Sustained Stab Wounds Research Articles

Subcutaneous and visceral fat are associated with worse outcomes in gunshot injuries but not stab injuries to the torso

PurposeThe effect of obesity in penetrating trauma outcomes is poorly understood. The purpose of this study was to determine if there is a protective effect of subcutaneous or visceral fat...

Treatment of Traumatic Brain Injury in Youth: The Integral Role of the Family

During my first year of child fellowship, I cared for a 16-year-old girl who suffered a traumatic assault with subsequent brain injury. “Alicia” had sustained stab wounds to her neck, large vessel injury, and cerebrovascular accident, necessitating numerous procedures, including a craniectomy. My path and Alicia’s would cross again and again during my various clinical rotations. As I worked with her and my colleagues to help her regain her health, her story proved instructive, not only about the rocky path to recovery for those with traumatic brain injuries (TBIs), but also about how that path might have been smoothed, particularly with the help of her family.

Selective management of penetrating neck injuries using “no zone” approach

Selective management has been the standard management protocol in penetrating neck injuries (PNIs) since this approach has significantly reduced unnecessary neck exploration. The purpose of this study is to evaluate outcomes of selective management in PNIs using the "no zone" approach, in which the management is guided mainly by clinical signs and symptoms, not the location of the neck wounds. A retrospective study was performed in patients treated for PNIs at King Chulalongkorn Memorial Hospital (KCMH) from January 2003 to December 2013. The patients with hard signs of neck injury (i.e., active bleeding, significant haematoma, massive subcutaneous emphysema, and air bubbling through the neck wound) underwent emergency neck exploration. The asymptomatic patients and the patients with soft signs (other symptoms) were considered to be candidates for selective management. Data collection included demographic data, emergency department parameters, details of neck injury, and outcomes in terms of mortality, negative exploration rate, and missed injury rate. Eighty-six PNI patients were treated at KCMH from 2003 to 2013, 64 of which sustained stab wounds, 12 gunshot wounds, 4 shotgun wounds, and 6 other causes. Thirty-six patients presenting with hard signs underwent immediate neck exploration and there were 2 negative explorations. Twenty-six patients with soft signs underwent selective investigations (including computed tomographic angiography in 21 patients), 5 patients required neck explorations due to positive results of the investigations with one negative exploration. All of the twenty-four asymptomatic patients were managed with close observation, none required subsequent neck exploration. There was no missed injury found in the present study. Successful non-operative management was carried out in 45 patients (52%). The overall negative exploration rate was 7% (3 in 41 patients undergoing neck exploration). Two patients with hard signs died from associated chest injuries (mortality rate 2%). Selective management of penetrating neck injuries based on physical examination and selective use of investigations (no zone approach) is safe and simple with low negative exploration rate and no missed injury.

