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Evaluation of stabbing assault injuries in a tertiary emergency department: a retrospective observational study

BMC Emergency Medicine volume 24, Article number: 168 (2024) Cite this article

Abstract

Background

Approximately 458,000 victims were deceased from intentional violence in 2021. A stabbing assault causes 25% of homicides. The study aims to evaluate injury patterns, trauma scores, radiological findings, types of treatment, and outcomes of stab assault patients admitted to a tertiary emergency department (ED).

Methods

This is a retrospective observational study of stabbing injury patients in the ED of Hacettepe University, Turkey. The sites and patterns of injury, radiological findings, treatment methods, consultations, and complications are acquired from the patient’s files. Trauma scores and frequency of outcomes, such as the need for surgery, hospitalization, or mortality, were calculated for all patients.

Results

Among the 648 patients, 564 (87%) were male. The median age was 28 (interquartile range [IQR]:13). The commonly injured body parts were the extremities (75%), thorax (21.9%), and abdomen (16.9%). The median RTS was 7,84 (IQR:0), and the median ISS was 2 (IQR:3). The fluid was detected in 13 of 88 patients by FAST, solid organ injuries in 21 patients, and gastric and intestinal injuries in 11 patients by abdominal CT. One hundred sixty-one patients underwent moderate and major surgery. Complications developed in 13 patients. 74,4% of the patients (n = 482) were treated in ED and 21.8% (n = 141) of patients were hospitalized in wards, 2.3% (n = 15) in intensive care unit and 1.5% (n = 10) patients died. GCS, RTS, and probability of survival (Ps) were significantly lower, and ISS was significantly higher in deceased patients and patients who needed erythrocyte replacement.

Conclusion

The majority of stab wounds were detected in extremities, but severe and lethal stabbing injuries were on the thorax and abdomen. In thoracoabdominal stabbing injuries, x-rays and FAST can be ineffective in detecting critical and fatal injuries. Therefore, thoracic and abdominal CT should be planned early to detect possible causes of death and make a timely and accurate diagnosis. Lower GCS, RTS, and Ps or higher ISS scores were related to the need for erythrocyte replacement.

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Background

Trauma is the leading cause of death in healthy young adults aged 5–29 years. The most common factors that cause death are traffic accidents, falls from height, gunshot wounds, and penetrating or stab wounds [1]. In 2021 approximately 458,000 victims were deceased from intentional violence. A stabbing assault causes 25% of homicides [2].

Stab trauma by a sharp object (knives, arrows) is classified as a low-velocity wound, and damage is related to depth and angle of attack. The importance of penetrating injuries varies according to the body part, and findings of some penetrating injuries may be initially obscured. Many of these patients could spend the golden hours of trauma in the admission process. Therefore, early evaluation and intervention in patients with penetrating injuries are crucial. This study aimed to evaluate injury patterns of patients admitted to the emergency department with stab wounds, results of the imaging studies, treatment modalities, outcomes, trauma scores, mortality ratios, and complications.

Methods

Study type and design

This retrospective observational study was conducted as a 10-year survey on 648 patients with stabbing assault admitted to Hacettepe University Emergency Department (ED), Turkey. The hospital is in a city with approximately 5,5 million population and contains all radiological facilities and surgical specialties.

All patients with stabbing assault injuries admitted to ED were reviewed. The data were derived from patient files. Patients under 18 or self-injured were excluded from the study. Demographic features of the patients, the mechanism of injury, results of computed tomography and extended focused assessment with sonography for trauma (FAST), modality of treatment (surgical intervention/suturing/follow up), consultations, hospitalization ratio, length of stay, and complication rate in one month and type were evaluated from the patient’s files. The Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Injury Severity Score (ISS), and Probability of survival (Ps) derived from Trauma and Injury Severity Score (TRISS) were calculated for all patients.

Data analysis and ethical issue

Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) version 21 for Windows, and p < 0.05 was considered significant. The mean values were used, and an independent t-test was applied in normally distributed variants. Median and interquartile range (IQR) values were used, and the Mann-Whitney U test was applied in non-normally distributed variants. The relations of categorical variants were evaluated with a Chi-Square test.

