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learning zone
CONTINUING PROFESSIONAL DEVELOPMENT
Page 58 Page 59 Page 60
Stab wounds multiple Read Helen Pegden’s Guidelines on how to
choice questionnaire practice profile on write a practice profile
rheumatoid arthritis

Emergency care and management

of patients with stab wounds
NS477 Bird J, Faulkner M (2009) Emergency care and management of patients with stab wounds.
Nursing Standard. 23, 21, 51-57. Date of acceptance: August 14 2008.

circulation and haemorrhage control, disability

Summary
This article discusses the assessment, management and treatment
of patients with stab wounds on arrival in the emergency
department. It describes the immediate approach to assessment.
The assessment of stab wounds to the chest, abdomen and limbs is
also examined.
Authors
James Bird is charge nurse, accident and emergency department,
St Mary’s Hospital, London, and Mark Faulkner is clinical support
paramedic, London Ambulance Service.
Email: james.bird@imperial.nhs.uk
Keywords
Emergency care; Emergency department; Patient assessment;
Penetrating trauma; Stab wounds; Wounds
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at nursingstandard.rcnpublishing.co.uk. For related
articles visit our online archive and search using the keywords.
Aims and intended learning outcomes
This article aims to equip nurses working in
emergency departments with the knowledge and
skills required to care for and manage patients
who have been stabbed. Initial assessment is
aimed at identifying, treating and managing
potentially life-threatening complications
associated with stab wounds. After reading this
article you should be able to:
 Identify penetrating trauma and associated
complications.
 Summarise the systematic ABCDE (airway with
cervical spine control, breathing and ventilation,
and neurological assessment, exposure and
environmental control) approach to assessment
and management of trauma patients.
 Recognise the need for a thorough examination
of patients who present with a stab wound.
Introduction
Attacks in which a knife was used in a successful
mugging rose from 25,500 in 2005 to 64,000 in
2007 (Leppard 2007). Patients with stab wounds
usually require urgent assessment and
stabilisation in an emergency department, with
prompt operative management, if necessary, to
ensure a successful outcome. These patients will
have different needs as they progress through
their hospital stay.
To stab is to ‘thrust a knife or other pointed
weapon into’ (Compact Oxford English Dictionary
2009). A stab wound is a penetrating trauma or
injury caused by a sharp object, such as a knife,
blade or broken glass. The sharp object pierces the
patient’s skin and enters the body, creating a wound
track through which it has passed and causing
localised tissue damage along the wound track. By
comparison blunt trauma, such as a fall from a
height or sudden deceleration in a motor vehicle
causing internal chest and abdominal injury, is
caused by energy transfer through body tissues,
which results in injury (Eaton 2005).
Time out 1
List the main types of injury
that you have observed in the
emergency department. Categorise
each of these injuries as either
penetrating trauma or blunt trauma.

