Why a Knife is a Great Weapon

[swatsurgeon]

Unfortunately no pictures to go with this......
Had a 20 year old stabbed 3 times by a knife that had about a 3 1/2 inch blade. First wound to his back, right side just over the 10th rib, second wound antero-lateral abdomen on the anterior axillary line just under the lowest rib and the third one more medial on the abdomen in the right upper quadrant under the nipple line.
I'm called 3 hrs after the incident by another hospital that states: "he had no breath sounds so we put in a right chest tube". What they didn't say was they has a CXR that was NORMAL before they decided to put in the tube. Anyway, they transfer for these wounds.
He arrives with a heart rate of 85, normal BP, minimal complaits about 5 hours post incident.
History from other hosp.: gave 4 liters IVF, 1 IV site, 32 F chest tube with confirmation CXR after tube that it is in the right chest, No airleak but 160mL of blood in tube (pleurovac).....ROCK STABLE. Anyone worried yet?

So I decide to send him to CT to evaluate abdomen. Retake CXR and their chest tube was placed really low but in the tube does end in the chest.
CT shows A LOT of blood and active hemorrhage RUQ....HR still in the 80's and SBP 130, no distress.
Go to OR and find 1200-1500mL blood in abd and active bleeding from the right lobe of liver, a small hole in the diaphragm....everything dealt with, pt doing fine.

ISSUES: some people think "it's just a flesh wound" vitals are stable, no worries. Now if you took the same patient and made it a GSW, everyone worries......so why not as much anxiety for a stab wound?
This guy was compensating very well for a long time...that won't last forever.
Knife length makes a difference. if you can determine if it was > 2-2 1/2 inches in the average size person without a thick layer of fat, it can get inside and cause significant bleeding.
Based on anatomy and experience, a blade that is 3 1/2 inches or greater typically causes internal injuries, that is not to say smaller blades can't but if you are using the odds for your defensive weapon, go with > 4 inches.
Nothing to really treat these can be done in the field. Stuffing a hemostatic agent into the wound would not have helped, the wound was not bleeding (skin, fat, muscle, fascia), the liver was. A tourniquet would help nothing, so you are left with supportive measures only and getting them to a trauma surgeon.
In general, stable vitals give a false sense of security for stab wounds, not GSW's....time to increase that paranoia for stab wounds also, especially for longer length blades. The old saying of "stabbed with a kitchen knife", well if true, be worried (if a carving knife with a 6 inch blade vs 2 inch paring knife).
Note, this was all about abdominal stab wounds, not chest, neck groin, etc.

ss

[doctom54]

Nice example. At least they knew enough to transfer the patient.
As an opposite example I was working the ED on the Waianae coast on Oahu. One brother stabbed another with an 8 inch kitchen knife (yes they brought it in with them when they both arrived).
They were both about 6' 3" and over 300 lbs (big native Hawaiians). In the ED I explored the wound then in radiology used contrast. The wound failed to penetrate to the fascia.
I sewed him up and they went home happy. Not even mad anymore
That was always an interesting place to moonlight.

[swatsurgeon]

if only it was like TV or the movies...8 inch blade should do some damage but not always, same for gun shots though the 'baby fat'.

[Red Flag 1]

Interesting case!

Rock stable can hit rock bottom in no time. I'd like to have seen at least a second large bore IV early on pre-op.

The most impressive stab wound I ever saw was in a medium sized town in rural MS. Patient brought to the ED via ambulance with a 3 " knife firmly impedded, to the hilt, medial to the right eye, but within the socket. Patient was awake and responsive. Bleeding was about what you would expect with a facial laceration. The eye did not move and there was loss of vision od. Patient was hemodynamically stable...though a bit tachy with elvated BP. Visual impact was such that folks had a tendency to turn away, and had to be redirected to engage the patient; ED folks just had a tough time with this. Films suggested the blade had not penetrated into the cranial vault. Wound was explored in the OR at another facility. Patient lost the right eye but did well overall. Impressive wound!

My $.02 with a memorable stab wound.

RF 1

[RichL025]

With the advent of nonoperative management for so many injuries nowadays, some people get in the mindset to "keep the patient out of the OR" that they feel a subtle pressure to underestimate injuries (IMHO).

An old graybeard who is one of my attendings keeps emphasizing that the "conservative" option is to take the patient to the OR and see for yourself!

[Eagle5US]

Though it goes without saying...
Nice save.

Eagle

[swatsurgeon]

Never let the skin stand in the way of a proper diagnosis....when all else fails and confusion reigns, retinal scans give sure answers.

ss

[koz]

I got this e-mail from a friend last week -


From a retired NYPD friend.

THIS WAS AN INJURY THAT COULD HAVE BEEN PREVENTED. DON'T BE A HERO...

