Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Division 3 Trauma Emergencies

Bledsoe et al., Essentials of Paramedic Care: Division 1II© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Division 3Trauma Emergencies


Chapter 20Soft-Tissue Trauma


Topics

Introduction to Soft-Tissue Injury

Anatomy and Physiology of Soft-Tissue Injury

Pathophysiology of Soft-Tissue Injury

Dressing and Bandage Materials

Assessment of Soft-Tissue Injuries

Management of Soft-Tissue Injuries


Introduction to Soft-Tissue Trauma

Skin is the largest, most important organ.

16% of total body weight.

Function:– Protection– Sensation– Temperature regulation

AKA: Integumentary system


Epidemiology

Open wounds– Over 10 million wounds present to ED.

Most require simple care and some suturing.

Up to 6.5% may become infected.

Closed wounds– More common– Contusions, sprains, strains


A&P of Soft-Tissue Injuries (1 of 6) Skin Layers– Epidermis

Outermost, avascular layer of dead cellsHelps prevent infectionSebum

Waxy, oily substance that lubricates surface

– DermisUpper layer (papillary layer)

Loose connective tissue, capillaries, and nervesLower layer (reticular layer)

Integrates dermis with SQ layerBlood vessels, nerve endings, glands

Sebaceous and sudoriferous glands

– SubcutaneousAdipose tissueHeat retention


A&P of Soft-Tissue Injuries (2 of 6) The Skin


A&P of Soft-Tissue Injuries (3 of 6)

Blood Vessels– Arteries– Arterioles– Capillaries– Venules– Veins

Layers– Tunica intima– Tunica media– Tunica adventitia


A&P of Soft-Tissue Injuries (4 of 6) Blood Vessels



Muscles– Beneath skin layers– Fascia

Thick, fibrous, inflexible membrane surrounding muscle that aids in binding muscle groups together



Tension Lines– Natural patterns in

the surface of the skin revealing tension within


Pathophysiology of Soft-Tissue Injury (1 of 12)

Closed Wounds– Contusions

Erythema

Ecchymosis

– Hematomas– Crush injuries

Open Wounds– Abrasions– Lacerations– Incisions– Punctures– Impaled objects– Avulsions– Amputations



Soft-Tissue Wounds



Hemorrhage– Arterial– Capillary– Venous



Wound Healing– Hemostasis

Body’s natural ability to stop bleeding and the ability to clot blood

Begins immediately after injury

– InflammationLocal biochemical process that attracts WBCs

– EpithelializationMigration of epithelial cells over wound surface



Neovascularization– New growth of capillaries in response to

healing

Collagen Synthesis– Fibroblasts: Cells that form collagen– Collagen: Tough, strong protein that

comprises connective tissue



The Wound Healing Process



Infection– Most common and most serious complication of open

wounds– 1:15 wounds seen in ED result in infection– Delay healing– Spread to adjacent tissues– Systemic infection: sepsis– Presentation

Pus: WBCs, cellular debris, and dead bacteria

Lymphangitis: visible red streaks

Fever and malaise

Localized fever



Infection– Risk factors

Host’s health and pre-existing illnessesMedications (NSAIDs)

Wound type and locationAssociated contaminationTreatment provided

– Infection managementAntibiotics and keep wound cleanGangrene

Deep space infection of anaerobic bacteriaBacterial gas and odor

TetanusLockjaw Uncommon with the exception of third-world country immigrants



Other Wound Complications– Impaired hemostasis

MedicationsAnticoagulants

Aspirin

Warfarin (Coumadin)

Heparin

Antifibrinolytics

– Re-bleeding– Delayed healing– Compartment syndrome– Abnormal scar formation– Pressure injuries



Crush Injury– Body tissues subjected to severe

compressive forces– Tamponading of distal tissue

Buildup of byproducts of metabolism

“Wood-like” distal tissue

– Associated injury



Crush Syndrome– Body is entrapped for >4 hours.– Crushed muscle tissue becomes necrotic.

