# Blunt Liver Injury — GCMD Library living collection

Everything in the library about blunt liver injury — built automatically from dossiers that name it.

Updated: n/a · 3 episodes · 42 cited statements

## Episodes
### Acute Management
- [Trauma Committee Solid Organ Injury Protocol - APSA Practice Gaps 2019](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308) — video · [machine version](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308.md)
- [Updated APSA Guidelines for the Management of Blunt Liver and Spleen Injuries](https://library.globalcastmd.com/watch/updated-apsa-guidelines-for-the-management-of-blunt-liver-and-spleen-injuries-7734) — video · [machine version](https://library.globalcastmd.com/watch/updated-apsa-guidelines-for-the-management-of-blunt-liver-and-spleen-injuries-7734.md)

### In-Depth Reviews
- [Trauma II: Solid Organ Injury](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978) — podcast · 37:47 · [machine version](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=0) Introduction and ATOMIC Study Background (Ep 2)
- [4:11](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=251) Hemodynamic Status vs Grade-Based Management (Ep 2)
- [10:31](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=631) Crystalloid Limitation and Early Blood Transfusion (Ep 2)
- [15:28](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=928) Massive Transfusion and Angioembolization (Ep 2)
- [18:16](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1096) ICU Admission, Bed Rest, and Observation Duration (Ep 2)
- [24:04](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1444) Follow-up, Activity Restrictions, and Complications (Ep 2)
- [30:35](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1835) Summary and Key Paradigm Shifts (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=0) Case presentation: 12-year-old with grade four splenic injury (Ep 1)
- [2:17](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=137) Updated APSA guidelines: hemodynamic status over injury grade (Ep 1)
- [5:26](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=326) Fluid resuscitation and transfusion thresholds (Ep 1)
- [6:49](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=409) Activity restrictions, diet advancement, and contrast blush management (Ep 1)
- [10:32](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=632) Clinical judgment in diet advancement for high-grade injuries (Ep 1)
- [13:40](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=820) Operative intervention threshold and massive transfusion protocol (Ep 1)
- [15:26](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=926) ATOMIC consortium background and contact sports clearance (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/updated-apsa-guidelines-for-the-management-of-blunt-liver-and-spleen-injuries-7734?t=0) APSA Blunt Liver and Spleen Injury Guideline Update (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "ATOMIC (A Trauma Outcomes and Management Investigation Consortium) began around 2010 as a multi-center prospective study to develop evidence-based algorithms for solid organ injury management, starting with 5 hospitals and expanding to 10." — David Notrica (clinical) [Ep 2 · 2:11](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=131)
- "Early research by Sam Smith and colleagues in Arkansas demonstrated that patients with solid organ injury could be managed based on hemodynamic status rather than CT grade of injury, published in papers including 'Throwing Out the Grade Book.'" — David Notrica (clinical) [Ep 2 · 4:27](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=267)
- "Hypotension is a late finding in pediatric hemorrhagic shock; almost half of patients requiring early transfusion are not hypotensive." — David Notrica (clinical) [Ep 2 · 6:36](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=396)
- "The terminology 'stable' and 'unstable' was abandoned in favor of 'bleeding or having bled recently' because defining hemodynamic stability in children is problematic: concurrent head injuries may prevent tachycardia, some unstable patients are not hypotensive, and tachycardia may be due to pain rather than bleeding." — David Notrica (clinical) [Ep 2 · 7:47](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=467)
- "When a hypovolemic pediatric patient arrives, you only know they have bled; you often don't know if they're still bleeding until you give them blood and they prove ongoing bleeding. Children have superior ability to stop bleeding compared to adults." — David Notrica (clinical) [Ep 2 · 7:47](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=467)
- "Shock Index Pediatric Adjusted (SIPAA) cutoffs: ages 4-6 greater than 1.2, ages 7-12 greater than 1.0, ages 13+ greater than 0.9. An elevated shock index misses very few patients in hypovolemic shock; if shock index is not elevated, the patient is probably not actively bleeding." — David Notrica (clinical) [Ep 2 · 8:38](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=518)
