Upload
balin
View
125
Download
0
Tags:
Embed Size (px)
DESCRIPTION
Soft Tissue Injury. April Morgenroth RN, MN David Peck RN, ARNP. Soft Tissue Defined. Soft tissues are structures of the body that connect, envelope, provide support, or move the structures around it. Examples: skin, muscle, fat. The Integumentary System. Hair. - PowerPoint PPT Presentation
Citation preview
Soft Tissue Injury
April Morgenroth RN, MNDavid Peck RN, ARNP
Soft TissueDefined
Soft tissues are structures of the body that connect, envelope, provide support, or move the structures around it.Examples: skin, muscle, fat
The Integumentary SystemIncludes all external coverings of the body
HairSkin Exocrine Glands
Protects body from infectionThermoregulationHelps to maintain fluid
balanceHelps to maintain electrolyte
balance
Function:
Skin
Hair
Skin is composed of three layers:
Epidermis: outermost layer of cells, contains melanin, gives skin pigment
Dermis: bottom layer of skin, contains blood vessels, connective tissue, nervesSubcutaneous layer: fatty tissue, stores nutrients
www.cawc.net/images/skin-sm.jpg
Soft Tissue Trauma
Fat/Adipose Tissue
The most vulnerable soft tissue to trauma and infection.
Adipose soft tissue heals more slowly Poor vascularity Limited capacity to form collagen
and tensile bonds.
ages.com
Soft Tissue Trauma Open vs. Closed
Open Soft Tissue Trauma: Outer most layer of skin is open. Damage may be only on the surface or it may be deep past the skin and fatty tissues.
Closed Soft Tissue Trauma: Inner layers of soft tissue are damaged but the outer most layer remains intact .
http://images.google.com/imgres?imgurl=http://www.cheneyhs.org/clubs/sportsmed/pics/injuries/thumbs/headhematoma-thmb.jpg
Classification of Soft Tissue InjuryAbrasion: epidermal and dermal layers
are affected. The injury is caused by friction.
Avulsion: skin flap, the edges cannot be approximated
Laceration: Tearing or splitting of the skin, can involve the fatty tissues as well
http:/www.healthatoz.com/healthatoz/Atoz/images/ency/00042924.jpg/
Degloving: large amounts of skin are torn away from the vascular supply
http://www.primary-surgery.org/ps/vol2/html/images/img-0054.png
Classification of Soft Tissue Injury
Contusion: damage to small blood vessels causes bleeding into the tissue, skin remains intact
http://sportsnmedicine.blogspot.com/2007_08_01_archive.html
Puncture: an open wound that tears through skin and damages underlying tissues. These wounds can be shallow or deep and some may even have an entry point and an exit point.
Soft Tissue Trauma Gunshot Wound Vocabulary
Wounds by projectiles are determined by size of the projectile, the force/velocity at entry, the density of the tissue and shape and design of the missile
Tumble & Yaw - how the bullet turns while inside tissue
Cavitation - the internal size of the wound tract
Speed - Lead bullet cores melt when propelled above a velocity of 2000ft/sec. causing internal burns as well as cavitation on entry
Cavitation tracts from various projectiles
Soft Tissue Trauma Gunshot Wound Vocabulary
Entry & Exit wounds- Two holes may indicate two separate gunshot wounds or the path that one bullet took through and out of tissue. Observing and documenting these wounds is an important trauma function.
Gunshot crepitis- Gasses injected into the tissues on bullet impact may become lodged there and cause a popping crepitis on palpation
Gunpowder tattoos- Residual gunpowder may burn the tattoo the skin surrounding the entry and exit wounds. Washing powder off during wound care may lessen this deformity
Wound Healing
“Golden Window for wounds” - 12 hours
Wounds closed/sutured open more than 12 hours following trauma display profound increases in
infection failed closure significant cosmetic deformity
• nevamwiti.com
Stages of Wound HealingPhase I Inflammatory Response- Day 1-5
A.D.A.M.
