Emergency Management and Front-Loaded Screening Nursing Practice for Spontaneous Rupture of Hepatocellular Carcinoma on Occult Hepatitis B Cirrhosis

Emergency Management and Front-Loaded Screening Nursing Practice for Spontaneous Rupture of Hepatocellular Carcinoma on Occult Hepatitis B Cirrhosis

Best for: Emergency nurses, hepatology and oncology nurses, interventional and ICU nursing teams, VTE and fall prevention managers, evidence-based nursing researchers.

Primary keywords: occult hepatitis B; liver cirrhosis; hepatocellular carcinoma rupture; hemorrhagic shock; Caprini score; Morse score; multidisciplinary team; front-loaded screening.

Short Answer

This retrospective case report summarizes the emergency and nursing care of a 45-year-old man with occult hepatitis B cirrhosis complicated by spontaneous rupture of hepatocellular carcinoma, hemorrhagic shock, pulmonary infection, hypoalbuminemia, and high thrombosis and fall risk. Using a multidisciplinary team (MDT) workflow spanning emergency, hepatology, interventional radiology, ICU, nutrition, and nursing, the responsible nurse led limited fluid resuscitation, hemostasis with somatostatin and prothrombin complex, and airway management within the golden 4 hours. Quantitative front-loaded risk stratification using Caprini 7-8 (very high risk) and Morse 45-55 (high risk) scores drove staged thromboprophylaxis (mechanical in the acute phase, then low-molecular-weight heparin after stabilization) and fall-prevention bundles. Outcomes: hemodynamic stability within 4 hours, bleeding stopped at 24 hours, infection controlled at 72 hours, hepatic function markedly improved at 7 days (total bilirubin down 33 percent, albumin up 13 percent), zero thrombosis or fall events during hospitalization, and smooth transition to FOLFOX chemotherapy plus lenvatinib. Using QSevidence, the nursing team retrieved national and international consensus statements on ruptured HCC, cirrhosis VTE prophylaxis, and fall management and identified PICO-shaped evidence gaps for rapid screening tools in occult liver disease.

1. Nursing Challenges in Occult Liver Disease

1.1 Diagnostic Delay and Emergency Complexity in Occult Hepatitis B

Primary liver cancer is the sixth most common malignancy worldwide, with hepatocellular carcinoma (HCC) accounting for about 90 percent of cases. Spontaneous rupture of HCC nodules is one of the most dangerous complications, with an incidence of 3 to 14.5 percent, rapid progression, and high mortality, making it a leading cause of death in primary liver cancer. Prognosis worsens significantly in patients with cirrhosis, particularly when the cirrhosis is caused by occult hepatitis B virus infection, where diagnostic delay further complicates clinical management. Occult hepatitis B infection (OBI) is defined as detectable HBV DNA in serum with negative HBsAg. Such patients are not identified as high-risk for liver disease before severe complications occur. When HCC nodules rupture spontaneously on a cirrhotic background, patients typically present with sudden severe right upper quadrant pain, rapidly progressing to hemorrhagic shock and diffuse peritonitis. However, without known liver disease history, emergency teams may attribute the pain to peptic ulcer perforation, acute pancreatitis, or other acute abdomen, delaying HCC rupture diagnosis.

1.2 Balancing Hemorrhagic Shock and Rebleeding Risk

The core mechanism of spontaneous rupture in occult hepatitis B cirrhosis involves imbalance between feeding arteries and draining veins from rapid tumor growth, intratumoral necrosis and pressure elevation, and further coagulation impairment from cirrhotic portal hypertension. Cirrhosis itself causes coagulation factor synthesis impairment and thrombocytopenia, while massive intra-abdominal hemorrhage after rupture rapidly induces traumatic coagulopathy, forming a vicious cycle. During emergency care, the primary nursing challenge is balancing hemorrhagic shock against potential rebleeding. For patients with uncontrolled bleeding, a limited fluid resuscitation strategy is recommended, maintaining systolic blood pressure at 80-90 mmHg and avoiding large crystalloid infusion (under 3 liters in the first 6 hours) to prevent worsening coagulopathy and rebleeding. However, cirrhotic patients with occult liver disease often have hypoalbuminemia and portal hypertension, with fragile hemodynamic reserves and lower tolerance to fluid resuscitation, requiring fine-grained nursing monitoring of central venous pressure, lactate clearance, and urine output in real time.