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Pathophysiology of trauma
The extent of the trauma caused by penetrating
injury depends on the energy of the object used.
The principles of kinetic energy, which are most
commonly used in reference to blunt trauma,
are also important when considering
penetrating trauma. This is commonly
expressed in the following equation: E = 1⁄2 mv2,
where E is the kinetic energy, m is the mass
(kilograms), and v is the speed (metres per
second). This means that the velocity at which
the knife strikes a person, not the size or shape
of the knife, determines the severity of the
injury (Dickinson 2004).
The size of the impact area will also play a
part in determining the amount of damage
sustained. If all the energy of the impact enters
the body’s tissues through a single point, as is
typical in a stab wound, it will produce more
damage to the tissues of the wound track, in
comparison to a blunt object which spreads the
impact force more widely.
The damage caused by penetrating trauma
depends on the underlying body structures. The
knife travels in a straight line from the point of
entry, creating a wound track and damaging
body structures in its path. The weapon might
have been moved once inside a person, and the
wound track might not appear straight, making
it difficult for healthcare professionals to view
where the wound ends. It is important to note
that there is the potential for an upturned
conical shaped area to develop below the entry
point in which there can be underlying damage
(National Association of Emergency Medical
Technicians 2003).
With a few exceptions, such as the trachea, the
body’s structures are not fixed in location and can
move into and away from the wound track at the
time of injury and post-injury. Like all traumas a
penetrating injury can cross anatomical
boundaries, for example an epigastric wound that
lacerated the contents of the abdomen may also
puncture the diaphragm and cause injuries to
either of the lungs or the heart.
Trauma care
Greaves and Porter (1999) highlighted the
importance of considering the type of weapon
used, and in particular its length, to gain a better
understanding of the main penetrating trauma
as well as other possible underlying injuries.
For example, if the weapon used was a
screwdriver, a small entry wound can hide
52 january 28 :: vol 23 no 21 :: 2009
significant damage to internal body tissues. The
ambulance service and police, who often
accompany patients to the emergency
department, can provide useful information
about the weapon used. The handling of any
weapons should be left to the police, where
possible, and nurses should be familiar with
forensic issues about the handling of evidence
(Pepper and Brompton 2002).
If a single stab wound has been sustained,
patients should be carefully examined to
exclude any other injuries (Greaves et al 2000).
Common sites for missed wounds include the
back, buttocks, axilla, groin and perineum. It is
also important to consider stab wounds in
patients who present with other trauma or
conditions. For example, patients presenting
with severe head injuries might also have a
small axillary stab wound that could be missed
while the main injury is treated. Consideration
should also be given to the likelihood of stab
wounds in an unconscious patient.
A large proportion of injuries caused by
stabbings are the result of acts of criminal
violence (Wilson et al 2006). Nurses should
consider not only patient safety, but also their
own. In some instances violence can occur in
the hospital as the perpetrator tries to attack
the victim again. In such cases it is advisable
to ensure that hospital security staff and/or
the police are present. In some circumstances
it might be necessary to treat patients in an
area of the hospital where access can be
easily controlled.
Time out 2
Consider how you would ensure
the safety of stabbed patients
and members of staff in your
hospital, while maintaining
patient confidentiality.
Assessment of penetrating trauma
Patients with trauma injuries are best managed
by a multidisciplinary trauma team. A trauma
team typically consists of at least three doctors,
three nurses and a radiographer (Driscoll and
Skinner 2000). The trauma team should be
given adequate time to assemble and prepare
for patients before their arrival. If patients are
being brought to hospital by ambulance,
paramedics and ambulance staff usually alert
the hospital to the approximate time of their
arrival and each patient’s condition. However,
if a patient self-presents to the emergency
department, this will not be possible and early
resuscitation may need to be started as the
trauma team assembles.
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Primary survey is undertaken immediately
on the patient’s arrival at hospital and involves
a structured approach to identify and treat
any life-threatening conditions promptly (Driscoll
and Skinner 2000). Systematic assessment involves
the ABCDE approach to care (Guly 2003).
Airway with cervical spine control Assessment
of the patient’s airway and consideration of
potential damage to the cervical spine are
important. Driscoll and Skinner (2000) advise
that a semi-rigid collar and secured head blocks
should be used if there is evidence of injuries
above the clavicle, or a dangerous mechanism
of injury. Nurses or doctors closest to a patient’s
head should attempt to talk to him or her to
assess responsiveness and possible airway
obstruction. If patients are able to respond
coherently to simple questions then
it is likely that the airway is clear and the brain
is adequately perfused with oxygen
(Hadfield-Law 2000).
If patients do not respond, the airway should
be checked by opening the mouth. In patients
with suspected cervical spine injury a
jaw-thrust manoeuvre should be used to open
the mouth to enable examination of the airway,
while minimising movement of the neck
(Driscoll and Skinner 2000). It may be that
the jaw thrust has moved the patient’s tongue
forward and this is all that is required. At this
point, any solid obstruction or foreign object
should be removed, and any fluid gently
suctioned out as required. If a cervical spine
injury is suspected the patient’s head should not
