STAB WOUNDS

Stab wounds are incised wounds where the length of injury on the surface is less than the depth of penetration into the body, and are the result of a thrusting action, where the force is delivered along the long axis of a narrow, pointed object. The force of impact is concentrated at the tip of the implement, and the sharper the tip, the easier it will penetrate the skin. The weapons of choice in the majority of assaults both domestic and on the street! include lock knives, sheaf knives and kitchen knives.

CHARACTERISTICS OF STAB WOUNDS

"lean cut edges #ne or both ends pointed $on pointed end may be s%uared off or split &fish tail or boat shaped defect' #ften gape &related to skin elasticity and (anger!s lines' "ross section of weapon may be illustrated when edges of wounds opposed )nderlying bone may be scored by blade *brasions may be present +re%uently shows notching or a change in direction &caused by relative movement of the knife and body'

ASSESSING STAB WOUNDS

,hen examining a stab wound, the length of the wound should be measured to the nearest mm. The wound should be measured and documented again following apposition of its edges, as this may provide additional information about the wound profile, particularly in skin which has not suffered from excessive -drying artefact-. Steristrips, or similar clear tape can be used to gently appose wound edges in preparation for photography. .t should be noted, however, that any attempt to determine the dimensions of a knife from the wound are fraught with inaccuracies, due to the effect of elasticity of skin shrinking slightly on withdrawal of the knife &by up to /mm'. .n addition, where the blade has entered the skin at an obli%ue angle, the length of the entry slit may be longer than expected. Solid organs, such as the liver may retain the characteristics of a knife causing a wound, and at autopsy, for example, these wounds can add to the information obtained from an examination of the surface characteristics of the stab wound. Stab and other incised wounds should be documented in terms of their anatomical position, and their relative position&s' to fixed anatomical landmarks, such as the top of the sternum, or the point of the shoulder!. +urther descriptive methods include the location of a stab wound in relation to the crown or heel, and the midline. The use of pre printed body diagrams and or drawings are excellent supplements to the medical notes, and access to digital photography in most accident and emergency units makes the photographic documentation of wounds with %uality images is becoming a realistic proposition for even the busiest of casualty physicians. Stab wounds are said by some authors to gape open! depending upon their anatomical location. (ines of tension in the skin are determined by the relative orientation of elastic and collagen fibres, and the cleavage lines of (anger correspond to body surface creases. * knife that has not fully entered the skin will only produce a wound of a si0e corresponding to that of the blade that has penetrated this will not necessarily represent the maximum dimensions of the knife, and any interpretation of knife wounds must take this into account. ,here there are several wounds,

measurements taken from each wound may go some way towards building up a composite picture of the true dimensions of the weapon. 1nives with single cutting edge such as kitchen knives cause wounds that have a clearly pointed edge, with the opposite edge being s%uared off &2boat shaped defect' or split &often termed a fish tail' 1nives with blade guards &usually referred to as hit guards' can also produce distinctive bruising at one edge of the wound, where the guard has impacted against the skin, particularly where the skin is supported, such as on the chest wall.

Factors to be assessed regarding the type of weapon involved in sharp force trauma (Knight 1996)

(ength, width and thickness of the blade Single3 double edged 4egree of taper from tip to hilt $ature of back edge e.g. serrated or s%uared off +ace of hilt guard *ny grooving, serration or forking of blade &e.g. hooked tip of knife in the -,igwam- murder case' Sharpness of edge and extreme tip of blade

movement of the knife in the wound

1nives are rarely pushed into the body and withdrawn at exactly the same angle &unless the victim is incapacitated at the time of the assault'. .n addition, both the assailant and victim are in a highly charged state during an altercation, and movements of the principle parties are therefore highly fluid. 1nife wounds reflect this dynamic situation, and are often 5! shaped or irregular also referred to as twisting cuts!.

6ocking movements of the knife during an assault distorts the appearances of the wound, and the resultant defect is often much larger than would otherwise have been created by the same knife in a more static situation.

depth of thrust
The clinician is interested in the depth of injury, in order to assess which deeper structures may be at risk. "ompressible body parts, such as the chest wall or abdomen can indent during a knife attack, and structures deep within that area can be damaged at a depth that at first indications seems to be beyond the reach of the suspect weapon. 7stimations of depth of thrust may be further complicated when it is considered that blades with back edges that are sharpened for a few millimetres will cause spindle shaped incisions when the knife is only introduced superficially, but when thrust deeper, it gives rise to a wound with a s%uared edge typical of a single edged weapon. 4epth of penetration estimations are therefore difficult to make, and may only be confirmed at autopsy, or during surgical dissection.