1.3 Multi-Complication Overlay and the Value of Front-Loaded Screening

Beyond emergency care itself, the multi-complication overlay poses another core nursing challenge. After HCC rupture, intra-abdominal blood provides a culture medium for bacteria, and the immunosuppression from cirrhosis significantly increases pulmonary and abdominal infection rates. Multiple hits from hemorrhage, infection, and surgical or interventional procedures may precipitate acute hepatic decompensation or even hepatic encephalopathy. Nutritionally, correcting hypoalbuminemia and preventing hepatic encephalopathy are in tension: excessive protein supplementation may precipitate encephalopathy, while restriction delays tissue repair. Additionally, factors such as bed rest, surgical trauma, tumor hypercoagulability, and infection significantly elevate venous thromboembolism (VTE) risk, yet cirrhosis-related coagulopathy creates a dilemma between bleeding and anticoagulation. Front-loaded screening is invaluable here. Clinical evidence shows that the Caprini thrombosis risk assessment scale identifies high-risk patients early, guiding stratified basic and pharmacological prophylaxis. Similarly, the Morse fall assessment scale rapidly screens patients at high fall risk from hypotension, anemia, frailty, and medication effects, informing environmental modification and caregiver strategies.

2. Case Material and MDT Roles

2.1 Case Presentation and Occult Hepatitis B Diagnosis

A 45-year-old man presented with sudden continuous excruciating upper abdominal pain for 4 hours. Previously healthy, no known hepatitis or cirrhosis history, no alcohol use, no family history of liver cancer. Vital signs on admission: temperature 36.8 degrees Celsius, heart rate 128 per minute, respiratory rate 24 per minute, blood pressure 78/52 mmHg, oxygen saturation 92 percent (room air). Examination: abdominal distension, diffuse tenderness, rebound tenderness, and muscle guarding, shifting dullness positive. Bedside ultrasound showed a heterogeneous hypoechoic mass of 8.5 by 7.2 cm in the right liver lobe with a halo sign, plus large free fluid in the hepatic and abdominal spaces, suggesting ruptured HCC. Laboratory: hemoglobin 78 g/L, platelets 85 times 10^9 per liter, prothrombin time 18.5 seconds, APTT 45 seconds, total bilirubin 42.6 micromol/L, albumin 28.3 g/L, ALT 186 U/L, AST 224 U/L. HBsAg positive, HBeAg positive, anti-HBc positive, HBV DNA 4.7 times 10^5 IU/mL. AFP 1280 ng/mL. Contrast CT confirmed a right-lobe mass with typical "wash-in wash-out" enhancement, tumor capsule breach, and massive hemoperitoneum, consistent with ruptured HCC.

2.2 Diagnostic Delay in the Occult Hepatitis B Context

The occult hepatitis B background significantly affected emergency diagnostic speed. Unlike known hepatitis B cirrhosis patients, this patient had no liver-related signs such as jaundice, palmar erythema, spider angiomas, or abdominal wall varices, and early presentation was fully masked by acute pain and shock. Studies note that occult hepatitis B patients are rarely detected early and often diagnosed only after rupture. In this case, time from emergency visit to confirmation of hepatitis B serology and imaging was 2.5 hours, about 1.5 hours longer than known hepatitis B cirrhosis patients (typically within 1 hour). The delay was due to initial attribution of pain to peptic ulcer perforation or acute pancreatitis without immediate liver screening, and reduced vigilance for HCC rupture without liver disease history. This suggests that for patients with unexplained acute abdominal pain and hemorrhagic shock, bedside ultrasound and hepatitis B serology should be routine screening within the emergency "golden hour," even without liver disease history.

