury · October 2026 edition

Blunt hepatic injuryNOM pathwayAAST gradingAAST grades ↓

Blunt hepatic injury identified

ATLS primary survey
FAST exam
CT abdomen/pelvis with IV contrast

Hemodynamically stable? After initial resuscitation

NoUnstable ↓YesStable ↓

Hemodynamically unstable

Non-responder or transient responder

Emergent laparotomy

Damage control surgery

Perihepatic packing
Pringle maneuver
Temporize → ICU resuscitation
Planned re-exploration at 24–48 h

Hepatic vein / IVC injury

Grade V — consider atriocaval shunt or total vascular isolation

High mortality — damage control priority

Yes

Hemodynamically stable

NOM candidate — all grades if stable

Grade I–II

Floor

Vital signs q4h
H/H q12h until stable × 2
Serial abdominal exams
LFTs at admission; repeat for clinical change
Early mobilization — no routine bed rest
Repeat CT only for clinical change

Grade III–V

ICU ≥ 24 h

Continuous HR; BP q1–2h for the first 24 h
H/H q6h × 24 h → q12h × 24 h → daily; step down only while stable
Serial abdominal exams; type & screen / crossmatch
LFTs at admission, 24 h, 48 h
Mobilize once H/H stable
No routine repeat CT; consider screening CT 3–5 days after injury, before discharge
Consider angioembolization if blush

Selected stable grade III without active bleeding may go to step-down.

Monitoring follows WTA (H/H q12h until stable × 2 for grade I–II; q6h until stable × 2 with ICU ≥ 24 h for grade III–V). The q12h → daily step-down and the LFT schedule are institutional practice; no guideline specifies either.

VTE chemoprophylaxis, if no active bleeding or contraindication: grade I–III within 24 h; grade IV–V 24–48 h once hemodynamically stable with stable H/H

Mechanical prophylaxis (SCDs) for all from admission

VTE prophylaxis chart →

Active arterial extravasation? Blush or PSA on CT

YesAngioembolization ↓NoContinue NOM ↓

Yes

Angioembolization

IR consult emergently
Selective hepatic artery embolization
Post-embolization: monitor for hepatic necrosis, biliary complications

Continue NOM monitoring

Serial H/H and abdominal exams; LFTs per admission tier above
Mobilization: grade I–II early; grade III–V once H/H stable

Monitor for biliary complications (Grade III–V)

Bile leak / biloma occurs in 3–20% of high-grade injuries

Rising bilirubin, RUQ pain, fevers → CT to evaluate

Treatment: percutaneous drain ± ERCP with stent

NOM failure triggers → operative intervention

Hemodynamic instability despite resuscitation
> 4 units pRBC in 24 h
Peritonitis (screen for hollow viscus injury)
Falling H/H despite transfusion

Discharge — Grade I–II

Minimum: ≥ 24 h from injury, stable H/H, tolerating diet
No routine follow-up imaging
Normal activity at (grade + 2) weeks: grade I → 3 weeks, grade II → 4 weeks

Discharge — Grade III–V

Minimum: ≥ 72 h from injury, stable H/H, tolerating diet
Normal activity at 6 weeks with clinical clearance
Biliary complications present later (mean ~12 days): return for pain, fever, jaundice

Return precautions — all grades

Increasing abdominal pain, lightheadedness, nausea or vomiting

AAST 2018 · CT imaging criteria

Liver injury grades

Any single criterion assigns the grade.

Vascular injury or active bleeding: where it lands sets the grade (inside the liver parenchyma versus beyond it into the peritoneum)

Contained within the liver parenchyma

Grade III

Beyond the liver parenchyma into the peritoneum

Grade IV

Drawing key

Parenchyma and capsule
IVC and hepatic veins (behind the liver)
Subcapsular hematoma
Intraparenchymal hematoma
Laceration, with depth bracket
Vascular injury (pseudoaneurysm or AV fistula)
Active bleeding, contained within the parenchyma
Active bleeding, extending into the peritoneum
Parenchymal disruption

Labels in the drawings: PSA = pseudoaneurysm. Depth brackets measure a laceration from the capsule inward.

Grade I

AIS 2

Subcapsular hematoma < 10% surface area
Parenchymal laceration < 1 cm in depth

Grade II

AIS 2

Subcapsular hematoma 10–50% surface area
Intraparenchymal hematoma < 10 cm in diameter
Laceration 1–3 cm in depth and ≤ 10 cm in length

Grade III

AIS 3

Subcapsular hematoma > 50% surface area
Ruptured subcapsular or parenchymal hematoma
Intraparenchymal hematoma > 10 cm
Laceration > 3 cm in depth
Any injury with liver vascular injury or active bleeding contained within the liver parenchyma

Grade IV

AIS 4

Parenchymal disruption involving 25–75% of a hepatic lobe
Active bleeding extending beyond the liver parenchyma into the peritoneum

Grade V

AIS 5

Parenchymal disruption > 75% of a hepatic lobe
Juxtahepatic venous injury (retrohepatic vena cava and central major hepatic veins)

All AAST grading scales and definitions →

Hepatic Injury Management

Hemodynamically unstable

Damage control surgery

⚠ Hepatic vein / IVC injury

Hemodynamically stable

Grade I–II

Grade III–V

Angioembolization

Continue NOM monitoring

Monitor for biliary complications (Grade III–V)

NOM failure triggers → operative intervention

Discharge — Grade I–II

Discharge — Grade III–V

Return precautions — all grades

Liver injury grades

Grade I

Grade II

Grade III

Grade IV

Grade V

Hepatic Injury Management

Hemodynamically unstable

Damage control surgery

⚠ Hepatic vein / IVC injury

Hemodynamically stable

Grade I–II

Grade III–V

Angioembolization

Continue NOM monitoring

Monitor for biliary complications (Grade III–V)

NOM failure triggers → operative intervention

Discharge — Grade I–II

Discharge — Grade III–V

Return precautions — all grades

Liver injury grades

Grade I

Grade II

Grade III

Grade IV

Grade V

Hepatic vein / IVC injury

Hepatic vein / IVC injury