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Penetrating stab injuries of the chest and abdomen
300
Injury
(1984)
15. 300-303
Penetrating A. L. Lambrianides St Charles
Hospital,
Printed in Great Brhn
stab injuries
of the chest and abdomen
and R. D. Rosin London
Summary
A retrospective review was carried out of IOU consccutt\c patients with penetrating stab injuries of the chest and.or abdomen, requiring admission to hospital. Laparotomies were performed in 44 patients. whtle a furthtx 7 were subjected to thoracotomy. Only 1 patient died. and this was a case of combined thoraco-abdominal injury. There was an annual increase in the numbers ofsuch injuries. which were particularly prevalent in young. unemployed pel-sons, often under the influence of alcohol.
INTRODUCTION PENETRATING stab injuries
of the chest and abdomen. as a result of civilian violence, were uncommon in this country a few years ago. A retrospective review was undertaken in order to establish the recent trends of such injuries in a busy general hospital, and to analyst the surgical management and outcome of such injuries
remainder the injury was thoraco-abdominal (T&e I). Fifty of the patients were British, the vast majority being Negroes. Of the remainder. 40 were Irish while 8 were of miscellaneous nationalities. Eighty-five of the patients were unemployed; most (77) of this group were drunk at the time of the injury. In 12 cases the cause was crime of passion. and robbery was the motive in IO. The interval between the incident and admission to hospital ranged from I5 minutes to 48 hours, the majority (55) of patients coming between half an hour and 2 hours after the injury (Fi
of penetrating
stab injuries in 100 patients
No. of cases
PATIENTS AND METHODS The case records of all patients with the diagnosis ot penetrating stab injuries of the abdomen or chest. OI combined thoraco-abdominal injury. who were admitted to St Charles Hospital in London during the period June 1976 to June 1982, were analysed. There were 100 such cases, of which 80 were male. The ages range from 10 to 79 years, the commonest being the third and fourth decades (Fig. I). Knife stab wounds were responsible for 75 of the cases, while broken glass and scissors were responsible for 20 and 5 cases respectively. The location of the injuries were as follows: in 58 patients the abdomen alone was involved, in 32 the thorax and in the
20-29
30-39
No. of cases
Chest
32
Right side Left side
17 15
Abdomen
58
Epigastrium Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant
10 15
Chest and abdomen _._~____
10
No. of cases
10-19
Site of injury
40-49
50-59
60-69
Age Fi‘y. I.Age Incidence In IO0 case5 ol‘ penetrating
stab injuries.
70-79
14 7 12
Lambrianidesand Rosin: Stab injuries
301
25 I 20 No. of cases 15
minutes
Fig. 2. Time
1hours
elapsed between wounding and admission to hospital.
theatre and explored after suitable preparation; if the injury was found to penetrate or bruise the peritoneum, a formal laparotomy was performed. Diagnostic peritoneal lavage was not employed. All patients undergoing laparotomy received perioperative antibiotics (metronidazole and cefuroxime); patients found at laparotomy to have gastrointestinal perforation were maintained on the same antibiotic therapy for 5 days. Injuries to the gastrointestinal tract were managed by wound toilet and closure for the stomach, duodenum and small intestine. Colonic injuries were managed by a variety of techniques including simple repair, exteriorization of the repair, resection and primary anastomosis, or colostomy. Injured spleens were removed; repair was not employed. The following principles were employed in the treatment of patients with iniured livers: 1. Control of haemokhage by ligation of individual vessels. 2. Suture-ligation of damaged biliary radicles. 3. Avoidance of approximation of gaping wounds, if they were not bleeding. 4. Excision of dead tissue. 