CHAPTER 24: SOFT TISSUE INJURIES

PATIENT ASSESSMENT & CARE II

EMS 246

Dr.Bushra Bilal

The Anatomy and Physiology of the Skin

• Skin has two principal layers: the epidermis and the dermis.

• Functions:Keeps pathogens outAssists in temperature regulationNerves in skin report to brain on environment and sensations.

Pathophysiology

• Three types of soft-tissue injuries:

Closed injuries

Open injuries

Burns

Closed Injuries (1 of 2)

Characteristics of closed injuries

History of blunt trauma

Pain

Swelling

Discoloration

Closed Injuries (2 of 2)

A contusion (bruise) causes bleeding beneath the skin but does not break the skin.

A hematoma is blood collected within damaged tissue or in a body cavity.

A crushing injury occurs when a great amount of force is applied to the body

Compartment syndrome results from the swelling that occurs whenever tissues are injured.

Open Injuries (1 of 5)

• Four types:

Abrasions

Lacerations

Avulsions

Penetrating wounds

Open Injuries (2 of 5)

• An abrasion is a wound of the superficial layer of the skin.

Caused by friction when a body part rubs or scrapes across a rough or hard surface

Open Injuries (3 of 5)

• A laceration is a jagged cut.

Caused by a sharp object or blunt force that tears the tissue

• An incision is a sharp, smooth cut.

Open Injuries (4 of 5)

• An avulsion separates various layers of soft tissue so that they become either completely detached or hang as a flap.

Often there is significant bleeding.

• An amputation is an injury in which part of the body is completely severed.

Open Injuries (5 of 5)

• A penetrating wound is an injury resulting from a sharp, pointed object.

Patient Assessment of Closed and Open Injuries

• Patient assessment steps

Scene size-up

Primary assessment

History taking

Secondary assessment

Reassessment

Scene Size-up

• Scene safety

Observe the scene for hazards and the potential for violence.

Take standard precautions.

• Mechanism of injury/nature of illness

Look for indicators of the MOI as you assess the scene.

Primary Assessment

• Form a general impression.

Check for responsiveness using the AVPU scale.

• Airway and breathing

Ensure that the patient has a clear and patent airway.

Inspect and palpate the chest for DCAP-BTLS.

• Circulation

Assess the patient’s pulse rate and quality.

Determine the skin condition, color, and temperature, and the capillary refill time.

• Transport decision

History Taking

• Investigate the chief complaint.

Obtain a medical/ SAMPLE history.

• Typical signs of an open injury include:

Bleeding

Break(s) in the skin

Shock

Hemorrhage

Disfigurement or loss of a body part

Secondary Assessment

• Physical examinations

Check the skin’s color and condition

Check for any signs of increased respiratory effortsRetractions, Nasal flaring, Pursed lip breathingUse of accessory muscles

Listen for breath sounds.

Assess pulse rate, quality, capillary refill time

Determine the skin condition, color, and temperature.

Assess the neurologic and musculoskeletal system

• Vital signs

Reassessment

• Repeat the primary assessment.

• Reassess vital signs and the chief complaint.

• Interventions

Assess the patients’ ABCs, control bleeding.

• Communication and documentation

Description of the MOI/Position in which you found the patient

Amount of blood loss

Location and description of any soft-tissue injuries or other wounds

Emergency Medical Care for Closed Injuries

• Treat closed soft-tissue injury using the RICES mnemonic:

Rest

Ice

Compression

Elevation

Splinting

Emergency Medical Care for Open Injuries (1 of 4)

• Follow standard precautions.

• Make sure the airway is open and administer high-flow oxygen.

• Control life-threatening bleeding using:

Direct, even pressure and elevation

Pressure dressings and/or splints

Tourniquets

Emergency Medical Care for Open Injuries (2 of 4)

• Abdominal wounds

An open wound in the abdominal cavity may expose internal organs.

The organs may even protrude through the wound, an injury called evisceration.

Cover the wound with sterile gauze.

Secure with an occlusive dressing.

Keep the organs moist and warm.

Emergency Medical Care for Open Injuries (3 of 4)

• Impaled objects

Only remove an impaled object when:• The object is in the cheek and obstructs breathing.• The object is in the chest and interferes with CPR.

• Neck injuries

Open veins may suck in air and cause cardiac arrest.

Cover the wound with an occlusive dressing.

Apply pressure but do not compress both carotid arteries at the same time.

Emergency Medical Care for Open Injuries (4 of 4)

• Small-animal bites

Wounds may require:• Antibiotics• Tetanus prophylaxis• Suturing

• A major concern is the spread of rabies.

Acute, potentially fatal viral infection of the central nervous system

Can affect all warm-blooded animals

Transmitted through biting or licking an open wound

Burns

• A burn occurs when the body receives more radiant energy than it can absorb.

Sources of this energy include heat, toxic chemicals, and electricity.

• Complications : Infection

Hypothermia

Hypovolemia

Shock

Burn Severity (1 of 5)

• Burn severity depends on:Depth of burn

Extent of burn

Critical areas involved

(Face, upper airway, hands, feet, genitalia)

Patient younger than 5 or older than 55

Burn Severity (2 of 5)

• Depth

Superficial (first-degree) burns• Only the top layer of skin

Partial-thickness (second-degree) burns• Epidermis and some portion of the dermis• Blisters are present.

