Clinical Case 014: “That’s not a knife….”

So this is a typical Broome case.  As always – I will not sugar-coat it for you , just a blow by blow description of how it rolled out. Oh, and this one has a happy ending

30 yo. woman presented via ambulance after being stabbed in the left chest (through the axillary tail of her breast).  Seen at 3AM, primary survey all OK, a bit drunk though.  Secondary survey – single stab wound only, explored under local – could not see any penetration through the intercostals, though difficult to say clinically. portable CXR = no pneumothorax, no effusion. No FAST scan done.  Admitted to the ward for observation, IV fluids and surgical RV in AM.  Obs were not normal, but steady overnight.  Hb 134 g/l on gas.

The next AM, complaining of abdo pain, now some shoulder tip pain on the left.  Repeat formal CXR – no PTX, small effusion left costophrenic angle.  I was on for anaesthetics – so called for pre-op review to explore the wound further.  P= 120/min, BP = 110/50, RR = 25/min, feeling sick / vomited.  Hmmm…. not good

I decided to put in a big IV and send bloods for repeat Hb, VBG, cross match etc…the surgeons opted for a CT to look into the cause of the abdo pain – ? occult visceral injury.  So off to the “doughnut of death”

So the VBG comes back: lactate is 4.2 So – something is up, not perfusing her organs as one might hope.  Meanwhile in CT they have found a large amount of blood in the left upper quadrant, a small left chest effusion but no clear source for the bleeding ? spleen.  Clearly she needs some volume resuscitation – the plan is “Haemostatic Resuscitation“, check out the link for an awesome lecture on this topic.  Bottom line – lots of salty water is a bad thing for a bleeding patient, you gotta give some red stuff and products.

So without further ado we whiz her off to OT for a laparotomy, she does pretty well on induction / RSI, art line, central line, IDC and so on.  We now get the formal Hb back – it is 59 g/l (Doh! not good) and we start the packed-cells.  I called for some FFP to give and well – we don’t have platelets.  Of course the lab want us to document ‘coagulaopathy’ before thawing the FFP.  This is one of my pet peeves – in the 60 minutes they take to thaw the FFP, we will likely be in the deep end of ‘coagulopathy’.  Can’t they just trust me, we need some FFP! (See Emcrit podcast on Massive transfusion for details)  My guess was we were dealing with a concurrent blunt trauma to the spleen.

Well, there was a hole in the diaphragm, about an inch lateral to the left ventricle, this wound continued through the following structures: left lobe of liver, lesser omentum (the source of the ongoing bleed), pancreas and just stopped short of the renal vein/artery. The spleen was intact!

At this point I started to get a bit nervous – I had been ventilating the patient for an hour and was starting to think – there must be a lung injury here, is she gonna blow a pneumothorax?  So what to do?  I got out the USS and took some intercostal views to look for a PTX.  None to be seen.

USS has been shown to be more sensitive and specific than supine CXR in trauma – see this review of the literature

So they got control of the bleeding and we got our PRBCs and FFP in and by the time we were closing she had a Hb of 100 and was peeing like a trooper.  We decided to fly her out – the pancreas injury is not one we wanted to “observe” in our little hospital – if she got sick from this we would be in a lot of trouble.  On follow-up all was well – no further surgery required.

The local con’stab’ulary popped in later to say they had found a very long, fishing knife at the scene – my estimate was that it had to be 40cm from the skin wound to the pancreas!


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