5. Adequate drainage. Before closing the abdomen, copious irrigation of the peritoneal cavity with warm normal saline solution was employed in all patients. Noxythiolin (5 g) was added to the last litre of irrigating solution. The result of exploratory laparotomy was considered positive if an intra-abdominal injury requiring repair or control of haemorrhage was found. A negative finding was defined as one in which there was little or no damage such as might have caused later trouble. Of the penetrating chest injuries 28 patients had various degrees of isolated haemo-, pneumo- or haemopneumothorax. Chest drains were used to treat 21 of the patients while thoracotomies were employed in the remainder. Several methods of repair were employed for the vascular injuries. Two left gastric arteries and 2 inferior pancreatico-duodenal arteries were ligated. A saphenous vein graft was necessary for one of the cases of superior
to
mesenteric arterial injury, and simple repair of the wounds of the external iliac arteries. RESULTS
Of the 100 patients analysed, 44 were subjected to laparotomy. The incidence of damage to various organs is shown in Table ZZ, the liver being the commonest site of injury, closely followed by the stomach, jejunum and transverse colon. There were only 5 negative laparotomies. Of the positive laparotomies none would have benefited from conservative management, as even simple tears in the mesentery without vascular damage had to be repaired in order to minimize subsequent complications such as internal herniation of loops of bowel. Only 8 of the patients had sustained abdominal vascular injuries. Table Il. Incidence of damage to various organs No. of times injured
Organ intercostal vessels Internal mammary vessels Pleura External iliac artery Superior mesenteric artery Inferior pancreatico-duodenal artery Left gastric artery Liver Stomach Jejunum Transverse colon Left kidney Omentum Spleen Pancreas Diaphragm Ascending colon Small bowel mesentery Sigmoid and descending colon Ileum Splenic flexure Appendix
12 4 26 2 2 2 2 18 14 14 8 : 4 4 4 2 2 2 2 1 1
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 5
302
There was no venous injury. Four of the vascular cases were hypotensive on arrival, while the remainder had normal blood pressures. Twenty-eight of a total of 31 isolated chest injuries had haemo-, pneumo- or haemopneumothorax, and for these, thoracotomies were carried out in 7 who continued to bleed, while the remainder were treated with chest drains. Sixty patients required blood transfusion (Fig. 3); the largest transfusion (16 units) was given to a patient with a penetrating wound of the left hemidiaphragm, spleen and left kidney. The incidence of complications is shown in Table III. Only 1 patient died; he suffered combined thoracoabdominal injury and refused blood transfusion on religious grounds. The direction of injury was found to be an important preoperative indication as to the site and extent of damage. Of the 58 patients with penetrating wounds of the abdomen, 45 were stabbed by an assailant standing behind them, and these wounds usually followed a downward direction. Thirteen were stabbed from in front and these wounds usually followed an upward direction.
1
2
3
4
of complications Site of injury Chest
Abdomen
Infection
3132 (9%)
8158 (14%)
Mortality
O/32
O/58
Complication
Thoraco-abdominal 2/l 0 (20%)
I/10 (10%)
The number of penetrating stab injuries of the chest and abdomen as a result of civilian violence has been shown to be steadily rising (Fig. 4). DISCUSSION
Penetrating stab injuries were uncommon in the United Kingdom a few years ago. Unfortunately times have now changed, and the surgical personnel in many of our hospitals are finding that deliberate penetrating wounds are on the increase. Roberts and Lavelle’s retrospective
5
Units Fig. 3. Number
Table 111. Incidence
6
7
8
9
10
16
of blood
of units of blood transfused.
No. of cases
76/77 Fig. 4. The increase 1981-1982.
