Soft Tissue Injuries

Equipment

Dressing v Bandages

• Dressings• Function

• Stop bleeding• Protect the wound from further injury• Prevent further contamination/infection

• Types• Universal dressings• 4X4 gauze pads• Adhesive-type• Occlusive

• Bandages• Function

• Holds dressings in place• Types

• Self adherent• Gauze rolls• Triangular bandages/Cravats• Adhesive Tape• Air splint

Soft Tissue Injuries the Skin

Integumentary System Skin

• Function• Largest organ system in the body• Protection from environment • Temperature regulation• Senses

• Heat, Cold, Touch, Pressure, Pain, etc. • Vitamin D synthesis• Storage

• Structure• Epidermis

• Outermost layer• No blood vessels• Protection, absorption of nutrients homeostasis

• Dermis• Deeper layer• Contains sweat/sebaceous glands, hair folicles, blood vessels, nerve endings• Gives skin its flexibility

• Subcutaneous layer• Fat layer• Insulation, protective padding, energy storage

Soft Tissue InjuriesTypes

• Closed• Skin is not broken• Underlying tissue damage• “Leaky vessels” = Edema • Contusion/Hematoma

• Open• Any wound that breaks the skin• Slight scrapping of skin --- amputation

Closed Injuries

• Contusion (Bruise) • Epidermis remains intact• Cells and vessels are damaged in dermis• Swelling and pain • Blood accumulated

• Hematoma • Collection of blood beneath the skin• Larger tissue damage than contusion• Larger vessels are damaged• 1 + Liter of blood loss

• Crush injuries • Crushing force applied to body• Internal organ rupture• Internal bleeding may be severe = Shock

Soft Tissue InjuriesClosed Injuries

Contusion Hematoma Crush InjuryHematoma

Care of Closed Injuries

• BSI• Gloves

• Airway control• Ventilation• If shock or internal bleeding suspected

• Treat for shock

• Splint painful, deformed, swollen extremities • Transport

Soft Tissue InjuriesOpen Injuries

• Abrasion• Outermost layer of skin is sheered off• Painful even though superficial• No/very little oozing of blood

• Laceration• Break in skin of varying depth• May be linear or non linear• Caused by forceful impact with sharp object• Bleeding may be severe

• Avulsion• Flap of skin/tissue is torn loose or torn off

Soft Tissue InjuriesOpen Injuries

Abrasion Laceration Avulsion

Soft Tissue InjuriesOpen Injuries

• Penetration/Puncture• Caused by sharp pointed object• May be no external bleeding• Internal bleeding may be severe• Exit wound may/may not be present

• I.e. Gunshot wound, Stab wound• Amputation

• Cutting away from the body of a limb/protruding structure• Extremities and other body parts• Massive bleeding may be present OR• Bleeding may be controlled

• Crush Injury• Damage to soft tissue and internal organs• May cause painful, swollen, deformed extremities • External bleeding may be present of absent • Internal bleeding may be severe

Soft Tissue InjuriesOpen Injuries

Penetration/Puncture Amputation Crush Injury

Care of Open Injuries

• BSI• Gloves – Gowns – Eye protection

• Maintain airway/Ventilation• Expose the wound• Control bleeding• Prevent further contamination• Apply dry sterile bandage to wound• Secure in place• Keep pt calm/quiet• Treat for shock if S/S present

Special Cases: Chest/Abdomen/Impalement

Penetrating Chest Injury

GSW

Evisceration Impaled Object Impaled ObjectEvisceration

Chest Injuries

• Flail Segment• Traumatic Asphyxia • Pneumothorax

• Open- “Sucking Chest Wound”

• Closed

• Hemothorax• Pericardial Tamponade

Flail Segment

• Definition:• 4 or more ribs broken in 2 or more places• Results in an unstable chest

• Presentation:• Paradoxical motion

• Movement of flail segment inward with inspiration and outward with exhalation • “Splinting”

