1 soft -tissue injuries beyond the objectives. 2 anatomy & physiology review layers of soft...

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Soft -Tissue Soft -Tissue InjuriesInjuries

Beyond the ObjectivesBeyond the Objectives

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Anatomy & Physiology ReviewAnatomy & Physiology Review

• Layers of soft tissueLayers of soft tissue– Cutaneous layerCutaneous layer

• EpidermisEpidermis• DermisDermis

– Subcutaneous layerSubcutaneous layer• Loose connective tissueLoose connective tissue• FatFat

– Deep FasciaDeep Fascia• Fibrous tissueFibrous tissue• Supportive & protectiveSupportive & protective

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Anatomy & Physiology ReviewAnatomy & Physiology Review

• Functions of Soft TissueFunctions of Soft Tissue– Protection from TraumaProtection from Trauma– ThermoregulationThermoregulation– Sensory functionsSensory functions

• Pain, Touch, TemperaturePain, Touch, Temperature

– Protection from infectionProtection from infection– Fluid maintenanceFluid maintenance

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Soft Tissue Injuries ReviewSoft Tissue Injuries Review

• AbrasionAbrasion– superficial injurysuperficial injury– outermost skin damaged by shearing forcesoutermost skin damaged by shearing forces– painful in proportion to degree of injurypainful in proportion to degree of injury– no bleeding or minor bleedingno bleeding or minor bleeding– contamination is primary concerncontamination is primary concern

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• LacerationLaceration– Skin disruption with greater depth than abrasionSkin disruption with greater depth than abrasion– jagged wound ends bleed easilyjagged wound ends bleed easily– may involve other soft tissue injuriesmay involve other soft tissue injuries– caused by forceful impact with sharp objectcaused by forceful impact with sharp object– bleeding may be severebleeding may be severe

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• IncisionsIncisions– Skin disruption with greater depth than abrasionSkin disruption with greater depth than abrasion– similar to laceration except wound ends are similar to laceration except wound ends are

smooth and evensmooth and even– tend to heal better than lacerationstend to heal better than lacerations– caused by very sharp objectscaused by very sharp objects

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• AvulsionAvulsion– flap of skin or tissue torn loose or pulled flap of skin or tissue torn loose or pulled

completely offcompletely off– avulsed tissue may or may not be viableavulsed tissue may or may not be viable

• AmputationAmputation– involves extremities or body partsinvolves extremities or body parts– jagged skin and/or bone edges at sitejagged skin and/or bone edges at site– three typesthree types

• complete, partial, deglovingcomplete, partial, degloving

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Compartment SyndromeCompartment Syndrome

• Crush InjuriesCrush Injuries– caused by a crushing (compressive) forcecaused by a crushing (compressive) force– may result in organ injurymay result in organ injury– often associated with severe fracturesoften associated with severe fractures– overlying skin may be intactoverlying skin may be intact– causescauses

• collapse of structure onto body areacollapse of structure onto body area

• compressive trauma to body areacompressive trauma to body area

• prolonged compression in a chronic situationprolonged compression in a chronic situation

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• Crush Injuries & Crush SyndromeCrush Injuries & Crush Syndrome– Injury sustained from a compressive force Injury sustained from a compressive force

sufficient to interfere with the normal sufficient to interfere with the normal metabolic function of the injured tissuemetabolic function of the injured tissue

– may lead to:may lead to:• rhabdomyolysisrhabdomyolysis

• electrolyte abnormalitieselectrolyte abnormalities

• acid-base abnormalitiesacid-base abnormalities

• hypovolemiahypovolemia

• acute renal failureacute renal failure

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• Compartment Syndrome Compartment Syndrome – local evidence of muscle ischemialocal evidence of muscle ischemia– results from compressive forces in a closed spaceresults from compressive forces in a closed space

• e.g. within fasciae.g. within fascia

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• Crush SyndromeCrush Syndrome– may be painful, swollen, deformedmay be painful, swollen, deformed– little or no external bleedinglittle or no external bleeding– internal bleeding may be severeinternal bleeding may be severe– reperfusion phenomenonreperfusion phenomenon

• systemic effects occur after the issue is reperfusedsystemic effects occur after the issue is reperfused

• oxygen free radicals result in muscle injuryoxygen free radicals result in muscle injury

• high intracellular calciumhigh intracellular calcium

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• Rhabdomyolysis - PathophysiologyRhabdomyolysis - Pathophysiology– muscle destroyedmuscle destroyed– extracellular fluid moves extracellular fluid moves intointo muscle cells muscle cells

• increased Hincreased H220, NaCl, Calcium0, NaCl, Calcium

– Fluid from muscle move into extracellular fluidFluid from muscle move into extracellular fluid• Lactic acidLactic acid

