Soft-Tissue Injury. Sections Introduction to Soft Tissue Injury Anatomy & Physiology of Soft- Tissue Injury Pathophysiology of Soft-Tissue Injury

Soft-Tissue InjurySoft-Tissue Injury

SectionsSections

Introduction to Soft Tissue Injury Anatomy & Physiology of Soft-Tissue

Injury Pathophysiology of Soft-Tissue Injury Dressing & Bandage Materials Assessment of Soft-Tissue Injuries Management of Soft-Tissue Injuries

Introduction to Soft Tissue Injury Anatomy & Physiology of Soft-Tissue

Injury Pathophysiology of Soft-Tissue Injury Dressing & Bandage Materials Assessment of Soft-Tissue Injuries Management of Soft-Tissue Injuries

Skin is the largest, most important organ

16% of total body weight Function

Protection Sensation Temperature Regulation

AKA: Integumentary System

Skin is the largest, most important organ

16% of total body weight Function

Protection Sensation Temperature Regulation

AKA: Integumentary System

Introduction to Introduction to Soft-Tissue InjurySoft-Tissue Injury

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

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

Introduction to Introduction to Soft-Tissue InjurySoft-Tissue Injury

A&P of Soft Tissue A&P of Soft Tissue InjuriesInjuries Skin Layers

Epidermis Outermost, avascular layer of dead cells Helps prevent infection Sebum

• Waxy, oily substance that lubricates surface

Dermis Upper Layer (Papillary Layer)

• Loose connective tissue, capillaries and nerves Lower Layer (Reticular Layer)

• Integrates dermis with SQ layer Blood vessels, nerve endings, glands

• Sebaceous & Sudoriferous Glands

Subcutaneous Adipose tissue Heat retention

Skin Layers Epidermis

Outermost, avascular layer of dead cells Helps prevent infection Sebum

• Waxy, oily substance that lubricates surface

Dermis Upper Layer (Papillary Layer)

• Loose connective tissue, capillaries and nerves Lower Layer (Reticular Layer)

• Integrates dermis with SQ layer Blood vessels, nerve endings, glands

• Sebaceous & Sudoriferous Glands

Subcutaneous Adipose tissue Heat retention

A&P of Soft Tissue A&P of Soft Tissue InjuriesInjuries Blood Vessels

Arteries Arterioles Capillaries Venules Veins

Layers Tunica Intima Tunica Media Tunica Adventitia

Blood Vessels Arteries Arterioles Capillaries Venules Veins

Layers Tunica Intima Tunica Media Tunica Adventitia

A&P of Soft Tissue A&P of Soft Tissue InjuriesInjuries Muscles

Beneath skin layers Fascia

Thick, fibrous, inflexible membrane surrounding muscle the aids to bind muscle groups together

Muscles Beneath skin layers Fascia

Thick, fibrous, inflexible membrane surrounding muscle the aids to bind muscle groups together

A&P of Soft Tissue A&P of Soft Tissue InjuriesInjuries Tension Lines

Natural patterns in the surface of the skin revealing tension within

Tension Lines Natural patterns in

the surface of the skin revealing tension within

Pathophysiology of Pathophysiology of Soft-Tissue InjurySoft-Tissue Injury

Closed Wounds Contusions

Erythema Ecchymosis

Hematomas Crush Injuries

Closed Wounds Contusions

Erythema Ecchymosis

Hematomas Crush Injuries

Open Wounds Abrasions Lacerations Incisions Punctures Impaled Objects Avulsions Amputations

Open Wounds Abrasions Lacerations Incisions Punctures Impaled Objects Avulsions Amputations

Hemorrhage Arterial Capillary Venous

Hemorrhage Arterial Capillary Venous


Wound HealingHemostasis

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

Begins immediately after injury Inflammation

Local biochemical process that attracts WBC’s Epithelialization

Migration of epithelial cells over wound surface

Wound HealingHemostasis

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

Begins immediately after injury Inflammation

Local biochemical process that attracts WBC’s Epithelialization

Migration of epithelial cells over wound surface


(continued)

