What is the proper treatment protocol for a stab wound in the emergency room (ER)?

Emergency Management of Stab Wounds

Patients with stab wounds should undergo immediate bleeding control procedures unless initial resuscitation measures are successful, with rapid transfer to the operating room for surgical intervention if presenting with hemodynamic instability. 1

Initial Assessment and Stabilization

• Immediately assess hemodynamic status using established grading systems such as the American College of Surgeons ATLS classification of hemorrhage severity 1
• For patients in hemorrhagic shock with an identified source of bleeding, proceed directly to bleeding control procedures 1
• For patients in hemorrhagic shock with an unidentified source of bleeding, perform immediate further assessment of chest, abdominal cavity, and pelvic ring 1
• Avoid hyperventilation in severely hypovolemic trauma patients as it can worsen outcomes 1
• When intubation is required, use protective ventilation with low tidal volume and moderate PEEP to prevent pulmonary complications 1

Diagnostic Approach

• Perform early focused sonography (FAST) to detect free fluid in patients with suspected torso trauma 1
• Patients with significant free intraabdominal fluid and hemodynamic instability should undergo urgent surgery 1
• Hemodynamically stable patients with suspected head, chest, and/or abdominal bleeding following high-energy injuries should undergo CT scanning 1
• In low-resource settings where CT or ultrasound is not available, consider diagnostic peritoneal lavage (DPL) 1

Management Based on Wound Location

Penetrating Injuries to Torso (Chest/Abdomen)

• All penetrating injuries to the torso require immediate evaluation and likely surgical intervention 1
• For stab wounds to the chest:
  • Immediately assess for pneumothorax or hemothorax and place chest tubes as needed 2
  • For cardiac injuries, immediate transfer to cardiothoracic operating theater is recommended 3
  • Consider emergency room thoracotomy for patients in extremis with signs of cardiac tamponade 4
• For stab wounds to the abdomen:
  • Patients with hemodynamic instability and abdominal stab wounds require immediate laparotomy 1
  • In stable patients, consider CT imaging to assess injury extent 1

Penetrating Injuries to Extremities

• Control external hemorrhage with direct pressure, wound packing, and tourniquets if needed 1
• Assess for vascular injury with physical examination and appropriate imaging 1
• Proximal extremity wounds (above elbow/knee) carry higher risk and should be evaluated at a trauma center 1

Resuscitation Strategies

• Target systolic blood pressure of 80-100 mmHg until major bleeding has been stopped (permissive hypotension) in patients without brain injury 1
• Begin fluid resuscitation with crystalloids; colloids may be added within prescribed limits 1
• Consider early blood product transfusion for patients with significant hemorrhage 1
• Monitor serum lactate and base deficit to estimate and track the extent of bleeding and shock 1

Definitive Management

• For patients requiring surgery, damage control surgery should be employed in severely injured patients presenting with deep hemorrhagic shock, ongoing bleeding, coagulopathy, hypothermia, or acidosis 1
• Early bleeding control techniques include packing, direct surgical control, and local hemostatic procedures 1
• Consider angiographic embolization for patients with ongoing hemodynamic instability despite adequate surgical management 1
• For post-traumatic biliary complications, consider percutaneous drainage and endoscopic techniques 1

Special Considerations

• Maintain high suspicion for cardiac injury with thoracic stab wounds, as mortality rates are high (23.3%) 4
• Poor prognostic factors include shock, cardiac arrest, need for CPR, and emergency room thoracotomy 4
• Avoid wound exploration near the inferior costal margin unless absolutely necessary 1
• Start thromboprophylaxis as soon as possible following trauma in stable patients 1
• Begin early mobilization and enteral feeding as soon as possible in stable patients 1

Pitfalls to Avoid

• Delaying surgical intervention for unstable patients with penetrating trauma 1
• Underestimating the extent of internal injury based on external wound appearance 1
• Failing to recognize tension pneumothorax or cardiac tamponade requiring immediate intervention 2
• Neglecting to reassess patients with serial clinical evaluations during non-operative management 1
• Overlooking associated injuries in patients with multiple stab wounds 1