Results

Seven hundred sixty-eight patients were examined for the study. Eighty-six patients with self-injury and 34 patients under 18 years old were excluded from the study. (Fig. 1) 564 (87%) of the 648 patients in the study were male. The median age was 28 (IQR:13) years. The most common mechanism was stabbing injuries with a knife (n = 348, 54%). When the injuries were ranked according to their location in the body, the most common injuries were detected in the upper extremities (n = 301, 46.5%), while the remaining injuries were in the lower extremities (n = 185, 28.5%), thorax (n = 142, 21,9%), head and neck (n = 107, 16,5%) and abdomen (n = 106, 16,9%) and genital area (n = 3, 0.5%). On admission, hypotension in 57 (8.8%) patients and tachycardia in 168 (26%) patients were detected. (Table 1) Four patients were hypotensive and tachycardic on admission, systolic/diastolic blood pressures could not be measured in 16 patients, and seven patients had cardiac arrest on admission. The median GCS score was 15 (IQR:0). The Glasgow Coma Scale score was lower than 13 in 14 (2.3%) patients. The median RTS was 7.84 (IQR:0). The median ISS was 2(IQR:3). The median Ps was 99.4% (IQR:0.28).

Fig. 1
figure 1

Flow chart of the study

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Table 1 Characteristics of patients
Full size table

FAST was performed on 88 patients, and fluid was detected in 13. The fluid was detected mostly in the perihepatic region (n = 6). Other areas in which the fluid was detected were the pelvis (n = 5), perisplenic region (n = 5), hemithorax (n = 4), pericardium (n = 3), and perirenal region (n = 1). Abdominal computed tomography (CT) was performed in 77 patients. Intra-abdominal solid organ injury in 17 and bowel injury in 10 patients were seen. Abdominal CT was superior to FAST in detecting intra-abdominal injury (p < 0.001). Thorax CT was performed in 58 patients, and pneumothorax, hemothorax, and lung or pericardium injuries were detected in 30 of them. Cranial CT was performed in 24 patients, and significant intracranial injuries were detected in 3 patients. Maxillo-facial CT was performed on four patients, and no pathological finding was found except soft tissue injury. Cervical CT was performed in 8 patients, and cervical vertebra injuries were detected in 3. Extremity CT angiography was performed in 7 patients, and vascular injuries were seen in 3. The findings of the diagnostic imaging are summarized in Table 2.

Table 2 Injury area and imaging studies
Full size table

Patients were mainly consulted for plastic surgery (32.9%), thoracic-cardiovascular surgery (21.8%), general surgery (18.8%), and orthopedics (6.6%), respectively. One hundred sixty-one patients (24.8%) underwent surgical treatment, local wound care and suturing were performed in 114 (17.6%) by the consulted department, and tube thoracostomy was performed in 29 (4.5%) patients. The consulted departments and the procedures are summarized in Table 3.

Table 3 Consulted departments and interventions
Full size table

Among the 648 patients in the study, blood transfusions were performed in 48 (7.4%) of them. In patients who needed erythrocyte replacement, ISS and RTS were significantly higher (p < 0.01), and Ps and GCS were found to be significantly lower (p < 0.01).

482 (74.4%) patients were treated and discharged from ED. 141 (21.8%) patients were hospitalized and discharged from various in-patient wards, 15 (2.3%) patients were hospitalized in the intensive care unit (ICU), and 10 (1.5%) patients died in ED. The average length of stay in the hospital was 30 h. The average lengths of stay in the ED, in-patient wards, and the ICU were 7 h, 133 h, and 81 h, respectively.

Of the patients that died, four patients had isolated severe thoracic injuries, two patients had thoracic injuries with abdominal injuries, one patient had thoracic injuries with the abdomen and head&neck injuries, one patient had thoracic injuries with lower extremity injuries, one patient had thoracic injuries with upper- extremity injuries, and one patient had lower extremity injuries (femoral artery laceration). Seven patients were brought to the ED in cardiopulmonary arrest. Thoracotomy could not be applied to these seven patients. The patients’ outcomes and trauma scores are summarized in Table 4.

