A 35-year-old woman is involved in a motor vehicle accident. On assessment in the trauma bay, her GCS is 14, BP is 95/60 mmHg, HR is 118/min, and FAST examination reveals free fluid in Morison's pouch and the pelvis. After two large-bore IV cannulas are inserted and 1 litre of crystalloid is given, her BP improves to 100/65 mmHg temporarily but then drops again to 88/55 mmHg. CT abdomen confirms Grade IV liver laceration with active arterial extravasation. What is the next best step?
- A Emergency exploratory laparotomy ✓
- B Angioembolisation of the hepatic artery
- C Continue IV fluid resuscitation and observe in ICU
- D Massive transfusion protocol and recheck FAST in 30 minutes
Explanation
A haemodynamically unstable patient with Grade IV liver laceration and active haemorrhage despite initial resuscitation requires emergency exploratory laparotomy — damage control surgery with perihepatic packing, control of haemorrhage, and temporary abdominal closure. Angioembolisation is appropriate for haemodynamically stable or transiently stabilised patients with Grade IV–V injuries. In an unstable patient, the time required for angiography is not available. Continued conservative management or reassessment in the ICU in a patient with recurrent haemodynamic instability risks exsanguination.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.