• Patient reduces motion of the chest wall• Dyspnea • Pain

• Complications• Hemothorax• Pneumothorax • Abdominal organ laceration/rupture

• Treatment• O2• Apply bulky trauma dressing to injured area and secure in place OR• Place patient with injured side down OR• Place padded board splint over injured area and secure to adjacent ribs • Assisted ventilations

Traumatic Asphyxia

• Definition:• Severe compression of the thorax• Blood within the veins are drive into:

• Upper Thorax, Neck, Brain• Presentation:

• Sever swelling and ecchymosis of the face• “Air hunger”• DCAP-BTLS to chest

• Complications:• Underlying injury

• Treatment:• O2• Positive pressure ventilation • Rapid transport

Pneumothorax

• Definition:• Collection of air in the pleural space• Results in a collapsed lung

• Types:• Open

• Penetration of the chest• “Sucking Chest Wound”

• Closed• Pneumothorax without an open wound to the chest

• Tension • Air entering the chest becomes trapped • Increases intrathoracic pressure• Collapses lung and shifts thoracic contents away from injury• Closed and open pneumothorax can present

Normal AnatomyInjury resulting in pneumothorax

Pneumothorax S/S, Treatment

• S/S• SOB• Chest pain• Absent/diminished lung sounds on injured side • Subcutaneous emphysema • Cyanosis • Tracheal deviation• Profound shock• JVD

• Complication:• Reduced surface area of lung =Hypoxia • Kinking of vena cavae = Reduced blood volume = Shock

• Treatment:• O2• Ventilatory assistance if needed• See next slide for “Sucking Chest Wounds” if Open pneumothorax • Rapid transport

Sucking Chest Wound:Treatment

• Cover with gloved hand initially• Ask patient to forcefully exhale• Place an occlusive dressing over the wound• Tape on 3 sides

Occlusive Dressing

Complete Seal with an Occlusive Dressing

Hemothorax

• Definition:• Injured blood vessel in thorax• Blood accumulates in pleural space

• Presentation:• Pneumothorax S/S• Shock• Flat neck veins• Diminishes/distant lung sounds• Tachypnea

• Complication:• Shock• Cardiac collapse/arrest

• Treatment:• O2• Treatment for shock• Rapid transport

Pericardial Tamponade

• Definition:• Collection of blood/fluid in the pericardium

• Presentation:• Beck’s Triad

• Muffled heart sounds• Narrowing pulse pressures

• Systolic BP- Diastolic BP• 40mmHg or less

• Shock• Pulsus Paradoxus

• A BP drop of 1OmmHg on inhalation • Complications:

• Decreased stroke volume • Shock• Cardiac collapse/arrest

• Treatment:• O2• Prepare for arrest• Rapid transport

Abdominal Injuries: Evisceration

• Definition: • Organs protruding through

wound• Treatment:

• DO NOT TOUCH OR REPLACE the organ

• Cover with a sterile dressing moistened with sterile water

• Cover with a dry sterile dressing and tape in place

• Cover with plastic wrap• Tape completely around the

border of the dressing • Flex the pts hips and knees, if

uninjured

Impaled Objects

• DO NOT REMOVE unless:• It is in the cheek

• Bleeding control inside and outside of cheek

• Keep suction ready • Would interfere with chest

compressions• Interferes with transport

• Treatment:• Manually secure the object• Expose the wound area• Control bleeding• Use a bulky dressing to

help stabilize the object

Soft Tissue InjuriesAmputations/Neck Wounds

Open neck wound Air embolism…

Amputations/Neck WoundsTreatment

• Amputations• Concerns for reattachment• Wrap the part in a sterile dressing• Wrap or bag the part in plastic and keep cool• Transport part with the pt• DO NOT COMPLETE PARTIAL AMPUTATIONS• Immobilize to prevent further injury

• Large open neck injuries• May cause air embolism• Cover with an occlusive dressing• Compress carotid artery ONLY if NECESSARY to control bleeding

Eye Injuries

• Impaled Objects:• NEVER REMOVE• Stabilize object with

several 4X4s• Cover with paper

cup/cardboard cone• Have patient close other

eye OR dress it as well.

