1. LESSON 17
SOFT-TISSUE INJURIES

2. Introduction Wounds common with trauma and burns
In open wounds, skin is torn or cut and often bleeding
Muscle and soft tissue may be injured
Open wounds have risk of infection

3. Types of Soft-Tissue Injuries
Type and amount of bleeding depend on wound type, location, depth

4. Closed Wounds No break in skin
Discoloration and swelling from internal bleeding
Musculoskeletal injuries may be present

5. Abrasions Superficial skin layers scraped off Often painful
Underlying tissues not usually injured
Capillary bleeding stops itself
Foreign material can cause infection

6. Lacerations May damage underlying tissue May cause severe bleeding
Laceration through artery may be life-threatening

7. Punctures, Penetrating Wounds
Caused by object penetrating skin and deeper tissues
Little or no external bleeding
Severe internal bleeding
May be both entrance and exit wounds
Likely to trap foreign material
Increased infection risk

8. Avulsions
Skin and soft tissue torn partially from body

9. Traumatic Amputations
Complete cutting or tearing off of all or part of extremity
Part may be surgically reattached

10. Burns
Damage caused to skin and other tissue by heat, chemicals or electricity

11. General Principles of Wound Care
Control serious bleeding after primary assessment
With less serious bleeding, complete assessment and standard patient care first

12. Always Perform Standard Assessment
Size up scene
Complete primary assessment
Take history
Perform secondary assessment and physical examination as appropriate
Complete reassessments

13. Always Perform Standard Patient Care
Ensure EMS has been activated
Use body substance isolation
Maintain patient’s airway
Provide artificial ventilation if needed
Comfort, calm and reassure patient

14. Additional Care for Soft-Tissue Injuries
Use needed BSI precautions
Control bleeding
Cover wound with sterile gauze
Apply direct pressure

15. Additional Care for Soft-Tissue Injuries (continued)
With minor wounds:
Irrigate with large amounts of running water
Irrigate wound to remove foreign matter from wound
Pat area dry, apply sterile dressing, bandage
Prevent contamination with dressing and bandage
If stitches needed or patient’s tetanus vaccination not current, ensure patient receives medical attention

16. Wound Cleaning Alert!
Do not use alcohol, hydrogen peroxide or iodine on wound
Avoid breathing or blowing on wound
Do not attempt to remove clothing stuck to wound; cut around clothing and leave in place
Do not scrub wound

17. Purpose of Dressings Helps control bleeding Prevents infection
Absorbs drainage
Protects wound while healing

18. Types of Dressings Sterile gauze pads Roller gauze
Non-stick gauze pads
Adhesive strips
Bulky
Occlusive
Improvised

19. Improvising Dressings
If sterile dressing not available, use clean cloth
Non-fluffy cloth less likely to stick
Use clean towel, handkerchief, other material
Avoid cotton balls or cotton cloth
For bulky dressings, use sanitary pads, towels, baby diapers or many layers of gauze

20. Ring Dressing Don’t put direct pressure over:
Skull fracture
Fractured bone protruding from a wound
Object impaled in wound
Control bleeding with pressure around object or fracture

21. Guidelines for Using Dressings
Wash hands and wear medical examination gloves
Choose dressing larger than wound
Do not touch part of dressing that will touch wound
Lay dressing on wound, cover whole wound

22. Guidelines for Using Dressings (continued)
If blood seeps through, do not remove dressing but add more on top
Use direct pressure to control bleeding if needed
Apply bandage to hold dressing in place

23. Purpose of Bandages Cover a dressing Keep dressing in place on wound
Maintain pressure to control bleeding
Support or immobilize musculoskeletal injury

24. Types of Bandages Adhesive compresses Adhesive tape rolls Tubular
Elastic roller
Self-adhering
Gauze roller
Triangular
Improvised

25. Guidelines for Bandaging
Should be clean, not necessarily sterile
Apply bandage firmly but don’t cut off circulation
Never encircle neck
Don’t cover fingers or toes
Check fingers or toes for color, warmth, sensation

26. Guidelines for Bandaging (continued)
If reduced circulation, unwrap bandage and reapply
Keep checking tightness of bandage
Be sure bandage is secure
Anchor first end and tie, tape, pin or clip ending section
Use elastic roller bandage to make pressure bandage around a limb to control bleeding

27. Guidelines for Bandaging (continued)
Elastic roller bandages support joints and prevent swelling
Wrap from bottom of limb upward
Bandage joint in position it will be kept
Use wide bandage with evenly distributed pressure for extremities

28. Puncture Wounds

29. Puncture Wounds May involve unseen deeper injuries
Check for exit wound
Carry great risk of infection
Internal bleeding may be significant

