Stab wound

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Stab wound
Beauchamp kills Sharp.jpg
An 1833 depiction of Jereboam O. Beauchamp stabbing Solomon P. Sharp.
Specialty Emergency medicine

A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. [1] [2] [3] [4] While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including broken bottles and ice picks. Most stabbings occur because of intentional violence or through self-infliction. [5] The treatment is dependent on many different variables such as the anatomical location and the severity of the injury. Even though stab wounds are inflicted at a much greater rate than gunshot wounds, they account for less than 10% of all penetrating trauma deaths.[ citation needed ]

Contents

Management

Stab wounds can cause various internal and external injuries. They are generally caused by low-velocity weapons, meaning the injuries inflicted on a person are typically confined to the path it took internally, instead of causing damage to surrounding tissue, which is common of gunshot wounds. [6] The abdomen is the most commonly injured area from a stab wound. Interventions that may be needed depending on severity of the injury include airway, intravenous access, and control of hemorrhage. [5] [7] The length and size of the knife blade, as well as the trajectory it followed, may be important in planning management as it can be a predictor of what structures were damaged. [1] [3] There are also special considerations to take into effect as given the nature of injuries, there is a higher likelihood that persons with these injuries might be under the influence of drugs which can make it harder to obtain a complete medical history. [8] Special precautions should also be taken to prevent further injury from a perpetrator to the victim in a hospital setting. [9] Similarly to treating shock, it is important to keep the systolic pressure above 90mmHg, maintain the person's core body temperature, and for prompt transport to a trauma center in severe cases. [10] [11]

To determine if internal bleeding is present a focused assessment with sonography (FAST) or diagnostic peritoneal lavage (DPL) can be used. Other diagnostic tests such as a computed tomography scan or various contrast studies can be used to more definitively classify the injury in both severity and location. [12] Local wound exploration is also another technique that may be utilized to determine how far the object penetrated. [13] Observation can be used in place of surgery as it can substitute an unnecessary surgery, which makes it the preferred treatment of penetrating trauma secondary to a stab wound when hypovolemia or shock is not present. [14] Laboratory diagnostic studies such as a hematocrit, white blood cell count and chemical tests such as liver function tests can also help to determine the efficiency of care. [15]

Surgery

Surgical intervention may be required but it depends on what organ systems are affected by the wound and the extent of the damage. [3] It is important for care providers to thoroughly check the wound site in as much as a laceration of an artery often results in delayed complications sometimes leading to death. In cases where there is no suspicion of bleeding or infection, there is no known benefit of surgery to correct any present injuries. [16] Typically a surgeon will track the path of the weapon to determine the anatomical structures that were damaged and repair any damage they deem necessary. [17] Surgical packing of the wounds is generally not the favored technique to control bleeding as it can be less useful than fixing the directly affected organs. [18] In severe cases when homeostasis cannot be maintained the use of damage control surgery may be utilized. [19]

Epidemiology

Hilt mark left from a knife Hilt wound.jpg
Hilt mark left from a knife

Stab wounds are one of the most common forms of penetrating trauma globally, but account for a lower mortality compared to blunt injuries due to their more focused impact on a person. [16] Stab wounds can result from self-infliction, accidental nail gun injuries, [20] [21] and stingray injuries, [22] however, most stab wounds are caused by intentional violence, as the weapons used to inflict such wounds are readily available compared to guns. [23] Stabbings are a relatively common cause of homicide in Canada [24] and the United States. [25] Typically death from stab wounds is due to organ failure or blood loss. They are the mechanism of approximately 2% of suicides. [26]

In Canada, homicides by stabbing and gunshot occur relatively equally (1,008 to 980 for the years 2005 to 2009). [24] In the United States guns are a more common method of homicide (9,484 versus 1,897 for stabbing or cutting in 2008). [25]

