Is this a laparotomy now, or a candidate for non-operative management?

NICE NG39

• “Limit diagnostic imaging (such as chest and pelvis X‑rays or FAST [focused assessment with sonography for trauma]) to the minimum needed to direct intervention in patients with suspected haemorrhage and haemodynamic instability who are not responding to volume resuscitation.” (1.5.29)
• “Be aware that a negative FAST does not exclude intraperitoneal or retroperitoneal haemorrhage.” (1.5.30)
• “Consider immediate CT for patients with suspected haemorrhage if they are responding to resuscitation or if their haemodynamic status is normal.” (1.5.31)
• “Do not use FAST or other diagnostic imaging before immediate CT in patients with major trauma.” (1.5.32)
• “Do not use FAST as a screening modality to determine the need for CT in patients with major trauma.” (1.5.33)

Whole-body CT

• “Use whole‑body CT (consisting of a vertex‑to‑toes scanogram followed by a CT from vertex to mid‑thigh) in adults (16 or over) with blunt major trauma and suspected multiple injuries. Patients should not be repositioned during whole‑body CT.” (1.5.34)
• “Do not routinely use whole‑body CT to image children (under 16s). Use clinical judgement to limit CT to the body areas where assessment is needed.” (1.5.36)

WSES, on the same axis

• “The choice of diagnostic technique at admission must be based on the hemodynamic status of the patient” GoR 1A, and “CT scan with intravenous contrast is the gold standard in hemodynamically stable or stabilized trauma patients” GoR 1A (WSES splenic 2017).
• “E-FAST is effective and rapid to detect free fluid” GoR 1A (WSES splenic 2017). Its job is to find free fluid in the crashing patient, not to clear the abdomen.

NICE addresses this by physiology rather than by organ:

• “Use damage control surgery in patients with haemodynamic instability who are not responding to volume resuscitation.” (NG39 1.5.37)
• “Consider definitive surgery in patients with haemodynamic instability who are responding to volume resuscitation.” (1.5.38)
• “Use definitive surgery in patients whose haemodynamic status is normal.” (1.5.39)

WSES names the abdominal indications directly:

• “NOM in splenic injuries is contraindicated in the setting of unresponsive hemodynamic instability or other indicates for laparotomy (peritonitis, hollow organ injuries, bowel evisceration, impalement)” GoR 1A (WSES splenic 2017).
• “Hemodynamically unstable and non-responder patients (WSES IV) should undergo OM” GoR 2A (WSES liver 2020).

Other findings that mandate laparotomy once identified: free intraperitoneal air (pneumoperitoneum), enteric contrast extravasation or a discontinuous bowel wall on CT, and diaphragmatic rupture. These are CT diagnoses — the resus-room gate is instability with free fluid, peritonitis, evisceration or impalement.

Non-operative management (NOM) is the default for the haemodynamically stable patient, and — this is the counter-intuitive part — it does not depend on the injury grade.

Spleen (WSES 2017)

• “Patients with hemodynamic stability and absence of other abdominal organ injuries requiring surgery should undergo an initial attempt of NOM irrespective of injury grade” GoR 2A.
• “NOM of moderate or severe spleen injuries should be considered only in an environment that provides capability for patient intensive monitoring, AG/AE, an immediately available OR and immediate access to blood and blood product … and only in patients with stable or stabilized hemodynamic and absence of other internal injuries requiring surgery” GoR 2A.
• “AG/AE may be considered the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan irrespective from injury grade” GoR 2B.
• “Injury grade on CT scan, extent of free fluid, and the presence of PSA do not predict NOM failure or the need of OM” GoR 1B.