30. Care for Puncture Wounds
Follow general principles of wound care
Remove small objects and dirt but not large impaled objects
Irrigate the wound with large amounts of water
With small punctures, gently press wound edges
Don’t put medication inside or over puncture wound
Dry the area and apply dressing and bandage
Seek medical attention if appropriate

31. Impaled Objects
Object often seals wound or damaged blood vessels

32. Impaled Object (continued)
Removing object could cause more injury and bleeding
Leave it in place and dress wound around it
Control bleeding by applying direct pressure at sides of object

33. Impaled Object (continued)
Dress wound around object
Use bulky dressings to stabilize object
Support object while bandaging dressings in place
Seek medical attention

34. Avulsion
With skin flap, try to move skin or tissue into normal position (unless contaminated)
Control bleeding
Provide wound care
If avulsed body part completely separated – care for it like an amputation

35. Amputation
Control bleeding and care for wound first, then recover and care for amputated part

36. Care for Amputated Part
Wrap severed part in dry sterile dressing or clean cloth; do not wash
Place part in plastic bag and seal
Place sealed bag in another bag or container with ice and water  part should not touch water or ice directly or be surrounded by ice
Do not let part become saturated with water
Give part to responding EMS

37. Animal Bites

38. Seriousness of Animal Bites
Bleeding and tissue damage can be severe
Increased risk of infection
All bites carry rabies risk

39. Care of Animal Bites Follow general principles of wound care
Clean with large amounts of water with or without soap (except when bleeding severely)
Control bleeding
Dress and bandage

40. Care of Animal Bites (continued)
Ensure patient sees health care provider as soon as possible
Do not try to catch animal  but note its appearance
Report bite to animal control or law enforcement

41. Chest Injuries

42. Care for Impaled Object in Chest
Follow general principles of wound care
Keep patient still, seated or lying down
Do not remove object unless it interferes with chest compressions when CPR is needed

43. Care for Impaled Object in Chest (continued)
Manually secure object while exposing wound area and controlling bleeding
Stabilize impaled object with bulky dressings
Bandage area around object
Monitor breathing and vital signs
Treat for shock

44. Sucking Chest Wound Open wound in chest caused by penetrating injury
Wound lets air move in and out of chest during breathing
Can be life-threatening
Use special dressing to allow air to escape through the wound but prevent air from being sucked in

45. Care for Sucking Chest Wound

46. Closed Chest Injury Organ damage or internal bleeding can be serious
Consider possibility of pneumothorax or hemothorax with any trauma to chest

47. Pneumothorax
Air escapes from injured lung into thoracic cavity causing collapse of some or all of lung
Results in respiratory distress

48. Hemothorax
Blood from injury accumulates in thoracic cavity, compressing the lung
Causes respiratory distress and possibly shock

49. Signs and Symptoms of Pneumothorax or Hemothorax
Little or no external evidence of injury
Signs and symptoms of shock
Respiratory distress

50. Care for Chest Injuries
Perform standard patient care
Help responsive patient to position of easiest breathing
Treat for respiratory distress
Follow local protocol for oxygen

51. Abdominal Injuries

52. Open Abdominal Wound
Usually injures internal organs (intestines, liver, kidneys or stomach)
Large wound may cause evisceration
Abdominal organs protrude through wound
Serious emergency

53. Care for Open Abdominal Wounds
Follow general principles of wound care
Position patient on back
Loosen tight clothing
Cover wound and organs with thick moist dressing

54. Care for Open Abdominal Wounds (continued)
Cover dressing with large, occlusive dressing
Cover area with blanket or towel
Monitor vital signs, and treat for shock

55. Genital Injuries

56. Genital Injuries Rare because of protected location
Occur from blunt trauma, an impact or sexual abuse
Provide privacy

57. Care for Genital Injuries
Injured testicles – support with towel between legs
Vaginal bleeding – have woman press sanitary pad or clean folded towel to area

58. Head and Face Injuries

59. Head and Face Injuries Consider possible neck or spinal injury
Do not move patient’s head while giving emergency care

60. Scalp Wound
Before controlling bleeding, confirm no signs of skull fracture:
Deformed area of skull
A depressed or spongy area in skull
Blood or fluid from ears or nose
Eyelids swollen shut or bruising
Raccoon eyes
Battle’s sign
Unequal pupils
Object impaled in skull

61. Care for Scalp Wound With no signs of skull fracture:
Apply dressing
Use direct pressure to control bleeding
Follow general principles of wound care
Never wrap bandage around neck

62. Scalp Wound Without Suspected Skull Fracture
Replace skin flaps and cover wound with sterile dressing
Control bleeding with direct pressure
Secure dressing with roller bandage or triangular bandage