MP3-01 SELECTIVE ARTERIAL EMBOLIZATION IN RENAL TRAUMA: THE PUERTO RICO TRAUMA CENTER EXPERIENCE

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery II1 Apr 2014MP3-01 SELECTIVE ARTERIAL EMBOLIZATION IN RENAL TRAUMA: THE PUERTO RICO TRAUMA CENTER EXPERIENCE Jose Silva, Antonio Puras, Marcos Perez, and Fernando Joglar Jose SilvaJose Silva More articles by this author , Antonio PurasAntonio Puras More articles by this author , Marcos PerezMarcos Perez More articles by this author , and Fernando JoglarFernando Joglar More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.180AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The kidneys are the most common genitourinary organs affected from external trauma. Low-grade renal injuries are typically managed conservatively. Although most high-grade renal injuries require surgical interventions, their treatment still lacks standardized management. Furthermore, the treatment algorithm in some of the most prominent Urological publications fail to mention selective renal artery embolization as a feasible alternative. METHODS We retrospectively reviewed the trauma registry of the Puerto Rico Trauma Center for all patients treated for renal trauma (ICD-9 codes 866.0, 866.02, 866.10, and 866.12) between January 1, 2007 and December 31, 2010. We performed an extensive chart review to asses all the multiple variables involved and for further characterization of these injuries. RESULTS Of 7,291 total admission to Trauma Hospital, 215 included kidney lacerations. Trauma to male gender represented most of renal trauma with 92% (198/215). Blunt trauma represented more than half of all injuries with 58% (125/215) cases while penetrating trauma only 42% (90/215). Forty two percent (90/215) of all kidney lacerations underwent exploratory laparotomy by Trauma Surgery Staff, including renal exploration. Of the 215 patients, a total of 12 patients underwent selective renal artery embolization for their renal injuries. None of these patients required OR interventions or exploratory laparotomy. Sixty seven percent of the patients (8/12) sustained blunt trauma while 33% (4/12) suffered a penetrating injury. Grade V renal laceration was seen in 38% (3/8) of the total patients with blunt trauma. Fifty percent (4/8) of patients with grade III renal laceration underwent embolization due to active blush of IV contrast on CT scan. Of the patients that sustained penetrating injury, seventy five percent (3/4) sustained stab wounds while the remaining 25% (1/4) had gunshot injury. Two patients (67%, n=3) with stab wound injuries developed pseudoaneurysms, which required selective renal artery embolization. All had an unremarkable post-procedural hospital course with no complications from the embolization procedure. CONCLUSIONS Selective renal artery embolization is a feasible and less invasive procedure than conventional open surgical approaches in the management of renal trauma in select patients. At present and based on availability, selective renal artery embolization should be considered as first line treatment for high-grade renal lacerations in patients not undergoing exploratory laparotomy for other associated traumatic injuries. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e34 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Jose Silva More articles by this author Antonio Puras More articles by this author Marcos Perez More articles by this author Fernando Joglar More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Diffusion tensor imaging and tractography in brown-sequard syndrome

Case report. To demonstrate the utility of diffusion tensor imaging and tractography in two patients with Brown-Sequard syndrome after penetrating cervical cord injury. Milwaukee, WI, USA. Two patients, who presented with features of Brown-Sequard syndrome after sustaining stab wounds to the neck, underwent DTI and tractography of the cervical cord within a week of the injury. DTI metrics were measured within the left and right hemicord around the level of injury. Diffusion tensor tractography was performed to visualize the site of injury and injured fiber tracts. Axial fractional anisotropy maps at the site of injury showed unilateral damage to the cord structure, and FA was significantly reduced within the injured hemicord in both patients. Tractography allowed for visualization of the injured fiber tracts around the level of injury. Both DTI metrics and tractography showed an asymmetry that corresponded to the neurological deficits exhibited by the patients. This report illustrates the utility of DTI and DTT in delineating regions of cord injury in two patients with traumatic Brown-Sequard syndrome. Our results indicate that DTI provides clinically relevant information that supplements conventional MR imaging for patients with acute SCI.

Reconstruction of an emergency thoracotomy wound with free rectus abdominis flap: Anatomic and radiologic basis for the surgical technique

An alcoholic 50-year-old male patient with a history of schizophrenia sustained stab wounds into both ventricles and left lung, and survived following an emergency department thoracotomy. The EDT wound, however became infected requiring serial debridements of soft tissue, rib cartilage and sternum. Regional flap options such as pectoralis major and latissimus dorsi muscle flaps could not be employed due to inadequate reach of these flaps. Additionally, bilateral transection of the internal mammary arteries during emergency thoracotomy eliminated the use of rectus abdominis muscles as pedicled flaps based on the superior epigastric vasculature. Therefore, the EDT wound was reconstructed by using the right rectus abdominis muscle as a free flap. The deep inferior epigastric vessels of the flap were anastomosed to the right internal mammary vessels proximal to their transection level in the third-forth intercostal space. The flap healed with no further wound complications.