77178
in the number
78179
of penetrating
79180 Year stab injuries
80181 between
81182 1976-1977
and
Lambrianides and Rosin: Stab injuries
303
review from the Birmingham Accident Hospital in 1966 clearly demonstrated an annual increase in the number of such injuries, although the total number of cases over a 6-year period was only 42. The present study, again over a 6-year period, indicates a continuing similar trend with penetrating stab wounds of the chest and abdomen. Of the total number of general surgical admissions to the authors’ hospital between 1976 and 1982, penetrating injuries accounted for 0.8 per cent of the total. During the year 19761977 they formed 0.5 per cent of general surgical admissions, while in 198 l-1982 the figure doubled to 1.0 per cent. Of interest is the fact that 85 of the patients in the present study were unemployed, and 77 were under the influence of alcohol. This is not only a sad reflection on our society, but is also an unnecessary burden in terms of cost to the National Health Service. The rate of exploration of penetrating stab injuries of the chest was 7 per cent. Graham et al. (1979) reported a series of 373 patients with 91 explorations (24 per cent). Griffiths et al. (1978) explored 12 out of 101 patients (11 per cent). Other series include heart wounds and therefore have a higher exploration rate. In principle, there is agreement on the treatment of these injuries. Insertion of a chest drain is sufficient in most cases, but a ‘large’ haemothorax requires exploration. The difficulty is to define ‘large’. In some centres (McNamara et al., 1970), an initial drainage through the chest tube of 1.Oor 1.5 1is sufficient reason for exploration. In our experience the initial drainage is not as important as the subsequent course of events. It must be remembered that evacuation of the blood is very important as adequate expansion of the lung helps to stop bleeding from the lung. Careful observation of the patient is a more reliable indicator of the adequacy of treatment. The rate of bleeding (Kish et al., 1976) is not as important as its effect on the patient. Furthermore, the amount of drainage can be misleading if the drain is not functioning properly. The management of injury of the colon in civilian practice has long been based on military experience. In 1945, Imes recommended primary repair of the colon. In our experience this should be applied to patients in good general condition with simple perforation, minimal peritoneal contamination, recent injuries (preferably less than 4 hours old), no injury to the mesentery and no more than one other injured organ. Injuries of the right colon, for which primary repair is not applicable, may be managed by right hemicolectomy. Exteriorization is preferable if it can be substituted for colostomy, particularly if the injured segment can be mobilized. Primary repair with proximal diversion is recommended in patients with left colonic injuries. The low mortality in the present series could be a reflection of the rapid transportation of the patients to hospital, due to the close proximity of the site of the incident and an effective Requests for reprints should be addressed to: A. L. Lambrianides,
ambulance service. Fifty-five patients arrived within 2 hours of the incident. Other factors contributing to the low mortality were first, the nature of the injuries, as there was a complete lack of high velocity injuries, which disrupt and deform structures that may or may not lie directly in the path of the injury, and second, the use of prophylactic antibiotics. Peritoneal lavage was not employed. There were only 5 negative laparotomies. We feel that the place of diagnostic peritoneal lavage in penetrating stab injuries of the abdomen is not as important as in cases of blunt injury provided that there is no question of altered level of consciousness, with the resultant unreliable physical examination. Diagnostic lavage is an insensitive indicator of retroperitoneal injuries such as pancreatic, duodenal or urological injuries. Moreover, erythrocytes in the lavage return, whether qualitatively or quantitatively measured, are usually the only diagnostic index of value. Leucocytes, bile and pancreatic juice are found infrequently. Local probing of the wound was not employed because it is an inaccurate method of determining the depth of a stab wound and may open false tracks or introduce infection. Peritoneoscopy may play a small role in the diagnosis of penetrating stab injuries but it is associated with complications and usually requires an anaesthetic. The major area of controversy regarding routine or selective laparotomy for abdominal injury is the management of stab wounds. Conservative management may reduce the number of negative findings at exploration, but it carries with it the danger of missing or delaying treatment of an extensive abdominal injury. We believe that exploration of the wound, and a formal laparotomy if any doubt exists, are required.
REFERENCES
Graham J. M., Mattox K. L. and Beall A. C., Jr (1979) Penetrating trauma of the lung. J. Trauma 19, 665. Griffiths G. L., Todd E. P. and McMillin R. D. (1978) Acute traumatic pneumothorax. Ann. Thorac. Surg. 26, 204. Imes P. R. (1945) War surgery of the abdomen. Surg. Gynecol. Obstet. 81, 608. Kish G., Kozloff L., Joseph W. L. et al. (1976) Indications for thoracotomy in the management of chest trauma. Ann. Surg. 22, 23.
McNamara J. J., Messersmith J. K., Dunn R. A. et al. (1970) Thoracic injuries in combat casualties in Vietnam. Ann. Thorac. Surg. 10, 389.
Roberts G. and Lavelle E. (1966) The management of stab wounds to the abdomen and thorax. Br. J. Surg. 53, 88. Paper accepted 21 July 1983.
St Charles Hospital, Exmoor Street, London, W 10 6DZ.