1. Plasma protein, blood cells, fibrin & antibodies flow into the wound.
2. Within 4 hours leukocytes causes localized edema, pain, & erythema.
3. Leukocytes and macrophages ingest & remove debris.
4. Skin margin basal cells begin migration over incision to close the wound.
5. Connective tissue fibroblasts begin reconstruction of non-epithelial tissue.
Stages of Wound HealingPhase II Migration/Proliferation- Day 5-14
1. Collagen, fibrin & fibronectin contract wound margins & initiate scar formation.
2. Tensile strength of the affected tissue increases, sutures are not needed for wound closure.
3. Lymphatics, blood vasculature and granulation tissues regenerate.
www.birminghammail.net
Stages of Wound HealingPhase III Maturation/Remodeling Day 14- complete healing
1. Tensile strength increases up to one year. Skin tissue regains 70-90% of it’s original strength Intestinal tissue may regain 100% of original strength within one
week!
2. Fibrous connective tissue stratifies to increase pliability 3. Scar structure remodels and retracts. A.D.A.M
Stages of Wound HealingDelayed Closure-
Some wounds are not able to be sutured closed because of extensive trauma, infection, tissue loss, or imprecise initial closure of wound.
These wounds are kept open to allow for drainage &prevent closed (anaerobic) pockets from forming, as in puncture wounds.
(note granulation of tissue margins)
Care of Open Soft Tissue Injury
Ensure a patient airway
Evaluate patients respiratory status
Note respiratory rateNote work of breathing
(labored, use of accessory muscles)
Care of Open Soft Tissue Injuries
Evaluate for signs of circulation and major bleeding
Control bleeding using appropriate method, stabilize impaled objects
www.through-the-maze.org.uk/.../blood_test.gif
Ensure fluid and electrolyte balanceCheck hematocrit and
electrolytes in the presence of any major injury
Open Wound Management Wound Assessment
following stabilization of patient
Observe for foreign objects in wound Note debris & cues to trauma source (glass
shards/dirt/bite marks) Assess for parasthesia/paralysis Monitor for pallor/pulselessness distal to
wound Observe deformity, contusion, other
ruptures of skin integrity, swelling Assess & manage pain (analgesics or local
block) Document wound depth, size, location &
appearance
Open Wound Management
The following categories can be used to describe & document wound characteristics based on a clinical estimation of microbial contamination
& risk for subsequent infection.
Clean Mechanism of injury relatively clean- knife/glass/plastic/milled wood
Clean/Contaminated Appears clean, but known contact with soil, stagnant water, feces
Contaminated (“dirty”) Visible debris in wound, possible foreign body
Contaminated and Infected Foul odor, signs of infection, visible debris or foreign body
Wound Cleansing & Care
Use normal saline if available, avoid tap water
Antimicrobial surgical scrub- Betadine
Scrub with soft brush or gauze, from the center of the wound out
Irrigate wound liberally and frequently
Consider antibiotics
The Solution to Pollution is Dilution! isips.org
Care of Open Soft Tissue Injuries
Evaluate the need for suturesWound is a deep and/or gaping
laceration, avulsion, or incision where the edges can be approximated
Skin grafts may be needed for major degloving injuries or major burns.
Tetanus (lockjaw)-
Non-immunized trauma victims with open wounds face a significant risk for tetanus.
A spore forming anaerobic bacteria Found in soil and the feces of domesticated animals Endemic in developing areas
(In Mexico, tetanus immunization is inconsistent. Rates of infections are unreported.
CDC, 2009).
