Stab Wounds is the second part of Doom and Bloom Medical’s bleeding management series. See the original article at Doom and Bloom Medical for more photos related to the article. See part one of the series here.
Any disaster can put your people at risk for injury. Many of those injuries cause bleeding, and, depending on the area damaged, a few can be life-threatening. In survival, a lot of activities involve the use of sharp objects. In this article, we’ll discuss how to deal with hemorrhage from knife wounds.
You could define a classic stab wound as a laceration where the puncture on the skin is smaller than the depth of penetration into the body. This is in contrast to a slash injury, which is generally longer on the skin than deep. Stab wounds tend to enter in line with the long axis of the knife, while slashes don’t.
These types of wounds are a type of penetrating trauma, which is further divided into two types: perforating and non-perforating. A perforating wound is one in which the object causing the damage goes in one side of the body and then exits through the other side. A wound from a .223 round or NATO .556 would be a good example of perforating trauma.
Stab wounds are an example of a non-perforating wound: the projectile causing the damage enters the body and either stays there or exits where it entered. There are some sharp instruments that could possibly do perforate: A crossbow bolt, for example, or a spearhead, but let’s assume these will be less common than knife wounds, even in a survival setting.
Bullets and other high-speed projectiles cause damage not only from the act of penetration, but also the shock wave produced as the bullet passes through the body at high speed. Low speed projectiles such as knives don’t produce much of a shock wave, so your concerns are mostly related to the area of entry and the structures located directly in the path of the offending instrument.
With stab wounds, blood loss will be the major issue. Your immediate action upon encountering a victim with a wound from a sharp instrument may save their life. The heart takes less than one minute to pump blood to the entire body; if the circulatory system is breached, arterial blood loss can become life-threatening very quickly.
Average-sized adult males have approximately 9-10 pints (about 5 liters) of blood in their body. Athletes and those living at very high altitudes may have more. You can’t afford to lose more than 40% of total blood volume without needing major resuscitation. To get an idea of how much blood this is, empty a 2-liter bottle of any liquid on the floor. It’s an eye opener. Imagine how much of your supply of bandages might be expended from just one major bleed.
HOW TO HANDLE A STAB WOUND
If you’re attending to an actively bleeding wound from a sharp object, you’ll need a level head and quick action. In normal times, of course, contact emergency services immediately.
In the meantime, follow these steps:
-Assess the safety of the situation. Make sure there is no active threat. it makes no sense for you to become the next casualty.
-Put on gloves if possible. Your hands are full of bacteria and you’ll reduce the risk of infection by doing so. If no gloves are available, any barrier or, at least, hand sanitizers will be useful if you have to touch the wound with bare hands (let’s face it, though; you might not have the time if the bleeding is that heavy).
-Verify the victim’s breathing and mental status. Clear airways if obstructed. Determine if the person is alert enough to follow commands.
-In a non-combat setting, remove clothing or otherwise fully expose the area and identify other injuries. Make sure that you have a bandage scissors or EMT shears in your medical pack.
-Apply pressure with some type of dressing, even your shirt if that’s all you have. Most non-arterial bleeding will stop with firm direct pressure on the wound. If the sharp instrument is still in place in the victim and help is on the way, place pressure down on either side towards the blade to prevent it from slipping out. The knife may actually be providing pressure on damaged vessels. Stabilize the wound with the weapon in place with ample dressings on either side and gauze or elastic rolls to secure. An example is seen below.
-If one dressing doesn’t work and you don’t have specialized blood-clotting materials (called “hemostatics”), place additional dressings on top of the first.
-Elevate the feet above the level of the heart and head (the “shock position”) to increase blood flow to the heart and brain. If the wound is to the abdomen, however, bend the knees instead.
-Lift an injured extremity above the level of the heart. Make it more difficult to pump blood out of the body.
-If direct pressure fails, apply a tourniquet to stop the bleeding. Our experience in Iraq and Afghanistan shows that tourniquets save lives in cases of severe or arterial hemorrhage. As a matter of fact, if the bleeding is obviously arterial (bright red blood spurting out of the wound), using a tourniquet should be your FIRST course of action.
-If you’re transporting a patient to a modern medical facility, make sure you mark a “T” on the victim’s forehead or otherwise notify emergency personnel of the location and length of time that the tourniquet’s been in place.
-I mentioned hemostatics earlier. In cases of heavy bleeding, the use of special blood clotting materials such as Quikclot, Celox, or ChitoSam is a life saver. We put these products in all our medical packs, even the smaller individual first aid kits. In this case, you would remove the blood-soaked bandages and place a hemostatic gauze directly on the bleeding vessel with pressure for 3 full minutes.
-Secure everything with a pressure dressing, of which there are various on the market. The Israeli Battle Dressing, known as The Emergency Bandage in the U.S., can apply up to 30 pounds of pressure if used properly.
-Keep the victim warm: Throw a mylar blanket or other cover over them. If help is coming, keep them as still and calm as possible to avoid further bleeding. Monitor breathing, pulses, and mental status. An unconscious patient should be placed, if possible, in the “recovery position”. This will, among other things, allow fluid to drain from airways and help them breathe.
Let’s say you placed a tourniquet successfully and there’s no help coming. Ever. You’re the end of the line when it comes to medical care for this victim. If a tourniquet is on, should you loosen it from time to time? You may be tempted to do this, but don’t: It can cause further bleeding.
That doesn’t mean you can leave the victim, now your patient, with a tourniquet on and a knife sticking out of them forever. Carefully transport them to a more controlled setting where you have the bulk of your medical supplies and remove the knife. Yes, I said remove the knife, there’s no hospital, no trauma surgeon, just you. You may have to place a second tourniquet above the first one if bleeding returns. You goal is to transition the patient from the tourniquet within, say, 2 hours or so, to a hemostatic gauze and a pressure bandage.
Once the bleeding is under control, clean the wound thoroughly and dress it. Remove hemostatic materials within 24 hours. Wound closure may be an option in some cases, but most back-country stab wounds will be dirty and should be left open. You’ll find daily wound care described in other articles on this website.
All of the above may not be necessary if you practice preventative measures. In other words, insist your people wear hand and eye protection when using sharp instruments, and don’t run with scissors. With some foresight, you may be able to avoid a mishap that could turn into a tragedy.
Joe Alton MD