Is the prevalence of deliberate penetrating trauma increasing in London? Experiences of an urban pre-hospital trauma service

Background Recent media interest in stabbings and shootings has lead to the general assumption that injury and death secondary to deliberate penetrating trauma are rising. The aim of this study was to establish the prevalence of deliberate penetrating trauma within a London-based physician-led pre-hospital trauma service, and evaluate whether the perceived increase reported by the media translates into a real increase in penetrating trauma caseload. Method A retrospective review of a physician-led pre-hospital care trauma database was conducted to identify all patients who sustained stabbing or shooting injuries over a 16-year period. Patients who died in the pre-hospital phase and paediatric patients were included. Other local and national datasets were examined to determine whether similar trends were observed. Results 1564 penetrating trauma victims were identified, including 92 children. 1358 patients (86.8%) sustained stab wounds; 206 patients were shot (13.2%). Penetrating injury accounted for 9.9% of the overall trauma caseload during the study period. The annual increase in patients sustaining stabbing injuries was 23.2%. Gun shot wounds increased by 11.0% per year. Conclusion The study demonstrates a significant annual rise in the number of cases of deliberate penetrating trauma managed by a UK physician-led pre-hospital trauma service.

Diagnostic Peritoneal Lavage: is 100,000 RBCs a Valid Figure for Penetrating Abdominal Trauma?

Controversy exists regarding the interpretation of diagnostic peritoneal lavage results. This is especially true in the evaluation of patients sustaining penetrating trauma, specifically stab wounds to the lower chest and abdomen. Ideally one wants to avoid missed injuries and minimize unnecessary operations. This is a retrospective review of 195 patients sustaining stab wounds to the anterior lower chest and abdomen at Parkland Memorial Hospital between 1993 and 2005, looking at missed injuries and false positive rates using red cell counts of 100,000, 10,000, and the standard criteria for blunt trauma including >500 white blood cells (WBCs), amylase, and/or bile. The first analysis used >100,000 red blood cells (RBCs)/mm3 as a positive value. The false positive rate was 12.2%. The second analysis used >10,000 RBCs/mm3 as a positive value with a false positive rate of 44%. When considering the entire study population (195 patients), the false positive rate increased when using the lower number (>10,000) from 2.5% to 15.8% (p < 0.001). There were no missed injuries when using >100,000 red cells and/or >500 white cells, the presence of bile or amylase. Decreasing the red blood cell count from >100,000 to >10,000 as the criteria for operating on patients with stab wounds to the anterior lower chest and/or abdomen will significantly increase the number of nontherapeutic procedures. Based on this study, >100,000 RBCs/mm3 appears to be a valid and safe number to use when evaluating these patients, particularly when used with other positive criteria such as increased white cells, bile, and amylase.

Penetrating Cardiac Injuries: Recent Experience in South Africa

Penetrating cardiac injury is a dramatic and lethal form of trauma. The majority of patients will die before reaching medical care, but for those who arrive at hospital alive, the diagnostic acumen and rapid surgical intervention of physicians and surgeons can lead to successful outcomes. A structured diagnostic and management approach is used in our trauma unit to deal with penetrating cardiac injury. A retrospective study of 117 patients with penetrating trauma to the heart was conducted over 32 months; the purpose of this study was to describe our protocol and review overall outcome with this type of injury. Demographic details, mechanism of injury, and mode of presentation were recorded. Mortality and morbidity data were collated and echocardiographic follow-up was performed. There were 109 male patients, mean age 29 years (range: 15-54 years) and 8 female patients, mean age 35 years (range: 23-56 years). Most patients (96/117) had sustained stab wounds, and the associated mortality was 15.6%. Twenty-one patients had sustained gunshot wounds (GSW), with a mortality of 81%. Gunshot wounds were significantly more likely to result in death (P<or=0.0001). Five patients sustained multiple cardiac wounds, and three of them died. The risk of death was not different between patients sustaining single or multiple cardiac wounds (P=0.11). Eleven patients had thoracoabdominal injury, and 3/11 (27%) died; all of those that died had sustained GSW. The risk of death was not different between patients sustaining thoracoabdominal wounds and those with isolated thoracic injury (P=1.0). Among the 51 patients with stab wounds who presented with cardiac tamponade, the mortality was only 8%. Compared to the other patients with stab wounds, cardiac tamponade conferred a significant survival advantage (P=0.02). A high index of suspicion for penetrating cardiac injury and an understanding of the modes of presentation can lead to rapid diagnosis even by inexperienced junior staff. Such a structured approach to patients with penetrating trauma to the chest leads to early definitive management and acceptable results.