be tilted to one side while suctioning takes place
as further injury may result (Driscoll and
Skinner 2000).
The use of a nasopharyngeal airway can be
useful in patients who are maintaining their
own gag reflex, but require help to maintain
their airway (Hadfield-Law 2000). For
patients who cannot maintain their own airway
and have no gag reflex, the early use
of intubation with an endotracheal tube is
recommended (Driscoll and Skinner 2000).
Excessive ventilation with a bag-valve mask can
increase the risk of patients vomiting. In some
instances it might be impossible to pass an
endotracheal tube successfully, either because
of the nature of a patient’s injuries or his or her
anatomy (Watson 2000). It may be necessary
for nurses to prepare for an emergency needle
cricothyroidotomy (a cannula placed into the
larynx) to establish a temporary airway before
attempting to establish a surgical airway
(Hadfield-Law 2000). Nursing staff do not
perform these highly invasive procedures, but
they often assist anaesthetic staff, and a
knowledge of how the procedure is carried out
and what equipment is required is useful.
NURSING STANDARD
Time out 3
How would you care for an
unconscious patient with a stab
wound, possible cervical spine
damage and airway obstruction?
List the advantages and disadvantages
of different types of equipment used to
maintain an open airway.
Breathing and ventilation All trauma patients
should have high flow oxygen applied through a
mask with a reservoir bag attached (American
College of Surgeons (ACS) 1997). The patient’s
breathing should then be examined. Some
clothing might need to be removed to observe the
patient’s chest movements. Observation should
include the rate and depth of breathing, use of
accessory muscles of respiration and tracheal
shift from the midline (Hadfield-Law 2000).
Pulse oximetry can also be used in a breathing
assessment to provide an indication of
haemoglobin saturation with oxygen.
Thoracic injuries can be life-threatening if they
are not recognised and treated promptly. These
injuries include (Greaves et al 2000):
 Airway obstruction.
 Tension pneumothorax – accumulation of air
under pressure in the pleural space. A one-way
valve is formed allowing air to enter the
pleural space and preventing air from
escaping naturally.
 Open pneumothorax – where a pneumothorax
communicates with the outside air through a
hole in the chest wall.
 Haemothorax – accumulation of blood in the
pleural space.
 Flail chest – a condition where there are
multiple fractures in adjacent ribs and a
segment moves independently to the rest of a
patient’s chest.
 Cardiac tamponade – accumulation of fluid in
the pericardium.
Penetrating trauma to the thorax can cause a
haemothorax or pneumothorax. A doctor
should auscultate a patient’s chest to identify
haemothorax or pneumothorax early in the
assessment process (Driscoll and Skinner 2000).
A pneumothorax or haemothorax should be
treated with a chest drain to allow air and fluid
to be drained from the chest, although this
should always be preceded by insertion of an
intravenous (IV) catheter to allow replacement
of blood should it become necessary (Driscoll
and Skinner 2000). Early use of chest X-ray in
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learning zone emergency nursing
thoracic stab wounds can also help to detect
some of these complications.
Time out 4
Revise or discuss with a more
experienced colleague the nursing
care of a patient with a chest drain.
What observations and vital signs
would you monitor? Write down the
rationale for your actions.
Although a flail chest is unlikely with a stab
wound, it is still worth considering because the
patient may have other blunt force trauma
injuries. The thoracic penetrating wound should
not be probed to determine the depth or
direction of the wound because of the risk of
haemorrhage resulting from the disruption of
clots (Mahoney et al 2005).
The thoracic cavity, unlike the abdominal
cavity, contains relatively few structures: the
lungs, heart, oesophagus and major vessels.
The diaphragm borders the cavity inferiorly
and the ribs and intercostal muscles form the
anterior and posterior borders. A penetrating
injury to the abdomen can breach the
diaphragm causing damage to thoracic
structures and vice versa.
Circulation and haemorrhage control Patients
with haemorrhagic shock as a result of
traumatic injury are among those with the
highest mortality in emergency departments
(Girisgin et al 2006). Rapid assessment of a
patient’s circulation status is necessary on
arrival in the emergency department.
Assessment should involve monitoring of his or
her blood pressure and pulse via an electronic
monitoring device.
Use of electronic monitors should not stop
staff from performing manual observations
on patients as the automated reading can be
unreliable, particularly in the case of
hypotensive or combative patients (Dawes
2005). It is important to continue to monitor
patients’ blood pressure and pulse throughout
resuscitation as this provides vital information
about the success or failure of interventions and
patient deterioration.
At this stage IV access should be obtained in
the event that IV fluids or blood need to be
administered. Ideally, two wide-bore (14-16G)
IV cannulae should be inserted in the patient’s
arms, and blood should be taken for grouping
and cross-matching in the laboratory (ACS
1997). In some patients who are shocked or
54 january 28 :: vol 23 no 21 :: 2009
have experienced excessive blood loss from the
wound, obtaining IV access can be difficult. If
staff are unable to site an IV catheter
adequately, help should be sought from a more
experienced colleague.
When the normal IV route is unobtainable
there are a number of other options available to
ensure adequate blood and fluid replacement.
The central venous route can be used if
peripheral access is difficult, and Dawes (2005)
recommends that a skilled doctor should
perform the procedure.
If peripheral access is not possible it might be
worth considering the intraosseous route
(Lavis et al 2000), where access is gained directly
into the patient’s bone. The intraosseous route
of administration is common in emergency
paediatric care, but has only recently been