SHOOT, SHOOT, SHOOT.

The photos are of an officer trained in hand-to-hand combat. The officer figured, due to his size and fighting skills, he could disarm a knife wielding aggressor.

Here is why I am forwarding these pictures on. To all the idiots out there who always say, "Why did the cops have to shoot him? He only had a (insert your choice of weapons here, i.e. knife, bat, club. whatever). He didn't have to be shot. To that, I respond,"tough crap ... shoot'em".

If an officer tells you to drop your weapon, just drop it. If you're a retard, stupid, on crack, mental or just "scared" ... too bad. No one deserves what this cop got for just doing his job. If you got a knife, then you should die ... period. This is vivid proof of how deadly people who are "only armed with a knife" can be. Some of the public think that officers should try to disarm someone armed with a knife but anyone who has had training in knife fighting will tell you - even if you win you are going to get cut.

Keep this in the back of your mind when confronting someone armed with an edged weapon.

[olhamada]

Thanks SS. Great case. Knives scare me. Reminds me of a case I saw about 10 years ago. I had just started my ER shift and took turnover from the doc covering the earlier shift. She said, "I've only got one patient to turn over to you. Nothing bad. He's been here about 4 hours. He can probably go home."

Story was: 22 yo athletic BM stabbed in the R trapezius with a pair of scissors. Right after I got settled and the other doc had left, I went in to see him to get a better picture of his condition. He was sitting up in bed with a nasal cannula running 2L O2. He was splinting his right side, leaning forward supporting himself with his left arm, breathing through his mouth. When I walked in he immediately said, "I can't breathe". I quickly evaluated the situation, looked at the vitals monitor and saw he was breathing 22/min, HR was 130, BP was 108/72. He didn't have any JVD, tracheal shift, or visible injury other than two small puncture wounds in his right trapezius consistent with the history I received. At this point I was cussing the previous doctor. I quickly listened to his chest and heard no breath sounds on the right. He was moving air fairly well on the left and CV was normal other than being tachycardic. I asked for a stat CXR and the nurse said one was done about 2 hours prior. I asked her to still call for XR but asked her to bring me the films. Within 30 seconds I was holding it up to the overhead light and saw a completely collapsed R lung with minimal mediastinal shift. I also saw the broken tips of the scissors deep in the trap and quickly guessed that both had most probably penetrated the pleura. (Good guess, huh?) Remember, this film was 2 hours old. Now, why the heck, didn't the first doc look at this? Or if she did, why didn't she act on it?

I quickly placed an angiocath in the 2nd IC space and he began to show some improvement.

XR was slow, so I went ahead and put a chest tube in and covered the posterior wounds with an occlusive dressing. Immediately, the chest tube began draining blood, and his breathing eased, his color returned, and he became visibly more comfortable. As I watched the pleurevac I saw the level of blood rise - 200 cc, 250, 300, 350, 400, 450, 500, 550...... I began to get nervous again. As he passed 850 cc, I reviewed my procedure. I was sure I didn't puncture his liver, thought there is no way I'm in the IVC, aorta, heart, etc....... His vitals were holding stable, but he began to get a bit anxious and I wondered if this was because he was about to crash, or I thought he may be reading my anxiety though I thought I was covering it well.

One thing I didn't say, is that this was an outlying hospital with no good surgical backup, and it would take at least an hour to get him to a trauma center even with LifeFlight. I didn't have an hour. I had a few minutes at most.

We had two large bore IVs going, O2 BFM, and I started running through my game plan in my head. I asked the nurse to bring in a chest cart.

What would you have done?

[olhamada]

Originally Posted by koz

I got this e-mail from a friend last week -


From a retired NYPD friend.

THIS WAS AN INJURY THAT COULD HAVE BEEN PREVENTED. DON'T BE A HERO...

SHOOT, SHOOT, SHOOT.

The photos are of an officer trained in hand-to-hand combat. The officer figured, due to his size and fighting skills, he could disarm a knife wielding aggressor.

Here is why I am forwarding these pictures on. To all the idiots out there who always say, "Why did the cops have to shoot him? He only had a (insert your choice of weapons here, i.e. knife, bat, club. whatever). He didn't have to be shot. To that, I respond,"tough crap ... shoot'em".

If an officer tells you to drop your weapon, just drop it. If you're a retard, stupid, on crack, mental or just "scared" ... too bad. No one deserves what this cop got for just doing his job. If you got a knife, then you should die ... period. This is vivid proof of how deadly people who are "only armed with a knife" can be. Some of the public think that officers should try to disarm someone armed with a knife but anyone who has had training in knife fighting will tell you - even if you win you are going to get cut.

Keep this in the back of your mind when confronting someone armed with an edged weapon.

