Liver trauma with hemorrhagic shock is a critical injury and an indication for intervention that requires early diagnosis and control of significant hemorrhage. A multidisciplinary approach is needed involving emergency services, diagnostic or interventional radiology suites, and an operation room (OR) [1]. This requires multiple transfers which take time from the emergency room (ER) to radiology for computed tomography (CT), and to the OR for treatment. In addition, postoperative angiography and angioembolization may be needed [2]. Management to reduce the time from presentation to diagnosis and treatment can improve the survival outcomes of patients with severe trauma [3].

In Japan, in recent years, the use of a hybrid ER system has expanded across Departments of Emergency Medicine [4]. The hybrid ER is a system whereby the ER, CT, interventional radiology (IR), and surgical capabilities are integrated and performed in one trauma resuscitation room. Multiple transfers are dangerous in trauma patients with severe shock. It has been reported that the use of a hybrid ER was significantly associated with a reduced time to diagnosis, improved definitive treatment, and reduced mortality [5,6].

A patient with penetrating liver trauma and hemorrhagic shock presented at the hybrid ER and was rapidly treated, from diagnosis to definitive care, without transferring the patient.

A 50-year-old man was transported to the hybrid ER because he sustained a stab wound in the right side of his chest. The length of time from injury to arrival at the hospital was about 90 minutes. Paramedics chose to transport the patient to a hybrid ER because of the critical injury sustained and the patient was in hemodynamic shock. On arrival, he had clear sensorium, a blood pressure of 76/55 mmHg, a heart rate of 110 beats/min, a respiratory rate of 22 beats/min, and an oxygen saturation of 95% (with a face mask). There was a stab wound into his 6^th intercostal space on the righthand side, the length of the wound was about 5 cm, and bleeding from the wound was persistent. He was intubated and initial resuscitation was started immediately. The abdominal examination revealed a soft, flat abdomen. The ultrasonographic examination showed fluid positive in the right thoracic cavity and pericardium, but fluid negative in the abdomen. A chest tube was inserted to his right thoracic cavity and a lot of blood drained out. He had agonal breathing, near cardiac arrest, and his blood pressure was too low to perform CT.

Immediately, a right anterior thoracotomy was performed where he lay. A pericardiotomy revealed negative hemopericardium. A pulsating bleed from the internal thoracic artery was observed, the puncture was found, and ligation was performed. In addition, a diaphragm injury on the right was discovered and found to have massive bleeding originating from the abdominal cavity. Subsequently, a laparotomy was performed, and penetrating liver injury was revealed (Figure 1A). The bleeding from the liver wound was persistent and the length of the liver injury was about 4 cm (the American Association for the Surgery of Trauma Grade III). Manual compression and hepatic packing were performed using the pringle maneuver. His blood pressure stabilized and suture of the liver laceration was performed (Figure 1B). Temporary abdominal closure, for damage control surgery, was performed with vacuum pack closure because the patient had developed the lethal triad of coagulopathy, acidosis, hypothermia. The thoracotomy was closed after repairing the diaphragmatic injury with interrupted sutures. At the time, his blood pressure was 110/75 mmHg and his heart rate was 90 beats/min.

After the operation, in situ (on the same bed), a contrast-enhanced CT scan was performed to investigate any extravasation from the liver (Figure 2A). The CT scan revealed a contrast extravasation in the right lobe of the liver. Thus, selective angioembolization was performed for the right hepatic artery in situ (Figure 2B). All procedures from resuscitation and diagnosis to definitive surgery were performed in one room (Figure 3). Following the patient’s arrival at hospital and the patient’s care delivered in the hybrid ER, it took about 240 minutes until the patient was admitted to the Emergency Intensive Care Unit.

The patient was given transfusion of 20 units red blood cells, 20 units freshly frozen plasma and 20 units platelet cells. The total amount of blood lost through hemorrhage was about 3,000 mL (Table 1). Thereafter, the patient was given definitive abdominal closure and returned home on postoperative Day 5.