Liver (WSES 2020)

• “NOM should be the treatment of choice for all hemodynamically stable minor (WSES I) (AAST I–II), moderate (WSES II) (AAST III), and severe (WSES III) (AAST IV–V) injuries in the absence of other internal injuries requiring surgery” GoR 2A.
• “Serial clinical evaluations (physical exams and laboratory testing) must be performed to detect a change in clinical status during NOM” GoR 2A.
• “AG/AE may be considered as a first-line intervention in hemodynamically stable patients with arterial blush on CT scan” GoR 2B. In children, “the presence of contrast blush on CT scan is not an absolute indication for AG/AE” GoR 2B.
• “NOM should be attempted in the setting of concomitant head trauma and/or spinal cord injuries with reliable clinical exam, unless the patient could not achieve specific hemodynamic goals for the neurotrauma and the instability might be due to intra-abdominal bleeding” GoR 2B.

NICE, on the interventional-radiology side

“Consider interventional radiology techniques in patients with solid‑organ (spleen, liver or kidney) arterial haemorrhage.” (NG39 1.5.41)

Who is more likely to fail NOM

Not an absolute contraindication, but a reason for a higher index of suspicion and closer monitoring: “age above 55-years old, high ISS, and moderate to severe splenic injuries are prognostic factors for NOM failure” GoR 2B (WSES splenic 2017). The spleen has a second trap the liver has less of: delayed rupture of a subcapsular haematoma or a pseudoaneurysm, days later.

Solid-organ injury bleeds and shows on CT. Hollow-viscus and mesenteric injury, and the retroperitoneal duodenum and pancreas, can do neither early — and this is where blunt abdominal trauma is missed.

• The seatbelt sign — a linear ecchymosis across the lower abdomen from a lap belt — is a recognised marker of bowel and mesenteric injury and should lower your threshold for repeat imaging and serial examination. (Association from standard trauma teaching and the trauma literature, not from NICE.)
• WSES on the retroperitoneal organs: “A repeat CT-scan within 12–24 h from the initial injury should be considered in hemodynamically stable patients with high clinical suspicion for duodeno-pancreatic injury … with negative CT-scan or non-specific CT findings on admission imaging, and/or elevated amylase and lipase, or persistent abdominal pain” GoR 2A.
• “Repeated and combined measurement of serum amylase and lipase levels, starting from 3 to 6 h after the initial injury, is a useful tool to support clinical evaluation in suspicion of pancreatic injury” GoR 1B.
• “Serial clinical examination is an important part of follow-up after biliary and pancreatic-duodenal trauma” GoR 2A.
• “In selected cases where an intra-abdominal injury is suspected in the days after the initial trauma, interval laparoscopic exploration may be considered” GoR 2C (WSES liver 2020).

The unifying point: a normal early CT does not clear the abdomen in a patient with the wrong mechanism, a seatbelt sign or persistent pain. Admit, examine serially, re-image, and do not discharge on a single reassuring scan.

Restrictive volume resuscitation

• “For patients with active bleeding use a restrictive approach to volume resuscitation until definitive early control of bleeding has been achieved.” (1.5.18)
• In hospital, “move rapidly to haemorrhage control, titrating volume resuscitation to maintain central circulation until control is achieved.” (1.5.20)
• “In hospital settings do not use crystalloids for patients with active bleeding.” (1.5.23)

Blood component ratio and the protocol trigger

• Adults (16 or over): “use a ratio of 1 unit of plasma to 1 unit of red blood cells to replace fluid volume.” (1.5.24) Children: “use a ratio of 1 part plasma to 1 part red blood cells, and base the volume on the child's weight.” (1.5.25)
• “For patients with active bleeding, start with a fixed‑ratio protocol for blood components and change to a protocol guided by laboratory coagulation results at the earliest opportunity.” (1.5.27)
• “Use physiological criteria that include the patient's haemodynamic status and their response to immediate volume resuscitation to activate the major haemorrhage protocol.” (1.5.13) “Do not rely on a haemorrhagic risk tool applied at a single time point” (1.5.14).

Tranexamic acid

• “Use intravenous tranexamic acid as soon as possible in patients with major trauma and active or suspected active bleeding.” (1.5.4)
• “Do not use intravenous tranexamic acid more than 3 hours after injury in patients with major trauma unless there is evidence of hyperfibrinolysis.” (1.5.5)

In February 2016 this was an off-label use of tranexamic acid. NG39 gives no dose; the widely used CRASH-2 regimen is 1 g IV over 10 minutes then 1 g over 8 hours — check your local major haemorrhage protocol and see the drug monographs. The dedicated major haemorrhage module runs this in full.

