Performance of pre-hospital evaluations in ruling out invasive chest stab wounds

Abstract

Background Some guidelines advocate for managing patients with penetrating thoracic wounds in trauma centres with cardiothoracic surgery. This systematic approach is questionable. Only 15% of these patients require surgery. It is known that clinical examination fails to detect hemopneumothorax in penetrating trauma. However, no studies have evaluated the combined diagnostic performance of vital signs and the clinical evaluation of wounds. The clinical characteristics of wounds have not been investigated. We aimed to evaluate the ability of combinations of pre-hospital signs to rule out invasive chest stab trauma. Methods This was a prospective observational study. All consecutive adult patients hospitalized in the perioperative acute care unit of a tertiary university hospital were included. Injury diagnoses were provided by exploratory surgery and imaging tests. Patients with a final diagnosis of invasive wounds (IWs) and patients with only superficial wounds were compared. Data regarding management and outcome were analysed. Results A total of 153 patients were included. After imaging or surgery, 58 (38%) patients were diagnosed with only superficial wounds, and 95 (62%) were diagnosed with thoracic or abdominal IWs. The false-negative rate of pre-hospital evaluations in the diagnosis of IWs was 42% [31–51]IQR25–75. In stable patients, pre-hospital data could not rule out IWs, with a negative predictive value of 58% and a positive predictive value of 70%. Twenty-nine (19%) patients required early emergent cardiothoracic surgery. Among these patients, 8 (28%) had no evidence of IWs in the pre-hospital period. Among the 59 patients without pre-hospital signs of IWs, 19 (33%) underwent at least one emergent procedure. Conclusions The combination of pre-hospital vital signs, visual evaluation of wounds, and physical examination failed to rule out IWs in patients with chest stab wounds. This implies that caution is needed in triage decision-making.

The contribution of helicopter emergency medical services in the pre-hospital care of penetrating torso injuries in a semi-rural setting

“…A certain degree of over-triage of patients initially presenting without significant hemodynamic- or ventilatory compromise by HEMS teams in this respect, is almost inevitable. Previous studies have demonstrated that the accuracy of clinical examination to establish the degree of bleeding and potential for internal damage after penetrating injury is poor [ 14 , 27 , 28 ]. Our clinical judgement in these patients is often obscured, as the scene of the incident is often not witnessed (making it hard to estimate the amount of blood loss), and the physiological response to blood loss in the patients may differ from non-penetrating injuries.…”

“…Especially with peritoneal breeching, relative bradycardia may be present, obscuring the normal baroreceptor response. Therefore, all torso stab wounds should be considered as invasive until imaging is complete [ 14 ] and HEMS teams should have a low threshold to escort these patients to hospital, irrespective of their physiological state. However, given the small proportion of hemodynamically stable patients who need a HEMS intervention, the clinical team must perform a risk assessment, to include potential for clinical deterioration.…”

“…Previous research has demonstrated that clinical examination alone is a poor predictor of both severity and depth of penetrating injuries [ 14 , 15 ]. Therefore, in this study we aim to describe the patient demographics and clinical interventions required in patients with penetrating torso injuries treated by a semi-rural HEMS service.…”

Complications associated with pre-hospital open thoracostomies: a rapid review

“…Injury to any of these can place a person at immediate threat of severe disability or death, making chest trauma a well-acquainted adversary of emergency pre-hospital care providers. Even though significant chest injuries are associated with adverse outcomes, they can manifest late and have proven difficult to identify on clinical examination [ 2 , 3 ]. Leech et al [ 4 ] list closed tension pneumothorax (T-PTX) as the most common severe pathology in major chest trauma (1 in 250), a condition where air is increasingly introduced to the pleural space without an ability to escape [ 1 ].…”

Development of a field artificial intelligence triage tool: Confidence in the prediction of shock, transfusion, and definitive surgical therapy in patients with truncal gunshot wounds

“…1,2 Despite implementation of these protocols, rates of overtriage, to transfer a patient to a center with higher-than-necessary level, and undertriage, to transfer a patient to a lower-than-necessary trauma center level, are found to exceed 35% and 5%, respectively. [3][4][5][6][7][8] Appropriate and timely triage is crucial, as undertriage is associated with poor survival and overtriage poses a preventable burden to healthcare infrastructure. [8][9][10] The limited availability of information in the field may negatively impact the accuracy of triage decisions.…”