The liver is one of the most frequently damaged organ in abdominal trauma [7]. Although non operative management has been increasingly performed for liver injury [8], it is obvious that surgery is required at the initial management for penetrating liver injury with hemodynamical shock. There are many resuscitative procedures such as intubation, central fluid access, and chest tube insertion before trauma surgery management. These procedures can be time consuming with the use of X-rays for conformation. Rapid control of hemorrhage is essential and therefore, it is important to reduce the time prior to surgery [9]. The hybrid ER with X-ray fluoroscopy can be very effective for resuscitative procedures before surgery. In fact, studies have reported that using the hybrid ER system may be significantly associated with reducing the time from arrival to diagnosis and improving mortality [9,10].

Until the 1980s, liver injury was often treated with surgical procedures to control bleeding and perform diagnostic peritoneal lavage [11]. Advances in imaging technology such as CT made it possible to determine the severity of the liver injury and damage to other organs, and consequently the number of cases that did not require surgery increased. Some studies indicated that about 80%-90% of blunt liver injuries could be safely managed without surgery [12,13]. For penetrating liver injury, surgery remains the standard treatment [14,15]. However, in recent years, cases of hemodynamically stable penetrating liver injury treated with nonoperative management have been reported [16–18].

Current multidisciplinary trauma management needs a lot of equipment and space such as resuscitative devices, a CT machine, IR suite, and OR. However, transporting a patient in hospital is time consuming and often has risk [13]. While a CT scan can provide a wealth of information, it is also associated with various risks. Therefore, the Advanced Trauma Life Support guidelines don’t recommend performing a CT scan for patients with hemodynamical shock. Change is needed to amend the current standard practice of trauma care.

In 2011, for the first time in the world, a trauma workflow concept that incorporated a sliding CT scan system with IR features was rolled out into the ERs in Japan [19]. This system was named “hybrid ER” because it was a revolutionary ER where initial medical care, CT scan, IR, and surgery could be performed in one room. This novel system in Japan is currently active in more than 20 hospitals. Our hospital actively uses the hybrid ER not only for trauma care but also for endogenous shock, and vital diseases, and treats approximately 1,000 patients annually.

It is controversial whether a CT scan should be performed before emergency surgery. Preoperative CT scans increase the possibility of identifying which organs are damaged. This makes it possible to perform surgery more efficiently and may lead to an overall reduction in time from presentation to diagnosis and treatment. On the other hand, early CT imaging may underestimate bleeding in the free space of the thoracic and abdominal cavities, which is a problem. Although the criteria for CT imaging in the hybrid ER has not yet been clearly defined, it is believed that CT scan should be performed only when safety is ensured following consideration of airways, breathing, and circulation [19].

In this case, the patient had a hemodynamically unstable perforating trauma and cardiac arrest was imminent, so, the patient required emergency surgery without performing a CT scan. Postoperatively, a CT scan was performed and an intrahepatic hemorrhage was discovered that had not been noticed during the intraoperative assessment. Subsequently, angioembolization was performed without transfer. Although intraoperative hepatic suture had succeeded in stabilizing the vitals to some extent, the vascular embolization procedure was evaluated to have prevented postoperative rupture of the pseudoaneurysm.

The utilization of a hybrid ER system may significantly decrease both the time and risk associated with trauma management. Additionally, it can alleviate stress for attending medical workers. However, the use of the hybrid ER for all trauma patients is too resource-intensive and time-limited. As part of our usual practice, emergency physicians promptly triage injured patients, directing them either straight to the hybrid ER or to an alternative course of action. This decision is informed prehospital details gathered at the scene by emergency medical service providers, and it strictly follows institutional guidelines (Table 2). In addition, the use of a hybrid ER needs many medical personnel who perform resuscitative ER, general anesthesia, surgery, and interventional radiology. Trauma code activation for hybrid ER involves key staff members, including not only trauma surgeons and emergency physicians but also anesthesiologists, nurse practitioners, medical engineers, and radiology technicians. The management of trauma using the hybrid ER is highly streamlined and complex, all within one room. Therefore, enhanced teamwork and collaboration are imperative. By unifying the chain of command to one person, confusion in the field is limited. It is also important for each member of medical staff to become accustomed to medical care in the hybrid ER. Our hospital conducts periodic simulations involving various types of medical care providers for the use of hybrid ER.

This is the first case report detailing the use of hybrid ER treatment for penetrating liver injury in combination with surgery and angioembolization. This novel modality allows for a multidisciplinary approach to be rapidly performed without the need for multiple transfers of the patient. Knowledge and training in the use of this novel modality are essential to fully benefit from the hybrid ER and contribute to trauma care.