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