Edyta Kuduk1, Wioletta Medrzycka-Dabrowska2, Sylwia Terech3, Renata Piotrkowska3, Piotr Jarzynkowski3, Katarzyna Kwiecien-Jagus2, Klaudiusz Nadolny4, *Daniel Slezak5
The importance of physical examination in chest injury following stabbing
Znaczenie badania fizykalnego w urazie klatki piersiowej w następstwie ugodzenia nożem
1Ambulance Service in Gdansk, Poland
2Department of Anaesthesiology Nursing and Intensive Care, Faculty of Health, Medical University of Gdansk, Poland
3Department of Surgical Nursing, Faculty of Health, Medical University of Gdansk, Poland
4Department of Emergency Medicine, Medical University of Bialystok, Poland
5Department of Emergency Medicine, Emergency Medicine Workshop, Faculty of Health, Medical University of Gdansk, Poland
Urazy przenikające klatkę piersiową występują stosunkowo rzadko, ale stanowią bezpośrednie zagrożenie życia dla poszkodowanego. Prawidłowa ocena urazu w ratowniczym postępowaniu przedszpitalnym ma istotne znaczenie dla późniejszego wyniku leczenia poszkodowanego. Postępowanie przedszpitalne oparte na przyjętych standardach, takich jak: ABCDE (airway, breathing, circulation, disability, exposure/fractures) i zasada „złotej godziny” zgodnie z wytycznymi w zaawansowanych urazach – ATLS, pozwalają szybko rozpoznać powikłania zagrażające życiu. W pracy opisano przypadek 44-letniego mężczyzny z raną kłutą klatki piersiowej w wyniku ugodzenia nożem oraz dokonano analizy postępowania zespołu pogotowia ratunkowego z pacjentem. Postępowanie zespołu pogotowia ratunkowego zgodnie z wypracowanymi standardami pozwoliło na szybkie i prawidłowe rozpoznanie urazu, stabilizację i odpowiednie zabezpieczenie podstawowych funkcji życiowych oraz przekazanie pacjenta do szpitala.
Injuries that penetrate the chest are relatively rare but pose a direct threat to the injured. Correct injury assessment in emergency pre-hospital treatment is important for the subsequent outcome of the treatment of the victim. Pre-hospital procedures based on accepted standards, such as ABCDE (airway, breathing, circulation, disability, exposure/fractures) and the “golden hour” principle according to the guidelines in advanced trauma – ATLS, allow to quickly identify life-threatening complications. The paper describes the case of a 44-year-old man with a stab wound in the chest as a result of stabbing with a knife and an analysis of the emergency team’s treatment with the patient. The operation of the ambulance service team in accordance with the developed standards ensured a quick and correct diagnosis of injury, stabilization and adequate protection of basic vital functions and transfer of the patient to the hospital.
The chest sustains numerous serious injuries. In most cases, they are caused by traffic accidents, accidents at work, as well as falls from a height, and are dull and non-penetrating. Penetrating chest wounds are less frequent but pose a direct life threat to the injured. The main causes of penetrating chest wounds in Poland are stab wounds resulting from a knife or another sharp object; gunshot wounds and impalement injuries are sporadic (1, 2).
Chest stab wounds are related to a high risk of damage to critical internal structures of the body and, therefore, require prompt and efficient actions. Medical care in the case of patients with penetrating wounds can be divided into three stages: prehospital care to deal with the injury, hospital care at the hospital emergency department or admission desk, and postoperative care at the surgery department. Nevertheless, a proper assessment of the injury in prehospital emergency treatment has a significant impact on the further outcome of treatment.
Prehospital procedures based on the ABCDE (airway, breathing, circulation, disability, exposure/fractures) standards and the “golden rule” principle (according to the ATLS guidelines for serious injuries) enable the diagnosis of life-threatening complications: airway obstruction, open pneumothorax, tension pneumothorax, and hemorrhage of the damaged mediastinal vessels to the pleural cavity (3-7).
The aim of this paper is to analyze emergency medical procedures in the case of a patient with chest injury following stabbing.
This is a retrospective analysis. The study was conducted at the Ambulance Services in Gdansk with the consent of the head of this unit. The research involved a case study of a patient with chest injury following stabbing. The team of the specialized ambulance was interviewed and the documentation was reviewed to collect data. The interview was related to the circumstances of the incident and the procedures taken as far as the intervention was concerned.
