A review of the National Trauma Data Bank [26] reported 956 trauma patients with cirrhosis (0.11% of 885,000 trauma admissions). The overall mortality for patients with cirrhosis was four times greater than those without (17.7% vs 4.4%, p < 0.001). Mortality remained much higher in cirrhotic trauma patients, even when accounting for age, preexisting comorbidities, ISS and TRISS. Cirrhotic patients undergoing laparotomy had a significantly higher mortality than cirrhotics who did not (44.2% vs 16.8%). In addition, cirrhotic patients undergoing laparotomy had mortality of 44.2% vs 17.3% in noncirrhotic patients who underwent laparotomy. Trauma patients with cirrhosis were also more likely to develop complications (27.4% vs 5.2%). The authors concluded that cirrhosis is a strong predictor of poor outcome in trauma patients, especially if undergoing laparotomy.

Christmas et al. appropriately describe trauma and cirrhosis as the deadly duo [32]. Sixty-one trauma patients with cirrhosis were compared to a matched group of control patients (1:2); with no difference in age, ISS or GCS between the groups. Intensive care unit stay, hospital length of stay, transfusion requirements in the first 24 h postinjury and mortality (33% vs 1%) were significantly higher in the trauma patients with cirrhosis. Fifty-five percent of the deaths in the cirrhotic group were due to sepsis. Mortality rose as Child’s class increased: Child’s A (15%), Child’s B (37%) and Child’s C (63%) (Fig. 27.2). Mortality in cirrhotics undergoing laparotomy incurred a 55% mortality vs 21% mortality in cirrhotics who did not require an exploratory laparotomy. The authors concluded that, regardless of the severity of injury, cirrhosis carries a poor prognosis in the trauma patient. In this study, splenectomy was the most common abdominal operation in the trauma patient with cirrhosis. As hemodynamic instability remains the primary indication for operation on the trauma patient with splenic injury, this management is compounded in the cirrhotic patient. Fang et al. [43] reported a significantly higher failure rate for nonoperative management of splenic injuries in the patient with cirrhosis (92 vs 19%). In fact, the cirrhotic patients who failed nonoperative management of blunt splenic injury had lower ISS, lower grade splenic injury, greater need for blood transfusion and higher mortality compared to noncirrhotic patients with splenic injury. The authors concluded that high-grade splenic injury, multiple injuries and elevated PT should prompt early laparotomy in the cirrhotic patient.

In a multicenter study of 77 cirrhotic patients with blunt splenic injury (case control matched with noncirrhotic trauma patients), Cook et al. [45] report an inpatient mortality of 27% for cirrhotics with blunt splenic injury, correlating with higher MELD scores, higher ISS, lower platelet count, and higher incidence of splenectomy. All patients with a MELD >19 died. Multivariable analysis demonstrated that the presence of cirrhosis was a significant risk factor for mortality in blunt splenic injury (OR 10.9).

In the largest and more recent series of blunt splenic injury in cirrhotics, Bugaev et al. [44] queried the National Trauma Data Bank for 2002–2010. Of 77,752 adult patients with blunt splenic injury, 289 had cirrhosis (0.37%). Initial nonoperative management of the splenic injury was attempted in 86% of cirrhotics and 90% of noncirrhotics. Patients with cirrhosis were more likely to fail nonoperative management (17% vs 10%, p = 0.004), despite more frequent use of angioembolization (13% vs 8%, p = 0.001). The patients with cirrhosis incurred more complications, had longer length of hospital and intensive care unit stay and higher mortality (22% vs 6%, p = 0.001) which was independent of mode of treatment. Mortality in patients with cirrhosis was 14% with successful nonoperative management of the splenic injury, 30% for patients undergoing immediate laparotomy, and 46% with failed nonoperative management (p < 0.05). Failure of observation was predicted by high-grade splenic injury (OR 11.6) and preexisting coagulopathy (OR 3.28). Mortality correlated with male sex (OR 4.34), hypotension (OR 3.15), preexisting coagulopathy (OR 3.06) and GCS less than 13 (OR 6.33). The authors suggest that patients with high-grade splenic injury (grade 4 or 5) or coagulopathy may benefit from prompt surgery (Table 27.2).

On the other hand, Barmparas et al. [42] reported no difference in success of nonoperative management of liver injury in cirrhotic trauma patients in a report from the National Trauma Data Bank (14% failure rate). However, cirrhotic patients had a higher mortality (28% vs 7%, p < 0.01), particularly if they required a laparotomy (58% vs 17%, p < 0.01) or if they failed nonoperative management (50% vs 4%, p < 0.01). The authors concluded that a trial of nonoperative management with blunt liver injury in the stable patient with cirrhosis was reasonable, acknowledging a higher risk of mortality of the patients required laparotomy.

The impact of cirrhosis on outcome after brain injury was addressed by Cheng et al. [28]. One year after traumatic brain injury, cirrhotic patients had higher mortality (52.2%) compared to noncirrhotic patients (30.6%) with increased risk of mortality of 1.75 (p, 0.001). Similarly, cirrhosis has a profound negative effect on outcome in burn patients [40]. The overall mortality rate in the burn patients was 50% in cirrhotics and 14.8% in noncirrhotics. With logistic regression, age (OR 1.08), total body surface area burned (OR 1.08), inhalation injury (OR 3.17), and cirrhosis (OR 8.78) had independent effects on mortality.

How can we summarize the literature on the trauma patient with cirrhosis? The injured patient with cirrhosis should be aggressively monitored and promptly treated. Blunt splenic injury is the most common indication for trauma laparotomy. The conundrum we have in management of the trauma patient with blunt injury to the spleen is the high mortality for the patient who fails nonoperative management of the splenic injury versus the high mortality for emergency laparotomy in the cirrhotic patient. The risk is greater with higher admission MELD, baseline coagulopathy or high-grade splenic injury. With no optimal answer, the balance may be monitoring of the cirrhotic patient who meets criteria for nonoperative management, understanding the high risk of failure and operating early with high-grade splenic injury or when failure of nonoperative management is apparent.