Traumatic rhabdomyolysisSkeletal muscle degradationRelease of toxins

MyoglobinPhosphatePotassiumLactic acidUric acid

When tissue is released, toxins move RAPIDLY into systemic circulation.

Impacts cardiac functionImpacts kidney function



Injection Injury– High-pressure line bursts– Injects fluid or other substance into skin

and into subcutaneous tissue


Dressing and Bandage Materials (1 of 2)

Sterile and Non-sterile Dressings– Sterile: direct wound contact– Non-sterile: bulk dressing above sterile

Occlusive/Non-occlusive DressingsAdherent/Non-adherent Dressings– Adherent: stick to blood or fluid

Absorbent/Non-absorbent– Absorbent: soak up blood or fluids

Wet/Dry Dressings– Wet: burns, postoperative wounds (sterile NS)– Dry: most common


Dressing and Bandage Materials (2 of 2)

Self-adherent Roller Bandage– Kerlex/Kling

Multi-ply, stretch: 1–6”

Gauze Bandage– Single-ply, non-stretch: 1–3”

Adhesive Bandages

Elastic (Ace) Bandages

Triangular Bandages



Scene Size-up

Initial Assessment

Focused H&P– Evaluate MOI and consider IOS– Rapid versus focused assessment

Detailed Physical Exam– Inquiry, inspection, palpation, auscultation

Ongoing Assessment


Management of Soft-Tissue Injury (1 of 4)

Objectives of Wound Dressing and Bandaging– Hemorrhage control

Direct pressure

Elevation

Pressure points

ConsiderIce

Constricting band

Tourniquet

– USE ALL COMPONENTS TOGETHER.



TourniquetDo– Apply in a way that

will not injure tissue beneath it.

– Use something at least 2” wide.

– Consider using a blood pressure cuff.

– Write TQ and time placed on patient’s forehead.

Don’t– Use unless you

cannot control the bleeding via other means.

– Use rope or wire.– Release it once

applied.



Objectives of Wound Dressing and Bandaging– Sterility

Keep the wound as clean as possible.

If wound is grossly contaminated, consider cleansing.

– ImmobilizationPrevents movement and aggravation of wound.

Do not use an elastic bandage: TQ effect.

Monitor distal pulse, motor, and sensation.



Pain and Edema Control– Cold packs– Moderate pressure over wound– Consider analgesic if approved by medical

direction:Morphine sulfate

2 mg SIVP every 5 minutes up to a total of 10 mg given.

Fentanyl (Sublimaze)25–50 mcg SIVP followed by an additional 25 mcg as needed.

If given too rapidly, chest wall rigidity may ensue leading to respiratory compromise.


Anatomical Considerations for Bandaging (1 of 17)

Scalp– Rich supply of blood vessels– Rarely account for shock– Can be severe and difficult to control– With skull fracture:

Gentle digital pressure around the wound

Pressure on local arteries

– Without skull fracture:Direct pressure



Face– Heavy bleeding.– Assess and protect the airway.– Blood is a gastric irritant.

Be alert for nausea and vomiting.

Ear or Mastoid– Cover and collect bleeding.– DO NOT STOP.

CSF.



Neck– Consider circumferential bandage.

Protect trachea and carotids.C-collar and dressing.

– Occlusive dressing if lacerated vessel.

Shoulder– Care to avoid pressure.

Axillary arteryTracheaAnterior neck



Trunk– Minor wounds: Dressing and tape.– Major wounds: Circumferential wrap.

Ladder splint behind back and wrap gauze over it.Prevents worsening of respiratory status.

Groin and Hip– Bandage by following contours of body.– Movement can increase tightness of bandage.