introduced for adult trauma patients. The
intraosseous route has the advantage of
allowing easy access irrespective of how
peripherally shut down patients are, and the
process requires limited training.
The administration of fluids to replace blood
lost following penetrating injury should be
considered in cardiovascularly unstable
patients, in small controlled amounts of
250-500ml, and the patient’s response should
be monitored carefully.
There is conflicting advice about the
administration of fluid in traumatic patients.
During initial assessment and management the
ACS (1997) recommends the infusion of
between one and two litres of crystalloid, for
example Hartmann’s solution. Revell et al
(2002) highlight that in some instances the
rapid infusion of fluid can have a detrimental
effect on patients because it can increase the
circulating volume, therefore potentially
increasing cardiac output and blood pressure,
and disturbing wounds in the body that may
have clotted.
A sudden infusion of fluid can also disrupt
wound sites where clotting mechanisms have
brought about cessation of haemorrhage
(Revell et al 2002). Although there are risks
associated with transfusion, blood is the ideal
fluid replacement as it allows clotting
factors and haemoglobin to be replaced and
ensures that end-organ perfusion is maintained
(Revell et al 2002).
A patient’s cardiovascular status can
appear stable, with no active bleeding.
However, careful monitoring should take place
to ensure any subtle changes are detected early.
Any cardiovascular instability requires
thorough clinical examination to determine
the point of bleeding, and with senior surgical
input, the early use of surgical interventions to
stop the bleeding.
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Disability and neurological assessment An
assessment of the patient’s conscious level
should be conducted using the Alert, Voice,
Pain, Unresponsive (AVPU) scale, which is a
quick tool for assessing his or her consciousness,
particularly if there is any suspicion that the
patient may have sustained a head injury.
Patients not alert on the AVPU scale should have
a full Glasgow Coma Score (GCS) assessment
carried out and neurological observations
should be monitored and recorded every 30
minutes until his or her GCS returns to 15/15
(National Institute for Health and Clinical
Excellence 2007). Unless there is a known
reason for a drop in GCS, such as the effect of
drugs that have been administered, then
hypoxia, hypovolaemia or a neurological
problem should be suspected, along with any
other injuries that are already known.
Exposure and environmental control At this
stage a patient’s clothing is usually removed and
patients are examined for further injuries. It is
possible that pain from another injury can mask
pain from a stab wound and vice versa. Nurses
should use blankets to ensure that patients do not
become hypothermic, and to maintain their
privacy and dignity.
If there are no immediate surgical problems
that require transfer to theatre then a secondary
survey should be performed. Secondary survey
involves a more detailed assessment of patients,
patients are examined from head to toe and
further tests and investigations are organised
(Driscoll and Skinner 2000). These tests can
range from a computed tomography (CT) scan
on a non-urgent basis, to an ultrasound scan of
a limb in the vascular studies department.
Tension pneumothorax
Emergency management is required if a tension
pneumothorax develops as patients deteriorate
rapidly. A tension pneumothorax develops
when air enters the potential space between
the two pleura and becomes trapped under
tension. This can occur as a result of a
penetrating injury to the lung, bronchus or
chest wall (Greaves et al 2000). Air that enters
the pleural space is unable to escape causing a
rapid accumulation of air, which can cause
collapse of the lung and eventual compromise
of the circulatory system as the pressure causes
a shift of the mediastinum.
Tension pneumothorax can be recognised by
respiratory distress, reduced or absent breath
sounds, overinflated or hyper-resonant
percussion notes on the affected side of the chest,
tracheal deviation, which is a late sign and absent
in the majority of cases, or distended neck veins,
which may not be seen in patients who are
NURSING STANDARD
hypovolaemic (Greaves and Porter 1999).
Primary management involves needle chest
decompression. A large IV cannula is inserted
into the chest, in the second intercostal space in
the midclavicular line. The needle is then
removed and the air allowed to escape. The
cannula should be left in place and secured. The
cannula should not be capped or the end covered
(Bjerke 2006). In most circumstances patients
will then have a chest drain inserted on the
affected side for further management during
their hospital stay (Bjerke 2006).
Abdominal stab wounds
An assessment of a patient’s abdomen,
especially if there is evidence of any injury, is
necessary soon after arrival in the emergency
department. A large amount of blood can
accumulate in the abdomen after injury, which
is not always easily detected and can have a
significant effect on a patient’s ability to
maintain end-organ perfusion. The large
surface area of the abdomen and the large
number of organs within, mean that any stab
wound to that area of the body can become life
threatening (ACS 1997). Unlike the thoracic
cavity there is no protective bone structure
surrounding the abdomen and once the surface
skin has been penetrated there is little other
resistance offered.
The surface appearance of a stab wound,
particularly on the abdomen (Figure 1), can hide
the seriousness of tissue damage underneath.
About one third of patients who have serious
tissue damage on exploration in theatre display
minimal pre-operative physical signs (Cope and
Stebbings 2000). Young patients are able to
compensate well for fluid loss and usually only
display a sudden deterioration, therefore the
involvement of a senior surgical doctor is
required early on in assessment.
FIGURE 1
Close-up of a penetrating stab wound
to the abdomen
SCIENCE PHOTO LIBRARY
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The main options open to a surgeon looking

