STAB WOUND MANAGEMENT

Any disaster puts your people at risk for injury. Wounds caused by sharp objects can be life-threatening, depending on the organs and blood vessels damaged. 

Stab wounds are a type of penetrating trauma, which is further divided into perforating and non-perforating injuries.  A perforating wound is one in which the object causing the damage goes into one side of the body and then exits through the other side.  A wound from .223 or NATO .556 would, commonly, be an example of perforating trauma. 

Bullets and other high-speed projectiles cause damage not only from the act of penetration, but also the shock wave produced as the bullet passes through the body. Luckily, low speed projectiles such as knives will not do this. Your concerns are related specifically to the area of entry and the structures located directly in the path of the offending instrument.

Stab wounds are an example of a non-perforating wound:  the projectile causing the damage enters the body and either stays there or exits where it entered. Some sharp instruments could possibly do this, say a crossbow bolt or a spearhead, but let’s assume that you’ll be unlikely to see these.

With stab wounds, blood loss and failure of damaged organs will be the major issue. A little about blood: Blood carries oxygen to the tissues and organs and removes waste products. It is made up of several components, including:

• Red blood cells: These cells carry oxygen to body tissues.
• White blood cells: These cells work to, among other things, fight infection and disease.
• Platelets and other clotting factors: These allow blood to coagulate and lessen blood loss.
• Plasma: A yellowish liquid in which the above are suspended.

Your immediate action upon encountering a victim of a wound with a sharp instrument may save their life. The heart takes less than one minute to pump blood to the entire body; if the circulatory system is breached, blood loss becomes life-threatening very quickly.

180 lb. (about 70 kg.) adult males have approximately 9-10 pints (about 5 liters) of blood in their body. Athletes and those living at very high altitudes may have more. You can’t afford to lose more than 40% of total blood volume without needing major resuscitation.  To get an idea of how much blood this is, empty a 2 liter bottle of fruit punch or cranberry juice on the floor.  You’ll be surprised at how much fluid that represents.

Hemorrhage (bleeding) is classified by the American College of Surgeons (of which I am a Fellow) as follows:

Class I:  Hemorrhage is less or equal to 15% of blood volume (1.5 pints/3/4 liter) in an average adult male.  A person donating 1 pint of blood is giving slightly less than 0.5 liters, for example. At this level there are almost no signs or symptoms, although some may feel vaguely faint.

Class II:  Hemorrhage is 15 to 30% loss of total blood volume (2-3 pints/1-1.5 liters).  The body tries to compensate at this point with, among other things, a faster heartbeat to speed oxygen to tissues.  This patient will appear pale and skin will be cool.  They will feel weak.

Class III: Hemorrhage is 30 to 40% loss of blood (3-4 pints/1.5-2 liters).  At this point, the heart will be beating very quickly and is straining to get enough oxygen to tissues and blood pressure is low. Smaller blood vessels in extremities are constricting to keep the body core circulation going. This patient will be confused, pale, and in hypovolemic (low blood volume) shock. Blood transfusion is usually necessary.  

Class IV:  Hemorrhage is more than 40% of total blood volume (greater than 4 pints/2 liters). The heart can no longer maintain blood pressure and circulation.  Without major resuscitative help at this point, organs will fail and the patient will likely be comatose and die.

If you’re attending to an actively bleeding wound from a sharp object, you will need a level head and quick action.  This is, sometimes, not as easy as it sounds; most people not accustomed to dealing with these issues on a daily basis will experience a type of paralysis that may waste precious time. If you can, contact emergency services immediately.

In the meantime, follow these steps:

Stab Wounds

• Assess the safety of the situation.  Make sure the situation is secure; it makes no sense for you to become the next casualty.
• Put on gloves if possible.  Your hands are full of bacteria and you will reduce the risk of infection by doing so.  Non-latex (nitrile) gloves are superior in avoiding allergic reactions to latex, more commonly seen than you’d think. If no gloves are available, plastic bags/wrap or, at least, hand sanitizers/soap will be useful if you have to touch the wound with bare hands.     
• Verify the victim’s breathing and mental status.  Clear airways if obstructed and determine if they are alert enough to help you by following commands.
• Remove clothing carefully to fully inspect the wound and identify other injuries.  Make sure that you have a bandage scissors or EMT shears in your medical pack.
• Apply pressure with some type of dressing, even your shirt if necessary.  Most non-arterial bleeding will stop with steady pressure on the wound. If the sharp instrument is in place and help is on the way, place pressure down on either side towards the blade to prevent it from slipping out.  It may be providing pressure on damaged blood vessels and decreasing the bleeding.  Stabilize the wound in place with dressings or in any way you can. 
• If one dressing doesn’t work, place additional dressings on top (an exception is special blood-clotting gauze, discussed below). If there is no chance of emergency services reaching you long-term, you may have to remove it at one point or another.  Don’t do this unless you are where the bulk of your medical supplies are.
• Elevate the feet above the level of the heart and head (the “shock position”) to increase blood flow to the brain. If the wound is to the abdomen, bend the knees instead.
• Lift the injured area above the heart (for example, an arm). Make it more difficult to pump blood out of the body.
• Some recommend applying additional pressure with your other hand to major arteries about the level of the wound (especially for extremities).  These areas are called “pressure points”.  For example, a major artery (the popliteal artery) is found behind the knee.  Pressure here might decrease bleeding from a lower leg wound.  There is an entire map of pressure points for most parts of the body, but a working knowledge of their locations is needed to be effective.
• Apply a tourniquet to stop the bleeding.  Our experience in Iraq and Afghanistan shows that tourniquets, when used as a first course of action, save lives in cases of severe or arterial hemorrhage. If you are transporting a patient to a modern medical facility, make sure you mark a “T” on the victim’s forehead or otherwise notify emergency personnel of the location and the length of time the tourniquet has been in place. (see Nurse Amy’s YouTube videos on the principles of tourniquet use and also how to use individual tourniquets appropriately).
• In cases of heavy bleeding, the use of special blood clotting dressings such as Quikclot, Celox, or ChitoSam is effective.  We keep these products in all our medical packs, even individual first aid kits. Remove saturated bandages and place a hemostatic gauze directly on the bleeding vessel for 3 minutes. It should be noted that the maximum time allotted for a hemostatic gauze to remain in place is 24 hours.
• Secure everything with a pressure dressing, of which there are various on the market.  The Israeli Battle Dressing, known as The Emergency Bandage in the U.S., can apply up to 30 pounds of pressure if used properly.
• Keep the victim warm: Throw a blanket or a coat over them.  If help is coming, keep them as still and calm as possible to avoid further bleeding.  Monitor breathing, pulses, and mental status.
• An unconscious patient should be placed in the “recovery position”.  This will, among other things, allow fluid to drain from airways and help them breathe.
• If a tourniquet is on, should you loosen it from time to time? You may be tempted to do this, but it can cause further bleeding. Transition from tourniquet within 2 hours to a hemostatic gauze and a pressure bandage only when no help is available in higher medical facilities.

Once bleeding is under control, your goal is to clean the wound thoroughly and dress it.  Wound closure may be an option in some cases, but most back-country stab wounds will be dirty and should be left open (subject of another article).

All of the above may not be necessary if you practice preventative measures.  In other words, don’t run with scissors.  With some foresight, you may be able to avoid a mishap that could turn into a tragedy.

Joe Alton MD

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