• MyoglobinMyoglobin

• Potassium, PhosphatePotassium, Phosphate

• Thromboplastin, Creatine kinase & CreatinineThromboplastin, Creatine kinase & Creatinine

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• Rhabdomyolysis - Potential Complications Rhabdomyolysis - Potential Complications – HypovolemiaHypovolemia– HypocalcemiaHypocalcemia– HyperkalemiaHyperkalemia– Metabolic acidosisMetabolic acidosis– HyperuricemiaHyperuricemia– HyperphosphatemiaHyperphosphatemia– Possible DICPossible DIC

Cardiotoxicity

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• Compartment SyndromeCompartment Syndrome– Tissue pressure > capillary hydrostatic pressureTissue pressure > capillary hydrostatic pressure

• Results in ischemia to muscleResults in ischemia to muscle

• Muscle cell edema beginsMuscle cell edema begins

– Prolonged ischemia (>6-8 hrs) leads to tissue Prolonged ischemia (>6-8 hrs) leads to tissue hypoxia and cell deathhypoxia and cell death

– Direct soft tissue trauma also adds to edema and Direct soft tissue trauma also adds to edema and ischemiaischemia

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• Compartment SyndromeCompartment Syndrome– Renal failureRenal failure

• hypovolemiahypovolemia

• renal tubules become obstructedrenal tubules become obstructed

• nephrotoxic agents presentnephrotoxic agents present

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• Compartment SyndromeCompartment Syndrome– Early signs of crush syndromeEarly signs of crush syndrome

• paralysis and sensory loss to injured areaparalysis and sensory loss to injured area

• rigor of joint distal to the injured musclesrigor of joint distal to the injured muscles

• pain, swelling, sensory changes, weaknesspain, swelling, sensory changes, weakness

• may have pulses present and warm skinmay have pulses present and warm skin

– Later signs indicating compartment syndromeLater signs indicating compartment syndrome• 5 Ps5 Ps

– pain, paresthesia, pallor, pressure, pulselessnesspain, paresthesia, pallor, pressure, pulselessness

– some include “polar”some include “polar”

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Hemorrhage ControlHemorrhage Control

• Direct pressureDirect pressure– useuse

• dressingdressing

• gloved hand or patient’s handgloved hand or patient’s hand

– quickest and most efficient methodquickest and most efficient method– promotes localized clottingpromotes localized clotting– avoid removing initial dressingavoid removing initial dressing– continue pressure by securing dressing and continue pressure by securing dressing and

applying additional dressingsapplying additional dressings

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• ElevationElevation– Useful in extremityUseful in extremity– Used WITH direct pressureUsed WITH direct pressure– Elevate above level of heartElevate above level of heart– Gravity used to slow hemorrhage & promote Gravity used to slow hemorrhage & promote

clottingclotting– Not always useful with extremity fractureNot always useful with extremity fracture

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• Pressure PointsPressure Points– Site where artery lies near surfaceSite where artery lies near surface– Direct compression appliedDirect compression applied– Most common areMost common are

• brachial arterybrachial artery

• femoral arteryfemoral artery

– Used when direct pressure, elevation and Used when direct pressure, elevation and continued pressure failcontinued pressure fail

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• TourniquetsTourniquets– Last resort method when all others failLast resort method when all others fail– Placed within 2 inches of woundPlaced within 2 inches of wound– Useful only on extremitiesUseful only on extremities– Never apply directly over a jointNever apply directly over a joint– Once in place, avoid looseningOnce in place, avoid loosening

• risk of emboli or continued hemorrhagerisk of emboli or continued hemorrhage

– Use wide materialUse wide material

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ManagementManagement

• General PrinciplesGeneral Principles– Control BleedingControl Bleeding– Apply DressingApply Dressing

• Method dependent on location of injuryMethod dependent on location of injury

– ImmobilizationImmobilization– BandagingBandaging– Antibacterial ointmentAntibacterial ointment– Consider need for further EvaluationConsider need for further Evaluation

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• Need for Further EvaluationNeed for Further Evaluation– Treat and ReleaseTreat and Release– Treat and ReferTreat and Refer– Treat and TransportTreat and Transport

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• Wounds Requiring Transport for EvaluationWounds Requiring Transport for Evaluation– Neural compromiseNeural compromise– Vascular compromiseVascular compromise– Muscular compromiseMuscular compromise– Tendon/Ligament compromiseTendon/Ligament compromise– Heavy contamination or High Risk WoundsHeavy contamination or High Risk Wounds– Cosmetic complicationsCosmetic complications– Foreign body complicationsForeign body complications

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Soft Tissue Injury ManagementSoft Tissue Injury Management

• Other ConsiderationsOther Considerations– Tetanus vaccineTetanus vaccine

• Caused by Caused by Clostridium tetaniClostridium tetani– anaerobic bacteriaanaerobic bacteria