Injury
(1984)
15. 300-303
Penetrating A. L. Lambrianides St Charles
Hospital,
Printed in Great Brhn
stab injuries
of the chest and abdomen
and R. D. Rosin London
Summary
A retrospective review was carried out of IOU consccutt\c patients with penetrating stab injuries of the chest and.or abdomen, requiring admission to hospital. Laparotomies were performed in 44 patients. whtle a furthtx 7 were subjected to thoracotomy. Only 1 patient died. and this was a case of combined thoraco-abdominal injury. There was an annual increase in the numbers ofsuch injuries. which were particularly prevalent in young. unemployed pel-sons, often under the influence of alcohol.
INTRODUCTION PENETRATING stab injuries
of the chest and abdomen. as a result of civilian violence, were uncommon in this country a few years ago. A retrospective review was undertaken in order to establish the recent trends of such injuries in a busy general hospital, and to analyst the surgical management and outcome of such injuries
remainder the injury was thoraco-abdominal (T&e I). Fifty of the patients were British, the vast majority being Negroes. Of the remainder. 40 were Irish while 8 were of miscellaneous nationalities. Eighty-five of the patients were unemployed; most (77) of this group were drunk at the time of the injury. In 12 cases the cause was crime of passion. and robbery was the motive in IO. The interval between the incident and admission to hospital ranged from I5 minutes to 48 hours, the majority (55) of patients coming between half an hour and 2 hours after the injury (Fi
of penetrating
stab injuries in 100 patients
No. of cases
PATIENTS AND METHODS The case records of all patients with the diagnosis ot penetrating stab injuries of the abdomen or chest. OI combined thoraco-abdominal injury. who were admitted to St Charles Hospital in London during the period June 1976 to June 1982, were analysed. There were 100 such cases, of which 80 were male. The ages range from 10 to 79 years, the commonest being the third and fourth decades (Fig. I). Knife stab wounds were responsible for 75 of the cases, while broken glass and scissors were responsible for 20 and 5 cases respectively. The location of the injuries were as follows: in 58 patients the abdomen alone was involved, in 32 the thorax and in the
20-29
30-39
No. of cases
Chest
32
Right side Left side
17 15
Abdomen
58
Epigastrium Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant
10 15
Chest and abdomen _._~____
10
No. of cases
10-19
Site of injury
40-49
50-59
60-69
Age Fi‘y. I.Age Incidence In IO0 case5 ol‘ penetrating
stab injuries.
70-79
14 7 12
Lambrianidesand Rosin: Stab injuries
301
25 I 20 No. of cases 15
minutes
Fig. 2. Time
1hours
elapsed between wounding and admission to hospital.
theatre and explored after suitable preparation; if the injury was found to penetrate or bruise the peritoneum, a formal laparotomy was performed. Diagnostic peritoneal lavage was not employed. All patients undergoing laparotomy received perioperative antibiotics (metronidazole and cefuroxime); patients found at laparotomy to have gastrointestinal perforation were maintained on the same antibiotic therapy for 5 days. Injuries to the gastrointestinal tract were managed by wound toilet and closure for the stomach, duodenum and small intestine. Colonic injuries were managed by a variety of techniques including simple repair, exteriorization of the repair, resection and primary anastomosis, or colostomy. Injured spleens were removed; repair was not employed. The following principles were employed in the treatment of patients with iniured livers: 1. Control of haemokhage by ligation of individual vessels. 2. Suture-ligation of damaged biliary radicles. 3. Avoidance of approximation of gaping wounds, if they were not bleeding. 4. Excision of dead tissue. 