Clinical Management of Stab Wound Victim:
On Site and During Transport to the Hospital
By:
Dr. Niru Prasad, M.D., F.A.A.P., F.A.C.E.P.
Department of Emergency Medicine
West Bloomfield Center
Henry Ford Hospital
Department of Ambulatory Pediatrics
St. Joseph Mercy Hospital
Pontiac, Michigan
Introduction –
Given the tremendous increase in the crime rate in the United States, it is very important for paramedics to learn the basic concept of initial assessment and stabilization of severely injured patients. Trauma is one of the major leading causes of death for Americans under forty and the initial assessment and stabilization of the patient strongly influences the ultimate outcome for the severely traumatized patient. Most jurisdictions require that injuries arising from acts of violence such as gunshot wounds, stab wounds be reported to the local police. A fundamental point to remember regarding blunt and penetrating trauma is that a patient who has been stabbed may also have been beaten and kicked and subsequently has sustained both blunt and penetrating injury to the body.
Pathophysiology of the stab wound –
Penetrating injury to the body usually results in a hemorrhage from the penetration to a major vessel or solid organ.
Perforation of a segment of bowel or bladder.
The victim usually presents with altered mental status, hypoxia, paralysis, unequal pupils, shock, or active major bleeding. The signs and symptoms depend upon which part of the body is involved.
Stab wound to the head and neck area –
Penetrating injury to the head causes an altered level of consciousness, which is the hallmark of brain injury. A stab wound to the head area may produce brain contusion, concussion, and massive intracranial hemorrhage due to epidural, subdural, and subarachnoid hemorrhage.
All foreign bodies protruding from the skull should be left as they are, since they act like tamponade to control the bleeding. Penetrating injury to the neck area causes:
Hemorrhage due to laceration of a major vessel.
Paralysis due to damage of the spinal cord or fracture of a cervical vertebra.
Hypoventilation due to paralysis of intercostal muscles and involvement of C3 through C5 spinal cord segments.
Penetrating injury to the chest –
A stab wound sustained to the chest area may cause tension pneumothorax, open pneumothorax, massive hemothorax, sucking chest wound, flail chest due to fractured ribs, and pericardial tamponade. The victim can also suffer from severe respiratory distress due to hypoxia, which results from:
Diminished blood volume due to bleeding.
Contusion of the lungs leading to ventilation failure.
Changes in the pressure relationship within the pleural space leading to displacement of mediastinal structures and collapse of the lung.
Since hypoxia is the most important feature of chest injury, early intervention is designed to ensure that an adequate amount of oxygen is delivered to the portions of the lung capable of normal ventilation and perfusion. Tension pneumothorax develops when a one-way valve air leak occurs, either from the lung or through the chest wall. The presence of air in the thoracic cavity causes collapse of the lung, mediastinal shift to the opposite side causing interference with venous return, and compression of ventilation to the other lung. Open pneumothorax causes noisy breathing, and bubbling air and blood from the wound.
Massive hemothorax results from the stab wound disrupting the systemic or pulmonary vessel, and occurs with a loss of 1500 cc or more of blood in the chest cavity. The neck veins may be flat due to severe hypovolemia, or distended due to the mechanical effects of the chest cavity full of blood.
Flail chest develops when a segment of the chest wall does not have any bony continuity with the rest of the thoracic cage.
Pericardial tamponade is caused by a stab wound to the anterior chest area. This frequently leads to a collection of blood in the pericardial sac and a rupture of the aorta or cardiac muscle.
Some further potentially lethal chest injuries caused by stab wounds are:
Pulmonary contusion.
Disruption of the aorta.
Tracheobronchial disruption.
Esophageal disruption.
Traumatic diaphragmatic hernia.
Myocardial contusion.
Penetrating injury to the abdomen –
A stab wound to the abdomen frequently leads to hemorrhage from the penetration of major vessels or solid organs, such as the liver or spleen.
Perforation of a bowel segment.
Evisceration of bowel content through a penetrating injury.
Injury to the kidneys and ureters.
Pancreatic injury.
Pelvic organ injury.
Penetrating trauma to the extremities –
Stab wounds sustained to the upper and lower extremities might lead to life threatening extremity injuries such as:
Massive open fracture with ragged, dirty wounds.
Bilateral femoral shaft fracture (open or closed).
Vascular injuries, with or without fracture, proximal to the knee or elbow.
Traumatic amputation of an arm or leg.
Crush of or penetrating injury to the pelvic organs.
Limb threatening injuries –
Tibial fracture with vascular impairment.