Neovascularization New growth of capillaries in response to healing

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

connective tissue

Neovascularization New growth of capillaries in response to healing

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

connective tissue


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: WBC’s, cellular debris, & dead bacteria Lymphangitis: Visible red streaks Fever & Malaise Localized Fever

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: WBC’s, cellular debris, & dead bacteria Lymphangitis: Visible red streaks Fever & Malaise Localized Fever


Infection Risk Factors

Host’s health & pre-existing illnesses• Medications (NSAID’s)

Wound type and location Associated contamination Treatment provided

Infection Management Antibiotics & keep wound clean Gangrene

• Deep space infection of anerobic bacteria• Bacterial Gas and Odor

Tetanus• Lockjaw

Infection Risk Factors

Host’s health & pre-existing illnesses• Medications (NSAID’s)

Wound type and location Associated contamination Treatment provided

Infection Management Antibiotics & keep wound clean Gangrene

• Deep space infection of anerobic bacteria• Bacterial Gas and Odor

Tetanus• Lockjaw


Other Wound Complications Impaired Hemostasis

Medications• Anticoagulants

Aspirin Warfarin (Coumadin) Heparin Antifibrinolytics

Re-Bleeding Delayed Healing Compartment Syndrome Abnormal Scar Formation Pressure Injuries

Other Wound Complications Impaired Hemostasis

Medications• Anticoagulants

Aspirin Warfarin (Coumadin) Heparin Antifibrinolytics

Re-Bleeding Delayed Healing Compartment Syndrome Abnormal Scar Formation Pressure Injuries


Crush Injury Body tissues are subjected to severe

compressive forces Tamponading of distal tissue

Buildup of byproducts of metabolism “Wood-like” distal tissue

Associated Injury

Crush Injury Body tissues are 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 Rhabdomyolysis• Skeletal Muscle Degradation• Release of toxins

Myoglobin Phosphate Potassium Lactic Acid Uric Acid

When tissue is released, toxins move RAPIDLY into systemic circulation

• Impacts Cardiac Function• Impacts Kidney Function

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

Traumatic Rhabdomyolysis• Skeletal Muscle Degradation• Release of toxins

Myoglobin Phosphate Potassium Lactic Acid Uric Acid

When tissue is released, toxins move RAPIDLY into systemic circulation

• Impacts Cardiac Function• Impacts Kidney Function


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

into subcutaneous tissue

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

into subcutaneous tissue


Sterile & Non-sterile Dressings Sterile: Direct wound contact Non-sterile: Bulk dressing above sterile

Occlusive/Non-occlusive Dressings Adherent/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

Sterile & Non-sterile Dressings Sterile: Direct wound contact Non-sterile: Bulk dressing above sterile

Occlusive/Non-occlusive Dressings Adherent/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 & Bandage Dressing & Bandage MaterialsMaterials

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

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

Dressing & Bandage Dressing & Bandage MaterialsMaterials

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

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

Assessment of Soft Assessment of Soft Tissue InjuriesTissue Injuries

Objectives of Wound Dressing & Bandaging Hemorrhage Control

Direct Pressure Elevation Pressure Points Consider

• Ice

• Constricting Band

• Tourniquet

USE ALL COMPONENTS TOGETHER

Objectives of Wound Dressing & Bandaging Hemorrhage Control

Direct Pressure Elevation Pressure Points Consider

• Ice

• Constricting Band

• Tourniquet

USE ALL COMPONENTS TOGETHER

Management of Management of Soft-Tissue InjurySoft-Tissue Injury


Do’s 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.

Do’s 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’ts Use unless you can not

control the bleeding via other means

Use rope or wire. Release it once

applied.

Don’ts Use unless you can not

control the bleeding via other means

Use rope or wire. Release it once

applied.