Lethal Injuries Occurring During Illegal Break-ins

Individuals who undertake criminal activity are often at risk of injury for a variety of reasons. Two cases are reported where individuals who were engaged in illegal breaking and entering activities sustained stab wounds from broken window glass and died of exsanguination. The cases both involved young males who were under the influence of alcohol and/or drugs and who sustained relatively minor tissue damage that had fatal consequences due to a variety of coincident factors. Critical location of wound sites over major vessels resulted in rapid bleeding that was enhanced by vasodilator effects of alcohol and stimulant effects of amphetamines. In addition, adrenergic effects of being engaged in illegal activities, and the subsequent pain from the wounds, may also have contributed to accelerated heart rate and blood loss. Failure to appreciate the potential effects of such wounds, which may initially have appeared relatively minor based on their small size, added to an impaired ability to apply first aid or seek appropriate medical assistance, may also have been due to the combined effects of drugs, alcohol, and concerns regarding the illegal nature of the underlying activity. Such a scenario constitutes a specific subgroup of offender injury that could be termed the break, enter, and die syndrome.

Assessment of Initial Base Deficit as a Predictor of Outcome: Mechanism of Injury Does Make a Difference

Initial base deficit in injured patients has been shown to predict the adequacy of resuscitation and outcome. The usefulness of base deficit as a predictor of outcome, however, may be dependent on the mechanism of injury. We conducted a retrospective review of the trauma registry, supplemented by chart review, of all trauma patients treated at a Level I trauma center from January 1995 through July 2001. Data collected included mechanism of injury, base deficit, Injury Severity Score, and outcome. From 1995 through 2001 a total of 3275 patients (23% of trauma admissions) at a mean age of 34 +/- 15 years had a base deficit recorded at the time of admission. The patients were 78 per cent male, and the mechanism of injury was blunt trauma in 58.2 per cent. Mortality increased with successive increases in base deficit but was markedly lower for a given base deficit in those patients having sustained stab wounds and/or severe lacerations as compared with those with gunshot wounds or blunt trauma. The value of the base deficit as a predictor of outcome depends upon the mechanism of injury and appears most useful for patients sustaining gunshot wounds or blunt trauma. Future studies in patients with penetrating trauma using base deficit as a predictor of outcome should separate patients with gunshot wounds from those with stab wounds or lacerations.

Needle thoracostomy in the prehospital setting

Objectives. To determine the effect of needle thoracostomy (NT) in the prehospital setting, its frequency of use, and its complication rate. Methods. This was a prospective case series from January 1, 1995, to December 31, 1996. Inclusion criteria were all patients who met trauma center criteria, were transported by paramedics to Los Angeles County/University of Southern California Medical Center (a large, urban, level I trauma center), and had placement of a prehospital NT. Results. Out of 6, 241 major trauma patients transported by paramedics over the study period, 108 (1.7%) underwent 114 NTs. Sixty-four patients (59%) sustained gunshot wounds, 32 (30%) sustained stab wounds, eight (7%) were involved in motor vehicle accidents, and the remainder had other types of blunt trauma. The mean injury severity score (ISS) was 22.3, and the overall mortality rate was 28%. Of the patients who received NTs, five (5%) showed objective improvement in field vital signs and seven (7%) had subjective improvement of their dyspnea. Two NTs were found to have not penetrated into the thorax with the catheter tip in the soft tissue. Two patients (2%) received NTs despite the absence of any chest injuries found upon operative intervention, resulting in two iatrogenic pneumothoraxes. No other complications, including vascular injury or infection, were found in any of the patients. Conclusion. Prehospital NT is a procedure infrequently performed by paramedics, even in a busy urban area. While there is a risk of the procedure's being done without proper indication, NT may improve outcomes in a small subset of chest-injured patients.