Full-thickness (third-degree) burns• Extend through all skin layers.

Burn Severity (3 of 5)

Burn Severity (4 of 5)

• ExtentCan be estimated using the rule of nines

Divides the body into sections, each representing approximately 9% of the total body surface area

Proportions differ for infants, children, and adults

Burn Severity (5 of 5)

Chemical Burns

• Can occur whenever a toxic substance contacts the body e.g. strong acids or strong alkalis

• Management

Remove any chemical from the patient.

Remove the patient’s clothing.

For liquid chemicals, immediately begin to flush the burned area with lots of water.

Continue flooding the area for 15 to 20 minutes after the patient says the burning pain has stopped.

Electrical Burns

• May be the result of contact with high- or low-voltage electricity

• Your safety is of particular importance.

Never attempt to remove someone from an electrical source unless you are specially trained to do so.

• Management

If indicated, begin CPR on the patient and apply an AED.

Give supplemental oxygen and monitor.

Provide prompt transport.

Thermal Burns

• Caused by heat

• Management

Stop the burning source, cool the burned area, and remove all jewelry.• A dry dressing applied to• Maintain body temperature• Prevent infection

Inhalation Burns

• Can occur when burning takes place in enclosed spaces without ventilation

Carbon monoxide intoxication should be considered whenever a group of people in the same place all report a headache or nausea.

Radiation Burns (1 of 2)

• Three types of ionizing radiation:

Alpha

Beta

Gamma• Very penetrating, easily passes through the body and

solid materials

Radiation Burns (2 of 2)

• Management

Irrigate open wounds.

Notify the emergency department.

Identify the radioactive source and the length of the patient’s exposure to it.

Limit your duration of exposure.

Increase your distance from the source.

Patient Assessment of Burns

• Patient assessment steps

Scene size-up

Primary assessment

History taking

Secondary assessment

Reassessment

Scene Size-up

• Scene safety

Observe the scene for hazards and safety threats.

• Mechanism of injury/nature of illness

Determine the type of burn that has been sustained and the MOI.

Primary Assessment (1 of 2)

• Form a general impression.

Be suspicious of clues that may indicate abuse.

Check for responsiveness using the AVPU scale.

• Airway and breathing

Ensure that the patient has a clear and patent airway.

• Inspect and palpate the chest wall for DCAP-BTLS

Primary Assessment (2 of 2)

Circulation

Assess the pulse rate and quality.

Observe the patient’s skin condition, color, temperature, and capillary refill time.

Control significant bleeding.

Assess for shock.

• Transport decision

Consider quickly transporting a patient who has:• An airway or breathing problem• Significant burn injuries/ external bleeding• Signs and symptoms of internal bleeding

History Taking

• Investigate the chief complaint.

• SAMPLE history

Secondary Assessment

• Physical examinations

Perform a full-body scan.

Make a rough estimate, using the rule of nines, of the extent of the burned area.

Determine the severity of the burn.

Package the patient for transport.

Assess the patient’s neurologic, respiratory and musculoskeletal system.

Reassessment

• Repeat the primary assessment and reassess the patient’s vital signs.

• Reassess the chief complaint.

• Reevaluate interventions

Assess and treat breathing.

Support circulation.

Provide rapid transport.

• Communication and documentation

Provide hospital personnel with a description of how the burn occurred.

Dressing and Bandaging (1 of 2)

• All wounds require bandaging.

Sometimes splints can help control bleeding and provide firm support for dressing.

Dressing and Bandaging (2 of 2)

• Dressings and bandages have three functions:

To control bleeding

To protect the wound from further damage

To prevent further contamination and infection

Sterile Dressings

• Most wounds will be covered by:

Universal dressings

Conventional gauze pads

• Universal dressings are ideal for covering large open wounds.

• Gauze pads are appropriate for smaller wounds.

• Adhesive-type dressings are useful for minor wounds.

• Occlusive dressings prevent air and liquids from entering (or exiting) the wound.

SUMMARY

There are three types of soft-tissue injuries: closed injuries, open injuries, and burns.

Closed soft-tissue injuries are characterized by a history of blunt trauma, pain at the site of injury, swelling beneath the skin, and discoloration. Contusions, hematomas, and crushing injuries are classified as closed injuries.

Treat a closed soft-tissue injury by applying the mnemonic RICES: Rest, Ice, Compression, Elevation, and Splinting.

SUMMARY

Open injuries differ from closed injuries in that the protective layer of skin is damaged. Abrasions, lacerations, avulsions, and penetrating wounds are classified as open injuries.

Treat an open soft-tissue injury by applying direct pressure with a sterile bandage using a roller bandage, and splint the extremity.

Burns are considered to be superficial, partial-thickness, or full-thickness based on the depth involved.

SUMMARY

When providing emergency care for burns: Use standard precautions. Cool burned area to prevent further damage. Remove jewelry and constrictive clothing. Ensure an open and clear airway, provide high-flow oxygen, Place sterile dressings over the burned area, cover patient with a

blanket, and transport promptly.

Dressings and bandages are designed to control bleeding, protect the wound from further damage, prevent further contamination, and prevent infection.

UNIT ASSESSMENT

What does the acronym RICES stand for?

Describe the steps used to control bleeding from an open soft-tissue injury.

When would it be appropriate to remove an impaled object?

 What are the critical areas of the body relating to burns?