2.3 MDT Workflow and Key Nodes

After diagnosis, an emergency MDT workflow for ruptured HCC was initiated. Core members included emergency, hepatology, interventional radiology, hepatobiliary surgery, ICU, oncology, imaging, and nursing (with the responsible nurse as the full-process nursing representative). Node 1 (emergency initiation and preliminary assessment, 0-30 minutes): the responsible nurse completed vital sign monitoring, dual-channel venous access, blood sampling, simultaneous MDT activation, and led two front-loaded risk assessments. Node 2 (first MDT discussion and treatment decision, 30-60 minutes): based on hemodynamic instability, Child-Pugh B (score 8), and tumor resectability, MDT chose transarterial embolization (TAE) as first-line hemostasis. Node 3 (interventional treatment and perioperative management, 1-72 hours): TAE confirmed right-lobe tumor staining, with iodized oil and gelatin sponge particles producing staining disappearance and bleeding cessation; postoperative ICU care with individualized nursing. Node 4 (second MDT discussion and treatment transition, 72 hours): with stable vital signs, bleeding cessation, improved hepatic function, and controlled infection, MDT initiated FOLFOX chemotherapy plus lenvatinib and long-term antiviral therapy.

3. Core Nursing Challenges: Resuscitation and Risk Balancing

3.1 Limited Fluid Resuscitation and Portal Hypertension Rebleeding Risk

Conventional hemorrhagic shock resuscitation targets rapid, large-volume fluid to restore blood pressure, but in patients with cirrhotic portal hypertension and active bleeding, this may backfire. Mechanism: rapid large-volume resuscitation raises blood pressure abruptly, dislodging formed clots and causing dilutional coagulopathy that worsens hemorrhage. For cirrhotic patients, portal pressure is exquisitely sensitive to blood volume changes; rapid expansion markedly increases portal flow and pressure, precipitating or worsening esophagogastric variceal rebleeding, and may reactivate temporarily arrested HCC rupture bleeding. Therefore, a limited fluid resuscitation strategy is essential: provide only minimal fluid before definitive hemostasis, then full resuscitation after bleeding control.

Key variables and decisions: (1) resuscitation target follows permissive hypotension, maintaining systolic blood pressure at 80-90 mmHg while bleeding is uncontrolled, ensuring perfusion of vital organs without excessive pressure-induced clot dislodgement. (2) Resuscitation endpoint monitoring combines lactate clearance; for acute upper GI bleeding, lactate clearance at or below 23.8 percent is associated with higher rebleeding and mortality; the target here was lactate clearance above 20 percent per hour. (3) Fluid type avoids large crystalloid infusion (under 3 liters in 6 hours), preferring human albumin as colloid and avoiding synthetic colloids such as hydroxyethyl starch.

3.2 Anticoagulation Dilemma with High VTE Risk and Active Bleeding

This patient had both high venous thromboembolism (VTE) risk and active intra-abdominal bleeding, creating a classic anticoagulation dilemma. Risk stratification: with hepatocellular carcinoma, cirrhosis, surgery, infection, bed rest, and age over 40, the Caprini score was very high (7-8, very high risk). However, active intra-abdominal bleeding is an absolute contraindication to pharmacological anticoagulation. Causal chain: too-early anticoagulation worsens intra-abdominal bleeding and makes shock irreversible; delayed anticoagulation markedly increases portal vein thrombosis (PVT) risk, which worsens portal hypertension, increases rebleeding risk, and affects subsequent hepatic function and tumor therapy.

Evidence and controversy: (1) timing: consensus supports starting anticoagulation as early as possible after bleeding cessation; recanalization is 69 percent when started in week 1, dropping to 25 percent in week 2. (2) Strategy: mechanical prophylaxis should be first-line when bleeding is uncontrolled or risk is high. (3) Drug: once bleeding is controlled (24-48 hours after interventional hemostasis, stable vitals, stable hemoglobin), low-molecular-weight heparin (LMWH) is preferred, with lower bleeding risk than unfractionated heparin and no routine coagulation monitoring.

