Head trauma s/p knife assault


• Scene – Full spinal immobilization with a cervical collar and long backboard (LBB), trauma system activation
• En route – 18g IV, 8mg Zofran, 2nd exam
• Hospital – CT, evaluation


• Response to treatment – Nausea improved somewhat w/ Zofran; patient vomited 2x between ambulance and hospital door.
• Disposition – Patient was diagnosed with concussion and discharged.
• Notes:
• Patients story about what happened changed from when we were on scene to when we were in the medic, and again when we were at the hospital. The thinking is this was because patient did not want to get attackers in trouble.
• People who witnessed event confirmed that a knife was used in assault.


• Elliot Williams, Paramedic Woodburn Ambulance
• David Jones, MD Associate Professor Oregon Health and Science University
• Vladamir Novikov, Paramedic Woodburn Ambulance


• David M. Spiro, MD, MPH Professor of Pediatrics University of Arkansas Medical Center
• Mohamud Daya, MD Professor Oregon Health & Science University

• Head trauma
• Knife wound
• Head laceration

Differential Diagnosis

• Head trauma
• Thoracic trauma
• Stab wounds
• Early hemorrhagic shock
• Assorted other injuries

Patient Workup

• Patient states he was involved in altercation with people he knew. He was fighting off someone with a knife, may have been stabbed or cut on the face, states that he also fell while attempting to run away and was hit multiple times.

Physical Exam

• Patient rubbed dirt and dry grass into head wound prior to EMS arrival
• BAC: 0.045
• GCS – 15
• EKG – Sinus tachycardia
• Hematoma, laceration and abrasion on right face and eyebrow
• Abrasion to right chest
• Abrasion to right arm
• Abrasion to right hand
• Abrasion to left knee
• Avulsion/laceration to toe on left foot
• No trauma to mouth or teeth
• Abdomen is grossly atraumatic
• No neck or back tenderness or deformities
• No numbness or tingling
• Lungs clear

Editor’s Notes

Scene safety is paramount when responding to assault calls. Your first priority is determining the location of the assailant(s) and weapon. If you can’t be sure, do not enter the scene until law enforcement have arrived and stabilized the scene.
As written on EMSWorld, “The National Association of Emergency Medical Technicians (NAEMT) found four in five medics have experienced some form of injury as a result of the job. The majority, 52%, claimed to have been injured by assault. More than 20% ranked personal safety as a primary concern.” – Dr. David Spiro
Read more in EMS World’s article: Violence Against EMS Providers: What can we do about it

Standard Approach

• Ensure scene safety before approaching the patient. In the case of an assault like this, police should be present and clear the scene before EMS approaches. Ideally, one should stage away from the scene.
• Approach every trauma patient the same way. The primary survey should focus on the following:
• Assess airway. Intervene as needed with jaw thrust, oral or nasopharyngeal (should not be used with maxillofacial trauma) airway or advanced airway, such as a supraglottic tube or endotracheal tube.
• Assess breathing by looking at chest movement and listening to lung sounds. Provide oxygen as needed. Consider needle decompression of the chest if there is concern for tension pneumothorax based on the presentation and clinical circumstance (decreased saturations, unilaterally diminished lung sounds, perfusion failure).
• Assess circulation. Establish IV access and consider IV fluids if there is evidence of perfusion failure.
• Assess for neurological deficits. Immobilize the spine when there is a concern for injury but the patient cannot be assessed – e.g., due to the presence of alcohol, drugs or other distracting injuries/circumstances. Check neurological status before and after spinal immobilization or with any patient movement.
• Expose as much of the patient as possible and search for occult injuries, especially with penetrating trauma. Always search for multiple wounds in assault victims.
• Be very suspicious of people who are intoxicated. They can hide severe injuries due to the alcohol on board.
• For isolated penetrating head, neck, or torso trauma, immobilization of the cervical spine is unnecessary unless:
• there is a neurologic deficit, or
• an adequate physical examination cannot be performed, e.g. in a patient with altered mental status or a patient with a distracting injury
• Stab wounds that seem benign can cause significant internal bleeding. A patient can lose enough blood to die if they are bleeding into the chest, abdomen, retroperitoneum (pelvis and back) or thighs.
• If there is obvious bleeding, apply a pressure dressing or pack the wound, if feasible. If bleeding continues, consider the use of a tourniquet, depending on the location of the injury.
• Evidence shows that traumatically injured patients have better outcomes when managed at designated trauma centers than at community hospitals.

Suggested References

Violence Against EMS Providers: What can we do about it
Tourniquet use for peripheral vascular injuries in the civilian setting


• Gender: Male
• Age: 37 years
• Height: Not Available


• Temperature: Not Available
• Blood Pressure: 142/78
• Heart Rate: 117
• Respiratory Rate: 20
• Pulse Oximetry: 100% RA
Signs and Symptoms
Bleeding; laceration; multiple abrasions


• PMH: Not obtained
• Dispatch info: Male bleeding from face. PD requesting Code 3 (lights and sirens) medics.


• Not obtained


• None

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