The recent knife attacks, on the Strip in Las Vegas, at Purdue University, and the fatal stabbing of FDNY Lt. Alison Russo-Elling, got me thinking about caring for stabbing patients. We devote a good deal of training time to blunt trauma and gunshot wounds, but stab wounds also present a real danger for patients. Knife wounds or stabbings from other sharp or pointed, handheld instruments, such as a shiv or a broken piece of glass are considered penetrating trauma and require careful assessment and timely treatment to enhance survival.
Penetrating trauma generally represents less than 10% of all trauma cases, although some geographic regions may see as high as 25%. Stab wounds occur much less commonly than gunshot wounds, accounting for 6% of penetrating trauma deaths according to CDC WISQARS data.
Keep the following in mind when called to a stabbing victim.
1. Double up on scene safety
Of course, we have to start with “scene safety, BSI!” for this one. Attention must be turned to knowing where the assailant and weapon are. Similarly, the patient must also be carefully checked for weapons. Depending on the situation, there is a good chance that the assailant was not the only one carrying. Use your head-to-toe survey as an excuse to clear them of any weapons that may become an issue later in transport or at the hospital.
2. Conduct a careful physical assessment
Speaking of assessments, stabbing patients require a thorough assessment to identify their injuries and life-threats. Stab wounds don’t always spurt blood like in the movies, so the EMS provider must seek them out. Cut away the patient’s clothing and carefully check for wounds. Remember that the holes may be very small. Don’t forget armpits, groins and under breasts. Once the physical assessment is complete, be sure to cover the patient to preserve body heat.
3. Hold off on the C-collar
It has been well established now that penetrating trauma rarely causes unstable cervical spine trauma. When it does, the neurological deficits are apparent immediately. If your stabbing patient does not exhibit any loss of motor or sensory capability in their extremities when you conduct your initial assessment, they do not likely need any form of C-spine precautions. It is more important for efforts to be directed at bleeding control, airway maintenance, and early transport to a trauma center.
4. Get a look at the weapon
While law enforcement on scene will hopefully have the stabbing weapon in their possession, take a moment to view the item and note some details about it, including length, width and shape. These will be helpful in determining the potential injury track in the patient. Relay the information to the trauma team at the hospital. If the weapon is no longer on scene, get as much information about it as you can from the patient and witnesses.
5. Recall your anatomy training
With the description of the weapon and the injuries you identified on the patient in hand, it is time to reach deep into your knowledge banks and recall the important anatomy that lays below the surface of those injuries. Was the knife long enough to reach that major artery or a chamber of the heart? Could the piercing have entered the pleural space? Are the involved abdominal organs solid or hollow?
Remember that the diaphragm lies at an angle within the thorax and moves with each breath. Assume that any penetration below the level of the nipples anteriorly or the bottom of the scapula posteriorly involves the diaphragm and is therefore both a thoracic and abdominal injury.
6. Think the worst and hope for the best
By now you should be ready to transport the patient to a hospital and the decision must be made whether is it truly “just a flesh wound” or a reason to transport urgently to a higher-level trauma center. The recently updated National Guideline for the Field Triage of Injured Patients lists “penetrating injuries to head, neck, torso and proximal extremities” first in the list of Red Criteria injuries and considers them high risk for serious injury. Since the presence of a stab wound is a very objective finding, these patients should never be under-triaged.
7. Keep current on trauma training
In general, EMS providers are called upon to treat stab wounds and other penetrating injuries less often than other types of trauma. Make it a point to seek out training on these topics through focused continuing education classes or formal programs like Prehospital Trauma Life Support (PHTLS) or International Trauma Life Support (ITLS).
Stay safe out there.
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