Elbow and Knee– Circumferential wrap and splint

Splinting reduces movementPosition of functionHalf flexion/half extension

Hand and Finger– Remove jewelry from wrist and fingers– Bulky dressing– Position of function

Ankle and Foot– Circumferential bandage



Complications of Bandaging– Always assess before and after:

Pulse

Motor

Sensation

– Developing ischemia:Pain

Pallor

Tingling

Loss of pulse

Decreased capillary refill

– Is dressing size appropriate to injury?



Specific WoundsAmputations– Patient

Control bleeding by bulky dressing.Consider tourniquet proximal to wound.Do not delay transport to locate amputated part.

Have a second unit transport the part.

– Amputated PartDry cooling and rapid transport.

Part in plastic bag (double bag).Immerse in cold water.Avoid direct contact between tissue and cold water.



Specific Wounds

Impaled Objects– Stabilize with bulky dressing in place.– Prevent movement of object.– Consider cutting or shortening LARGE impaled

objects.Prevent gross movement.Reduce heat to patient if cutting torch used.

– REMOVE ONLY IF:In cheek and interferes with airwayInterferes with CPR

Poor outcome



Specific Wounds

Crush Syndrome– Anticipate problems.– Victims of prolonged entrapment.– Ensure that scene is safe.

Initial assessment.Control any initial problems.

– Greater the body area compressed, the longer the entrapment, the greater the risk of crush syndrome.

– Once body part is freed, toxic by-products of crush injury are released into systemic circulation.

– General management for soft tissue and musculoskeletal injury.



Specific WoundsCrush Syndrome– Management

IV: 20–30 mL/kg of NS or D51/2 NS.AVOID LR or K+ based solutions.After bolus, continuous infusion of 20 mL/kg/hr.Consider sodium bicarbonate:

1 mEq/kg initial bolus0.25 mEq/kg/hr infusionCorrects systemic acidosis

Consider calcium chloride:500 mg IVPCounteracts hyperkalemia

Consider diuretics:Mannitol (Osmotrol)Furosemide (Lasix)



Specific WoundsCompartment Syndrome– Likely 4–8 hours post-injury– Symptom

Severe pain out of proportion with physical exam findings6 Ps

PainParesthesiaParesisPressurePassive stretching painPulselessness

Normal motor and sensory function



Specific Wounds

Compartment Syndrome– Management

Care of underlying injury.

Splint and immobilize all suspected fractures.

Cold packs to severe contusions:Most effective prehospital management

Reduces edema

Prevents ischemia



Face and Neck– Potential for airway obstruction or

compromise– Aggressive suctioning and oxygenation– Consider intubation:

Verify ET tube placement.Ensure tube remains in the airway by using continuous waveform capnography.If excessive swelling or damage:

Needle or surgical cricothyroidotomy.



Thorax– Superficial injury can be deep.– Always suspect the worst due to underlying

organs.– NEVER explore a wound internally.– Alert for:

Subcutaneous emphysema

Pneumothorax or hemothorax

Tension pneumothorax

– Consider occlusive dressing sealed on 3 sides.



Abdominal Region– Always suspect injury to ribs or thoracic

organs if between the level of the 5th and 9th rib.

– Damage to hollow or solid organs from blunt or penetrating trauma.

– Signs of symptoms of internal injury may be subtle and slow to progress.

– Supportive treatment unless aggressive care is warranted.



Wounds Requiring Transport– Any wound that involves

Nerves

Blood vessels

Ligaments

Tendons

Muscles

Significantly contaminated

Impaled object

Likely cosmetic injury



Soft-Tissue Treatment and Refer or Release– Typically requires on-line medical direction.– Evaluate and dress wound.– Inform the patient about:

Preventing infection.

Follow-up care with a physician.

Inquire about tetanus and inform of risks.

– Document treatment, referral, and teaching.


Summary

Introduction to Soft-Tissue Injury

Anatomy and Physiology of Soft-Tissue Injury

Pathophysiology of Soft-Tissue Injury

Dressing and Bandage Materials


Management of Soft-Tissue Injuries

Documents

Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Division 3 Trauma Emergencies