Penetrating knife wounds

Question 1

A 68 year old man is brought in by ambulance to the ED after a fight on the streets. He has been stabbed multiple times in the abdomen with a 20cm knife. Outline your management of this patient.

Answer 1

Impression
In this patient with multiple stab wounds, I am concerned about hypovolaemic shock secondary to blood loss, and other intra-abdominal injuries/lacerations. This is a medical emergency demanding immediate assessment and management.

Begin with A to E assessment. hierarchy of multi-trauma cases is head - C-spine - thoracic - abdominal - long bones, penetrating wounds at C-Spine if present.

Question 2

Abdominal stabbing - Assessment

Answer 2

Assessment
A - patent, maintaining, tube pending GCS +/- other adjuncts
o consider C-Spine before performing Chin lift
B - RR/SP02. Assess air intake (?pneumothorax from thoracic stab wounds), auscultate for air entry/breath sounds
o eFAST scan; haemothorax, abdominal free fluid
o CXR + trauma series Xray
C - HR/BP/ECG. 2xIVC access, initial bloods: G+xmatch, FBC, UEC, LFT, VBG. replace blood loss in conjunction with HD status initially with 0- and then crossmatched blood, likely activate MTP (PRC + FFP + Cryoprecitate). Other fluid resus.
D - GCS, PEARL.
E - Look for other wounds/injuries sustained. log roll
F - insert IDC for monitoring urine output.
G - BSL

Initial emergency management
- Stabilise patient with blood transfusion
- Likely urgent referral to gen surg for exploratory laparotomy to identify and stem source of bleeding. Priorities of exploratory lap; 1 - haemostasis, 2. -damage control, 3 - temporary closure for definitive management in 24-48 hours.

Question 3

Abdominal stabbing - History

Answer 3

History
- MIST AMPLE

Question 4

Abdominal stabbing - Examination

Answer 4

Examination
- as per A to E
- local wound exploration to assess depth of penetration
- secondary survey for any injuries that may have been missed

Question 5

Abdominal stabbing - Investigations

Answer 5

Investigations
Key/Diagnostic
- CXR + trauma series X-Ray
- eFAST scan at the bedside
- VBG, Group+Xmatch, FBC

Rest as per A to E assessment

• consider further CT brain/spine imaging if concerns re other injuries.

Question 6

Abdominal stabbing - Management

Answer 6

Management
Supportive
- IV fluids, electrolyte replacement
- Prophylactic ABx if requiring surgery
- Tetanus prophylaxis
- Analgesia
- Manage other injuries as identified
- Notify police re. assault

Definitive
Achieve haemostasis
- Gen Surf referral for exploratory lap +/- proceed
- Suture for primary wound closure if no penetration into peritoneum
- Tertiary survey to exclude other injuries