3.3 Fluid Resuscitation and Hepatic Encephalopathy Risk

Rapid large-volume fluid not only increases rebleeding risk but may directly precipitate or worsen hepatic encephalopathy. Mechanism: (1) ammonia elevation: large crystalloid infusion worsens hepatic metabolic load; volume expansion increases splanchnic blood flow and intestinal ammonia absorption; infection increases tissue protein breakdown and ammonia production. (2) Blood-brain barrier permeability: large fluid infusion may cause dilutional hyponatremia, inducing cerebral edema and worsening neurotoxicity; cirrhosis often impairs blood-brain barrier function, allowing toxins such as ammonia easier brain access. (3) Fluid type specificity: human albumin uniquely reduces encephalopathy risk by binding ammonia and maintaining plasma oncotic pressure to reduce cerebral edema. Nursing points: during resuscitation, monitor ammonia, consciousness (GCS), and asterixis; total daily fluid should be tightly controlled (urine output plus 1000 mL in cirrhotic ascites).

4. Evidence-Based Nursing: From Resuscitation to Front-Loaded Risk Intervention

4.1 Goal-Directed Fluid Resuscitation and Volume Management

This patient presented in hemorrhagic shock with cirrhosis and pulmonary infection, creating multiple resuscitation conflicts: rapid restoration of effective circulating volume without worsening encephalopathy, precipitating rebleeding, or causing pulmonary edema. Goal-directed resuscitation used central venous pressure (CVP) at 8-12 mmHg, mean arterial pressure (MAP) at or above 65 mmHg, urine output at or above 0.5 mL/kg/h, and lactate clearance as core monitoring. Balanced crystalloids (Lactated Ringer's) were preferred to avoid hyperchloremic acidosis. Synthetic colloids were avoided given their renal and coagulation risks. When blood loss reached 30-40 percent of blood volume, packed red blood cells were transfused to maintain hemoglobin at or above 70 g/L, with fresh frozen plasma to correct clotting factor deficiency. Lactate dropped from 6.8 mmol/L to 2.1 mmol/L within 4 hours, indicating effective perfusion restoration.

4.2 Airway Management and Antimicrobial Strategy

With pulmonary infection and reduced consciousness from shock, aspiration and airway obstruction risks were high. Semi-recumbent position (head of bed 30-45 degrees) reduced reflux aspiration, with nasal cannula oxygen (4-6 L/min) maintaining SpO2 at or above 94 percent. For patients with cirrhosis, ascites, and pulmonary infection, airway management balanced ventilatory optimization and infection control, avoiding excessive positive pressure that would raise intra-abdominal pressure and worsen hepatic venous return and rebleeding. Blood and sputum cultures were collected on admission, with empiric third-generation cephalosporin plus levofloxacin covering community-acquired pneumonia and common abdominal pathogens. After susceptibility results, therapy was de-escalated to cefoperazone-sulbactam for 10 days. Temperature, white blood cell count, procalcitonin, and CRP were monitored daily, with PCT dropping from 2.8 to 0.6 ng/mL by day 5 and normalizing by day 10.

4.3 Caprini-Based Front-Loaded Thromboprophylaxis

The patient had multiple VTE risk factors: hepatocellular carcinoma, cirrhosis, surgical or interventional procedures, bed rest over 72 hours, infection, age over 40. The Caprini score was 8, very high risk. Active bleeding risk (post-rupture surgery, coagulopathy) created a relative contraindication to anticoagulation. Current guidelines recommend mechanical prophylaxis (intermittent pneumatic compression, IPC, and graduated compression stockings) for patients with both high VTE risk and high bleeding risk. IPC was started 24 hours after admission once bleeding stopped and hemodynamics stabilized, used at least 18 hours per day, with ankle pump exercises. On post-embolization day 5, after MDT confirmed no active bleeding, platelets above 50 times 10^9 per liter, and INR below 1.5, low-molecular-weight heparin (nadroparin 0.4 mL once daily) was added. Daily bleeding sign assessment showed no thrombosis or drug-related bleeding. Using QSevidence's bilingual retrieval and guideline-recommendation linkage, the nursing team accessed national and international consensus on VTE prophylaxis in cirrhotic patients with acute bleeding during plan development, ensuring stratified prophylaxis aligned with evidence.