learning zone emergency nursing after a patient with an abdominal stab wound
involve whether to take patient to theatre for a
laparotomy or consider conservative
FIGURE 2 management. Small stab wounds can be
Multiple stab wounds to the chest explored by surgeons in the emergency
department using local anaesthetic. It is
estimated that this allows the discharge of
approximately 25% of patients after a short
period of observation (Lawson and Goosen
2008). Patients who are haemodynamically
unstable or show signs of peritonitis should
not have their wounds explored and should
be taken for immediate laparotomy
(Lawson and Goosen 2008).
Some patients will have an ultrasound
scan. In the majority of emergency
departments this will be a portable Focused
Assessment with Sonography for Trauma
(FAST) scan. While the FAST scan has poor
sensitivity (Brooks et al 2005) and does not rule
MEDISCAN

out the presence of blood in the abdominal

cavity, it is non-invasive and can be repeated as
often as required. A CT scan of the abdomen
FIGURE 3 might also be undertaken. However, this is
usually only appropriate if a patient’s
Stab wound to the upper arm cardiovascular system is stable enough for
him or her to be transferred to the radiology
department (Ertekin et al 2005).
Nurses’ preparation of patients going to
theatre should include completion of any
necessary pre-theatre check lists and informing
the next of kin. It is important to note that
the transfer of patients to theatre for an
emergency operation should never be delayed
under any circumstances.

Extremity stab wounds

While a stab wound to a patient’s limbs might
MEDISCAN

initially appear less serious than those to the

abdomen or thorax (Figure 2), such wounds
can result in life-threatening complications
FIGURE 4 (Figure 3). Major blood vessels perfuse the
Knife wound to the hand arms and legs, and vessel injury can result in
excessive haemorrhaging.
With the majority of limb wounds
(Figure 4), simple direct pressure will be
successful in stemming haemorrhage. A stab
wound that will not stop bleeding from direct
or indirect pressure requires further action.
The ACS (1997) advises against the application
of a tourniquet to assist in haemorrhage
control, because of the damage that can occur
to the underlying tissue. The application of
SCIENCE PHOTO LIBRARY

tourniquets can occur in specific situations –

although these are limited – where their
application will halt excessive haemorrhage
loss before immediate surgical intervention
(Lee et al 2007).

56 january 28 :: vol 23 no 21 :: 2009 NURSING STANDARD

p51-57w21 26/1/09 12:16 Page 57

should be taken with patients who present with

Time out 5 penetrating trauma to ensure that they are
examined fully and that any other injuries are not
Using the information in this
overlooked. A structured ABCDE approach to
article, structure a plan of action
assessment should be adopted by all members of
for staff to use to assess and
the trauma team to ensure that the patient
manage patients with stab wounds.
receives the best possible care NS

Conclusion
Time out 6
Assessing and managing patients who have Now that you have completed
sustained a stab injury can be challenging because the article, you might like to
their wounds can be life threatening and the write a practice profile. Guidelines
patient can deteriorate quickly. Special care to help you are on page 60.

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