• Initial vaccineInitial vaccine

• BoosterBooster– q 10 yearsq 10 years

– q 5 years for high risk personsq 5 years for high risk persons

• Potential for allergic reaction Potential for allergic reaction

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• Other ConsiderationsOther Considerations– Potential Risk of InfectionPotential Risk of Infection

• Common complicationCommon complication

• Risk factorsRisk factors– Microflora common on skin surfaceMicroflora common on skin surface

– Source on wound mechanismSource on wound mechanism

– Patient immunocompromisedPatient immunocompromised

• Infection MinimizationInfection Minimization– minimize contaminationminimize contamination

– clean wound soon after injuryclean wound soon after injury

– protectprotect

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• Management of Specific InjuriesManagement of Specific Injuries– AvulsionAvulsion

• ABCsABCs• Control bleedingControl bleeding• Dress and BandageDress and Bandage• Package avulsed tissue for transportPackage avulsed tissue for transport

– Wrap in sterile gauzeWrap in sterile gauze– Place in plastic bagPlace in plastic bag– Place plastic bag in bag of icePlace plastic bag in bag of ice

• Transport to appropriate facilityTransport to appropriate facility– Consider surgery & plastic surgery capabilitiesConsider surgery & plastic surgery capabilities

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• Management of Specific InjuriesManagement of Specific Injuries– AmputationAmputation

• ABCsABCs

• Control bleedingControl bleeding

• Do not complete partial amputationsDo not complete partial amputations

• Dress and BandageDress and Bandage

• Package amputated part for transportPackage amputated part for transport

• Transport to appropriate facilityTransport to appropriate facility– Consider surgery & plastic surgery capabilitiesConsider surgery & plastic surgery capabilities

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• Management of Specific InjuriesManagement of Specific Injuries– Crush InjuriesCrush Injuries

• GoalsGoals– Prevent sudden deathPrevent sudden death

– Prevent renal failurePrevent renal failure

– Salvage limbSalvage limb

• Treat early -- Before arrival at EDTreat early -- Before arrival at ED

• Fluid for hypovolemiaFluid for hypovolemia– Consider bolus of 1 - 1.5 liters in 250 ml incrementsConsider bolus of 1 - 1.5 liters in 250 ml increments

– No IV sites distal to crush injury!!No IV sites distal to crush injury!!

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• Alkalinize urineAlkalinize urine– Consider NaHCOConsider NaHCO33: Add 50 mEq to 1 liter bag of fluid: Add 50 mEq to 1 liter bag of fluid

– Goal: Urine pH > 6.5Goal: Urine pH > 6.5

– Controls hyperkalemia and acidosis to prevent acute Controls hyperkalemia and acidosis to prevent acute myoglobinuria renal failure by changing structure of myoglobinuria renal failure by changing structure of myoglobin so it passes thru renal tubulesmyoglobin so it passes thru renal tubules

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• Maintain urine outputMaintain urine output– Diuresis of at least 300 cc/hrDiuresis of at least 300 cc/hr

– Consider MannitolConsider Mannitol

– Avoid loop diuretics (may acidify urine)Avoid loop diuretics (may acidify urine)

– Ideal fluid is D5 1/2 normal saline with 50 mEq NaHCOIdeal fluid is D5 1/2 normal saline with 50 mEq NaHCO33 and and

MannitolMannitol

– Treat hypovolemiaTreat hypovolemia

– Correct acidosisCorrect acidosis

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• Other possible therapiesOther possible therapies– Consider insulin/glucose for severe hyperkalemia (12.5 g D50 Consider insulin/glucose for severe hyperkalemia (12.5 g D50

followed by 10 units regular insulin IV)followed by 10 units regular insulin IV)

– AmilorideAmiloride

» potassium sparing diureticpotassium sparing diuretic

– Hemodialysis (if needed)Hemodialysis (if needed)

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• Management of Specific InjuriesManagement of Specific Injuries– Compartment SyndromeCompartment Syndrome

• Clinical signs and symptoms may indicate need for Clinical signs and symptoms may indicate need for emergency fasciotomyemergency fasciotomy

• Early fasciotomy can preserve limb, avoid Volkmann’s Early fasciotomy can preserve limb, avoid Volkmann’s contracture and preserve sensationcontracture and preserve sensation

• Seldom but occasionally performed in out of hospital Seldom but occasionally performed in out of hospital settingsetting

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QUESTIONSQUESTIONS

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1 soft -tissue injuries beyond the objectives. 2 anatomy & physiology review layers of soft...

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tissue hypoxia

offavulsed tissue

soft tissue injuriesbeyond

skin damaged

greater depth

muscle cellsincreased

body areacompressive

severe fracturesoverlying