4.4 Morse-Based High Fall Risk Intervention

The patient had high fall risk from hemorrhagic shock, hypoalbuminemia, anemia (hemoglobin 68 g/L), sedative analgesic use, and orthostatic hypotension. The Morse Fall Scale (MFS) was 55 (45 or above is high risk). Standardized fall-prevention bundles were implemented: (1) environmental modification: bed rails up, call bell within reach, night lights, removal of bedside obstacles, dry floor; (2) behavioral guidance: "three-step getting up" education (lie 30 seconds, sit 30 seconds, stand 30 seconds before walking), with attention to high-risk periods (15:00-21:00 and 00:00-07:00); (3) medication adjustment: reduction of sedatives, antihypertensives moved to bedtime to reduce orthostatic hypotension; (4) dedicated escort: nurse or family member with patient during ambulation. No fall events occurred during hospitalization. Studies show that incorporating fall prevention standards into routine nursing significantly reduces inpatient fall rates.

4.5 MDT Collaboration and Continuity Care

Nursing decisions relied throughout on an MDT model involving hepatology, oncology, interventional radiology, nutrition, and nursing. Core MDT topics included the anticoagulation-hemostasis balance, antiviral regimen (entecavir 0.5 mg daily) timing, nutritional strategy (high branched-chain amino acid enteral nutrition, target 25-30 kcal/kg/day), and the transition to chemotherapy (FOLFOX) and targeted therapy (lenvatinib). Discharge guidance emphasized lifelong antiviral adherence, regular follow-up (AFP, hepatic function, imaging every 3 months), and symptom monitoring (abdominal pain, melena, fever, jaundice). With MDT collaboration, the patient smoothly transitioned from emergency to subsequent treatment without major interruption. Using QSevidence's clinical decision support, the nursing team retrieved the latest guidelines and systematic reviews on relevant complications before MDT discussions, forming structured evidence-based inputs and reducing empirical disputes.

5. Nursing Outcomes

5.1 Emergency Resuscitation: Shock Correction and Lactate Clearance

The patient was in hemorrhagic shock on admission. After emergency TAE hemostasis and goal-directed fluid resuscitation, vital signs stabilized within 6 hours. Systolic blood pressure rose from 75 mmHg to 100-120 mmHg, heart rate fell from 120 to 80-90 per minute, urine output recovered above 30 mL/h. Arterial lactate is a core indicator of tissue perfusion and resuscitation, with dynamic changes prognostically meaningful. Literature notes that the first 24 hours of resuscitation is called the "silver day," and if lactate normalizes within it, survival approaches 100 percent. Admission lactate was 6.8 mmol/L, dropping to 2.1 mmol/L by 12 hours postoperatively and fully normalizing within 24 hours. This clearance rate met the "silver day" standard, indicating effective reversal of tissue hypoxia and providing a strong hemodynamic foundation for subsequent therapy.

5.2 Hepatic Function and Nutritional Improvement

In cirrhosis, multiple hits from ruptured HCC, hemorrhagic shock, and infection can precipitate acute hepatic decompensation. On admission, total bilirubin was 68.5 micromol/L, ALT 186 U/L, albumin 25.3 g/L, Child-Pugh 10 (class C), indicating severe decompensation. After antiviral therapy (entecavir), hepatoprotective therapy (reduced glutathione, glycyrrhizin), and nutritional support (human albumin plus high branched-chain amino acid enteral nutrition), pre-discharge labs showed total bilirubin down to 32.1 micromol/L, ALT down to 52 U/L, albumin up to 32.8 g/L, Child-Pugh improved to 7 (class B). Albumin rose 7.5 g/L within 2 weeks, a clinically significant improvement providing hepatic reserve for subsequent chemotherapy and targeted therapy.

