bledsoe et al., paramedic care: principles & practice, volume 4: trauma emergencies, 3rd. ed. ©...

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Paramedic Care:Principles & Practice

Volume 4Trauma Emergencies


Chapter 5Soft-Tissue Trauma


Topics

Introduction to Soft-Tissue InjuriesAnatomy and Physiology of Soft-Tissue InjuriesPathophysiology of Soft-Tissue InjuryDressing and Bandage MaterialsAssessment of Soft-Tissue InjuriesManagement of Soft-Tissue Injury


Introduction to Soft-Tissue Injuries


Introduction to Soft-Tissue Injuries

Skin is the largest organ16% of total body weightFunction:– Protection

Keeps invading pathogens out while containing body substances and fluids

– Sensation– Temperature regulation


Introduction to Soft-Tissue Injury

Epidemiology– Open wounds

Over 10 million wounds present to emergency departments

– Closed woundsMore commonContusions, sprains, strains

– Risk factors for soft-tissue wounds AgeAlcohol and drug abuseOccupation

– Prevention


Anatomy and Physiology of Soft-Tissue Injuries



Layers of the Skin– Epidermis

A layer of cells just above the dermis

– DermisConnective tissue that helps contain the body

– Subcutaneous Is rich in fatty or adipose tissue


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

Layers– Tunica intima– Tunica media– Tunica adventitia


Click here to view the anatomy of 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.

Lacerations across the tension lines have a tendency to be pulled apart. Lacerations parallel to the tension lines tend to gape very little.



Pathophysiology of Soft-Tissue Injury



Closed Wounds– Contusions

Blunt, nonpenetrating injuries that crush and damage small blood vessels Characterized by erythema and ecchymosis

© Edward T. Dickinson, MD


Closed Wounds

Hematoma– Blood separates tissue and pool in a pocket

Dangerous in head injuriesSome may cause hypovolemia


Closed Wounds

Crush Injuries– A body part is

compressed, injuring muscles, blood vessels, bones, and other internal structures

– Crush SyndromeUsed to describe the systemic effects of a large crush injury

© Edward T. Dickinson, MD



Open Wounds– Abrasion

Typically the most minor of injuries Carries the danger of serious infection

– LacerationPenetrates more deeply into the dermis than an abrasion Endangers the deeper and more significant vasculature, nerves, muscles, tendons, ligaments, and organs

© Charles Stewart, MD


Open WoundsIncision– A surgically smooth

laceration

Puncture– A small entrance

wound with damage that extends into the body’s interior

– A puncture additionally carries an increased danger of infection


Open Wounds

Impaled Object– A wound

complication often associated with a puncture or laceration

– May cause worsening damage if withdrawn © Charles Stewart, MD


Open Wounds

Avulsion– A flap of skin,

although torn or cut, is not torn completely loose from the body

– Degloving injury Ring injury


Open WoundsAmputations– Partial or complete

severance of a digit or limb

– Hemorrhage associated with the amputation may be limited

– Care is used to ensure that the stump will be as functional as possible

© Mark C. Ide



Hemorrhage– Arterial– Venous – Capillary

The nature of the soft-tissue wound may be more important than the size or type of vessel involved– Clean lacerations and amputations generally do

not bleed profusely



Wound Healing– Hemostasis

Vessels have a muscular layer that reflexively constricts the vessel in response to local injury Platelets begin the clotting process

Stick to the vessel wall and to one another forming a plug

Proteins activate a complicated series of enzyme reactions

Coagulation


Wound Healing

Inflammation– Involves a host of elements

Various kinds of white blood cells Proteins involved in immunity Hormone-like chemicals that signal other cells to mobilize

– Chemotactic factors Recruit cells

Granulocytes and macrophages Phagocytosis


Wound Healing

Inflammation (cont.)– Lymphocytes and immunoglobins– Histamine dilates precapillary blood vessels

Increases blood flow to affected areaBrings much-needed oxygen and more phagocytes to the injured area


Wound Healing

Result of the inflammatory stage– Clearing away of dead and dying tissue – Removal of bacteria and other foreign substances– Preparation of the damaged area for rebuilding


