Haf_Bräunig_Stab wound care

The European Journal of

TACTICAL RESPONSE & MEDICINE

Stab Wound Care   Penthrox in TCCC   IED and CBRN Weapons

Impact of Vehicle-Borne IED Attacks on Bollard Structures   Hostage-Taking in Prisons

Authors:

Dr David Haf

Senior Medical Officer

Assistant Physician

German Armed Forces Hospital Hamburg, Clinic for Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy

Lesserstr. 180 22049 Hamburg davidhaf@ bundeswehr.org

Dr Jan Bräunig

Fleet physician

Specialist in anesthesiology, emergency medicine

German Armed Forces Hospital Hamburg, Clinic for Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy

Lesserstr. 180 22049 Hamburg janbraeunig@ bundeswehr.org

Stab Wound Care:

Always Assume the Worst

Penetrating injuries are reported to have a worldwide prevalence of 15%. However, there are variations between regions. For example, studies indicate that the incidence rate ranges from 25% to 45% in the USA and 60% in South Africa. Fortunately, the incidence rate in Germany is only 4 – 5%. Therefore, German healthcare professionals rarely have to treat such injuries. However, such wounds often present life-threatening acute injury patterns. Therefore, they must master how to treat such injuries. This article focuses on treating stab wounds, particularly in the context of tactical decisions.

Always Assume the Worst

Due to the increasing number of offences involving knives and other sharp instruments, German Police Crime Statistics (PCS) have uniformly recorded incidents of knife crime since 1 January 2020. Watson’s 1993 study states that the 5% of penetrative injuries in Germany include gunshot wounds (0.6%), stab wounds (1.8%) and other penetrating injuries such as those caused by impalement.

The German TraumaRegister DGU® states that stab wounds in Germany result in a 6.2% mortality rate, which increases significantly when the injury is to the torso or its transitional circulatory zones. Furthermore, the morphology and configuration of the wound, as well as the patient’s history, are

decisive factors. First responders and other medical professionals can assess the depth of a wound and its resulting potential injuries to vital organs and internal body structures by the length of the blade that caused the injury (if that information is available). However, wounds may be more extensive than the length of the knife due to the compression of fatty tissue. Likewise, first responders and other medical professionals have no way of knowing the internal angle of a stab wound. Therefore, they must assume the worst-case scenario, such as a two-cavity wound and internal bleeding. If the knife (or other sharp instrument) is still in the puncture canal, first responders should leave it where it is because removing it may increase bleeding and make the puncture canal more challenging to trace. Exsangui-

nation is the primary cause of death in those who have sustained penetrating injuries. Therefore, first responders and other medical professionals must focus on treating bleeding immediately.

Effective treatment begins with rapid bleeding control using proven trauma algorithms.

Treating Stab Wounds:

<x>ABCDE and MARCH

The primary goal of first responders and other medical professionals when treating stab wounds is to identify potentially life-threatening injuries and treat them immediately. To do so effectively, they must prioritise treatment by following the classic <C>ABCDE (for treating a catastrophic haemorrhage), <x>ABCDE (for preventing exsanguination), or MARCH (for treating a massive haemorrhage) algorithms and the Tactical Rescue and Emergency Medical Association (TREMA) guidelines. The first step in all three action algorithms (C, x, and M) is to recognise external bleeding.

The second step is to control the bleeding via manual compression, a compression bandage or a tourniquet. First responders may supplement these measures with haemostyptics. However, while first responders should apply the tourniquet a hand’s width from the injury under controlled conditions, in a threatening situation, they should place it as close to the wound as possible. Haemostasis indicates that the tourniquet is in the correct position. If the tourniquet is too loose, it may cause venous congestion or increase bleeding. First responders must urgently reapply such tourniquets. A limb ischaemia of up to two hours is typically unproblematic. However, first responders should always document when they apply the tourniquet and reevaluate and adjust its position regularly. Afterwards, the tourniquet may be converted to pressure bandages in the ambulance or hospital. For stab wounds close to the trunk (neck, axilla, groin), first responders should use wound tamponades because circular compression bandages and tourniquets frequently fail to control bleeding. They should also use haemostyptics when available. The key is to ensure that the wound bed is as dry as possible, dress it correctly and then apply pressure. After removing the tamponade, medical professionals should manually compress the area for at least five minutes.

The third step (A for Airway) involves evaluating the patient’s airway. If the patient has suffered

a thoracic stab wound, first responders should use an airtight dressing, such as a chest seal, to prevent inappropriate intrathoracic valve mechanisms. If the first responder or medical professional detects or suspects that the patient is suffering from tension pneumothorax, they must relieve it immediately and ventilate or remove the dressing to allow the intrathoracic air to escape or create a relief puncture in the Bülau (4th/5th intercostal space anterior to mid axillary line) or Monaldi position (2nd/3rd intercostal space midclavicular line) which doctors can later extend with a minithoracotomy.

The fourth step (C for Circulation) involves first responders assessing the patient’s circulation to determine whether they are bleeding internally and establishing IV or IO access. If the patient is suffering from an uncontrollable intrathoracic or intra-abdominal haemorrhage, first responders should take them to a suitable hospital as quickly as possible because medical staff can only achieve haemostasis surgically. In such cases, first responders should not delay transport due to postponable preclinical measures. Instead, they should aim to achieve controlled hypotension (systolic blood pressure of 80 – 90 mmHg) through moderate volume therapy. First responders can supplement crystalloid infusion solutions with circulatory-stabilising drugs such as colloidal infusion solutions (e.g., HAES®) in individual cases. However, European guidelines state that first responders should not induce hypotension in patients with cardiac diseases, traumatic brain or spinal traumas or those who may be pregnant. First responders should use tranexamic acid (TXA) and maintain adequate perfusion pressure for patients with massive haemorrhages. TXA counteracts hyperfibrinolysis and, therefore, stabilises physiological thrombi. The German Polytrauma/Severe Injury Treatment S3 guideline recommends administering 1 g of TXA over 10 min as soon as possible,

followed by an infusion of 1 g over 8 h if necessary. However, first responders (and other medical professionals) should only administer TXA preclinically if the patient is suffering from haemorrhagic shock and/or uncontrollable bleeding.

The fourth step (D for Disability) involves assessing the patient’s neurological status and administering analgesics if possible.

The fifth step (E for Exposure and Environment) involves examining the patient for hidden wounds and maintaining the patient’s body temperature to prevent the lethal triad of acidosis, hypothermia and coagulation disorder. Primary haemostasis and plasmatic coagulation slow when the body temperature drops below 35°C. Coagulation decreases by 10% with every 1°C decrease in body temperature.

Stop the Bleeding: Treat and Run

The most common cause of death in stab wound patients is a haemorrhage. Therefore, first responders must reduce or stop bleeding (haemostasis) from extremities as soon as possible, by using manual compression, pressure dressings, and tourniquets. However, that is challenging when dealing with wounds in transition zones such as the neck, axilla, or groin. In such cases, first responders should consider haemostyptics and tamponading the wound (wound packing). However, transition site bleeding can be so complex that first responders must use the “treat and run” principle by doing whatever they can to stop the bleeding and immediately transfer the patient to a suitable clinic for surgical haemostasis. First responders should treat patients with severe bleeding using TXA or other methods to induce hypotension unless the patient displays contraindications. They should also be mindful that hypothermia reduces the rate of blood

coagulation; therefore, they should take all possible steps to maintain the patient’s body temperature above 35°C.

Outlook

Ambulances are increasingly equipped with portable ultrasound devices so that their crews can detect thoracic and abdominal bleeding. However, first responders should not delay transport to use sonography.

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