Lacerations and dislocation of the knee or hip.
Open fractures of the wrist or forearm, with circulatory impairment.
Amputation (complete or incomplete).
Crush injuries.
Assessment –
The most important functions of the paramedics are to identify and treat any life threatening conditions, and to assess the patient for other injuries that need emergency treatment, before transporting the patient to the hospital. Paramedics should understand the sequence of assessment and treatment priorities including arrival at the scene, the first assessment, the primary survey, resuscitation of the vital organs, vital signs, history of present illness, and the secondary survey.
The first assessment of the patient is performed by the dispatcher who receives the call. The EMS dispatcher should obtain important information from the caller including the:
Nature and severity of the injury or accident.
Exact location of the incident.
Number of patients involved.
Responses by police.
Special directions or advisories, such as adverse road or traffic conditions at the time the units are dispatched.
The dispatcher should then alert and mobilize the advance units to the scene, and notify the police for the safety of the paramedics and people at the site.
Arrival at the scene –
It is very important for the EMT to assess the scene for personal danger or danger to uninvolved bystanders. The presence of police cars may indicate a possibility of violence or trauma.
When called to the scene of a crime, the EMT should wait for clearance from the police before approaching the patients. Once the police have controlled the scene, the safety of the patient should be considered. A quick assessment of the victim will determine if the victim is conscious, unconscious, agitated, or actively bleeding. The EMT should proceed in an organized manner. A brief report should be prepared including the history of the event, caliber of weapon, extent of injury, most recent status, and vital signs of the patient.
Primary survey –
The purpose of the primary survey is to identify and treat the most life-threatening emergencies on a priority basis. This is done by assessing and stabilizing the following systems in a systematic approach:
Airway with C spine control.
Breathing.
Circulation with hemorrhage control.
Disability with neurologic status.
Airway with C spine control –
Gently arouse the patient by asking, "Are you okay?" If the victim can speak, his airway is patent, breathing is intact, and cerebral circulation is adequate, then go to the next phase.
If the patient is unresponsive, gently open the airway with a chin lift or jaw thrust maneuver with gentle in-line traction of the cervical spine, and remove any foreign debris from the mouth or nose. If no gag reflex is present, insert the oropharyngeal airway and administer humidified oxygen by face mask.
In a conscious, spontaneous, breathing patient, supplemental oxygen 2 to 10 1/m should be given by face mask. If respiratory efforts are inadequate, or the airway is unprotected by gag reflex due to central nervous system depression or flail chest, then maintain ventilation with oxygen delivered by bag mask device at a high flow rate (10 L/mt) until tracheal intubation is performed. In patients with suspected neck injury, the neck area should be immobilized with a rigid cervical collar, tape and neck rolls, while an assistant provides axial head traction. A nasotracheal or orotracheal intubation should be performed in an unconscious, non-breathing patient. Following the intubation, the victim should be ventilated with 100% humidified oxygen through the bag valve mask device.
Breathing –
The patient’s chest should be completely exposed to assess the ventilatory exchange. A careful physical examination is done by the look, listen, and feel technique. Look for any obvious respiratory distress, cyanosis, tachypnea, and inadequate chest expansion. Listen for breath sounds in both lung fields, and feel for any crepitus or bony deformity. A stab wound to the chest area might have caused a sucking chest wound or active bleeding. Treat the sucking chest wound by sealing the wound with an occlusive dressing (Petrolatum impregnated dressing at 3 points, and control hemorrhage by applying firm dressing and pressure the to area). The flail chest segment should be stabilized properly. A flail anterior chest wall segment can be stabilized by having the patient hold a pillow firmly against the chest wall.
If the patient is intubated and breath sounds are diminished on one side, withdraw the ET tube 2-3 cms, in case the tip is residing in the right main stem bronchus, and recheck the breathing sound. Persistent diminished unilateral breath sound implies pneumothorax. If the patient with pneumothorax who sustained a stab wound is hypotensive, in shock, and in severe respiratory distress, decompress the chest with a 14 gauge angiocatheter inserted in the second intercostal space in the mid clavicular line on the side of the pneumothorax.
Circulation with hemorrhage control –
During the primary survey, the adequacy of peripheral perfusion and oxygenation is determined by checking the pulse, skin color, and capillary refilling time. The patient’s pulse should be assessed for quality, rate, and regularity. Check the heart sounds. Muffled heart tones indicate pericardial tamponade. Exsanguinating hemorrhage should be identified and controlled by applying direct pressure on the wound. A cardiac monitor also should be applied to the patient.
