What is the appropriate management of a trauma patient with flank ecchymosis (Grey‑Turner sign) and a splenic laceration?

Management of Flank Ecchymosis with Splenic Laceration

In a trauma patient presenting with flank ecchymosis (Grey-Turner sign) and splenic laceration, immediate management depends entirely on hemodynamic status: hemodynamically unstable patients require immediate operative management with splenectomy, while stable patients should undergo non-operative management (NOM) with angiography/angioembolization (AG/AE) as the first-line approach, regardless of injury grade. 1

Initial Assessment and Hemodynamic Stratification

The presence of flank ecchymosis (Grey-Turner sign) indicates retroperitoneal hemorrhage and suggests significant bleeding, requiring urgent evaluation. 2 Your immediate priority is determining hemodynamic stability:

• Hemodynamically unstable is defined as: systolic blood pressure <90 mmHg with altered level of consciousness and/or shortness of breath, OR >90 mmHg but requiring bolus infusions/transfusions and/or vasopressor drugs, OR admission base excess >-5 mmol/L, OR shock index >1, OR transfusion requirement of at least 4-6 units of packed red blood cells within the first 24 hours. 1

• Transient responders (those showing initial response to adequate fluid resuscitation, then signs of ongoing loss and perfusion deficits) who cannot be sufficiently stabilized for interventional radiology should be managed operatively. 1

Management Algorithm Based on Hemodynamic Status

For Hemodynamically Unstable Patients

Proceed directly to operative management with splenectomy. 1, 3 Do not delay for imaging or attempt NOM in this setting. 1

• Splenectomy should be performed when the patient remains hemodynamically unstable despite resuscitation, shows significant drop in hematocrit levels, or requires continuous transfusions. 1, 3

• The reported overall hospital mortality of splenectomy in trauma is approximately 2%, but postoperative bleeding occurs in 1.6-3% of cases with mortality near 20%. 1

For Hemodynamically Stable Patients

Initiate non-operative management with CT scan followed by angiography/angioembolization. 1, 4

• Perform contrast-enhanced CT scan immediately to define the anatomic splenic injury and identify associated injuries. 1

• The presence of contrast blush (active extravasation) occurs in approximately 17% of cases and is an important predictor of NOM failure (>60% failure rate), but AG/AE should be considered even without blush in high-grade injuries. 1

• AG/AE should be performed in hemodynamically stable patients with vascular injuries identified on CT scan, as this significantly improves NOM success rates and achieves overall spleen salvage rates exceeding 85%. 4, 5

Critical Management Components During NOM

Monitoring Requirements

NOM should only be attempted in centers with:

• Capability for intensive patient monitoring in high dependency/ICU environment 1
• Serial clinical examination and laboratory assays with frequent vital signs and serial hematocrit measurements 4
• Immediately available operating room and immediate access to blood products 1
• Interventional radiology capabilities available 24/7 1

Repeat Imaging Indications

Consider repeat CT scanning during admission for patients with: 4

• Moderate/severe lesions
• Decreasing hematocrit
• Vascular anomalies on initial CT
• Underlying splenic pathology
• Coagulopathy
• Neurologic impairment

DVT Prophylaxis - Critical and Often Overlooked

Initiate mechanical prophylaxis (intermittent pneumatic compression devices) immediately upon admission. 6 This is safe even in high-grade splenic injuries and should not be delayed. 1, 6

Start LMWH-based chemical prophylaxis within 24-48 hours once active bleeding is controlled. 1, 6 This is crucial because:

• Without prophylaxis, >50% of trauma patients develop DVT, and pulmonary embolism carries approximately 50% mortality. 1, 6
• Splenic trauma without ongoing bleeding is NOT an absolute contraindication to LMWH-based prophylactic anticoagulation. 1
• Delaying chemical prophylaxis beyond 72 hours increases VTE rates over fourfold. 6

Special Considerations and Common Pitfalls

Concomitant Brain or Spinal Injuries

In patients with severe traumatic brain injury (STBI) or blunt spinal trauma (BST) plus high-grade (IV-V) splenic injuries:

• In centers without AG/AE availability: immediate splenectomy may provide survival benefit. 1
• In centers with AG/AE availability: immediate splenectomy does not show improved survival benefit, so NOM with AG/AE is preferred if hemodynamically stable. 1

Delayed Splenic Rupture

Maintain high index of suspicion for delayed rupture, which can occur within 48 hours but more commonly between 4-10 days post-injury. 4, 7 Even patients with normal-appearing spleen on initial CT can develop delayed rupture, particularly with high-impact injuries or peri-splenic organ injuries. 7

Activity Restriction

• Minor injuries: restrict activity for 4-6 weeks 4
• Moderate-severe injuries: restrict activity for 2-4 months 4
• Complete healing typically occurs in 12.5 days for grades I-II and 37.2 days for grades III-V 4

Absolute Indications for Conversion to Splenectomy

Convert from NOM to operative splenectomy if: 1, 4, 3

• Hemodynamic instability develops or persists despite resuscitation
• Significant drop in hematocrit requiring continuous transfusions
• Failed AG/AE with ongoing bleeding
• Development of splenic abscess unresponsive to antibiotics
• Peritonitis or other indications for laparotomy develop

Do not attempt laparoscopic splenectomy in the acute trauma setting with active bleeding. 1, 3 This is contraindicated and dangerous.