What is the initial evaluation and treatment approach for a patient with a stab wound injury, considering vital signs, medical history, and wound severity?

Assessment and Management of Stab Wound Injuries

Immediate Hemodynamic Assessment Determines All Management

The single most critical decision point is hemodynamic stability: patients with blood pressure <90 mmHg, heart rate >120 bpm, cool/clammy skin, altered consciousness, or shortness of breath require immediate operative management without delay for extensive imaging. 1

Primary Assessment Algorithm

Step 1: Determine Hemodynamic Status

Unstable patients (any of the following):

• Systolic BP <90 mmHg 1
• Heart rate >120 bpm 1
• Cool, clammy skin with decreased capillary refill 1
• Altered level of consciousness 1
• Shortness of breath 1

Action for unstable patients: Immediate transfer to operating room after chest X-ray and FAST ultrasound only—no CT scan. 2, 3

Step 2: Assess for Hard Signs Requiring Immediate Surgery

Even in hemodynamically stable patients, the following mandate immediate operative exploration:

• Evidence of peritonitis on physical examination 1
• Evisceration of abdominal contents 1
• Signs of hollow viscus perforation 1
• Active hemorrhage 4

Step 3: Hemodynamically Stable Patients Without Hard Signs

For stable patients, management depends on wound location and depth:

Anterior Abdominal Stab Wounds:

• Perform local wound exploration (LWE) to determine if anterior fascia is breached 1, 3
• If fascia intact: patient can be discharged (other injuries permitting) 1
• If peritoneum violated but patient stable: proceed to selective non-operative management (NOM) with intensive monitoring 1

Flank/Back Stab Wounds:

• CT scan with IV contrast is mandatory to assess retroperitoneal organs and colon, as clinical examination is unreliable for these locations 1
• CT has 80% sensitivity for detecting bowel injury in stab wounds 1

Non-Operative Management Protocol (NOM)

NOM is only appropriate when ALL of the following resources are available: 1

• Serial clinical examinations by experienced clinicians every 4-6 hours 1
• Continuous vital signs monitoring 1
• Serial hemoglobin and inflammatory marker testing 1
• Immediate access to operating room (within minutes) 1
• ICU admission capability 1
• Immediate access to blood products 1

Minimum observation period: 48 hours 1

Triggers for immediate operative intervention during NOM:

• Hemoglobin drop ≥2 g/dL without alternative explanation 1
• Worsening vital signs 1
• Development of peritoneal signs on serial examination 1
• Increasing abdominal pain or distension 1

Imaging Strategy

CT Scan Indications:

• All hemodynamically stable patients with flank or back wounds 1
• Stable anterior abdominal wounds when depth/trajectory unclear 1
• CT should include chest, abdomen, and pelvis with IV contrast 1

CT Findings Requiring Surgery:

• Free fluid with mesenteric stranding 1
• Bowel wall thickening with adjacent fluid 1
• Active contrast extravasation 1
• Pneumoperitoneum (expected but concerning if extensive) 1
• Metallic fragments within intestinal wall/lumen 1

Critical pitfall: A negative CT scan alone should NOT be used to discharge a patient unless a tangential extraperitoneal wound tract is confirmed. Clinical observation remains mandatory. 1

Wound-Specific Considerations

Thoracoabdominal Wounds (Below Nipple Line to Costal Margin):

• High risk for diaphragmatic injury and intra-abdominal organ damage 5
• Require CT imaging even if stable 5
• Local wound exploration near inferior costal margin should be avoided due to risk of intercostal vessel injury 1

Impaled Objects:

• Never remove in the field or emergency department 5
• Transport patient with object in place 5
• Remove only in operating room with surgical control available 5
• Unintentional dislodgement can cause critical bleeding 5

Antibiotic Management

For all penetrating abdominal stab wounds: 4, 6

• First-generation cephalosporin with or without aminoglycoside 4, 6
• Duration: 48-72 hours 4, 6
• Add penicillin if gross contamination present (covers Clostridium species) 4, 6

Common Pitfalls to Avoid

• Do not delay surgery for CT in unstable patients—hemodynamic instability is an absolute contraindication to NOM 1
• Do not rely on initial hemoglobin—it takes hours to equilibrate and may be falsely reassuring 1
• Do not discharge based on negative CT alone—clinical observation over 48 hours is required 1
• Do not perform extensive local wound exploration near the costal margin—risk of iatrogenic vascular injury 1
• Do not attempt NOM without proper resources—this requires ICU-level monitoring and immediate OR access 1