Table 4 Outcome and trauma scores
Full size table

Complications, such as replantation failure, microcirculation disorder, motor dysfunction, wound infection, suture reaction, suture opening, and Richter hernia, developed in 13 (2%) patients. The most frequent complication was peripheral nervous system injury (motor dysfunction) seen in 4 patients.

Discussion

Trauma is one of the leading causes of death between the ages of 5 and 29 [1]. Penetrating trauma cases is increasing nowadays in parallel with the increase in violence [3]. Injuries due to sharp tools constitute a significant majority of patients in emergency services, which may cause serious health problems in society. Our study aims to examine the results of stab injuries, trauma scores, treatment, and outcomes.

Penetrating injuries are more common in men and young-middle age groups, up to 90% [4,5,6,7]. As in other studies in the literature, the majority of the cases (87%) in our study were male patients, and the median age was 28 years for males and 27 years for females. Regarding injury sites, the extremities are most frequently affected in stab injuries, while the thorax, abdomen, and head and neck regions are less frequently affected, respectively [6, 7]. Similarly, our study found the extremities to be the most common injury site. This was followed by thorax, abdomen, and head and neck injuries.

Even though mortality increases with higher scores of ISS, as proposed in 1974, the predictive value of ISS for blood transfusion requirements remained unclear [8]. In many studies, there has been a correlation between ISS and blood transfusion [9,10,11]. As the ISS increases, the need for blood transfusion will also increase [12]. Furthermore, Komori et al. and Reppucci et al. said a decrease in GCS will increase the need for blood transfusion in childhood trauma [13, 14]. Like in the other trauma scoring system, as RTS decreases, blood transfusion rates, even massive transfusion protocol, increase [15]. In our study, while ISS values were significantly higher, Ps, RTS, and GCS values were significantly lower in patients undergoing blood transfusion. Although all trauma scoring systems have a good mortality predictive value, Ps -as TRISS in original research- was selected as the most efficient scale for predicting mortality [16, 17]. Parallel to the literature, Ps and RTS were lower in deceased patients in our study.

FAST ultrasonography is a quick, cost-effective imaging method used in trauma patients [18]. The sensitivity and specificity of FAST ultrasonography are quite high [19, 20]. Similar to the study of Smith et al., our study found that the number of patients who underwent FAST increased significantly in the last 3–4 years [20]. This shows that FAST imaging is performed more frequently by emergency physicians. FAST ultrasonography, performed after a primary survey and combined with physical examination, provides an opportunity for early diagnosis in patients without vital sign changes. A positive finding is useful. However, it is inadequate to exclude all significant injuries, and in a stable patient, more definitive imaging may be appropriate before deciding on intervention.

CT is a practical and required method for evaluating stabbing injuries [21]. CT imaging is one of the most critical facilities for managing trauma patients. The short processing time and ability to provide clear and high-quality images are among the most important advantages of CT imaging. In some examinations, high radiation dosage and opaque substances can be considered disadvantages of CT imaging. In our study, soft tissue injury, cranial fracture, intracranial bleeding, and pneumocephalus were the most common findings in brain CT of the patients. The neck region contains vital structures such as major vessels, the spinal canal, and the trachea, so stabbing trauma in the neck requires careful examination. Therefore, CT angiography is often preferred in penetrating neck injuries and is used as an initial diagnostic method for carotid arterial injuries [22]. In the present study, the most common findings in cervical CT were soft tissue injuries and cervical fractures. Thoracic CT provides detailed information about lung, heart, major vascular structures, and diaphragm injuries in penetrating thoracic injuries. Hemothorax, pneumothorax, and rib fractures are the main pathologies detected in many patients who underwent thoracic CT, as in the study [23]. Although FAST provides rapid data on intra-abdominal injuries in stabbing injuries, it is insufficient to detect retroperitoneal, luminal organ, and diaphragm injuries [24]. Therefore, abdominal CT requests should be planned early in cases with stabbing injuries to the abdomen. Using extremity CTs in stabbing traumas provides a great advantage, especially in detecting vascular injuries. Extremity CT is a non-invasive imaging method with high sensitivity and rapid application in detecting vascular injuries [25,26,27]. In our study, vascular injury was observed in 3 of 7 patients with extremity injuries by extremity CT.

