A = acidosis (base deficit > −8)

B = blood loss (hemoperitoneum > 1,500 mL)

C = cold (temperature < 35 C)

D = damage (New ISS [NISS] > 35)

At the same time, concepts of damage control surgery are simultaneously performed such as abdominal packing, aortic cross clamping, shunt placements for vascular trauma, and fecal contamination control [5].

Grade I: Upon removal of perihepatic packing, liver bleeding has stopped or requires simple techniques of hemostasis such as topical hemostatic agents and/or hepatorrhaphy and the procedure is truncated.

Grade II: The bleeding is controlled by combining a Pringle maneuver and perihepatic packing. The initial immediate liver packing upon laparotomy is removed, the extent of the liver injury is determined, a Pringle maneuver is placed resulting in a significant decrease in the bleeding, and then a definitive 8–10 packs are placed perihepatically. The definitive packing should be done as quickly as possible before the patient becomes coagulopathic. A prime principle of perihepatic packing is that the vectors of compression created by the selective placement of the packs should result in an adequate compressive opposition of the fractured liver borders. To obtain this kind of packing, the liver needs to be completely mobilized and compressed manually by an assistant while the surgeon places the perihepatic packs. This usually requires two to four packs on each vector plane of compression. If there is a large deep laceration, then placement of intraparenchymal hemostatic agents should be done first, followed by gauze packing in a folded accordion fashion. We have learned that there are several technical mishaps regarding liver packing. The first is the issue of overpacking which can result in intra-abdominal hypertension with an associated decrease in cardiac preload and subsequent hemodynamic instability due to the decrease blood return from the compressed retrohepatic vena cava. Another common error is the other extreme of too few packs placed which results in an inefficacious compression of the liver injury and subsequent persistent bleeding. The initial damage control surgery should not be terminated until all ongoing surgical bleeding from the liver has been controlled. This can be verified by assuring that the most superficial packs remain dry and white. If this is not the case, then the packs should be removed and the liver injury reevaluated. In the case that the packs are dry, the Pringle maneuver is removed, and the condition of the packs is re-examined, if dry, then the surgery can be truncated. All of this should be done in the least time possible to avoid that the patient develops the triad of death: hypothermia, coagulopathy, and acidosis. The abdomen is washed out, temporary abdominal closure coverage is placed, and the patient is taken immediately to the intensive care unit to continue his damage control resuscitation.