63. Neck Injuries
Bruising, swelling, difficulty speaking, airway obstruction may result
Treat minor wounds like other wounds
Significant open wounds are medical emergencies  bleeding can be profuse

64. Care for Neck Injuries Follow general principles of wound care
Control bleeding with direct pressure
Place occlusive dressing over wound and tape on all sides
Apply pressure on dressing to control bleeding
When bleeding is controlled, apply pressure dressing over occlusive dressing
Do not obstruct airway or compress other blood vessels in neck

65. Eye Injuries Serious because vision may be affected
Avoid putting pressure on eyeball
Movement of eye will worsen injury
Keep unaffected eye covered

66. For a Blow to the Eye Follow general principles of wound care
If eye is bleeding or leaking fluid, patient needs emergency medical care immediately
Put cold pack over eye with a barrier, but do not put pressure on eye
Do not try to remove a contact lens
Cover both eyes

67. Care for a Large Object Embedded in the Eye
Follow general principles of wound care
Do not remove object
Stabilize with dressings or bulky cloth (paper cup for large object)
Cover both eyes

68. Dirt or Small Particle In Eye
Do not let patient rub eyes
Wait to see if patient’s tears flush out object
Gently pull upper eyelid out and down over lower eyelid to catch particle on lashes
If particle remains and is visible, try to brush it out
If particle still remains or patient has any vision problems or pain, cover both eyes and seek medical care

69. For Chemical or Substance Splashed in Eye
Follow general principles of wound care
Have patient lie flat with head tilted to affected side
Hold eyelid open with gloved hand
Flush eye with running water or saline until additional EMS providers arrive  use specialized solution if available
Follow local protocol to consult PCC

70. Ear Injuries
Bleeding or cerebrospinal fluid from ear is sign of serious head injury
Do not use direct pressure to stop fluid coming out of ear
Do not remove any foreign object
If insect in ear, gently pour lukewarm water into ear to float it out

71. Care for External Ear Injuries
Control bleeding with direct pressure
Dress wound

72. Care for Internal Ear Injuries
Follow general principles of wound care
Help patient sit up
Tilt affected ear lower than unaffected ear
Cover ear with loose sterile dressing
Don’t apply pressure or plug ear closed

73. Nose Injuries Nose trauma can cause heavy bleeding
Bleeding from back of nose down throat needs immediate medical attention
Allow blood to drain from mouth

74. Care for Nose Injuries Follow general principles of wound care
Patient sits with head slightly forward with mouth open
Don’t remove objects from nose
Don’t tilt patient’s head backward
Pinch nostrils just below bridge of nose for 10 minutes

75. Care for Nose Injuries (continued)
Place cold compress on nose
After 10 minutes release pressure slowly
If bleeding continues, pinch nostrils for another 10 minutes
Put unresponsive patient on side and pinch nostrils
Don’t pack nostrils with dressing

76. Cheek Injuries Object impaled in cheek (possible airway obstruction)
Remove it only if airway cannot be controlled
Place dressing inside mouth between wound and teeth
Place another dressing on outside of wound
Apply pressure as needed
Position unresponsive patient with head turned to side

77. Teeth and Mouth Injuries
Control bleeding with direct pressure on dressing
Priorities:
Ensure airway is open
Ensure blood drains from mouth

78. Bleeding in Mouth
Have patient sit with head tilted forward to let blood drain out
Wound penetrating lip:
Put rolled dressing between lip and gum
Second dressing against outside lip
Bleeding tongue:
Put dressing on wound and apply pressure
Do not repeatedly rinse mouth or let patient swallow blood

79. Tooth Knocked Out Control bleeding with rolled gauze over socket
Save tooth
May be reimplanted if patient sees dentist
Touch only tooth’s crown
Do not clean or scrub tooth
Place in container of milk or clean water
Get patient and tooth to dentist

80. Burns

81. Burns Major cause of death and injury
Caused by sun, heat, chemicals, electricity

82. Assessing a Heat Burn Perform the standard assessment Consider:
Burn depth
Burn size or extent
Respiratory involvement
Specific body areas burned
Patient’s age and health status

83. Classification of Burns
Superficial
Partial-thickness
Full-thickness

84. Superficial Burns Also called first-degree burns
Damage only outer layer (epidermis)
Skin is red, dry, painful
Some swelling may occur
Usually minor except for extensive area

85. Partial-Thickness Burns
Also called second-degree burns
Damage skin’s deeper layer (dermis)

86. Partial-Thickness Burns (continued)
Skin is red, mottled, very painful
Blisters and weeping clear fluid may be present
Often need medical attention