Anticoagulation (NG39 1.5.6–1.5.12)

• “Rapidly reverse anticoagulation in patients who have major trauma with haemorrhage” (1.5.6), and “Do not reverse anticoagulation in patients who do not have active or suspected bleeding” (1.5.12).
• Adults on a vitamin K antagonist with active bleeding: “Use prothrombin complex concentrate immediately” (1.5.8); “Do not use plasma to reverse a vitamin K antagonist” (1.5.9).
• Any other anticoagulant in an adult (1.5.10), or any anticoagulant in a child (1.5.11): consult a haematologist immediately.

The dose calculation and the DOAC agents are in the bleeding & reversal module.

Heat (NG39 1.6.1)

“Minimise ongoing heat loss in patients with major trauma.” Hypothermia, acidosis and coagulopathy are the lethal triad; the exposed, wet, transfused trauma patient is the one who gets cold.

Pain (NG39 1.7.4–1.7.6)

“For patients with major trauma, use intravenous morphine as the first‑line analgesic and adjust the dose as needed to achieve adequate pain relief.” (1.7.4) If no IV access, consider intranasal atomised diamorphine or ketamine (1.7.5, off-label in 2016); “Consider ketamine in analgesic doses as a second‑line agent” (1.7.6). No doses in NG39; use the drug monographs and, for children, the paediatric tool. Analgesia should not be withheld for fear of masking the abdominal examination — but it is a reason to examine serially and document.

• It does not grade the injury. AAST-OIS grading is a radiological classification made on the CT; the ED decisions above turn on physiology, not grade. The AAST grades are in the classifications tool.
• It does not give drug doses. NG39 gives none for TXA, morphine or reversal; the drug and paediatric tools do.
• It does not run the whole major haemorrhage protocol. It points to the physiological trigger NICE names; the major haemorrhage module and your trust's protocol are the operational documents.
• It does not cover the pelvis as a separate bleeding source — that has its own module — nor the operative technique of laparotomy, packing or resection, which are surgical decisions.
• It does not extend to penetrating abdominal trauma. The operative logic there is different; the resuscitation recommendations still apply.

• NICE NG39. Major trauma: assessment and initial management. Published 17 February 2016. The full Recommendations chapter was parsed for this module; the haemorrhage, imaging, damage-control, heat and pain recommendations used here are in sections 1.5–1.7. Recommendations apply to both children (under 16s) and adults (16 or over) unless otherwise specified.
• WSES splenic trauma guidelines 2017. Coccolini F, Montori G, Catena F, et al. Splenic trauma: WSES classification and guidelines for adult and pediatric patients. World J Emerg Surg 2017;12:40. Diagnostic and management statements quoted with their grade of recommendation (GoR).
• WSES liver trauma guidelines 2020. Coccolini F, Coimbra R, Ordonez C, et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020;15:24. Statements quoted with their GoR.
• WSES-AAST duodeno-pancreatic and biliary trauma guidelines 2019. Coccolini F, Kobayashi L, Kluger Y, et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES-AAST guidelines. World J Emerg Surg 2019;14:56. Diagnostic statements quoted with their GoR.

Every NICE quotation on this page is verbatim from the recommendation named beside it. Every WSES statement is quoted verbatim and carries its published grade of recommendation. The principal element attributed to neither — the seatbelt-sign association with hollow-viscus injury — is labelled as standard teaching wherever it appears; a few background didactic points (delayed splenic rupture, the lethal triad, the CRASH-2 TXA regimen, trauma-in-pregnancy principles) are likewise flagged as standard teaching rather than guideline recommendations. The WSES guidelines are international, not UK national guidance, and are used here for the abdomen-specific questions NICE does not address; where they and NICE overlap, they agree.