European Journal of Cardiovascular Medicine

Assault-related penetrating injuries continue to present significant clinical and medico-legal challenges in India. Such injuries typically follow a predictable chronological pathway beginning with the mechanism of assault, followed by prehospital delay, arrival to casualty, and initial hemodynamic assessment (1,2). In the present series, all four patients arrived at the Trauma Care Center (TCC), GIMS Kalaburagi, within hours of the assault events, often brought by family or bystanders. Two patients were under alcohol influence, a known factor contributing to altered sensorium and delayed self-reporting (3). The next chronological stage observed was the primary survey, where tachycardia, hypotension, active bleeding, or respiratory compromise were noted. This aligns with ATLS guidelines emphasizing rapid identification of life-threatening issues (4). Immediately afterward, the secondary survey revealed penetrating stab wounds to the chest, abdomen, and back, with visible omental herniation or muscular bleeding in some cases. Following stabilization, each patient underwent early diagnostic imaging—primarily CECT abdomen, ultrasonography, and chest radiography—allowing identification of liver lacerations, diaphragmatic rupture, mesenteric tears, duodenal perforations, pneumothorax, or haemothorax (5–7). This imaging-to-surgery transition is a critical chronological turning point in penetrating trauma care. The chronology progressed to emergency operative decision-making, with all four patients taken for exploratory laparotomy within hours of admission. Such early intervention is frequently associated with better outcomes, especially for high-grade abdominal injuries (8,9). This case series presents four patients with grievous assault-related stab injuries managed at the Trauma Care Centre, Gulbarga Institute of Medical Sciences (GIMS), Kalaburagi. The report highlights their clinical presentations, radiological findings, operative management, postoperative course, complications, and recovery outcomes, thereby contributing practical insights into managing complex penetrating trauma in a tertiary care setting.

This study is a retrospective case series conducted at the Trauma Care Center (TCC) of Gulbarga Institute of Medical Sciences (GIMS), Kalaburagi, Karnataka. The analysis included four consecutive medico-legal assault cases presenting with penetrating stab injuries between March 2025 and April 2025. All patients who sustained grievous injuries requiring surgical intervention or critical care monitoring were eligible for inclusion. Cases involving blunt trauma, road traffic accidents, or incomplete clinical documentation were excluded. Data were extracted from hospital case sheets, emergency department registers, radiology reports, operative notes, and SICU monitoring charts. The variables collected included demographic details, circumstances of injury, vital signs at presentation, wound characteristics, radiological findings (CECT abdomen, chest radiograph, ultrasonography), intraoperative observations, procedures performed, blood transfusion requirements, postoperative complications, and length of hospital stay. Imaging findings were interpreted by radiologists on duty as part of routine clinical care. All patients were managed according to institutional protocol, which included initial resuscitation based on Advanced Trauma Life Support (ATLS) principles, hemodynamic stabilization, early imaging, and timely surgical exploration where indicated. Postoperative monitoring was performed in the SICU, and patients were followed daily until discharge. Ethical approval was exempted as this was a retrospective descriptive analysis without patient identifiers, and all data were obtained from routine hospital documentation. The objective of this case series is to describe patterns of penetrating injuries, operative management strategies, complications, and outcomes in grievously injured assault victims managed in a tertiary trauma center.

Penetrating trauma from stab injuries continues to be an important cause of surgical emergencies, particularly in low- and middle-income countries where interpersonal violence and alcohol-related altercations are increasing (1,2). The present case series demonstrates the wide spectrum of injuries that can occur following assault and highlights the critical importance of rapid, protocol-driven trauma care. Each of the four cases managed at the Trauma Care Center (TCC), GIMS Kalaburagi, illustrates key principles of diagnosing and managing penetrating trauma, supported by established evidence.

The first major finding in this series is the predominance of abdominal organ involvement, especially the liver. Liver trauma accounts for nearly 35–45% of abdominal penetrating injuries in multiple large trauma series (3,4). Case 1 presented with a Grade IV liver laceration, which is considered a high-grade injury associated with significant bleeding and mortality if not managed promptly (5). Early imaging with contrast-enhanced CT (CECT) played a pivotal role in identifying the extent of liver damage and associated diaphragmatic rupture. According to Di Saverio et al., CT imaging is the gold standard for hemodynamically stable patients, allowing precise grading of liver injury that directly influences management strategy (6). Operative repair, including direct hemostasis and packing, continues to be recommended for high-grade liver trauma accompanied by ongoing hemorrhage, as performed in this case (7).

Another important observation is the occurrence of associated diaphragmatic injuries, which often escape early detection. Missed diaphragmatic tears can lead to delayed herniation, strangulation, and mortality (8). In this series, diaphragmatic rupture was promptly identified and repaired, consistent with literature emphasizing the need for routine diaphragmatic evaluation during laparotomy for thoracoabdominal stab wounds (9). This early recognition prevented long-term sequelae.

Mesenteric injuries, as seen in Case 2, are particularly challenging because their clinical presentation can be subtle. Studies by Shanmuganathan et al. show that CT signs such as mesenteric stranding, active contrast extravasation, and bowel wall thickening are highly suggestive of mesenteric tears requiring surgical intervention (10). The timely laparotomy performed in Case 2 aligns with recommendations that mesenteric vascular injuries must be promptly repaired to prevent bowel ischemia and late perforations (11).

Case 3 highlights the complexity of posterior penetrating trauma. Although vertebral or spinal cord involvement is a concern, multiple studies report that most posterior stab injuries result in injury to muscular and paraspinal vessels rather than neural structures (12). The arterial bleeding encountered in this case is typical of gluteal or paraspinal vascular injuries described in trauma literature and requires rapid hemostasis and blood transfusion (13). The absence of neurological deficits in this patient mirrors findings from Ivatury et al., who reported that true spinal cord injury from stab wounds is relatively rare and depends heavily on trajectory (14).

Case 4 demonstrates one of the most serious complications of penetrating abdominal trauma—duodenal perforation. Duodenal injuries are rare (<5% of abdominal stab wound) but carry significant morbidity due to retroperitoneal contamination, risk of sepsis, and delayed diagnosis (15). Early identification and primary repair, as performed in this case, are associated with significantly improved outcomes. Feliciano et al. reported that delayed diagnosis beyond 24 hours markedly increases mortality and the need for complex reconstruction (16). The timely operative decision in this patient prevented further complications.

A notable pattern across the series was the presence of surgical site infection (SSI) in two cases. According to Moore et al., SSI is common in contaminated penetrating wounds and typically appears between postoperative days 4–7, consistent with the timeline seen in this series(17). Appropriate antibiotic therapy and wound care facilitated resolution without deep infection or sepsis.

Another significant observation is that there was no mortality in any of the four cases despite the severity of injuries. This outcome is strongly supported by literature showing that survival improves dramatically when trauma care adheres to ATLS guidelines, rapid imaging, early hemorrhage control, and coordinated SICU monitoring (3,18). The presence of an organized trauma system at GIMS—including availability of rapid CT scanning, experienced surgeons, anesthesiology support, and ICU care—likely contributed to these positive outcomes.

 Finally, this series reinforces the importance of documenting regional patterns of penetrating trauma. Studies from India remain limited, and region-specific data can help strengthen trauma protocols, resource allocation, and violence-prevention policies. 

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