Stab wounds occur four times more than gunshot wounds in the United Kingdom, but the mortality rate associated with stabbing has ranged from 0-4% as 85% of injuries sustained from stab wounds only affect subcutaneous tissue. [7] [9] [27] In Belgium, most assaults resulting in a stab wound occur to and by men and persons of ethnic minorities. [28]

History

Some of the first principles of wound care come from Hippocrates who promoted keeping wounds dry except for irrigation. [40] Guy de Chauliac would promote removal of foreign bodies, rejoining of severed tissues, maintenance of tissue continuity, preservation of organ substance, and prevention of complications. [40] The first successful operation on a person who was stabbed in the heart was performed in 1896 by Ludwig Rehn, in what is now considered the first case of heart surgery. [41] In the late 1800s it was hard to treat stab wounds because of poor transportation of victims to health facilities and the low ability for surgeons to effectively repair organs. However, the use of laparotomy, which has been developed a few years earlier, had provided better patient outcomes than had been seen before. [42] After its inception, the use of exploratory laparotomies was highly encouraged for "all deep stab wounds" in which surgeons were to stop active bleeding, repair damage, and remove "devitalized tissues". [43] Because laparotomies were seen to benefit patients, they were used on most every person with an abdominal stab wound until the 1960s when doctors were encouraged to use them more selectivity in favor of observation. [44] During the Korean war, a greater emphasis was put on the use of pressure dressings and tourniquets to initially control bleeding. [40]

See also

Related Research Articles

<span class="mw-page-title-main">Injury in humans</span> Physiological wound caused by an external source

An injury is any physiological damage to living tissue caused by immediate physical stress. Injuries to humans can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or overexertion. Injuries can occur in any part of the body, and different symptoms are associated with different injuries.

<span class="mw-page-title-main">Stabbing</span> Wounding with a pointed object at close range

A stabbing is penetration or rough contact with a sharp or pointed object at close range. Stab connotes purposeful action, as by an assassin or murderer, but it is also possible to accidentally stab oneself or others. Stabbing differs from slashing or cutting in that the motion of the object used in a stabbing generally moves perpendicular to and directly into the victim's body, rather than being drawn across it.

<span class="mw-page-title-main">Internal bleeding</span> Medical condition

Internal bleeding is a loss of blood from a blood vessel that collects inside the body, and is not usually visible from the outside. It can be a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding. Severe internal bleeding into the chest, abdomen, pelvis, or thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly. Internal bleeding is a medical emergency and should be treated immediately by medical professionals.

<span class="mw-page-title-main">Major trauma</span> Injury that could cause prolonged disability or death

Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Depending on the severity of injury, quickness of management, and transportation to an appropriate medical facility may be necessary to prevent loss of life or limb. The initial assessment is critical, and involves a physical evaluation and also may include the use of imaging tools to determine the types of injuries accurately and to formulate a course of treatment.

<span class="mw-page-title-main">Penetrating head injury</span> Medical condition

A penetrating head injury, or open head injury, is a head injury in which the dura mater, the outer layer of the meninges, is breached. Penetrating injury can be caused by high-velocity projectiles or objects of lower velocity such as knives, or bone fragments from a skull fracture that are driven into the brain. Head injuries caused by penetrating trauma are serious medical emergencies and may cause permanent disability or death.

<span class="mw-page-title-main">Hemothorax</span> Blood accumulation in the pleural cavity

A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury, but they may occur spontaneously due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to pneumothorax, or rarely in association with other conditions.

<span class="mw-page-title-main">Platysma muscle</span> Human neck muscle

The platysma muscle is a superficial muscle of the human neck that overlaps the sternocleidomastoid. It covers the anterior surface of the neck superficially. When it contracts, it produces a slight wrinkling of the neck, and a "bowstring" effect on either side of the neck.

<span class="mw-page-title-main">Splenic injury</span> Injury to the spleen

A splenic injury, which includes a ruptured spleen, is any injury to the spleen. The rupture of a normal spleen can be caused by trauma, such as a traffic collision.