Occult hemorrhage into thoracic or abdominal cavity, into the muscle body surrounding a fracture, as a result of a penetrating injury can account for a large amount of blood loss. The abdominal or lower extremity hemorrhage can be controlled by the application and inflation of MAST trousers. The paramedics should attempt to start two large bore intravenous lines with 16 gauge needle, while drawing some blood for type and crossmatch and baseline hematologic and chemical studies. The IV fluids of choice for stab wound victims in hypovolemic shock are isotonic normal saline and ringer’s lactate.
Brief neurologic evaluation (disability) –
After completion of the primary survey, a brief neurologic evaluation of the patient includes:
The level of consciousness.
The pupillary size and reaction.
The patient’s level of consciousness is determined by:
Alertness.
Responds to vocal stimuli.
Responds to painful stimuli.
Unresponsiveness.
A decrease in the level of consciousness indicates decreased cerebral oxygenation and perfusion. Immediate re-evaluation of the patient’s oxygenation and ventilation status should be made. The patient should be completely undressed for a thorough examination.
Secondary survey –
During the secondary survey a complete head to toe examination is performed by the look, listen, and feel technique. If the victim has sustained life threatening injuries due to an inflicted stab wound, then immediate resuscitation and transport to the hospital is a priority before the secondary survey. Immediate contact with the baseline station should be made, and the patient should be transported. If time permits, then a complete head to toe examination should be done in systematic approach.
Head - During the secondary survey the head should be examined for bruises, deformity, and scalp wounds. Impaled knives to the head and neck area should be left alone, and bandages should be applied around the would.
Face - Look for maxillofacial trauma, loose teeth, blood, and presence of cerebrospinal fluid leadage from the nose. If needed, gastric intubation should be performed through the oral route.
Spine and Neck - Examine the neck carefully for cervical spine fracture by gently palpating for crepitus, tenderness, or step-off deformity. Again, active bleeding should be controlled by pressure dressing.
Chest Area - A careful physical examination of both the anterior and posterior area will reveal a sucking chest wound, entrance and exit of stab wounds, or large flail chest. Breath sounds are auscultated at the apex for pneumothorax, or at the base for hemothorax. Distant heart tones and engorged neck veins indicate cardiac tamponade.
Abdomen - Examine the abdomen for distension and abdominal wall wounds. Palpate the liver and spleen for tenderness, guarding, rigidity, and listen for bowel sounds. Examine the back area for bruises, lacerations or any abnormal findings.
Extremities - Check the extremities and pelvic area for any obvious wounds, bleeding, bony deformity, or crepitus. If the victim is hypotensive, a MAST trousers should be applied simultaneously.
The neurologic examination should be frequently evaluated. A complete neurologic examination not only includes motor and sensory evaluation of the extremities, but also the level of consciousness and Glasgow coma scale.
A quick examination of the genitalia and perineal area is done for any obvious deformity, bruises, or active bleeding.
Definitive Care - Before transfer, the patient should be transferred to a long or short spine board with adequate immobilization.
Stabilization of all serious injuries should have been done, while continuing to assure the adequacy of the patient’s vital signs through periodic monitoring.
The patient should be adequately ventilated with humidified oxygen, IV fluids, and the cardiac monitor should be in place. All the bleeding areas should have been properly controlled.
The paramedics should make a careful recording of all findings and treatment. Repeated assessments should also be documented. The progression of vital signs and neurologic status are especially important to hospital personnel, and should be carefully documented.
A careful history should be obtained from the patient and relatives regarding allergies, medications, health alert bracelets, alcohol or drug abuse.
Documentation - A written record of the problem, treatment given, and status at the time of transfer is essential, and must accompany the patient prior to transfer.
Obtain written permission from the patient or family if it is available.
Make certain the patient has been fully resuscitated and stabilized prior to placing him in the ambulance.
Contact the hospital and transfer the patient to the trauma center.
Management during transport –
Monitor vital signs.
Continue support of respiratory and circulatory systems, including blood volume replacement.
Make sure adequate support personnel and equipment accompany the patient during transport.
Use appropriate medications as ordered by the physician, or as provided by written protocol.
Maintain communication with the receiving physician during transfer.
Maintain accurate records of the patient’s response to therapy during transfer.
Conclusion –
The author has discussed the on-site management of stab wound victims, with particular emphasis on initial stabilization and resuscitation of the patient prior to transportation to the major trauma center. Psychological and social support for the patient and family should be available with the onset of therapy. An emphasis has been put on early aggressive pre-hospital management of these patients for a better prognosis and survival.