At 6.40 p.m., a medical dispatcher of the emergency response center was informed about a domestic fight with a 44-year-old male injured. The patient was stabbed with a knife in his chest. The medical dispatcher dispatched the closest available specialized ambulance (with a doctor, a nurse, a paramedic, and a driver) and a police unit to ensure safety on the crime scene. The emergency team arrived at the place of incident within 6 minutes. The police officers had already been there, checked and emptied the flat, and had been hearing witnesses. Upon arrival, the emergency team also evaluated the situation to ensure safety of the rescuers and the injured.
The patient was sitting in an armchair, leaning forwards, unable to maintain logical verbal contact. According to the witnesses, the man had been stabbed by his female partner during an argument. The emergency medical team evaluates the situation as safe and recognizes the injury mechanism as localized (a stab wound). The doctor, who was the team lead, initiates a preliminary diagnosis. The patient was unconscious, unable to maintain logical verbal contact, with a shallow respiration (respiratory rate: 10/min) and a visible wound of the left part of the chest at the level of the 3-4 intercostal space. The paramedics and the nurse measured the basic life parameters and reported an indeterminable blood pressure, muffled heart tones (65/min), and an indeterminable saturation. The patient’s skin was pale, covered with sweat, and maintaining a normal temperature. The SAMPLE interview was impossible to apply. The doctor requests oxygen administration (flow rate: 9 l/min) and, due to the injury mechanism, initiates a local examination. Chest auscultation resulted in no respiratory sounds reported on the left side and chest percussion resulted in a tympanic sound reported on the left side of the chest. The team lead diagnosed dilation of jugular veins, the placement of trachea along the central line, a proper pupil reaction to light, with a proper width. The patient was assigned 3 points of the Glasgow scale (eye 1, verbal 1, motor 1). The abdomen was soft with no pain and no further injuries. The doctor diagnosed tension pneumothorax and initiates an emergency decompression of the direct life-threatening tension pneumothorax. After having confirmed the location of tension pneumothorax on the left side, he identified the other intercostal space in the clavicle central line. After the disinfection of the decompressed part, the doctor introduced a 14 G catheter, removes the needle, and fastens the catheter to the chest wall. The paramedic secured the catheter by means of a gauze with a one-way valve, the Asherman Chest Seal in this case. The doctor repeated chest auscultation and reported increased respiratory sounds. Two iv access ways were ensured by the nurse as a result of doctor’s request. HEAS 6% 500 ml of a rapid flow and 0.9% NaCl 500 ml were administered. The total amount of iv fluids provided to the patient was 2000 ml. Simultaneously, the paramedic passed the endotracheal intubation equipment and the patient was intubated by means of a 9 mm intubation tube and an AMBU-bag assisted respiration. After the above-mentioned procedures, a hemodynamic improvement was reported (blood pressure 130/80 mmHg, heart rate 130/min). A preparatory action was taken to immediately transport the patient to hospital in order to replace the chest decompression catheter by a pneumothorax drainage. For the time of transfer, the injured was placed on a stretcher, monitored by an ECG device and a pulse oximeter. Moreover, the team monitored all procedures that had been performed and used the radio equipment to inform one of the nearby hospitals about the expected arrival of an unconscious, intubated patient with maintained independent breathing function and tension pneumothorax decompression performed. The personnel of the hospital emergency department had enough time to prepare the unit for the admission of a critical case patient. The information exchanged between the emergency team and the hospital department enabled the implementation of further specialized procedures to treat the patient.
Penetrating chest injuries are always life-threatening cases as it is difficult to predict the scope of damage of deep structures and because such injuries have a tendency to dynamically develop. The injured person whose life is threatened requires prompt actions based on verified standards and procedures (4).
The priorities in prehospital emergency procedures are rescuers’ and patient’s safety, a detailed interview and a precise examination of basic life functions of the injured. A preliminary assessment of the event is initiated as soon as the emergency response center dispatcher is informed about the incident. The reported fact that the injured was involved in a fight (as in the case described in this paper) leads to the preliminary assumption that the place of incident may not be safe enough and that a police unit is required.
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