What are the initial steps in emergency room (ER) management of a stab wound?

Emergency Room Management of Stab Wounds

Patients with stab wounds presenting in hemorrhagic shock require immediate surgical bleeding control and should be transferred to the operating room within 60 minutes, while hemodynamically stable patients should undergo systematic assessment using the ATLS classification, local wound exploration, and selective operative management based on anatomical location and injury pattern. 1

Initial Assessment and Hemorrhage Classification

Immediately classify hemorrhage severity using the American College of Surgeons ATLS grading system upon patient arrival to determine the urgency of surgical intervention and guide resuscitation strategy. 1

The ATLS classification defines four classes based on:

• Class I: <750 mL blood loss, HR <100, normal BP, slightly anxious 1
• Class II: 750-1,500 mL loss, HR >100, normal BP, decreased pulse pressure, mildly anxious 1
• Class III: 1,500-2,000 mL loss, HR >120, decreased BP, anxious/confused, requires crystalloid and blood 1, 2
• Class IV: >2,000 mL loss, HR >140, decreased BP, lethargic, requires immediate blood products and emergency surgery 1, 2

Immediate Surgical Indications

Transfer immediately to the operating room without delay if the patient presents with: 1

• Hemorrhagic shock (Class III-IV)
• Peritonitis or evisceration 3
• Unexplained ongoing blood loss despite initial resuscitation 4

The time from injury to surgical bleeding control must be minimized—establish a 60-minute emergency department time limit for patients in hemorrhagic shock, as this significantly reduces mortality. 1

Anatomical Location-Specific Management

Thoracic Stab Wounds

• Perform transthoracic echocardiography in the emergency room to exclude cardiac injury and pericardial effusion, as neither hemodynamic stability nor normal ECG excludes potentially fatal cardiac injury 5
• Obtain chest X-ray to identify pneumothorax or hemothorax 5
• Immediate thoracotomy is indicated for cardiac tamponade or ongoing hemorrhage 5

Abdominal Stab Wounds

For hemodynamically stable patients without peritonitis or evisceration: 4, 3

• Perform local wound exploration first to determine fascial penetration 4, 3
• If fascia is intact, discharge from emergency department with appropriate follow-up 4, 3
• If fascial penetration is confirmed, perform diagnostic peritoneal lavage (DPL) 4, 3
• Proceed to laparotomy if RBC count >1,000/mm³ (92% of patients with >50,000 RBCs have organ injury; 43% with 1,000-50,000 have injury including 59% with hollow viscus perforation) 3
• CT imaging can be used as an adjunct in stable patients to detect bowel or mesenteric injury 1

Extremity Stab Wounds

• Apply tourniquet for life-threatening arterial bleeding from extremity wounds until surgical control is achieved, but minimize duration (ideally <2 hours, maximum 6 hours reported in military settings) 1
• Pressure bandages are sufficient for minor bleeding 1
• Assess for vascular injury requiring surgical repair 2

Resuscitation Principles

Avoid hyperventilation during resuscitation—maintain normoventilation as hyperventilated trauma patients demonstrate increased mortality compared to non-hyperventilated patients. 1

Do not use excessive positive end-expiratory pressure (PEEP) in severely hypovolemic patients, as this decreases cardiac output and worsens outcomes in hemorrhagic shock. 1

Antibiotic Prophylaxis

Administer first-generation cephalosporin with or without aminoglycoside for 48-72 hours for penetrating wounds, particularly high-velocity injuries. 2

Add penicillin for grossly contaminated wounds to cover anaerobes including Clostridium species. 2

Critical Pitfalls to Avoid

• Do not delay surgical intervention for extensive diagnostic workup in unstable patients—penetrating injuries with shock require immediate operative bleeding control 1
• Do not rely solely on initial hemodynamic stability—patients can have significant cardiac or intraabdominal injuries despite normal vital signs 5
• Do not perform mandatory laparotomy for all abdominal stab wounds—selective nonoperative management using local wound exploration and DPL reduces unnecessary laparotomies from 38% to <10% 4, 3
• Do not remove impaled objects in the field or emergency room—this can precipitate uncontrolled hemorrhage and should only occur in the operating room with surgical control available 6