Point of care ultrasound and sub-xiphoid window reduce uncertainty in the management of potential dual-cavity injuries in patients with torso stab wounds

Jim Hsu-Shun Wang; Victor Kong; Jonathan Ko; Jonah Qi; John Bruce; Grant Laing; Damian Clarke

doi:10.1016/j.injury.2024.111565

Point of care ultrasound and sub-xiphoid window reduce uncertainty in the management of potential dual-cavity injuries in patients with torso stab wounds

Injury. 2024 Apr 15:111565. doi: 10.1016/j.injury.2024.111565. Online ahead of print.

Authors

Jim Hsu-Shun Wang¹, Victor Kong², Jonathan Ko³, Jonah Qi³, John Bruce⁴, Grant Laing⁴, Damian Clarke⁴

Affiliations

¹ Department of Surgery, University of Auckland School of Medicine, 85 Park Road, Grafton, Auckland, New Zealand. Electronic address: jim.hs.wang@gmail.com.
² Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa.
³ Department of Surgery, University of Auckland School of Medicine, 85 Park Road, Grafton, Auckland, New Zealand.
⁴ Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.

PMID: 38670872
DOI: 10.1016/j.injury.2024.111565

Abstract

Introduction: This paper reviews our experiences with the management of patients with torso stab wounds and potential injuries in both the chest and abdomen over the last decade. The aim of the project is to clarify our approach and provide an evidence base for clinical algorithms. We hypothesize that there is room for our clinical algorithms to be further refined in order to address the diverse, life threatening injuries that can result from stab wounds to the torso.

Methods: Patients with one or more torso stab wounds, and a potential injury in both the chest and the abdomen were identified from a local database for the period December 2012 to December 2020.

Results: A total of 899 patients were identified. The mean age was 29 years (SD = 9) and 93% of patients were male. Amongst all patients, 686 (76%) underwent plain radiography, 207 (23%) a point of care ultrasound assessment, and 171 (19%) a CT scan. Following initial resuscitation, assessment and investigation, a total of 527 (59%) patients proceeded to surgery. A total of 185 patients (35%) underwent a semi elective diagnostic laparoscopy to exclude an occult diaphragm injury. Of the 342 who underwent an emergency operation, 9 patients (1%) required thoracotomy or sternotomy exclusively, 299 patients (33%) required a laparotomy exclusively and 34 patients (4%) underwent some form of dual cavity exploration. In total, there were 16 deaths, a mortality rate of 2%. The use of laparoscopy, point of care ultrasound and subxiphoid pericardial window increased over the period of this study.

Conclusions: Patients with torso stab wounds and potential injuries above and below the diaphragm are challenging to manage. The highly structured clinical algorithm of the ATLS course should be complemented by the use of point of care ultrasound and sub-xiphoid window to assess the pericardium. These adjuncts reduce the likelihood of negative exploration and incorrect operative sequencing.

Keywords: ATLS; Double jeopardy; Dual cavity, torso; Subxiphoid pericardial window; Thoracoabdominal stab wounds; Trauma surgery; Ultrasound.