TourniquetTourniquet

Objectives of Wound Dressing & Bandaging Sterility

Keep the wound as clean as possible If wound is grossly contaminated consider cleansing

Immobilization Prevents movement and aggravation of wound Do not use an elastic bandage: TQ effect Monitor distal pulse, motor, and sensation

Objectives of Wound Dressing & Bandaging Sterility

Keep the wound as clean as possible If wound is grossly contaminated consider cleansing

Immobilization Prevents movement and aggravation of wound Do not use an elastic bandage: TQ effect Monitor distal pulse, motor, and sensation


(continued)

Pain & Edema Control Cold packs Moderate pressure over wound Consider analgesic if approved by medical control

Pain & Edema Control Cold packs Moderate pressure over wound Consider analgesic if approved by medical control


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

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

Anatomical Anatomical Considerations Considerations for Bandagingfor Bandaging

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

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 artery Trachea Anterior neck

Neck Consider circumferential bandage

Protect trachea and carotids C-Collar and dressing

Occlusive dressing if lacerated vessel

Shoulder Care to avoid pressure

Axillary artery Trachea Anterior 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 & Hip Bandage by following contours of body Movement can increase tightness of bandage

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 & Hip Bandage by following contours of body Movement can increase tightness of bandage


Elbow and Knee Circumferential wrap and splint

Splinting reduces movement Position of function Half flexion/half extension

Hand and Finger Bulky dressing Position of function

Ankle and Foot Circumferential bandage

Elbow and Knee Circumferential wrap and splint

Splinting reduces movement Position of function Half flexion/half extension

Hand and Finger 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?

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?


Amputations Patient

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

• Have a second unit transport the part

Amputated Part Dry cooling and rapid transport

• Part in plastic bag (Double bag)• Immerse in cold water• Avoid direct contact between tissue and cold water

Amputations Patient

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

• Have a second unit transport the part

Amputated Part Dry cooling and rapid transport

• Part in plastic bag (Double bag)• Immerse in cold water• Avoid direct contact between tissue and cold water

Anatomical Anatomical Considerations Considerations

for Bandaging: Specific for Bandaging: Specific WoundsWounds

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 airway Interferes with CPR

• Poor outcome

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 airway Interferes with CPR

• Poor outcome



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.

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.



Crush Syndrome Management

IV: 20-30ml/kg of NS or D51/2NS AVOID LR or K+ based solutions After bolus, continuous infusion of 20ml/kg/hr Consider Sodium Bicarbonate

• 1 mEq/kg initial bolus• 0.25 mEq/kg/hr infusion• Corrects systemic acidosis

Consider Calcium Chloride• 500 mg IVP• Counteracts hyperkalemia

Consider Diuretics• Mannitol (Osmotrol)• Furosemide (Lasix)

Crush Syndrome Management

IV: 20-30ml/kg of NS or D51/2NS AVOID LR or K+ based solutions After bolus, continuous infusion of 20ml/kg/hr Consider Sodium Bicarbonate

• 1 mEq/kg initial bolus• 0.25 mEq/kg/hr infusion• Corrects systemic acidosis

Consider Calcium Chloride• 500 mg IVP• Counteracts hyperkalemia

Consider Diuretics• Mannitol (Osmotrol)• Furosemide (Lasix)



Compartment Syndrome Likely 4-8 hours post-injury Symptom

Severe pain out of proportion with physical exam findings

6 – P’s• Pain• Paresthesia• Paresis• Pressure• Passive stretching pain• Pulselessness

Normal motor and sensory function

Compartment Syndrome Likely 4-8 hours post-injury Symptom

Severe pain out of proportion with physical exam findings

6 – P’s• Pain• Paresthesia• Paresis• Pressure• Passive stretching pain• Pulselessness

Normal motor and sensory function



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

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 & Neck Potential for airway obstruction or

compromise Aggressive suctioning and oxygenation Consider intubation

If excessive swelling or damage• Needle or surgical cricothyroidotomy

Face & Neck Potential for airway obstruction or

compromise Aggressive suctioning and oxygenation Consider intubation

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

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


Abdomen 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.

Abdomen 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

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 online medical control 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.

Soft-Tissue Treatment and Refer or Release Typically requires online medical control 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.


Documents

Soft-Tissue Injury. Sections Introduction to Soft Tissue Injury Anatomy & Physiology of Soft- Tissue Injury Pathophysiology of Soft-Tissue Injury