Cedarcrest.edu
Tetanus Immunization
Tetanus can be prevented in trauma patients through prophylactic treatment
Trauma victims with high-risk wounds may be given tetanus immune globulin (TIG) in addition to tetanus toxoid if their immunization status is unknown or not current
Tetanus toxoid ‘booster’ at least every 10 years, every 5 years in cases of tetanus-prone exposures
Assessment and documentation of immunization status and tetanus-prone wounds is a vital component of trauma care
Tetanus Prone WoundsClinical Features Non-Tetanus Prone
WoundsTetanus-Prone Wounds
Age of Wound ≤ 6 hours > 6 hours
Configuration Linear, abrasions Stellate wound, avulsions
Depth ≤ 1 cm > 1cm
Mechanism of injury Sharp surface (knife, glass)
Missile, crush, burn, frostbite
Sign of infection Absent Present
Contaminants (dirt/feces/soil/saliva)
Absent Present
Denervated/ischemic tissue
Absent Present
Soft Tissue Trauma- Respiratory
Types of Pneumothorax-Simple pneumothorax- a portion of the inflated lung pulls away from the pleural wall causing a partial collapse
Treatment- Chest tube (small pneumothorax may be allowed to
reinflate spontaneously)
Hemothorax- blood fills a portion of space between lung tissue & the pleural wall. Blood loss into the pleural cavity can be up to 1/3 total blood volume
Treatment- Chest tube If large volume of blood is retrieved, auto
transfusion is performed to return the patient blood volume. Surgical thoracotomy may be required to stop hemorrhage resolve accompanying tamponade
Tension PneumothoraxA Medical Emergency Air is forced through a
“one way valve” through the lung tissue into the pleural space
Lung collapse Mediastinal shift Limited cardiac circulation Applies pressure on the
remaining lung with risk of complete respiratory collapse
Treatment is Needle Decompression: large bore needle is inserted into the second intercostal space at the midclavicular line- converting the defect to a simple pneumothorax. Then a chest tube is inserted.
Chest trauma can sometimes result in blood or other fluids collecting in the pericardium
Pressure builds up and restricts movement of the heart
Signs and symptoms: anxiety, chest pain, shortness of breath, narrowing pulse pressure, signs of poor perfusion, death
This an emergency, call the physician immediately
Monitor closely, obtain IV access, give supplemental oxygen
services.epnet.com/getimage.aspx?imageiid=6512
history.amedd.army.mil/.../chapter2figure20.jpg
The physician will need to perform a pericardiocentesis.
Tamponade
Sucking Chest Wound
http://www.armystudyguide.com/content/moxiepix/b3_2237.gif
A puncture to the thoracic wall that communicates with the pleural space may cause a sucking chest wound
When the patient inhales, intrathoracic pressure drops below atmospheric pressure creating a vacuum which sucks air into the pleural space. (Air will also escape the pleural space to some degree following pressures)
Pressure in the pleural space builds and the lung begins to collapse. The patient now has a pneumothorax.
Sucking Chest Wound Evaluation and Treatment Make a three way occlusive
dressing This makes a one way valve They will need a chest tube Use the sterile side of plastic
packaging that contained something sterile
Plastic bag…. Tape down three sides
Soft Tissue Trauma- Respriatory
Cardiac Tamponade TensionPneumothorax
Breath sounds
Equal on both sides
Decreased or absent on affected side
Trachea Midline Deviated away from affected side
Percussion Normal resonance
Tympanic (Hyperresonant)
Pulse Affected by breathing
Normal
Tension Pneumothorax & Cardiac Tamponade are: Two very different medical emergencies that present with very similar symptoms-
The diagnosis of each is determined by clinical evaluation you could make in a trauma care setting!
Abdominal Trauma Evaluate for internal bleeding Note any external bleeding Treat for shock If the wound is open and
intestines are exposed (eviscerated organs) use sterile saline on sterile gauze, then cover with plastic
This will be an occlusive dressing
Impaled ObjectsDo not attempt to remove the object
UNLESS: it is in the cheek and is obstrubstructing the airway
If an object in the cheek needs to be removed, gently pull it the rest of the way through
Control bleeding using appropriate methods
Minimize damage to internal organs by stabilizing the object to minimize movement and vibration
Treat patient for shock
Prepare for emergent surgical interventionwww.cprpgh.fanspace.com/images/pencil.jpg
Burns
Three Mechanisms Thermal: caused by heat Chemical: caused by
caustic chemicals Electrical: caused by
electicity (ex. Electical shock)
Burn Classification First Degree/Shallow Thickness: involves just
the outer layer of skin, the skin is reddened, hot, painful but overall the skin is intact
Sunburn, minor scald burns
Treatment: may use aloe on the skin to restore skin moisture and sooth the burn
Prevention is key: protect from intense sun
Images from A.D.A.M.