87. Full-Thickness Burns Also called third-degree burns
Damage through subcutaneous layer and may include muscle and other tissues

88. Full-Thickness Burns (continued)
Skin is charred and blackened or white, yellow, tab
Burn feels leathery
Pain is not present but likely in adjacent areas
Medical emergency

89. Assessing Burn Size and Severity
Rule of Nines

90. Emergency Burns by Size
Burn size influences whether shock and complications develop
Emergencies:
Any full-thickness burn >50-cent piece
Partial-thickness burn >10% of adult body (5% of child or older adult)
Superficial burn over >50% of body

91. Assess Burn Location
Partial- or full-thickness burns on face, genitals, hands or feet need immediate medical care
Circumferential burns should receive immediate medical attention
Burns around nose and mouth may affect breathing and are medical emergencies

92. Assess Burned Patient’s Age and Health
Burns in those <5 or >55 are more serious
Chronic health disorders make burns more serious

93. Principles of Care for Heat Burns
Cool with cold water except for burn over 20% of body or 10% in child
Cool as long patient feels pain
Continually add fresh water
Protect burned area from additional trauma and pathogens
Provide supportive care

94. Emergency Care for Heat Burns
Perform standard patient care
Follow general principles of wound care
Remove the heat source and smoldering clothing
Cool burn with sterile or clean room-temperature water or cold running tap water (except large, full-thickness burns)

95. Emergency Care for Heat Burns (continued)
Remove constricting clothing and jewelry
If clothing sticks cut around it
Treat for shock
Cover burn with non-stick dressing  use sheet over large area
Follow local protocol for oxygen
Don’t apply cream or ointment
Don’t break blisters

96. Emergency Care for Heat Burns (continued)
Don’t give patient anything to drink
Monitor breathing and give BLS if needed
For large burns in children:
Keep environment warm
With suspicious pattern of burn marks, consider possibility of child abuse

97. Smoke Inhalation

98. Smoke Inhalation Airway may swell and make breathing difficult
Damage to alveoli may affect ability to receive oxygen
Carbon monoxide poisoning may also have occurred

99. Signs and Symptoms of Smoke Inhalation
Coughing, wheezing, hoarse voice
Possible burned area
Blackening on face or chest
Difficulty breathing

100. Care for Smoke Inhalation
Perform standard patient care
Get patient to fresh air, or fresh air to patient
Follow local protocol for oxygen
Help position into easy breathing
Put unresponsive patient in recovery position
Monitor breathing
Be ready to give BLS if needed

101. Chemical Burns

102. Chemical Burns Strong chemicals can burn skin on contact
Sometimes burns develop slowly
Acids, alkalis, liquids and solids can cause burns
Flush substance off skin with water as soon as possible
Check Material Safety data Sheet in work settings

103. Signs and Symptoms of Chemical Burns
Pain or burning sensation
Chemical on patient’s skin or clothing
Spilled substance on or around unresponsive patient
Smell of fumes

104. Emergency Care for Chemical Burns
Perform standard patient care
Send someone for the Material Safety Data Sheet
Wear gloves and eye protection
Move patient or ventilate area
With dry chemicals, brush off skin

105. Emergency Care for Chemical Burns (continued)
Flush area as soon as possible with copious running water until additional EMS personnel arrive

106. Emergency Care for Chemical Burns (continued)
Don’t try to neutralize an acid with an alkaline or vice versa
Remove clothing and jewelry while flushing
With a splash injury, consider possibility of an eye burn
With chemical in the eye, flush with running water until additional EMS personnel arrive

107. Electrical Burns and Shocks

108. Electrical Burns and Shocks
Occur when body contacts electricity
Typical injuries occur with faulty appliances or power cords or appliance in contact with water

109. Injuries From Electricity
External burns caused by heat of electricity
Electrical injuries caused by electricity flowing inside body
High-voltage electricity in body can cause heart rhythm irregularities that threaten circulation or cause heart to stop
Patient may be in cardiac arrest on your arrival

110. Signs and Symptoms of Electrical Injury
Source of electricity nearby
External entrance and exit wounds
Unresponsiveness, seizures, changing levels of responsiveness
Breathing abnormalities
Weak or irregular pulse
Can cause unseen severe internal injuries

111. Emergency Care for Electrical Burns
Perform standard patient care
Don’t touch patient until area is safe
Stop burning and cool area
Remove clothing and jewelry
Cover burn with a sterile dressing
Treat for shock
Maintain normal body temperature

112. Emergency Care for Electrical Burns (continued)
Keep unresponsive patient in recovery position
Monitor breathing and vital signs
Assume patient with lightning strike or high-voltage shock has spinal injury  stabilize head and neck
Care for shock and give BLS as needed