Stab wound to the thoracoabdominal area

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Hi Matthieu,

In my setting (South Africa, state service, high incidence of violent
trauma) this really is 'bread and butter'.  Patient would almost certainly
not have got the CT scan; may have had a FAST if there was someone on duty
able to perform and an U/S machine was available (usually stolen from the
gynae department...)

Management would have been ABCD etc, followed by simple tube thoracostomy.
With a benign abdominal examination the patient would get admitted to the
ward for 'abdo obs' - serial abdominal examination, preferably by the same
examiner and every four hours.  Development of haemodynamic instability or
peritonitis would earn him an immediate "full colour real-time stereotactic
CT" (aka laparotomy, *grin*).

I know some of the academic hospitals have studies on the go where this
class of patient is getting diagnostic thoracoscoopy/laparoscoy to examine
the diaphragm, and are picking up more diaphragmatic injuries.  Tim
Hardcastle will hopefully comment on his (extensive) experience in this type
injury.

Serial abdominal examination remains one of the cheapest and best ways to
assess the stable penetrating trauma patient with a quiet belly.

Hope this is helpful,
Ross.

2009/9/15 Matthieu G. <mat.genz at gmail.com>

> Dear list members,
>
> I would greatly appreciate your input on this case:
>
> 28 y.o. male, presents to the ER 24 hours after being stabbed twice to the
> thoracoabdominal area during a mass gathering. The patient is obviously
> intoxicated on psychoactive drug, complains of swelling and only very little
> pain. Vitals within normal limits. Clinical exam is remarkable for a massive
> cervical and left thoracic subcutaneous emphysema, 2 small stab wounds to
> the left latero-inferior chest wall and sub-xyphoid area. Hemodynamic is ok,
> positive Hamman sign, no dyspnea, abdomen is soft and non tender. Images of
> chest xray and chest CT scan are attached: subcutaneous emphysema,
> pneumomediastinum, small left PTX. Abdominal CT is negative, with no
> evidence of solid organ injury, no free air or fluid in peritoneal cavity.
>
> How would you manage this case? I know this kind of trauma is bread and
> butter in some countries, but penetrating trauma are rather infrequent in my
> practice. I am particularly worried about a possible left diaphragmatic
> injury.
>
> Matthieu Gensburger
>
> Matthieu Gensburger
> --
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-- 
Dr Ross Hofmeyr
wildmedic at gmail.com
ross at wildmedix.com
www.wildmedix.com
Tel: +2784 54 99259
Skype:  wildmedic
“Semper Paratus”

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