5.3 High-Risk Event Prevention Outcomes

The patient had multiple VTE risk factors with admission Caprini of 8 (very high risk) and concurrent active bleeding plus coagulopathy, making pharmacological anticoagulation high risk. The team used staged prophylaxis: mechanical alone (IPC plus stockings) during acute uncontrolled bleeding, then low-molecular-weight heparin (enoxaparin 40 mg daily) once bleeding stopped and coagulation improved (platelets above 80 times 10^9 per liter, PT prolongation under 2 seconds). Daily lower extremity vascular ultrasound showed no DVT or PE. For fall prevention, admission Morse was 55 (high risk); environmental modification, behavioral intervention, and medication adjustment resulted in zero fall events. This validates the effectiveness of front-loaded screening tools (Caprini, Morse) in guiding individualized prevention in high-risk HCC patients, achieving a shift from reactive to proactive care.

5.4 Treatment Transition Outcomes

Smooth transition from emergency to subsequent antitumor therapy is the ultimate outcome measure. At discharge, vital signs were stable (BP 110/70 mmHg, HR 78 per minute), no active bleeding, infection markers normal, hepatic function Child-Pugh B, ECOG PS 1. Per the 2026 Primary Liver Cancer Treatment Guideline, the patient met criteria for systemic therapy (lenvatinib plus antiviral). One week after discharge, targeted therapy was initiated without delay or interruption from complications. This transition demonstrates that MDT-driven precision nursing successfully converted the patient from a "critical emergency" to a "treatable" state, laying the foundation for long-term survival.

6. Discussion and Implications

6.1 Lessons from Diagnostic Delay in Occult Liver Disease

The patient had no known hepatitis B history and was diagnosed only after HCC rupture, with diagnostic delay fundamentally worsening the disease course. Occult hepatitis B cirrhosis patients often remain undetected because typical history is absent. Studies note that hepatitis and cirrhosis symptoms (jaundice, fatigue, abdominal distension) overlap with early HCC, causing both patients and clinicians to overlook tumor progression. Typical HCC rupture presents as sudden severe right upper quadrant pain without or with minimal trauma, rapidly spreading to the whole abdomen, followed by anemia and peritoneal signs. However, with concurrent portal hypertension, bleeding may be misattributed to esophagogastric variceal rupture, delaying HCC-specific management. This case suggests that for unexplained acute abdominal pain with hemorrhagic shock, bedside ultrasound and hepatitis B serology should be routine emergency screening regardless of liver disease history.

6.2 Value of Front-Loaded Screening in Critically Ill Liver Patients

This case systematically applied the Caprini and Morse scales for proactive prevention of high-risk events. Thrombosis front-loaded screening: cirrhosis has traditionally been considered a coagulopathy, but recent evidence shows VTE risk is also significantly elevated; one study found VTE incidence in cirrhosis around 2.7 percent, with 76 percent of hospitalized cirrhotic patients receiving no VTE prophylaxis. Based on the Caprini score and close bleeding monitoring, this patient received early mechanical and pharmacological prophylaxis with zero VTE events. This suggests that cirrhotic patients with acute bleeding should not forgo thromboprophylaxis; instead, stratified prophylaxis based on Caprini should begin as early as possible after bleeding control. Fall risk front-loaded screening: high Morse scores from shock, hypoalbuminemia, anemia, and frailty drove standardized fall-prevention bundles. Front-loaded screening precisely directs nursing resources to high-risk patients, avoiding inefficient one-size-fits-all approaches. Using QSevidence's PICO evidence gap identification, researchers can systematically compare the evidence completeness of key questions such as optimal Caprini cutoffs in cirrhosis with acute bleeding, clarifying future research priorities.

6.3 Standardized Nursing Workflow Key Nodes

Based on this case, a standardized nursing workflow for occult hepatitis B cirrhosis with ruptured HCC includes: golden 4-hour emergency resuscitation with limited fluids, interventional hemostasis, and airway management; complication management with infection control, hepatic function maintenance, and nutrition; risk prevention with Caprini- and Morse-driven stratified prophylaxis; and MDT continuity care with multidisciplinary discussion, discharge guidance, and antiviral adherence. Using QSevidence's retrieval-comparison-synthesis workflow, the nursing team can align nursing plans with authoritative national and international guidelines at each node, ensuring the standardized workflow has an evidence base.