Damn.

Great reminder. Thanks, Koz.

[RichL025]

Originally Posted by olhamada

Thanks SS. Great case. ... He was splinting his right side, leaning forward supporting himself with his left arm, breathing through his mouth. When I walked in he immediately said, "I can't breathe"....
...I breathing 22/min, HR was 130...

... I quickly listened to his chest and heard no breath sounds on the right....

...What would you have done?

No offense, but he should have had a needle or chest tube RIGHT AT THIS POINT.

XRay should have been an afterthought to confirm your proper chest tube placement.

One thing I didn't say, is that this was an outlying hospital with no good surgical backup, and it would take at least an hour to get him to a trauma center even with LifeFlight. I didn't have an hour. I had a few minutes at most.

No, you DID have an hour. You had several hours. He has already demonstrated that his hemothorax is not that brisk (he accumulated those 850 ccs in his chest over the 4 hours he was sitting there), not in the seconds after you placed the tube) and you addressed his limmediate life-threatening injury already.

I would submit you have no options other than transferring the patient to a trauma center. An ED thoracotomy has a dismal save rate (to hospital discharge) in experienced hands.

Give him two large bore lines, get blood flowing, FFP and platelets as necessary, and get him to a trauma center stat.

[olhamada]

Originally Posted by RichL025

No offense, but he should have had a needle or chest tube RIGHT AT THIS POINT.

XRay should have been an afterthought to confirm your proper chest tube placement.

No, you DID have an hour. You had several hours. He has already demonstrated that his hemothorax is not that brisk (he accumulated those 850 ccs in his chest over the 4 hours he was sitting there), not in the seconds after you placed the tube) and you addressed his limmediate life-threatening injury already.

I would submit you have no options other than transferring the patient to a trauma center. An ED thoracotomy has a dismal save rate (to hospital discharge) in experienced hands.

Give him two large bore lines, get blood flowing, FFP and platelets as necessary, and get him to a trauma center stat.

Good points. However, my assumptions upon entering the room were that he had been recently been evaluated by a competent senior attending physician who had worked him up and had been watching him for 4 hours. I wanted to know what caused his sudden change while prepping for what I felt certain to be a needle followed by a tube thoracostomy.

Secondly, if you read carefully, I said he passed 850 cc. The drainage stopped at around 1250. Also the CXR done 2 hours previous showed no signs of hemothorax. So as far as I knew, this was new fairly well oxygenated blood, and he was young and athletic so could compensate fairly well before a sudden crash. The time between 850 and 1250 cc was quite anxiety provoking as, at that point given the information I had, I was not in a position to assume that he did not have an active bleed as you suggest.

The point you bring up about survivability of ED thoracotomy is key. The question running through my head was, "what if this is an active bleed and this guy decompensates? Am I going to let him die right here in front of me without doing anything?" In the end you were right. The blood coming out of the tube did stop - albeit at 1250 cc. He remained stable, and was transferred to a Level 1 Trauma Center.

However, the answer to the questions running through my head at the time was, "With my lack of thoracic surgery training, I will not crack his chest." The reason I brought this up is that this is a frequent question we face in the ED and in residency training programs that attracts much debate.

[bcsomedic]

That was an excellent reminder. Each officer or operator should forward these pictures to everyone they know. Remember, the most important part of your job is to go home safe to your family at the end of your shift or your tour.

Stay safe.

[Razor]

Originally Posted by bcsomedic

Remember, the most important part of your job is to go home safe to your family at the end of your shift or your tour.

Certainly no disrespect or diminishing of the essential service law enforcement provides is intended, but is the concept that individual officer safety really takes precendence over fulfilling the public safety enforcement role truly prevalent in LE, or do sayings such as the quote above just make for a convenient, short reminder to stay as safe as one can, given the dangers inherent in the job?

[ChickenMcFuggit]

Originally Posted by Razor

Certainly no disrespect or diminishing of the essential service law enforcement provides is intended, but is the concept that individual officer safety really takes precendence over fulfilling the public safety enforcement role truly prevalent in LE, or do sayings such as the quote above just make for a convenient, short reminder to stay as safe as one can, given the dangers inherent in the job?

If I may, it refers to the latter, sir. Do your job to the best of your ability, but use caution in all things. No matter how good youi think you are, there's always somebody out there better than you, etc. Runs along the same lines as "Be polite. Be professional. Have a plan to kill everyone you meet."
Probably the only real good advice I took from the academy 12 years ago, and its kept me alive a few times, came from a retired QP who taught us Building Entry. He said,"You guys know that most of what you're being taught at this academy is bullsh#t but if there's one thing you need to remember its this. 'If you hit somebody, make sure they stay hit.'" Words to live by...