Burn Classification Continued
Second Degree/Partial Thickness: The damage is deeper and involves more layers. The area may be blistered, red, and painful
Example: hand on a hot stove
Stop the burning!
Do Not: Put ointments on it (this keeps the heat in) Lance the blisters
Images from A.D.A.M.
Burn ClassificationContinued
Third Degree/Full Thickness The burn is full thickness, open, weepy, there
may be nerve damage Keep it clean Dress with dry gauze Protect patient from hypothermia If the burn involves fingers or toes, they will
need to be separated when bandaging
Burn ClassificationEstimation of the
percentage of body area affected by the burns is important as it helps us to make clinical decisions.
Estimate the extent of a burn by using the rule of nines
img.tfd.com/dorland/thumbs/rule_of-nines.jpg
Soft Tissue Burns
Thermal injuries/Smoke inhalation
Clinical indications of inhalation injury Face/neck burns “ Sooty” sputumCarbon deposits and inflammation of oropharynx Singeing of eyebrows and nasal passageHoarseness Impaired mentation after confinement in burning
environmentExplosion with burns to head and torsoThe presence of any of these findings suggests acute inhalation injury
allergyconsumerreview.com
Burns and Breathing Sometimes burns can affect breathing
and the airway (smoke inhalation, swelling)
Inhalation of chemicals and smoke can cause burns and/or damage to the airway and lungs
Protect the airway through: positioning, placement of an artificial airway if needed
Provide supplemental oxygen
www.aic.cuhk.edu.hk/web8/Hi%20res/Burn%202.jpg
www.fotosearch.com/thumb/LIF/LIF131/AWAYBURN.jpg
Soft Tissue BurnsThermal injuries/Smoke inhalationAssessment-
History of burn injury is vital to management
Obtain information from witnesses & victim
Inhalation injury may not appear for 24 hours
Length of exposure to fumes/thermal assault affects severity of injury
Consider internal and orthopedic injuries from explosions, falling debris
Soft Tissue BurnsCarbon Monoxide (CO) -
Always assume CO exposure for patients burned in enclosed areas
CO levels- < 20% rarely result in symptoms> 20% headache & nausea> 30% confusion> 40% coma> 60% death
Patients with CO exposure need 100% O2 because of CO’s ability to bind oxyhemoglobin and cause decreased O2 absorption in the blood
Soft Tissue Burns
Escharotomy –
Incisions through the skin layers in circumferential burns to avoid compartment syndrome
A surgical procedure used to maintain circulation & relieve pressure from massive edema and rigid/non-elastic burned skin (eschar)
Not usually needed within the first 6 hours following burn trauma
Soft Tissue Burns
Fasciotomy -A rare surgical ‘limb saving’ procedure where fascia is removed to relieve pressure and prevent compartment syndrome
In addition to use in deep burns, fasciotomy is also used in the following conditions
Skeletal traumaCrush injuriesHigh voltage electrical injury
Fluid Resuscitation for BurnsIn the case of severe burns the
body looses fluids due to the impaired skin integrity and fluid shifts that naturally occur during inflammation.
The blood may become “sludgy” as fluids are lost but cells are retained, this is sometimes called burn shock
Fluid Resuscitation for Burns
Patients weightX
% body burnedX
4 ml lactated ringers=
Volume needed
Give 50% total amount over the first 8 hours.
Give 25% total amount during hours 8 to 16.
Give the remaining 25% of total volume during hours 16-24
Time for fluid resuscitation begins at the time of the injury.
Use this formula for all patients with airway trauma and patients who have 20% body surface area burned.