5. Adequate drainage. Before closing the abdomen, copious irrigation of the peritoneal cavity with warm normal saline solution was employed in all patients. Noxythiolin (5 g) was added to the last litre of irrigating solution. The result of exploratory laparotomy was considered positive if an intra-abdominal injury requiring repair or control of haemorrhage was found. A negative finding was defined as one in which there was little or no damage such as might have caused later trouble. Of the penetrating chest injuries 28 patients had various degrees of isolated haemo-, pneumo- or haemopneumothorax. Chest drains were used to treat 21 of the patients while thoracotomies were employed in the remainder. Several methods of repair were employed for the vascular injuries. Two left gastric arteries and 2 inferior pancreatico-duodenal arteries were ligated. A saphenous vein graft was necessary for one of the cases of superior
to
mesenteric arterial injury, and simple repair of the wounds of the external iliac arteries. RESULTS
Of the 100 patients analysed, 44 were subjected to laparotomy. The incidence of damage to various organs is shown in Table ZZ, the liver being the commonest site of injury, closely followed by the stomach, jejunum and transverse colon. There were only 5 negative laparotomies. Of the positive laparotomies none would have benefited from conservative management, as even simple tears in the mesentery without vascular damage had to be repaired in order to minimize subsequent complications such as internal herniation of loops of bowel. Only 8 of the patients had sustained abdominal vascular injuries. Table Il. Incidence of damage to various organs No. of times injured
Organ intercostal vessels Internal mammary vessels Pleura External iliac artery Superior mesenteric artery Inferior pancreatico-duodenal artery Left gastric artery Liver Stomach Jejunum Transverse colon Left kidney Omentum Spleen Pancreas Diaphragm Ascending colon Small bowel mesentery Sigmoid and descending colon Ileum Splenic flexure Appendix
12 4 26 2 2 2 2 18 14 14 8 : 4 4 4 2 2 2 2 1 1
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 5
302
There was no venous injury. Four of the vascular cases were hypotensive on arrival, while the remainder had normal blood pressures. Twenty-eight of a total of 31 isolated chest injuries had haemo-, pneumo- or haemopneumothorax, and for these, thoracotomies were carried out in 7 who continued to bleed, while the remainder were treated with chest drains. Sixty patients required blood transfusion (Fig. 3); the largest transfusion (16 units) was given to a patient with a penetrating wound of the left hemidiaphragm, spleen and left kidney. The incidence of complications is shown in Table III. Only 1 patient died; he suffered combined thoracoabdominal injury and refused blood transfusion on religious grounds. The direction of injury was found to be an important preoperative indication as to the site and extent of damage. Of the 58 patients with penetrating wounds of the abdomen, 45 were stabbed by an assailant standing behind them, and these wounds usually followed a downward direction. Thirteen were stabbed from in front and these wounds usually followed an upward direction.
1
2
3
4
of complications Site of injury Chest
Abdomen
Infection
3132 (9%)
8158 (14%)
Mortality
O/32
O/58
Complication
Thoraco-abdominal 2/l 0 (20%)
I/10 (10%)
The number of penetrating stab injuries of the chest and abdomen as a result of civilian violence has been shown to be steadily rising (Fig. 4). DISCUSSION
Penetrating stab injuries were uncommon in the United Kingdom a few years ago. Unfortunately times have now changed, and the surgical personnel in many of our hospitals are finding that deliberate penetrating wounds are on the increase. Roberts and Lavelle’s retrospective
5
Units Fig. 3. Number
Table 111. Incidence
6
7
8
9
10
16
of blood
of units of blood transfused.
No. of cases
76/77 Fig. 4. The increase 1981-1982.