Symptoms of a stab wound include:

(aceration 8uncture wound 8ain around the wound Skin swelling around the wound Skin pain around the wound 9leeding from the wound $umbness of the skin around the wound

* severe stab wound can damage blood vessels, resulting in severe bleeding.

Symptoms of a severe stab wound include:

+aintness

Severe weakness or fatigue 8oor circulation to the fingers or toes: o *bnormal capillary refill test o "ool extremities 8ale skin (ow blood pressure: o (ess than ;< 6apid heart rate: o #ver =/< beats per minute *bdominal pain "hest pain 4ifficulty breathing (ethargy: o 7xcessive sleepiness "onfusion +ainting

Stab Wounds Treatment

Treatment for a stab wound varies with the depth of penetration and the anatomic location of the wound. 8enetrating wounds to the neck, chest, back, and abdomen are among the most serious locations for a stab wound. >any stab wounds will re%uire wound care, antibiotics, and tetanus vaccination. 8ain may be managed with narcotic pain medications or nonsteroidal anti inflammatory medications. *dditional treatment for a severe stab wound may re%uire intravenous fluids, a blood transfusion, or surgery to repair damaged tissue. Stab wounds to the abdomen of indeterminate depth re%uire surgery to exclude damage to the internal organs.

Specific treatment for a stab wound may include:

,ound irrigation o 6insing the wound ,ound cleansing

,ound exploration: o 7xamining the wound for foreign bodies or injuries to structures beneath the skin ,ound debridement: o 6emoval of dead or dirty tissue o 6emoval of foreign bodies in the wound (aceration repair: o "uts and punctures are repaired with sutures, staples or skin adhesive $onsteroidal anti inflammatory medications for pain: o .buprofen &>otrin, *dvil, .buprin, $uprin' o $aproxen &*leve, *naprox, $aprosyn' o 1etoprofen &#ruvail, #rudis, *ctron' $arcotic pain medication: o +or moderate to severe pain o +or short term use only *ntibiotics for stab wounds: o To treat or prevent infections Tetanus vaccination Surgery for skin lacerations: o To remove foreign bodies or repair damaged tissue.

Treatment for a severe stab wound may include:

.ntravenous fluids ? 9lood pressure monitoring ? "ardiac monitoring ? 9lood transfusion ? Surgery for a stab wound: o To repair damaged tissue under the skin *bdominal stab wound exploration forms part of a strategy developed by surgeons to allow a more selective approach. .t is a safe, rapid, and cost effective tool in the management of asymptomatic patients who present with an anterior abdominal stab wound. This approach has no place in the treatment of patients who are unstable, who have peritonitis, or who have evisceration. 8atients with peritonitis and those who are hemodynamically unstable should undergo mandatory laparotomy.
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*bdominal stab wound exploration is indicated in a patient who presents with a stab wound to the anterior abdomen@ normal vital signs, no signs of peritonitis, and no evidence of evisceration &see the image '.

CONTRAINDICATIONS

*bdominal stab wound exploration is contraindicated if immediate laparotomy is indicated. The situations in which immediate laparotomy is indicated include the following: )nstable patient 8eritonitis 7visceration &This remains controversial@ see paragraph / in Selecting "andidates for (aparotomy section.'

9lood on rectal examination or blood in nasogastric tube aspirate suggests intra abdominal injury &* low threshold for operative intervention is suggested.' #ther contraindications to abdominal stab wound exploration include the following: (ower chest wounds: 7xploration of these wounds carries a high risk of iatrogenic pneumothorax. +lank and back wounds: Some authors advocate exploration of these wounds if they are suspected to be superficial. Aowever, this expectation may be unreliable, and the strong musculature makes the tract difficult to predict or to follow. (ocal wound exploration may result in further injury or a restart of hemorrhage that had stopped. 8atient refusal or uncooperative patient. 6elative contraindications include the following: #besity >ultiple abdominal stab wounds