An algorithm for the management of patients with stab wounds to the neck has been proposed by authors of a review of the topic.
‘Hard’ signs of vascular injury include severe active bleeding, unresponsive shock, evolving stroke, and large/expanding haematoma. ‘Soft’ signs include a non-expanding moderate haematoma, a bruit/thrill, or a radial pulse deficit (although some consider the latter two to be hard signs). Mentioned in the text, but omitted from the algorithm, is the option of placing a Foley catheter into the wound and inflating the balloon to blindly control bleeding in a crashing haemodynamically unstable patient in order to buy time to get to the operating room.
Review article: Emergency department assessment and management of stab wounds to the neck.
Emerg Med Australas. 2010 Jun;22(3):201-10
The old idea of three-sided taping of an occlusive dressing to treat open / sucking chest wounds has been replaced with just closing the hole with an occlusive dressing and treating any tension pneumothorax. If you don’t have an alternative then you can use an adhesive defibrillator pad to achieve this.
Tactical Combat Casualty Care
Military doctors in Afghanistan reviewed their experience of thoracotomy done within 24 hours of admission to their hospital. The ballistic nature of thoracic penetrating trauma (mainly Afghan civilians without body armour) differs from the typical knife-wound related injury seen in survivors of thoracotomy reported in the pre-hospital literature.
Six of the patients presented in cardiac arrest – four PEA and two asystole. One of the PEA patients survived; this patient had sustained a thoracoabdominal GSW and had arrested 8 minutes from hospital. Following emergency thoracotomy, aortic control, and concomitant massive transfusion, return of spontaneous circulation (ROSC) was achieved and damage control surgery undertaken in both chest and abdomen.
The two patients in asystole had sustained substantial pulmonary and hilar injuries, and ROSC was never achieved. The patients in PEA all had arrested as a consequence of hypovolaemia from solid intra-abdominal visceral haemorrhage. All patients in PEA had ROSC achieved, albeit temporarily.
Following thoracotomy, patients required surgical manoeuvres such as pulmonary hilar clamping, packing and temporary aortic occlusion; hypovolaemia was the leading underlying cause of the cardiac arrest. These factors lead the authors to conclude that although isolated cardiac wounds do feature in war, they are unusual and the injury pattern of casualties in conflict zones are often complex and multifactorial.
Is pre-hospital thoracotomy necessary in the military environment?
Injury. 2010 Jul;41(7):1008-12
In a retrospective study of 45,284 penetrating trauma patients, unadjusted mortality was twice as high in the 4.3% of patients who underwent spine immobilisation, compared with those who were not immobilised.
An accompanying editorial comments: ‘The number needed to treat with spine immobilization to potentially benefit one penetrating trauma patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.‘
Spine immobilization in penetrating trauma: more harm than good?
J Trauma. 2010 Jan;68(1):115-20
The Eastern Association for the Surgery of Trauma has published guidelines on the nonoperative management of penetrating abdominal trauma.
- Patients who are hemodynamically unstable or who have diffuse abdominal tenderness should be taken emergently for laparotomy (level 1).
- Patients who are hemodynamically stable with an unreliable clinical examination (i.e., brain injury, spinal cord injury, intoxication, or need for sedation or anesthesia) should have further diagnostic investigation performed for intraperitoneal injury or undergo exploratory laparotomy (level 1).
- A routine laparotomy is not indicated in hemodynamically stable patients with abdominal stab wounds (SWs) without signs of peritonitis or diffuse abdominal tenderness (away from the wounding site) in centers with surgical expertise (level 2).
- A routine laparotomy is not indicated in hemodynamically stable patients with abdominal gunshot wounds (GSWs) if the wounds are tangential and there are no peritoneal signs (level 2).
- Serial physical examination is reliable in detecting significant injuries after penetrating trauma to the abdomen, if performed by experienced clinicians and preferably by the same team (level 2).
- In patients selected for initial nonoperative management, abdominopelvic CT should be strongly considered as a diagnostic tool to facilitate initial management decisions (level 2).
- Patients with penetrating injury isolated to the right upper quadrant of the abdomen may be managed without laparotomy in the presence of stable vital signs, reliable examination, and minimal to no abdominal tenderness (level 3).
- The majority of patients with penetrating abdominal trauma managed nonoperatively may be discharged after 24 hours of observation in the presence of a reliable abdominal examination and minimal to no abdominal tenderness (level 3).
- Diagnostic laparoscopy may be considered as a tool to evaluate diaphragmatic lacerations and peritoneal penetration (level 2).
Practice Management Guidelines for Selective Nonoperative Management of Penetrating Abdominal Trauma
J Trauma. 2010 Mar;68(3):721-733
The UK General Medical Council provides guidance on the reporting to police of gun and knife wounds.
The guidance describes a two-stage process:
- You should inform the police quickly whenever a person arrives with a gunshot wound or an injury from an attack with a knife, blade or other sharp instrument. This will enable the police to make an assessment of risk to the patient and others, and to gather statistical information about gun and knife crime in the area
- You should make a professional judgement about whether disclosure of personal information about a patient, including their identity, is justified in the public interest.
GMC Guidance on Reporting Gunshot & Knife Wounds
British military physicians reported the outcomes of patients sustaining penetrating neck injury from the Iraq and Afghanistan conflicts. Three quarters were injured in explosions, one quarter from gunshots.
Of 90 patients, only 1 of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation. This patient later died as result of a co-existing head injury. The authors conclude that penetrating ballistic trauma to the neck is associated with a high mortality rate, and their data suggest that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk, and cervical collars may hide potential life-threatening conditions.
Learning the lessons from conflict: Pre-hospital cervical spine stabilisation following ballistic neck trauma
Injury. 2009 Dec;40(12):1342-5
This short cut review in the Best Bets format attempted to answer the question: “is cervical spine protection always necessary following penetrating neck injury?”
From the available evidence they draw the following conclusions:
- In stab wounds to the neck (with or without neurological deficit) an unstable spinal injury is very unlikely and c-spine immobilisation is not needed
- In gunshot wounds the value of cspine immobilisation is limited: for gunshot wounds without neurological deficit no immobilisation is required, while in cases of gunshot wounds with neurological deficit, or where the diagnosis cannot be made (ie, altered mental status), a collar or sandbag is advised once ABCs are stable, with close observation and intermittent removal to inspect and reassess.
- In the rare event of penetrating injury with combined blunt force trauma, a collar or sandbag is advised if possible, once ABCs are stable, with intermittent removal to reassess.
Emerg Med J. 2009 Dec;26(12):883-7
Full text at BestBets.org
A retrospective review of 4204 patients sustaining gunshot wounds (GSW) to the head, neck or torso examined the incidence of spinal cord injury and bony spinal column injury required operative spinal intervention. None of the patients demonstrated spinal instability requiring operative intervention, and only 2/327 (0.6%) required any form of operative intervention for decompression. The authors concluded that spinal instability following GSW with spine injury is very rare, and that routine spinal imaging and immobilisation is unwarranted in examinable patients without symptoms consistent with spinal injury following GSW to the head, neck or torso.
The role of routine spinal imaging and immobilisation in asymptomatic patients after gunshot wounds
Injury. 2009 Aug;40(8):860-3
The physician-led pre-hospital service London HEMS examined its penetrating trauma caseload between 1991 and 2006. Overall, stabbings rose annually by 23.2% and shootings by 11.0%.
Is the prevalence of deliberate penetrating trauma increasing in London? Experiences of an urban pre-hospital trauma service
Injury. 2009 May;40(5):560-3