Stab Wounds Associated With Terrorist Activities in Israel

To describe injuries resulting from terrorist-associated knife stabbings. Retrospective case series. Israel (population 5.5 million). Israeli victims (N=154) of knife stabbings on nationalistic basis (the intifada) between July 1987 and April 1994. A total of 125 men and 29 women sustained stab wounds associated with terrorist activities. The median age was 28 years (range, 12-92 years), and 99 victims were aged 18 to 35 years. Seventy percent (108 patients) of the stabbing events occurred between 7 AM and 11 AM. The 154 victims sustained a total of 327 stab wounds, the median number of injuries was 2 per person (range, 1-28), and 68 individuals (44%) sustained more than 1 stab wound. The chest was the most commonly involved site (146 wounds), with the right posterior chest stabbed in 71 patients. The knife penetrated the heart in 20 patients and penetrated the peritoneal cavity in 29 patients. Overall, 29 patients (19%) had superficial injuries, 86 (56%) had internal organ injuries that mandated operative interventions, and 39 died (overall mortality, 25.3%). Unlike other civilian stabbings, wounds resulting from terrorist-associated stabbings represent severe and highly lethal injuries.

Posttraumatic osseous tunnel formation causing sciatic nerve entrapment

Sciatic nerve entrapment in an osseous tunnel has only been reported twice previously. We describe a 19-year-old man evaluated for left lower limb pain and weakness that began one and one half years after sustaining stab wounds to the left buttock and midline back near the T11 vertebrae. The patient had sciatica and demonstrated motor and sensory deficits on physical exam. Electrodiagnostic studies demonstrated a localized injury to the sciatic nerve in the proximal thigh. Radiographic studies of the left pelvis and femur showed an 8 to 10cm linear opacification overshadowing the left femoral head and anatomic neck. An arteriogram of the left leg demonstrated a 3 x 4cm lobulated aneurysm arising from the distal portion of the inferior gluteal artery. Surgical exploration revealed the sciatic nerve to be encased in cylindrical bone. The ectopic bone was removed and the sciatic nerve released. The patient had gradual improvement with a nearly complete neurological recovery by three months after surgery.

Cardiac stapling in the management of penetrating injuries of the heart: rapid control of hemorrhage and decreased risk of personal contamination.

The resuscitation of patients with cardiopulmonary arrest from a penetrating injury of the heart requires emergency thoracotomy and control of hemorrhage. Suture control may be technically difficult in patients with large or multiple lacerations. Emergency cardiac suturing techniques expose the surgeon to the risk of a contaminated needle stick. After we determined that rapid control of hemorrhage from cardiac lacerations could be achieved in anesthetized sheep with the use of a standard skin stapler, the technique was applied in the clinical setting. Twenty-eight patients underwent emergency stapling of 33 cardiac lacerations at our institution from September 1987 to December 1991. Seventy-nine percent (22) of the patients sustained stab wounds, and 21% (6) were injured by gunshots. Fifty-eight percent (19) of the injuries involved the right ventricle, 27% (9) involved the left ventricle, 9% (3) involved the right atrium, and 6% (2) involved the left atrium. In 93% (26) of the patients, control of hemorrhage was achieved within 2 minutes of exposure of the injuries. Both patients in whom control could not be achieved had sustained large-caliber gunshot injuries. Fifteen (54%) of the patients survived, including one patient with two cardiac lacerations and another with three lacerations. Of the surviving patients, two had mild neurologic deficits. No personal contamination occurred related to the use of the stapler. We conclude (1) cardiac stapling is highly effective in the management of hemorrhage from penetrating injury, particularly in the setting of multiple cardiac lacerations; (2) the technique may not be effective with certain types of gunshot wounds; and (3) the use of the stapler for emergency cardiorrhaphy eliminates the risk of personal contamination from a needle stick.