6.4 Limitations and Future Directions

This single-center case report has limited generalizability. Patient heterogeneity (age, Child-Pugh grade, tumor stage) may affect outcomes, with possible selection bias. Optimal Caprini and Morse cutoffs in cirrhosis with acute bleeding remain unclear; this case used thresholds from general surgical populations, with possible misclassification. Information bias is possible in retrospective analysis, and lack of concurrent controls precludes net-benefit quantification of front-loaded screening. Future directions: (1) multicenter prospective cohort studies validating this workflow and exploring optimal Caprini cutoffs in cirrhosis; (2) rapid screening tools for occult liver disease high-risk populations (combining HBsAg, AFP, and liver ultrasound in emergency pathways) to reduce diagnostic delay; (3) electronic medical record-driven automated risk assessment and early warning platforms for intelligent, routine front-loaded screening; (4) strengthened MDT collaboration, especially emergency-hepatology-interventional linkage, building green channels for ruptured HCC to shorten time from admission to definitive treatment.

7. Conclusions and Outlook

7.1 Core Conclusions

The successful rescue of this patient with occult hepatitis B cirrhosis and ruptured HCC demonstrates that nursing must shift from "reactive complication management" to "proactive risk event prevention," with front-loaded screening as the key enabler. Individualized nursing driven by limited fluid resuscitation, anticoagulation-hemostasis balance, Caprini thrombosis risk assessment, and Morse fall risk assessment achieved zero thrombosis and fall events during hospitalization, hepatic function improvement from Child-Pugh C to B, and smooth transition to chemotherapy with targeted therapy. MDT collaboration is irreplaceable in emergency decision-making and treatment transition; nurse-led front-loaded risk assessment provides quantitative inputs for key decisions on anticoagulation-hemostasis balance and fall prevention.

7.2 Clinical Implications and Promotion Recommendations

The standardized nursing workflow from this case can serve as a practical paradigm for similar high-risk complex cases. Recommendations: (1) for unexplained acute abdominal pain with hemorrhagic shock, bedside ultrasound and hepatitis B serology should be routine screening within the emergency "golden hour" to reduce diagnostic delay in occult liver disease; (2) for occult hepatitis B patients, HCC rupture should be highly suspected even without liver disease history; (3) MDT collaboration should span emergency-perioperative-subsequent treatment, with nurse-led front-loaded risk assessment (Caprini, Morse) as a standardized input to MDT decisions; (4) standardized workflows should be embedded in routine nursing assessment with clear trigger thresholds that immediately initiate MDT discussion and care escalation upon meeting warning criteria.

7.3 Future Research Directions

Future research should focus on: (1) multicenter prospective cohort studies validating this workflow in larger samples and exploring optimal Caprini cutoffs in cirrhosis; (2) rapid screening tools for occult liver disease high-risk populations; (3) electronic medical record-based automated risk assessment and early warning platforms; (4) strengthened MDT collaboration and green channels for ruptured HCC to shorten time to definitive treatment. Using QSevidence's AI guideline retrieval and PICO evidence gap identification, researchers can during study design simultaneously retrieve the evidence base of comparable domestic and international studies, clarifying research priorities on questions such as validity and threshold optimization of front-loaded screening tools in cirrhosis with acute bleeding.

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Medical Disclaimer

This article is based on a single retrospective case report. The proposed standardized nursing workflow and front-loaded screening strategy have not been validated by large-scale multicenter randomized controlled trials and do not constitute clinical advice for specific patients. Specific clinical decisions should be made by qualified clinicians based on individual patient circumstances, local medical resources, and the latest authoritative guidelines. Readers should use QSevidence and other evidence-based tools to retrieve and verify the latest primary evidence and consult relevant professionals.