- "After 20 mL/kg of crystalloid, blood transfusion should be initiated if non-operative management is desired and good outcomes are the goal. This contrasts with older ATLS guidelines recommending 60 mL/kg crystalloid before blood." — David Notrica (guideline) [Ep 2 · 10:31](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=631)
- "Adult literature shows that excessive crystalloid dilutes the benefit of 1:1:1 resuscitation (Duchesney, New Orleans) and decreases success of non-operative management (John Holcomb). Children are somewhat more resistant to negative effects of crystalloid than adults, but excess crystalloid still causes adverse effects including prolonged ventilation." — David Notrica (host_summary) [Ep 2 · 10:31](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=631)
- "One massive transfusion trial found that giving blood early and often prevented patients from progressing to require massive transfusion, suggesting early blood prevents DIC." — David Notrica (host_summary) [Ep 2 · 10:31](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=631)
- "TEG (thromboelastography) and ROTEM (rotational thromboelastometry) directed component therapy makes theoretical sense and is used at Phoenix Children's Hospital, but definitive evidence comparing directed therapy to 1:1:1 ratios in children requires a randomized controlled trial." — David Notrica (opinion) [Ep 2 · 14:35](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=875)
- "Angioembolization is safe in pediatric blunt liver and spleen injury. For splenic injury, no patients who underwent embolization went on to fail non-operative management." — David Notrica (clinical) [Ep 2 · 16:08](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=968)
- "Many patients with hepatic injury who underwent angioembolization still required laparoscopy or washout, often converted from active bleeding to managing bile complications or intra-abdominal blood." — David Notrica (clinical) [Ep 2 · 16:08](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=968)
- "Many patients with contrast extravasation on CT will stop bleeding spontaneously without angioembolization. Angioembolization criteria should be similar to failure of non-operative management: persistent bleeding requiring ongoing blood transfusion." — David Notrica (clinical) [Ep 2 · 16:08](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=968)
- "For ICU admission: grade 1-4 injuries can be managed on the floor if hemodynamically stable or not actively bleeding. Grade 5 injuries should go to the ICU based on injury grade alone, though this represents a small subset of patients." — David Notrica (guideline) [Ep 2 · 18:23](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1103)
- "The threshold for failure of non-operative management is 40 mL/kg of all blood products, based on data from NEF and military experience showing patients transfused more than 40 mL/kg are more likely to need operation and more likely to die." — David Notrica (clinical) [Ep 2 · 20:22](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1222)
- "Bed rest was never included in the original APSA protocols (per Steve Stiglianos) but became part of the culture. There is no literature supporting bed rest for solid organ injury." — David Notrica (clinical) [Ep 2 · 20:22](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1222)
- "One adult study comparing bed rest versus no bed rest found no increased incidence of bleeding without bed rest. For renal injury, bed rest makes no difference whether patients walk to the bathroom or remain on strict bed rest." — David Notrica (clinical) [Ep 2 · 20:22](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1222)
- "Patients with blunt liver or spleen injury showing no signs of bleeding, no hemodynamic instability, and no hematocrit drop do not need a minimum hospitalization time. An 18-hour observation period is sufficient; if they haven't bled in 18 hours, they are very unlikely to bleed. This is supported by data showing all transfused patients and all failures occurred early." — David Notrica (clinical) [Ep 2 · 22:00](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1320)
- "Serial hemoglobins are not necessary in stable patients. Hemoglobin drops for multiple reasons unrelated to bleeding: lab error, drawing upstream from IV, dilution from excess fluid. Physical examination and vital signs (especially rising heart rate, poor capillary refill, pallor, cold extremities) are better indicators of ongoing bleeding and will identify every patient needing transfusion or failing non-operative management." — David Notrica (clinical) [Ep 2 · 22:00](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1320)
- "Half of patients who fail non-operative management do so because they develop peritonitis, not because of continued bleeding." — David Notrica (clinical) [Ep 2 · 24:03](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1443)
