Chapter 31: SOFT TISSUE TRAUMA

EMS 363 By: Dr.Bushra Bilal

INTRODUCTION

• The skin is the largest organ of the body. Injuries are common.Wound: any injury to soft tissue

INCIDENCE, MORTALITY, AND MORBIDITY

• Soft tissue can be injured by:Blunt injuryPenetrating injuryBurns

• Soft-tissue trauma is the leading form of injury.

STRUCTURE AND FUNCTION OF THE SKIN

• Skin: complex organ with crucial role in homeostasis

Protects underlying tissue from injuryAids in temperature regulationPrevents excessive water lossActs as sense organ

EPIDERMIS

• First line of defense

• Consists of 3 layers

DERMIS

Composed of:• Collagen and elastic fibers• Layer beneath the epidermis

Specialized structures Nerve endingsBlood vesselsSweat glandsHair folliclesSebaceous gland

SUBCUTANEOUS TISSUES

• Layer beneath the dermis

• Mostly adipose tissue

DEEP FASCIA

• Thick, dense layer of fibrous tissue below subcutaneous tissue

CLOSED WOUNDS

• Soft tissue is damaged but skin is not brokenCharacteristic closed

wound is a contusion.

• If small blood vessels are damaged, ecchymosis will cover the area.

• If large blood vessels are torn, a hematoma will appear.

OPEN WOUNDS

• Characterized by disruption in the skin• Potentially more serious than closed wounds

CRUSH INJURIES

• An injury to the underlying soft tissues and bones

• Caused by a body part being crushed between two solid

objects

• May lead to compartment syndrome

• May lead to rupture of internal organs

• Crush injuries often result in difficult-to-control hemorrhage

THE PROCESS OF WOUND HEALING

• HemostasisThe release of chemicals:

• Constricts the blood vessels • Activates platelets

• InflammationAdditional cells enter area for repair.White blood cells combat pathogens.Lymphocytes destroy bacteria and pathogens.Mast cells release histamine.

THE PROCESS OF WOUND HEALING

• Epithelialization: New epithelial cells move to outer layer of skin to replace those lost in injury.

• Neovascularization: New blood vessels form to bring oxygen and nutrients to injured tissue.

• New capillaries form from intact capillaries.

• Collagen synthesis Collagen: Tough, fibrous protein in scar tissue, hair, bones,

connective tissue

ALTERATIONS OF WOUND HEALING

• Anatomic factorsBody areas with repeated motion Relationship of open wound to skin tension linesMedications Medical conditions

• High-risk woundsHuman and animal bites Injuries from foreign bodies or organic matter

• Do not remove an impaled object in the field.

ALTERATIONS OF WOUND HEALING

• Abnormal scar formation: can lead to:• Hypertrophic scar• Keloid scar

• Pressure injuries: Occur from• Being bedridden• Pressure applied for prolonged periods

PATHOPHYSIOLOGY OF WOUND HEALING

• Visible signs of infection:• Pus• Warmth• Edema• Local discomfort• Red streaks

• Systemic signs• Fever• Shaking• Chills• Joint pain• Hypotension

PATHOPHYSIOLOGY OF WOUND HEALING

• Gangrene• Causes foul-smelling gas

If untreated:• Infection may lead to sepsis.

• TetanusCauses a potent toxin, resulting in:

• Painful muscle contractions • Muscle stiffness

PATIENT ASSESSMENT

• Skin trauma is rarely life-threatening.

Stay focused on assessment process.

SCENE SIZE-UP

• Address safety first.• Evaluate MOI.• Determine the number of patients involved.• Protect yourself and patient from bodily fluid.

PRIMARY ASSESSMENT

• Form a general impression Check for potential injuries to neck and spine. Evaluate level of consciousness.

• Airway and breathing Correct anything that interferes with airway. Assess the patient’s breathing.

• Circulation Assess circulation by:

• Palpating a pulse• Palpating and inspecting the skin

• Transport decision Transport patients with significant trauma.

PRIMARY ASSESSMENT

• Significant MOI

Serious trauma indicated by:• Altered level of consciousness• Lack or airway protection or patency• Inadequate breathing• Uncontrolled bleeding• Significant MOI

PRIMARY ASSESSMENT

If possibility of serious injury, perform a rapid exam, assessing:• Head and neck• Chest• Abdomen• Pelvis• Lower and upper extremities• Posterior

Identify need for attention using DCAP-BTLS After assessment, apply a cervical collar. Perform a complete set of vital signs and a SAMPLE

history.

HISTORY TAKING

• Ask about events leading to injury.• Ask about the last tetanus booster.• Ask about over-the-counter medicines.• Use the mnemonic SAMPLE.