Treatment of stab wounds may differ depending on the trauma’s location, size, and severity. However, most patients are discharged with primary suturing [7, 28]. In our study, in parallel with the literature, the majority of the patients were treated with simple treatments such as primary suturing and dressing, including suturing by consulted departments in the emergency room.

Surgery is frequently applied to patients admitted to the emergency department with stab wounds. Surgery is needed for diagnostic or therapeutic purposes, especially in trunk and neck injuries [4, 7, 29]. In our study, 25% of the patients required surgery. The most common surgical procedures were performed by Plastic and Reconstructive Surgery, General Surgery, and Thoracic Surgery, respectively.

The most common complications in stab injuries after discharge are wound infections, followed by other potentially fatal complications [30]. In the present study, complications developed in 13 patients. Examination of the outcome of the patients shows that the majority of patients with penetrating trauma are discharged after their treatment in the emergency department as in the other studies [31], and the mortality rate due to penetrating stab injury is less than 10% in most studies [4, 6]. In our study, while most patients were discharged from the emergency department, the mortality rate associated with penetrating stab injury was 1.5%. Most of the deceased patients were brought to the emergency department for cardiac arrest.

Limitations

Since this study was planned as a retrospective study in a single center, the data are limited to patient records. Complications might be overlooked in the period after discharge. The population size could be more significant.

Conclusion

In our study, the majority of stab wounds were detected in extremities, but severe and lethal stabbing injuries were on the thorax and abdomen. In thoracoabdominal stabbing injuries, x-rays and FAST can be ineffective in detecting critical and fatal injuries. Therefore, although patients are hemodynamically stable, thoracic and abdominal CT should be planned early to detect possible causes of death and make a timely and accurate diagnosis. Lower GCS, RTS, and Ps or higher ISS scores were related to the need for erythrocyte replacement.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due the patients’ files were derived from archives of Hacettepe University but are available from the corresponding author on reasonable request.

Abbreviations

GCS:

Glasgow Coma Scale

RTS:

Revised Trauma Score

ISS:

Injury Severity Score

TRISS:

Trauma and Injury Severity Score

SPSS:

Statistical Package for Social Sciences

FAST:

Focused Assessment with Sonography for Trauma

CT:

Computed Tomography

ED:

emergency department

ICU:

intensive care unit

Ps:

Probability of survival

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Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Vocational School of Health Services, First and Emergency Aid Program, Hacettepe University, Ankara, Turkey

    Nil Deniz Kartal Yeter

  2. Faculty of Medicine, Department of Emergency Medicine, Hacettepe University, Ankara, Turkey

    Mehmet Ali Karaca, Elif Öztürk İnce & Bülent Erbil

  3. Emergency Service, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey

    Ahmet Sefa Yeter

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  1. Nil Deniz Kartal Yeter
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Contributions

NDKY and MAK have set up the main idea and hypothesis of the study. NDKY and MAK developed the theory and organized the material and method section. EOİ and BE evaluated the data given in the conclusion. NDYK and ASY wrote the discussion part of the article, after MAK reviewed it, made necessary regulations, and approved it. All authors discussed the entire study and approved the final version of the manuscript.

Corresponding author

Correspondence to Nil Deniz Kartal Yeter.

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Ethics approval and consent to participate

Ethics Committee approval was obtained before the study to derivate the patient files from the Ethics Committee of Hacettepe University. (GO 141 49 − 45). The need for consent to participate was also waived by the ethics committee.

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Not Applicable.

Competing interests

The authors declare no competing interests.

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Kartal Yeter, N.D., Karaca, M.A., Yeter, A.S. et al. Evaluation of stabbing assault injuries in a tertiary emergency department: a retrospective observational study. BMC Emerg Med 24, 168 (2024). https://doi.org/10.1186/s12873-024-01077-9

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BMC Emergency Medicine

ISSN: 1471-227X

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