Prediction of Injury Caused by Penetrating Wounds to the Abdomen, Flank, and Back

Controversy about the appropriate evaluation of penetrating abdominal, flank, and back injuries prompted this retrospective review of 311 patients at an urban level 1 trauma center over 5 years. Seventy-five (24%) patients sustained gunshot wounds to the abdomen. All patients with gunshot wounds underwent exploratory laparotomy; results of 67 laparotomies (89%) were positive. Of 236 patients sustaining stab wounds (140 abdominal wounds, 51 flank wounds, 26 back wounds, and 19 wounds to multiple sites), 147 were treated according to a selective protocol, based on results of physical examination, wound exploration, peritoneal lavage, and ancillary diagnostic studies. No injuries were found at celiotomy in three (2%) of these 147 patients. One false-negative result of evaluation of a flank wound occurred. Significant injuries were found in 13 patients (68%) with stab wounds to multiple sites, 61 patients (44%) with abdominal stab wounds, 15 patients (29%) with flank stab wounds, and four patients (15%) with back stab wounds. Mandatory exploration of gunshot wounds is justified. Physical findings of intra-abdominal injury or positive results of peritoneal lavage identify stab wound victims likely to benefit from surgical exploration. A policy of mandatory observation or routine celiotomy for treatment of stab wounds is not justified.

Assessment of probability of survival in penetrating injuries using the TRISS methodology

By the TRISS methodology, probability of survival in injury can be estimated. It is based on a statistical analysis of outcome which is influenced by the severity of the injuries as expressed in the Injury Severity Score (ISS), the physiological function as expressed in the Trauma Score (TS) and the patient's age. We have used the TRISS formula in 206 patients with penetrating injury. Of these patients, 149 sustained stab wounds, 32 gunshot wounds and 25 others. ISS ranged from 2 to 38, the mean ISS being 9. The function was good (TS > 14) in 85 per cent. Estimated probability of survival ranged from 1.00 to 0.42. Three patients (1.5 per cent) died. The probability of their survival was 0.92, 0.96 and 0.98, respectively. All the fatal cases had serious predisposing conditions: chronic pulmonary disease, alcoholism, and psychiatric illness. In penetrating injury, the patient's functional status at the start of treatment is of greater importance for the outcome than the anatomical severity. The concept of the methodology of TRISS for assessment of probability of survival seems useful for review and comparison in injury care.

Penetrating cardiac trauma.

During a 10 1/2 year interval ending in June 1980, 47 patients with penetrating cardiac trauma were managed at The University of Alabama Medical Center. Thirty-nine patients (83%) were male. Mean age was 31 years (range, 13 to 69). Thirty-two patients (68%) sustained stab wounds (SW) and 15 patients (32%) gunshot wounds (GSW). Forty-two patients (89%) arrived hypotensive (systolic blood pressure less than 90 mm Hg). Twenty-seven patients (57%) had evidence of cardiac tamponade (central venous pressure greater than 15 cm H2O) and 25 of these 27 patients were also in shock. Forty patients (85%) presented with a normal sinus rhythm and seven patients (15%) had an idioventricular rhythm or asystole. Overall mortality was 23% (11 of 47 patients). Forty-three per cent of the patients sustaining GSW (6/14) died compared to 17% (5/33) of the patients with SW (p = 0.04). Mortality for the patients in shock was 26% and for those with cardiac tamponade 15%. Mortality was 16% for the patients with both shock and cardiac tamponade. Thirteen per cent of the patients in normal sinus rhythm died, while 87% of the patients with idioventricular rhythm or asystole died (p less than 0.0001). Mortality in penetrating cardiac trauma remains high, particularly in patients with GSW and in those patients presenting with an idioventricular rhythm or asystole.

Pneumothorax of late onset after chest stabbings

Pneumothorax is a well known immediate complication of penetrating chest injuries, but its late occurrence is not widely recognized. In a retrospective study of 56 patients who sustained stab wounds of the chest, 6 (10 per cent) developed pneumothorax between twelve hours and three days after injury. Combined thoraco-abdominal stab wounds were present in three patients and surgical emphysema was also apparent in three other patients. We conclude that pneumothorax of late onset may be commoner than has been suspected and this emphasizes the need for observation in hospital for 48 h and for serial radiography of the erect chest to detect this dangerous complication.