SECONDARY ASSESSMENT

• Conduct a more thorough examination en route if there is:A significant MOIAdequate time Patient in stable condition

REASSESSMENT

• Do frequent reassessments en route.Stable patient—every 15 minutesSerious condition—every 5 minutes minimum

• Check interventions and monitor patient.• Complete written documentation.• Note specific injuries, describing wounds.• Note assessment findings for:

Distal neurovascular statusPresence or absence of infection

TREATMENT OF CLOSED WOUNDS

• Minimize bleeding and swelling (ICES):Apply Ice or cold packs.Apply firm Compression.Elevate the injured part higher than the heart.Apply a Splint.

• Using ice as early as possible may speed up healing time.

BANDAGING AND DRESSING WOUNDS

• Used to:Cover woundControl bleedingLimit motion

COMPLICATIONS OF IMPROPERLY APPLIED DRESSINGS

• Always use as sterile technique as possible. Irrigate open wounds with normal saline.Apply antibiotic ointment to smaller wounds.Assess and readjust if necessary.When extremity dressings are in place, assess:

• Distal pulses• Motor function• Sensation

CONTROL OF EXTERNAL BLEEDING

• Bleeding can be characterized by type of blood vessel damaged.Capillary bleeding—slow flow, bright or dark redVenous bleeding—slow, steady, darker colorArterial bleeding—spurts, bright red color

CONTROL OF EXTERNAL BLEEDING

• Direct pressureSteps for management:

• Follow standard precautions.• Maintain airway.• Apply direct pressure with a dry, sterile dressing. • Apply a pressure dressing and gauze.

If bleeding is not controlled, apply a tourniquet.Apply high-flow oxygen as necessary.Monitor serial vital signs, and watch for shock.Assess circulation before and after application.

CONTROL OF EXTERNAL BLEEDING

• ElevationCan substantially slow venous bleeding

• ImmobilizationMotion disrupts clotting process.Limit injured extremity movement. If necessary, apply a splint.

CONTROL OF EXTERNAL BLEEDING

• TourniquetEspecially useful if:

• Extremity injury below the axilla or groin is severely bleeding.

• Other bleeding control methods are ineffective.

Courtesy of Steven Kasser

CONTROL OF EXTERNAL BLEEDING

• Tourniquet (cont’d)Take the following precautions:

• Do not apply over a joint.• Use the widest bandage possible.• Never use material that could cut into the skin.• If possible, use wide padding under the tourniquet.• Never cover with a bandage.• Inform the hospital.• Do not loosen after it is applied.

DRESSING SPECIFIC ANATOMIC SITES

• Scalp dressingsDirect pressure is usually effective.

• Facial dressingsReassure patient.Direct pressure is effective to control bleeding.Assess for airway compromise.

DRESSING SPECIFIC ANATOMIC SITES

• Ear or mastoid dressingsDo not place a dressing in the ear canal.Use gauze sponges to aid in stopping blood loss.Do not try to directly stop blood flow from the ear canal.

Place a bulky dressing over the external ear.

• Neck dressingsUse occlusive dressings.

DRESSING SPECIFIC ANATOMIC SITES

• Truncal dressingsCover open wounds with occlusive dressing, taping only

three sides.Assess breath sounds.Use medical tape to secure dressing.

• Groin and hip dressingsCombined with direct pressureGenitalia injuries should be managed by someone of the

same gender.

DRESSING SPECIFIC ANATOMIC SITES

• Hand, wrist, and finger dressingsPlace the hand in a position of function.The hand and wrist can be splinted.Leave fingers exposed.

• Elbow and knee dressings For larger wounds, immobilize joint.Assess distal neurovascular status.

DRESSING SPECIFIC ANATOMIC SITES

• Ankle and foot dressingsControl bleeding with direct pressure.

• If bleeding is arterial and not controlled, consider a tourniquet proximal to injury.

Always assess distal neurovascular function before and after caring for a wound.

ABRASIONS

• Superficial wound Occurs when part of epidermis is lost from being rubbed or

scraped over a rough surface

• Assessment and managementOozes small amounts of bloodDo not clean in the field.Cover lightly with sterile dressing.

LACERATIONS

• Cut from a sharp instrument that produces a clean or jagged incision

Courtesy of Rhonda Beck

PUNCTURE WOUNDS

• Caused by a stab from a pointed object• Assessment and management

• Look for entrance and exit wounds.• Take steps to prevent infection.• Monitor for edema.• Treat swelling with ice.

PUNCTURE WOUNDS

If the object is still embedded in the wound:

• Immobilize the object.

• Transport the patient.

