Nonoperative treatment of civilian gunshot wound of the liver with hemodynamic instability: report of two cases

Background

The conservative approach of blunt hepatic trauma and low-energy (stab) penetrating injuries is well established. Nonoperative treatment of patients who suffered civilian (medium-energy) gunshot wound (GSW) of the torso, including the liver, although controversial, could be conducted without surgery in selected patients presenting to the emergency room hemo-dynamically stable and without evidence of peritonism. Physical examination and abdominal computed tomography (CT) are essential to guide the initial therapy. The nonoperative management is attractive once it avoids the morbidity of a nontherapeutic laparotomy, reported to be as high as 41.3%. In a hemo-dynamically unstable patient with GSW of the liver, nonoperative treatment carries great controversy.

Objective

To report two cases of nonoperative treatment of GSW of the liver with hemodynamic instability guided by an institutional protocol in the emergency department.

Methods

Case reports.

Results

Case 1

A 37-year-old male patient became hemo-dynamically unstable and had systolic blood pressure of 90 mmHg 12 hours after admission on an institutional protocol to the emergency department. After infusion of 1,500 ml saline solution the patient rapidly became stable and 2 units red blood packed cells were administered. The abdominal CT scan showed injuries in segments 5, 6, 7 and 8. The control abdominal CT showed good evolution.

Case 2

An 18-year-old female patient suffered an isolated GSW in the right hippocondrius. The patient was admitted to the emergency room with hemodynamic instability, systolic blood pressure of 80 mmHg, cardiac frequency of 128, agitated and without verbal response. After infusion of saline solution the patient rapidly became stable and 2 units red blood packed cells were administered. The abdominal CT showed injuries in segments 7 and 8. A control abdominal CT was not necessary.

Conclusion

Nonoperative treatment of GSW of the liver with hemodynamic instability is possible in selected young patients, who rapidly became stable after initial fluid reanimation, in the emergency room and guided by an institutional protocol.