77178
in the number
78179
of penetrating
79180 Year stab injuries
80181 between
81182 1976-1977
and
Lambrianides and Rosin: Stab injuries
303
review from the Birmingham Accident Hospital in 1966 clearly demonstrated an annual increase in the number of such injuries, although the total number of cases over a 6-year period was only 42. The present study, again over a 6-year period, indicates a continuing similar trend with penetrating stab wounds of the chest and abdomen. Of the total number of general surgical admissions to the authors’ hospital between 1976 and 1982, penetrating injuries accounted for 0.8 per cent of the total. During the year 19761977 they formed 0.5 per cent of general surgical admissions, while in 198 l-1982 the figure doubled to 1.0 per cent. Of interest is the fact that 85 of the patients in the present study were unemployed, and 77 were under the influence of alcohol. This is not only a sad reflection on our society, but is also an unnecessary burden in terms of cost to the National Health Service. The rate of exploration of penetrating stab injuries of the chest was 7 per cent. Graham et al. (1979) reported a series of 373 patients with 91 explorations (24 per cent). Griffiths et al. (1978) explored 12 out of 101 patients (11 per cent). Other series include heart wounds and therefore have a higher exploration rate. In principle, there is agreement on the treatment of these injuries. Insertion of a chest drain is sufficient in most cases, but a ‘large’ haemothorax requires exploration. The difficulty is to define ‘large’. In some centres (McNamara et al., 1970), an initial drainage through the chest tube of 1.Oor 1.5 1is sufficient reason for exploration. In our experience the initial drainage is not as important as the subsequent course of events. It must be remembered that evacuation of the blood is very important as adequate expansion of the lung helps to stop bleeding from the lung. Careful observation of the patient is a more reliable indicator of the adequacy of treatment. The rate of bleeding (Kish et al., 1976) is not as important as its effect on the patient. Furthermore, the amount of drainage can be misleading if the drain is not functioning properly. The management of injury of the colon in civilian practice has long been based on military experience. In 1945, Imes recommended primary repair of the colon. In our experience this should be applied to patients in good general condition with simple perforation, minimal peritoneal contamination, recent injuries (preferably less than 4 hours old), no injury to the mesentery and no more than one other injured organ. Injuries of the right colon, for which primary repair is not applicable, may be managed by right hemicolectomy. Exteriorization is preferable if it can be substituted for colostomy, particularly if the injured segment can be mobilized. Primary repair with proximal diversion is recommended in patients with left colonic injuries. The low mortality in the present series could be a reflection of the rapid transportation of the patients to hospital, due to the close proximity of the site of the incident and an effective Requests for reprints should be addressed to: A. L. Lambrianides,
ambulance service. Fifty-five patients arrived within 2 hours of the incident. Other factors contributing to the low mortality were first, the nature of the injuries, as there was a complete lack of high velocity injuries, which disrupt and deform structures that may or may not lie directly in the path of the injury, and second, the use of prophylactic antibiotics. Peritoneal lavage was not employed. There were only 5 negative laparotomies. We feel that the place of diagnostic peritoneal lavage in penetrating stab injuries of the abdomen is not as important as in cases of blunt injury provided that there is no question of altered level of consciousness, with the resultant unreliable physical examination. Diagnostic lavage is an insensitive indicator of retroperitoneal injuries such as pancreatic, duodenal or urological injuries. Moreover, erythrocytes in the lavage return, whether qualitatively or quantitatively measured, are usually the only diagnostic index of value. Leucocytes, bile and pancreatic juice are found infrequently. Local probing of the wound was not employed because it is an inaccurate method of determining the depth of a stab wound and may open false tracks or introduce infection. Peritoneoscopy may play a small role in the diagnosis of penetrating stab injuries but it is associated with complications and usually requires an anaesthetic. The major area of controversy regarding routine or selective laparotomy for abdominal injury is the management of stab wounds. Conservative management may reduce the number of negative findings at exploration, but it carries with it the danger of missing or delaying treatment of an extensive abdominal injury. We believe that exploration of the wound, and a formal laparotomy if any doubt exists, are required.
REFERENCES
Graham J. M., Mattox K. L. and Beall A. C., Jr (1979) Penetrating trauma of the lung. J. Trauma 19, 665. Griffiths G. L., Todd E. P. and McMillin R. D. (1978) Acute traumatic pneumothorax. Ann. Thorac. Surg. 26, 204. Imes P. R. (1945) War surgery of the abdomen. Surg. Gynecol. Obstet. 81, 608. Kish G., Kozloff L., Joseph W. L. et al. (1976) Indications for thoracotomy in the management of chest trauma. Ann. Surg. 22, 23.
McNamara J. J., Messersmith J. K., Dunn R. A. et al. (1970) Thoracic injuries in combat casualties in Vietnam. Ann. Thorac. Surg. 10, 389.
Roberts G. and Lavelle E. (1966) The management of stab wounds to the abdomen and thorax. Br. J. Surg. 53, 88. Paper accepted 21 July 1983.
St Charles Hospital, Exmoor Street, London, W 10 6DZ.