Wound Healing

Epithelialization– Epithelial cells migrate over the surface of the

woundRestores a uniform layer of skin cells along the edges of the healing wound

– The new epithelial layer is not a perfect facsimile of the original, undamaged skin

Usually quite functional and cosmetically similar


Wound Healing

Neovascularization– New growth of capillaries in response to healing– Neovascularized tissue is very fragile and has a

tendency to bleed easily

Collagen Synthesis– Fibroblasts: Cells that form collagen– Remodeling


Wound Healing Process



Infection– Most common and most serious complication of

open wounds– Delay healing– Spread to adjacent tissues– Systemic infection: sepsis– Presentation

Pus: WBCs, cellular debris, and dead bacteriaLymphangitis: visible red streaksFever and malaiseLocalized fever


Infection

Risk factors– Host’s health and pre-existing illnesses

Diabetics, the infirm, the elderly, and individuals with serious chronic diseases

– Wound type and locationWell-vascularized areas such as the face and scalp are very resistant to infection Distal areas such as extremities heal more slowly

– Associated contamination– Treatment provided


Infection

Infection management– Antibiotics and keep wound clean

Gangrene– Deep space infection of anaerobic bacteria– Bacterial gas and odor

Tetanus– Lockjaw – Uncommon with the exception of third-world

country immigrants



Other Wound Complications– Impaired hemostasis

Medications can interfere with hemostasis and the clotting process

Aspirin, anticoagulants, fibrinolytics, and penicillins

Abnormalities in proteins involved in the fibrin formation cascade may result in delayed clotting

Hemophilia


Other Wound Complications

Re-bleeding– Re-bleeding is possible from any wound

Movement of underlying structuresHemorrhage continues in large wounds unnoticedPostoperative wounds

Delayed healing– Patients at risk include:

Diabetics, the elderly, the chronically ill, and the malnourished


Other Wound ComplicationsCompartment Syndrome– Extremity injury

causes significant edema and swelling in the deep tissues

– Pressure in the compartment will rise

Results in decreased blood flow and ischemia


Other Wound Complications

Abnormal Scar Formation– Keloid– Hypertrophic scar formation

Associated with dynamic skin tension lines Flexion joints

Pressure Injuries– Caused by prolonged compression of the skin and

tissues beneath – Compressed tissue induces hypoxic injury



Crush Injury– Body tissues subjected to severe compressive

forces– A crush injury disrupts the body’s tissues

Creates an excellent growth medium for bacteria

– Tissue hypoxia and acidosis may result in muscle rigor


Crush Injury

Associated Injury– Additional fractures – Open or closed soft-tissue injuries – Direct injury

Blunt and penetrating

– Dehydration and hypothermia



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

Resultant release of metabolic byproducts traumatic rhabdomyolysis

– By-products of cellular destruction MyoglobinPhosphate and potassium Lactic acid Uric acid



Injection Injury– High-pressure line

bursts– Injects fluid or other

substance into skin and into subcutaneous tissue


Dressing and Bandage Materials



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

Self-adherent Roller Bandage– Kerlex/Kling

Multi-ply, stretch: 1–6”

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

Adhesive BandagesElastic (Ace) BandagesTriangular Bandages


Assessment of Soft-Tissue Injuries



Scene Size-up– Rule out or eliminate

any threats to yourself or fellow care providers

– Determine the mechanism of injury

– Standard Precautions



Initial Assessment– Establishing manual cervical in-line immobilization– Form a general impression– Assess the airway, breathing, and circulation – Correct any immediate threats to the patient’s life



Focused History and Physical Exam– Significant MOI

Rapid trauma assessmentPerform a swift evaluation of the patient’s head, neck, chest, abdomen, pelvis, extremities, and posterior body Confirm the decision either to transport the patient immediately with further care provided en route to the hospital



Focused History and Physical Exam– No significant MOI

Focused trauma assessmentUse the examination techniques of inquiry, inspection, and palpation to evaluate the injury and the surrounding area