- "Many patients with low-grade injuries never showed for follow-up clinic appointments. Telephone follow-up was implemented for low-grade injuries to confirm patient status without requiring additional missed school days." — David Notrica (clinical) [Ep 2 · 24:41](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1481)
- "Follow-up visits for higher-grade injuries have not provided much benefit to patients. Patients with complications presented to the emergency room with symptoms; the follow-up visit itself did not identify problems or change management." — David Notrica (clinical) [Ep 2 · 24:41](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1481)
- "Discharge instructions should list symptoms that indicate complications: abdominal pain, respiratory problems (for splenic injury), and jaundice. All direct patients back to the emergency room except jaundice, which warrants a phone call to the office for triage since it may represent hematoma mobilization rather than bile leak." — David Notrica (guideline) [Ep 2 · 25:40](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1540)
- "Most patients with spleen injuries do not need follow-up imaging. Patients with liver injuries might benefit from follow-up ultrasound, but this remains uncertain." — David Notrica (opinion) [Ep 2 · 27:27](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1647)
- "Studies performing routine ultrasounds found many pseudoaneurysms, but the number was discordant with patients who developed delayed bleeding or complications. Having an asymptomatic pseudoaneurysm does not mean the patient will have delayed bleed or complication; the risk is less than 10% and likely much lower." — David Notrica (clinical) [Ep 2 · 27:27](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1647)
- "It is extremely rare for any patient who goes home from the hospital doing well to develop a finding that would put them at risk for life-threatening bleed." — David Notrica (clinical) [Ep 2 · 27:27](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1647)
- "Children with solid organ injury can return to school but need to change classes 5 minutes before other students to avoid hallway contact. They cannot participate in gym class or physical education." — David Notrica (guideline) [Ep 2 · 28:30](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1710)
- "Activity restriction duration follows the APSA recommendation of grade plus 2 weeks (e.g., grade 4 injury = 6 weeks restriction). This is based on expert opinion, not scientific evidence." — David Notrica (guideline) [Ep 2 · 28:30](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1710)
- "Early recurrent hypotension (patient responds to transfusion, becomes stable, then becomes unstable again before reaching ICU) represents failure of non-operative management. This is different from hemoglobin drifting down in the ICU. The patient needs to go to the operating room or angio suite very quickly." — David Notrica (clinical) [Ep 2 · 35:38](https://library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=2138)
- "The APSA Outcomes Committee and Trauma Committee conducted a retrospective review to update guidelines on liver and spleen blunt trauma." — Cecilia (host_summary) [Ep 3 · 0:00](https://library.globalcastmd.com/watch/updated-apsa-guidelines-for-the-management-of-blunt-liver-and-spleen-injuries-7734?t=0)
- "The updated guidelines divide treatment into four stages using the acronym APSA: A for admission, P for procedures, S for set free or discharge, and A for aftercare." — Cecilia (host_summary) [Ep 3 · 0:00](https://library.globalcastmd.com/watch/updated-apsa-guidelines-for-the-management-of-blunt-liver-and-spleen-injuries-7734?t=0)
- "The main change in the updated guidelines is that treatment is based on clinical signs and symptoms instead of grade of injury." — Cecilia (host_summary) [Ep 3 · 0:00](https://library.globalcastmd.com/watch/updated-apsa-guidelines-for-the-management-of-blunt-liver-and-spleen-injuries-7734?t=0)
- "The updated APSA blunt liver and splenic injury guidelines were presented at the APSA annual meeting and developed by the APSA Trauma Committee and the ATOMIC group." — Lee (host_summary) [Ep 1 · 2:17](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=137)
- "Management should be based on the patient's hemodynamic status (whether the patient is bleeding or has recently bled, or is stable) rather than injury grade." — Lee (host_summary) [Ep 1 · 2:45](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=165)
- "A modified shock index for pediatrics (heart rate over systolic blood pressure, interpreted by age) can be used to determine if a patient may still be bleeding." — Lee (host_summary) [Ep 1 · 3:20](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=200)
