Tag Archives: stab wounds

Abdomen, Pop quiz

What Would You Do? Teensy Weensy Stab To The Abdomen – Part 3

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In my last post, I described the plight of a young man who had sustained a stab to the abdomen. It appeared that a very tiny bit of omentum was hanging out of the wound. What to do?

I listed three options:

  • Local wound exploration
  • CT scan of the abdomen
  • Proceed to the operating room

So let’s work through these. First, local wound exploration (LWE).

LWE is a diagnostic procedure to determine if a sharp wound has actually or potentially penetrated a vital area. It is usually performed in the neck to determine if the platysma has been violated, or in the abdomen top check for peritoneal violation. In this case, you would use it if you just couldn’t believe that the bit of odd fat was actually omentum, or if you were unsure what you were looking at. You could also grab it (gently) and give it a little tug. If more comes out, you’ve made your diagnosis. Fortunately, this is rarely necessary because omentum has a very distinctive appearance. You know it when you see it.

What about probing the wound? One of my mentors, John Weigelt, used to ask, “Michael, does your finger / q-tip / instrument have an eyeball on the end of it?” His point was that probing is like so many other medical tests: diagnostic if positive, but unsettling if it’s not. What happens if the wound does penetrate, but you can’t find the path that the knife/bullet took? You can only call that indeterminate. I suppose you could take an approach that includes probing first, then proceeding to full LWE if that is negative.

I’ll describe the proper technique for local wound exploration in a later post.

And what about CT scan? This is another unsatisfying test, because it is very likely to be negative with small wounds. The fascial defect in this case will be very small, and can easily be missed on the scan. Not recommended.

Given all this discussion, my vote is to proceed to the operating room. I know this is omentum, and I know that there is a good likelihood that there will be an injury that needs repair. So let’s go get it done.  But what procedure should I do, and how should I do it? That’s the subject for my next post.

As always, please leave comments below or tweet them out!

 

General

To Probe or Not To Probe: Penetrating Wounds

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There is considerable variability in the way that penetrating wounds are approached. Some are located over areas of lesser importance (distal extremities) or are so superficial that they obviously don’t fully penetrate the skin.

Unfortunately, some involve high-value structures (much of the neck and torso), or are too small to tell if they penetrate (ice pick injury). How should these injuries be approached?

Too often, someone just probes the wound and makes a pronouncement based on that assessment. Unfortunately, there are major problems with this technique:

  • The tract may be too small to appreciate with a finger or even a cotton-tip swab
  • The tract may be oriented in an unexpected direction, or the soft tissues may have moved after the penetration occurred. In this case, the examiner may not appreciate any significant depth to the wound.
  • Inserting an object may violate a structure that you wish it hadn’t (resulting in a hissing sound after probing a chest wound, or a column of blood after probing the neck)

A better way to approach these wounds is as follows:

  • Is the patient unstable? If so, you know the penetration caused the problem and the patient belongs in the OR.
  • Is there other evidence of deep injury, such as peritonitis with a penetrating abdominal wound? If so, the patient still needs to go to the OR.
  • Do a legitimate local wound exploration. This entails making the hole bigger with a knife, and using surgical instruments and your eyes to find the bottom of the tract. Obviously, there are some parts of the body where this cannot be done, such as the face, but they probably don’t need this kind of workup anyway.

As one of my mentors, John Weigelt, used to say, “Doctor, do you have an eye on the end of your finger?” In general, don’t use anything that doesn’t involve an eyeball in your local wound explorations!

General

How To Read A Stab Wound

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Most emergency departments do not see much penetrating trauma. But it is helpful to be able to learn as much as possible from the appearance of these piercing injuries when you do see them. This post will describe the basics of reading stab wounds.

Important: This information will allow some basic interpretation of wounds. It will not qualify you as a forensics expert by any means. I do not recommend that you document any of this information in the medical record unless you have specific forensic training. You should only write things like “a wound was noted in the midepigastrium that is 2 cm in length.” Your note can and will be used in a court of law, and if you are wrong there can be significant consequences for the plaintiff or the defendant. This information is for your edification only.

1. What is the length of the wound? This does not necessarily correspond to the width of the blade. Skin stretches as it is cut, so the wound will usually retract to a length that is shorter than the full width of the blade.

2. Is the item sharp on one side or both? This can usually be determined by the appearance of the wound. A linear wound with two sharp ends is generally a two sided knife. A wound with one flat end and one sharp end is usually from a one-sided weapon. The picture below shows a knife wound with one sharp side.

3. Is there a hilt mark? This can usually be detected by looking for bruising around the wound. The picture below shows a knife wound with a hilt mark.

4. What is the angle? If both edges are symmetric, the knife went straight in. If one surface has a tangential appearance, then the knife was angled toward that side. You can approximate the direction of entry by looking at the tangential surface of the wound edge. In this example, the blade is angling upward toward the right.

5. How deep did it go? You have no way of knowing unless you have the blood stained blade in your possession. And yes, it is possible for the wound to go deeper than the length of the knife, since the abdominal wall or other soft tissues can be pushed inwards during the stab.

General

What Would You Do? Knife To The Back!

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Here’s an interesting case to consider. A young male is assaulted and stabbed to the back. Paramedics bring him to your ED as a trauma team activation, and the full team is assembled prior to his arrival. 

He is brought into the room on the stretcher in the prone position. Here is a representative picture. This is not the actual patient, just a picture I found on another blog site that looks pretty close to the real case.

Let’s walk through the thought processes of managing this over the next few days.

First, what do you need to know right now to navigate your critical decision points? And what are you going to do regarding positioning, evaluation, and imaging?

Tweet or comment with your replies! More on Monday.

General

Best Of: How To Read A Stab Wound

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Most emergency departments do not see much penetrating trauma. But it is helpful to be able to learn as much as possible from the appearance of these piercing injuries when you do see them. This post will describe the basics of reading stab wounds.

Important: This information will allow some basic interpretation of wounds. It will not qualify you as a forensics expert by any means. I do not recommend that you document any of this information in the medical record unless you have specific forensic training. You should only write things like “a wound was noted in the midepigastrium that is 2 cm in length.” Your note can and will be used in a court of law, and if you are wrong there can be significant consequences for the plaintiff or the defendant. This information is for your edification only.

1. What is the length of the wound? This does not necessarily correspond to the width of the blade. Skin stretches as it is cut, so the wound will usually retract to a length that is shorter than the full width of the blade.

2. Is the item sharp on one side or both? This can usually be determined by the appearance of the wound. A linear wound with two sharp ends is generally a two sided knife. A wound with one flat end and one sharp end is usually from a one-sided weapon. The picture below shows a knife wound with one sharp side.

Single edge knife wound

3. Is there a hilt mark? This can usually be detected by looking for bruising around the wound. The picture below shows a knife wound with a hilt mark.

Knife wound with hilt mark

4. What is the angle? If both edges are symmetric, the knife went straight in. If one surface has a tangential appearance, then the knife was angled toward that side. You can approximate the direction of entry by looking at the tangential surface of the wound edge. In this example, the blade is angling upward toward the right.

Angled knife entry

5. How deep did it go? You have no way of knowing unless you have the blood stained blade in your possession. And yes, it is possible for the wound to go deeper than the length of the knife, since the abdominal wall or other soft tissues can be pushed inwards during the stab.