<span class="mw-page-title-main">Blunt trauma</span> Trauma to the body without penetration of the skin

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, sports-related injuries, and are notably common among the elderly who experience falls.

Hemoperitoneum is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs. Hemoperitoneum is generally classified as a surgical emergency; in most cases, urgent laparotomy is needed to identify and control the source of the bleeding. In selected cases, careful observation may be permissible. The abdominal cavity is highly distensible and may easily hold greater than five liters of blood, or more than the entire circulating blood volume for an average-sized individual. Therefore, large-scale or rapid blood loss into the abdomen will reliably induce hemorrhagic shock and, if untreated, may rapidly lead to death.

<span class="mw-page-title-main">Gunshot wound</span> Injury caused by a bullet

A gunshot wound (GSW) is a penetrating injury caused by a projectile from a gun. Damage may include bleeding, bone fractures, organ damage, wound infection, loss of the ability to move part of the body, and in severe cases, death. Damage depends on the part of the body hit, the path the bullet follows through the body, and the type and speed of the bullet. Long-term complications can include bowel obstruction, failure to thrive, neurogenic bladder and paralysis, recurrent cardiorespiratory distress and pneumothorax, hypoxic brain injury leading to early dementia, amputations, chronic pain and pain with light touch (hyperalgesia), deep venous thrombosis with pulmonary embolus, limb swelling and debility, and lead poisoning.

Emergency bleeding control describes actions that control bleeding from a patient who has suffered a traumatic injury or who has a medical condition that has caused bleeding. Many bleeding control techniques are taught as part of first aid throughout the world. Other advanced techniques, such as tourniquets, are taught in advanced first aid courses and are used by health professionals to prevent blood loss by arterial bleeding. To manage bleeding effectively, it is important to be able to readily identify types of wounds and types of bleeding.

<span class="mw-page-title-main">Penetrating trauma</span> Type of injury

Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or non-penetrating trauma may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment. The penetrating object may remain in the tissues, come back out the path it entered, or pass through the full thickness of the tissues and exit from another area.

<span class="mw-page-title-main">Tracheobronchial injury</span> Damage to the tracheobronchial tree

Tracheobronchial injury is damage to the tracheobronchial tree. It can result from blunt or penetrating trauma to the neck or chest, inhalation of harmful fumes or smoke, or aspiration of liquids or objects.

<span class="mw-page-title-main">Abdominal trauma</span> Medical condition

Abdominal trauma is an injury to the abdomen. Signs and symptoms include abdominal pain, tenderness, rigidity, and bruising of the external abdomen. Complications may include blood loss and infection.

<span class="mw-page-title-main">Diaphragmatic rupture</span> Tear in the thoracic diaphragm

Diaphragmatic rupture is a tear of the diaphragm, the muscle across the bottom of the ribcage that plays a crucial role in breathing. Most commonly, acquired diaphragmatic tears result from physical trauma. Diaphragmatic rupture can result from blunt or penetrating trauma and occurs in about 0.5% of all people with trauma.

An exploratory laparotomy is a general surgical operation where the abdomen is opened and the abdominal organs are examined for injury or disease. It is the standard of care in various blunt and penetrating trauma situations in which there may be life-threatening internal injuries. It is also used in certain diagnostic situations, in which the operation is undertaken in search of a unifying cause for multiple signs and symptoms of disease, and in the staging of some cancers.

<span class="mw-page-title-main">Liver injury</span> Form of trauma sustained to the liver

A liver injury, also known as liver laceration, is some form of trauma sustained to the liver. This can occur through either a blunt force such as a car accident, or a penetrating foreign object such as a knife. Liver injuries constitute 5% of all traumas, making it the most common abdominal injury. Generally nonoperative management and observation is all that is required for a full recovery.

Damage control surgery (DCS) is surgical intervention to keep the patient alive rather than correct the anatomy. It addresses the "lethal triad" for critically ill patients with severe hemorrhage affecting homeostasis leading to metabolic acidosis, hypothermia, and increased coagulopathy.