- "Patients who respond to normal saline bolus and remain hemodynamically stable need only to be observed and do not require ICU admission." — Lee (host_summary) [Ep 1 · 3:40](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=220)
- "Management is not based on the grade of injury, as shown multiple times in prospective studies." — Lee (clinical) [Ep 1 · 4:00](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=240)
- "Patients admitted to the ward need another hemoglobin check in six hours, can have a regular diet, and have no activity restrictions." — Lee (host_summary) [Ep 1 · 4:20](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=260)
- "Transfusion is indicated only if patients are unstable or have hemoglobin less than seven, or if there are signs of ongoing bleeding." — Lee (host_summary) [Ep 1 · 4:50](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=290)
- "Angioembolization in stable patients does not need to be done even with contrast blush, particularly in patients with splenic injuries, as these have been shown not to continue to bleed." — Lee (host_summary) [Ep 1 · 5:10](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=310)
- "Angioembolization should be performed if there is evidence of ongoing bleeding." — Lee (host_summary) [Ep 1 · 5:10](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=310)
- "After the first 20 ml per kilo normal saline bolus, if the patient still requires additional fluids, give blood rather than another fluid bolus." — Lee (guideline) [Ep 1 · 5:52](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=352)
- "The blood transfusion dose is 10 ml per kilo." — Lee (guideline) [Ep 1 · 6:19](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=379)
- "The original APSA guidelines did not address in-house bed rest or activity restrictions." — Lee (guideline) [Ep 1 · 7:16](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=436)
- "Patients admitted to the ward do not need any activity restrictions and can go to the bathroom and walk around." — Lee (guideline) [Ep 1 · 7:41](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=461)
- "Contrast blush on CT does not require intervention unless there is evidence of bleeding." — Lee (guideline) [Ep 1 · 8:37](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=517)
- "Physical exam (capillary refill, heart rate) is probably a better indicator of hemodynamic status than hemoglobin monitoring." — Lee (opinion) [Ep 1 · 9:11](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=551)
- "In splenic injuries, if the patient has stopped bleeding (responded to normal saline bolus), advancing to a regular diet is advocated." — Lee (opinion) [Ep 1 · 10:05](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=605)
- "By the time a patient with significant injury and contrast blush gets to the floor (a four to six hour process), if the patient is stable, starting a regular diet is not unreasonable." — Lee (opinion) [Ep 1 · 11:24](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=684)
- "The risk of actually going to the operating room for splenic trauma is very low." (opinion) [Ep 1 · 12:15](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=735)
- "If a patient has a bad hemoperitoneum and ileus, they probably will not eat even if a regular diet is ordered." (clinical) [Ep 1 · 13:14](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=794)
- "Based on the ATOMIC protocol, operative intervention is indicated when patients require more than 40 ml per kilogram of packed red blood cells." — Lee (host_summary) [Ep 1 · 14:28](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=868)
- "Contact sports including football can be resumed within weeks after splenic injury, regardless of grade." — Lee (host_summary) [Ep 1 · 15:26](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=926)
- "ATOMIC is a group of level one pediatric trauma centers (Arkansas, Texas, Oklahoma, Memphis, Arizona, Akron, Kansas City, and others) that came together in 2010 to prospectively study vital trauma questions." — Lee (clinical) [Ep 1 · 15:53](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=953)
- "ATOMIC initially developed guidelines for management of isolated blunt liver and splenic injuries, then prospectively studied them, leading to publications that redefined the guidelines adopted by APSA." — Lee (clinical) [Ep 1 · 15:53](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=953)
- "There is not great evidence in the pediatric literature for 1:1:1 massive transfusion protocol, with mixed results." — Lee (clinical) [Ep 1 · 17:56](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=1076)
- "Massive transfusion protocol should be considered when the patient is still bleeding and unstable." — Lee (guideline) [Ep 1 · 17:56](https://library.globalcastmd.com/watch/trauma-committee-solid-organ-injury-protocol-apsa-practice-gaps-2019-2308?t=1076)

## Changelog
- Sep 25: 3 items added automatically

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