CASE : 18 YEAR OLD MALE WITH STAB WOUND

by: Joe Kaplan, MD
Editing: Robin R. Hemphill, MD and David E. Manthey, MD

History
Subsequent History
Past Medical/Surgical History
Physical Findings
Pertinent Labs/Diagnostics
Diagnosis
Treatment
Disposition

HISTORY

Pre-hospital report by EMS - 18 year old male with a 1 inch wide stab wound to his left back which occurred after he and his brother had been sniffing paint. Patient was ambulatory at the scene . He stated that his brother stabbed him shortly before his call to 911 for help. Vital signs are pulse 96, BP 112/78, Resp 20, pulse ox 100%. The wound has been covered with an occlusive dressing Run time 12 minutes.

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SUBSEQUENT HISTORY:

Upon arrival, the patient states he and his brother had just finished a 12 pack of beer 2 hrs prior to the incident. Additionally, they had used a large amount of cocaine. Once the cocaine supply was exhausted they had then begun huffing paint. His brother stabbed him with a 10 inch long paring knife, but he does not know why ( he was just minding his own business). He last ate about 6 hours ago. Upon arrival his chief complaint is of abdominal discomfort.

PAST MEDICAL/SURGICAL HISTORY

NKDA.
Meds: None
PMHx: None
PSHx: None

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PHYSICAL EXAM

Vital signs- BP 130/80 P 129 R 20 Pulse ox 97%

Primary Survey

Airway: Open with patient speaking without difficulty
Breathing: Clear, equal bilateral breath sounds
Circulation: Vital signs as above. Capillary refill l.t. 2 seconds
Disability: Pt A&O times 3, Glasgow coma scale 15, moving all 4 extremities without difficulty
Exposure: A 2 cm stab wound is noted at the tip of the left scapula with minimal bleeding noted (refer to above picture).

TREATMENT OPTIONS

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Secondary Survey

Heent: Atraumatic, normocephalic, PERRL, EOMI, Tympanic membranes are normal, oropharynx is without lesions, nares are clear. No ulceration or septal perforation noted in the nose.
Neck: Non-tender without thyromegaly, adenopathy or cervical tenderness. There is no JVD.
Cardiovascular: The patient continues to be tachycardic with a pulse of 109 after a 1 liter fluid bolus, no murmurs, rubs or gallops.
Lungs: Clear to auscultation in all fields. He is moving air well and has equal, bilateral breath sounds.
Abdomen: Soft, mildly diffusely tender without guarding or rebound . The patient has normal bowel sounds. No organomegally, no masses noted.
Extremities: The Patient has no injuries. He has normal pulses and moves all extremities normally.
Pelvis: Stable
Rectal: Normal tone guaiac negative.
Neuro: CN 2-12 grossly intact. Answers questions appropriately. Pupils are 3mm and equally reactive. Strength is equal in all extremities and is 5/5. Sensory is grossly intact in all extremities and DTR's are symmetric and 3+.

LABORATORY AND RADIOGRAPHIC FINDINGS

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Chest film reveals no hemothorax or pneumothorax, no free air below the diaphragm

Labs/Diagnostics

Hb 14, HCT 43, WBC 19.4, PLT 190,000.
ETOH 115
Na -140,K- 4, Cl- 109, CO2- 18, BUN -4 Cr- 0.6, Glu- 123.
Urinalysis shows specific gravity 1.007, pH 6.0,50- rbc, 0- wbc.

ABG results pH 7.28, PCO2= 41, po2=109, bicarb= 19.1, O2 sat 97% , Base excess =-7.1.

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DISPOSITION

Surgery was consulted immediately and the patient was typed and crossed for 4 units of blood. The blood bank was called and 2 units of O- blood were made available. The patient was placed on 100% oxygen by face mask and given a 2 liter bolus of warmed normal saline. Despite this initial therapy his heart rate remained approximately 110-115 bpm. He underwent an abdominal CT scan which showed a splenic laceration, and a collection of left perinephric fluid consistent with a left renal laceration. He was taken to the operating room for exploratory laparotomy. Surgical findings were a small laceration of the spleen which was repaired. Additionally, a small laceration to the superior pole of the left kidney was noted, and this was packed with good hemostatsis. The patient did well post-operatively and was discharged one week later.

DISCUSSION

Every trauma situation is different, and this case is reminds us that ATLS is really only a general guideline. By following ATLS dogmatically (i.e. full immobilization, multiple radiographs, etc) valuable time might have been lost. This case also demonstrates the importance of integrating multiple pieces of information. It would have an error to think that because there was no pneumothorax, and the stab wound was small, that there was no serious injury. It would have ben easy to interprete the mild tachycardia as secondary to his cocaine use. In this case is was helpful to remember that it is not the width, but the length, of the knife that is critical. A steak knife is only 1/2" wide but can be 8 inches long and may penetrate to any intrathoracic and most intra/retro peritoneal organs. The patient had a persistant tachycardia, diffuse abdominal pain, an acidosis, and a base deficit. All of these findings were clues that the patient had a significant injury.