Check the distal extremity for pulses, capillary refill, color, and temperature

Transport Decision



Detailed Physical Exam– Detailed exam should follow a planned and

comprehensive process – The detailed physical exam is usually performed

during transport Never delay transport to perform it



Assessment Techniques– Inquiry

The mechanism of injury, any pain, pain on touch or movement, and any loss of function or sensation specific to an area

– InspectionCarefully observing a particular body region

– PalpationPalpate the body’s entire surface



Ongoing Assessment– Reassess the patient’s mental status, airway,

breathing, and circulation – Inspect any interventions you have performed – Perform at least every 5 minutes with unstable

patients – Perform at least every 15 minutes with stable

patients


Management of Soft-Tissue Injury



Objectives of Wound Dressing and Bandaging– Hemorrhage control

Direct pressureElevationPressure pointsConsider

IceConstricting bandTourniquet


Management of Soft-Tissue Injury - Tourniquet

Do– 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 possibleIf wound is grossly contaminated, consider cleansing

– ImmobilizationPrevents movement and aggravation of woundDo not use an elastic bandage: TQ effectMonitor 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 IVP every 5 minutes up to a total of 10 mg given.

Fentanyl (Sublimaze)25–50 mcg IVP 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

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 woundPressure 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 from ears or nose



Neck– Consider circumferential bandage

Protect trachea and carotidsC-collar and dressing

– Occlusive dressing if lacerated vessel

Shoulder– Take care to avoid pressure

Axillary arteryTracheaAnterior neck



Trunk– Minor wounds: Dressing

and tape– Major wounds:

Circumferential wrapLadder splint behind back and wrap gauze over it

Groin and Hip– Bandage by following

contours of body– Movement can increase

tightness of bandage© Ray Kemp/911 Imaging



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:

PulseMotorSensation

– Developing ischemia:PainPallorTinglingLoss of pulseDecreased capillary refill


Care of Specific WoundsAmputations– Patient

Control bleeding Consider tourniquet Do not delay transport

– Amputated PartDry cooling and rapid transportPart in plastic bag (double bag)Immerse in cold waterAvoid direct contact between tissue and cold water


Care of Specific WoundsImpaled Objects– Stabilize with bulky dressing in place– Prevent movement of object– Consider cutting or shortening large impaled

objects– Consider removal if:

In cheek and interferes with airwayInterferes with CPR


Care of Specific Wounds Crush Syndrome– Anticipate problems– Victims of prolonged entrapment– Ensure that scene is safe– 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


Care of Specific Wounds

Crush Syndrome– Management

IV: 20–30 mL/kg of NS or D51/2 NSAVOID LR or K+ based solutions

After bolus, continuous infusion of 20 mL/kg/hrConsider sodium bicarbonateConsider calcium chloride:

500 mg IVPCounteracts hyperkalemia

Consider diuretics:Mannitol (Osmotrol)Furosemide (Lasix)


Care of 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


Care of Specific Wounds

Compartment Syndrome (cont.)– Management

Care of underlying injurySplint and immobilize all suspected fracturesCold packs to severe contusions:

Most effective prehospital managementReduces edemaPrevents ischemia


Special Anatomical SitesFace and Neck– Potential for airway obstruction or compromise– Aggressive suctioning and oxygenation– Consider intubation:

Verify ET tube placementEnsure tube remains in the airway by using continuous waveform capnographyIf excessive swelling or damage:

Needle or surgical cricothyroidotomy


Special Anatomical Sites

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

organs– NEVER explore a wound internally– Alert for:

Subcutaneous emphysemaPneumothorax or hemothoraxTension pneumothorax

– Consider occlusive dressing sealed on 3 sides


Special Anatomical Sites

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/Release

Typically requires on-line medical direction– Evaluate and dress wound– Inform the patient about:

Preventing infectionFollow-up care with a physician Inquire about tetanus and inform of risks

– Document treatment, referral, and teaching


Summary

Introduction to Soft-Tissue InjuriesAnatomy and Physiology of Soft-Tissue InjuriesPathophysiology of Soft-Tissue InjuryDressing and Bandage MaterialsAssessment of Soft-Tissue InjuriesManagement of Soft-Tissue Injury

bledsoe et al., paramedic care: principles & practice, volume 4: trauma emergencies, 3rd. ed. ©...

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