© Custom Medical Stock Photo

PUNCTURE WOUNDS

• Assessment and managementBasic management points for impaled objects:

• Do not try to remove an impaled object.• Use direct compression, but not on the impaled object or

adjacent tissues.• Do not try to shorten the object.• Stabilize the object with bulky dressing, and immobilize

the extremity.Removal of impaled object may be necessary:

• If object directly interferes with airway control • If object interferes with chest compression • If patient is impaled on an immovable object

AVULSIONS

• Occurs when a flap of skin is partially or completely torn looseAmount of bleeding is dependent on the depth of injury. If wound is contaminated, provide irrigation.Gently fold and align the skin flap back as close to its

normal position as possible.• Cover it with a dry, sterile compression dressing.

AMPUTATIONS

• An avulsion involving the complete loss of a body part

© E. M. Singletary, MD. Used with permission.

Amputations• Assessment and management

The body part may be completely detached or soft tissues may remain attached.

Degloving injury: unraveling of skin from the hand

If a body part is completed amputated, try to preserve it in optimal condition.

• Wrap it loosely in saline-moistened sterile gauze.• Seal it in a plastic bag; place it in a cool container.• Never warm it or place it in water.• Never place it directly on ice or use dry ice.• Transport as soon as possible

BITE WOUNDS

• Animals bites can be serious.Cat and dog mouths are

contaminated with virulent bacteria.

Human bites usually occur on the hand.

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BITE WOUNDS

• Assessment and managementPlace a sterile dressing and transport promptly.Splint an arm or leg if it is injured.Determine and document:

• When the bite occurred• Type of animal• What led to the biting incident

Rabies is a major concern with dog bites.• Once signs appear, it is almost always fatal.• Spread by bites or licking an open wound• Can be prevented by a series of vaccine injections

CRUSH SYNDROME

• Can develop if a body area is trapped for longer than 4 hours and arterial blood flow is compromised If muscles are crushed beyond repair, tissue necrosis leads

to rhabdomyolysis.

• Freeing the body part from entrapment may result in release of harmful products. “Smiling death” may occur.Other significant complications include:

• Renal failure • Life-threatening dysrhythmias

CRUSH SYNDROME

• Assessment and managementScene safety is the first consideration.Complete primary assessment as possible.Obtain IV access before removing the object. Infuse normal saline.Add sodium bicarbonate as part of the IV fluid. If pretreatment not possible, apply a tourniquetRapidly transport once the patient is freed.

COMPARTMENT SYNDROME

• Develops when edema and swelling cause increased pressure within a closed soft-tissue compartmentLeads to compromised circulationCommonly develops in extremitiesCan cause tissue necrosis

COMPARTMENT SYNDROME

• Assessment and managementPresents with six Ps:

• Pain• Paresthesia• Paresis• Pressure• Passive stretch pain• Pulselessness

FACIAL AND NECK INJURIES

• May involve airway or large blood vesselsAirway compromise may arise.

• Suctioning and positioning may be necessary.Open injuries to the jugular or carotid vessels can result in

exsanguinations.• Assessment and management

Assess airway patency, protection, and oxygen.May require more invasive management:

• Endotracheal tube• A Combitube• Laryngeal mask airway

THORACIC INJURIES

• May appear minor but produce deadly internal damage• Determine MOI during primary assessment to detect life

threats.• Assessment and management

Four steps to assessment:• Inspection• Palpation• Auscultation• Percussion

SUMMARY

• The skin fulfills crucial roles, including maintaining homeostasis, protecting tissue, and regulating temperature.

• In a closed wound, soft tissues beneath the skin are damaged but the skin is not broken.

• In an open wound, the skin is broken, and the wound can become infected and result in serious blood loss.

• In a crush injury, a body part is crushed between two solid objects, causing damage to soft tissues and bone.

• Cessation of bleeding is the first stage of wound healing. • Inflammation is the second stage of healing.

SUMMARY

• Factors that affect wound healing include the amount of movement the part is subjected to, medications, and medical conditions.

• Infection signs include redness, pus, warmth, edema, and local discomfort.

• Controlling bleeding is a part of soft-tissue injury management. Follow the ICES mnemonic for closed injuries.

• When managing open wounds, control bleeding and keep wound clean by irrigating and sterile dressings.

• Dressings and bandages cover wounds, control bleeding, and limit motion.

SUMMARY

• Bleeding control methods include direct pressure, elevation, immobilization, and tourniquets.

• Do not remove impaled objects. • Animal and human bites can cause serious infection. Dogs and

cats can carry rabies. • Crush syndrome may develop after a body part has been

trapped more than 4 hours.• Compartment syndrome results from pressure increase in a

closed soft-tissue compartment. Presentation includes some or all of the six Ps.