<span class="mw-page-title-main">Vaginal evisceration</span>

Vaginal evisceration is an evisceration of the small intestine that occurs through the vagina, typically subsequent to vaginal hysterectomy, and following sexual intercourse after the surgery. It is a surgical emergency.

References

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  2. ↑ Taber, Clarence Wilbur; Venes, Donald (2009). Taber's cyclopedic medical dictionary. F a Davis Co. p. 2189. ISBN   978-0-8036-1559-5.
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  5. 1 2 Sugrue M, Balogh Z, Lynch J, Bardsley J, Sisson G, Weigelt J (August 2007). "Guidelines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen". ANZ Journal of Surgery . 77 (8): 614–20. doi:10.1111/j.1445-2197.2007.04173.x. PMID   17635271. S2CID   71976611.
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  15. ↑ Marx. 2014. p. 464.
  16. 1 2 Oyo-Ita, Angela; Chinnock, Paul; Ikpeme, Ikpeme A. (2015-11-13). "Surgical versus non-surgical management of abdominal injury". The Cochrane Database of Systematic Reviews (11): CD007383. doi:10.1002/14651858.CD007383.pub3. ISSN   1469-493X. PMID   26568111.
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  20. ↑ Jodati, A.; Safaei, N.; Toufan, M.; Kazemi, B. (2011). "A unique nail gun injury to the heart with a delayed presentation". Interactive Cardiovascular and Thoracic Surgery. 13 (3): 363–365. doi: 10.1510/icvts.2011.272120 . ISSN   1569-9293. PMID   21636580.
  21. ↑ Kaljusto ML, Tønnessen T (May 2012). "How to mend a broken heart: a major stab wound of the left ventricle". World J Emerg Surg. 7 (1): 17. doi: 10.1186/1749-7922-7-17 . PMC   3467162 . PMID   22640705.
  22. ↑ Parra MW, Costantini EN, Rodas EB, Gonzalez PJ, Salamen OJ, Catino JD, Taber PM, Puente I (May 2010). "Surviving a transfixing cardiac injury caused by a stingray barb". The Journal of Thoracic and Cardiovascular Surgery. 139 (5): e115–6. doi: 10.1016/j.jtcvs.2009.02.052 . ISSN   0022-5223. PMID   19660402.
  23. ↑ Eades, Chris (2007). Knife crime : review of evidence and policy. London: Centre for Crime and Justice Studies. ISBN   978-1906003067.
  24. 1 2 "Homicides by method". Archived from the original on 2012-01-10. Retrieved 2012-01-10. Homicides by method
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  29. ↑ UNODC Homicide Statistics 2013, used two tables: Homicide counts and rates, time series 2000-2012 & Percentage of homicides by mechanism, time series 2000-2012. Retrieved May-20-2014
  30. ↑ Murder Victims by Weapons (FBI). Retrieved May-20-2014
  31. ↑ U.S. Population 2012: Nearly 313 Million People. Retrieved May-20-2014
  32. ↑ Chart 9: Victims of homicide by main method of killing, Scotland, 2012-13. Retrieved May-20-2014
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  37. ↑ Australia’s population. Retrieved May-20-2014
  38. ↑ Knife crime statistics. Retrieved May-20-2014
  39. ↑ Every person in England and Wales on a map. Retrieved May-20-2014
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  41. ↑ Sharpe, William (June 17, 1961). "Laceration of the Heart: Repair and Recovery: 1877". Journal of the American Medical Association. 176 (11): 964. doi:10.1001/jama.1961.63040240024023.
  42. ↑ Oliver, J.C. (1899-01-09). "Gun Shot Wounds of the Abdomen with Report of Fifty Eight Cases". Academy of Medicine of Cincinnati: 354–75. Retrieved 2012-02-04.
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  44. ↑ Marx. 2014. p. 459.

Bibliography

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