Burns

• Sources• Thermal – Electrical - Chemical

• Types• Superficial (1st degree)

• Upper level of the skin (epidermis)• Redness and pain

• Sunburn• Partial Thickness (2nd degree)

• Upper and lower level of skin (Epidermis/Dermis)• Does not involve underlying tissue• White to red skin• Moist to mottled • BLISTERS • VERY painful

• Full Thickness (3rd degree)• Extension through upper and lower layers of skin• May involve subcutaneous layers, muscles, or bone• Black/charred red, Yellow/Brown, Dark red, White/Translucent • Hard to touch • Little pain, pain from associated 1st and 2nd degree burns

Burn SeverityRule of 9’s

• Depth of burn• Superficial• Partial thickness• Full thickness

• Percentage of body surface burned

• Rule of 9’s • Pt palm = 1%• Adult

• Head and neck = 9%• Each upper extremity= 9%• Anterior trunk = 18%• Posterior trunk = 18%• Each lower extremity = 18%• Genitalia= 1 %....\

• Child• Head and neck = 18%• Each upper extremity= 9%• Anterior trunk = 18%• Posterior trunk = 18%• Each lower extremity = 14%

• Depth of burn• Superficial• Partial thickness• Full thickness

• Percentage of body surface burned

• Rule of 9’s • Pt palm = 1%• Adult

• Head and neck = 9%• Each upper extremity= 9%• Anterior trunk = 18%• Posterior trunk = 18%• Each lower extremity = 18%• Genitalia= 1 %....\

• Child• Head and neck = 18%• Each upper extremity= 9%• Anterior trunk = 18%• Posterior trunk = 18%• Each lower extremity = 14%

Burn Severity Cont’d

• Location• Face• Upper airway• Hands• Feet• Genitalia

• Pre existing medical conditions

• Age of pt• Less than 5 y/o• Greater than 55 y/o

Criticality of Burns

• CRITICAL BURNS• Body Surface Area

• Full thickness – 10%• Partial thickness- 30%

• Location• Full thickness Hands/Feet• Burns assoc with resp. injury

• Complications• Burns encompassing any body part

• i.e. –Leg, -Arm, -Chest • Painful, swollen, deformed

extremity• Age

• Moderate burns of • Young Children• Elderly pts

• Moderate Burns• Body Surface Area

• Full thickness- 2-10%• Excludes: - Hands –Feet – Face –

Genitalia – Respiratory tract• Partial Thickness- 15-30%• Superficial burn – Greater than

50%• Minor Burns • Body Surface Area

• Full thickness- 2-10%• Excludes: - Hands –Feet – Face –

Genitalia – Respiratory tract• Partial Thickness- 15-30%• Superficial burn – Greater than

50%

Burn Care

• Stop the burning process, initially with water/saline• Remove smoldering clothing/jewelry• BSI• CONTINUALLY monitor airway for compromise• Prevent further contamination• Cover the burned area with a DRY sterile dressing• Do no use any lotion, ointment, or antiseptic• Do not break blisters• Transport• Refer to local protocols for transport decision

Electrical Burns

• SCENE SAFE• Do not remove pt from source

unless trained to do so• If pt still in contact with source

or you are unsure… DON’T touch the pt

• Emergency Care• O2• Monitor CLOSELY for

respiratory and/or cardiac arrest

• Often more severe than external indications

• Treat associated soft tissue injuries

• Note entrance and exit wounds

Chemical BurnsCare

• SCENE SAFETY• BSI• Emergency Care

• Dry Powders = Brush off• Flush with large amounts of water

• 20 minutes

• Continue flushing area while en route• Do not contaminate uninjured areas

Soft Tissue InjuriesInfant/Child Considerations

• Concerns • Greater surface area v body size• Greater fluid/heat loss• Higher risk of

• Shock• Hypothermia• Airway compromise

• Consider possibility of child abuse• Critical Burn Values

• Critical• Full Thickness OR Partial thickness – greater than 20% • Hands, feet, face, genitalia, or airway

• Moderate• Partial thickness greater than 10-20%

• MinorPartial thickness – less than10%

Now go and treat soft tissue injuries….

Reason #1 why you’re supposed to wear a helmet!