Soft-Tissue Injury

Sections  Introduction to Soft Tissue Injury  Anatomy & Physiology of Soft- Tissue Injury  Pathophysiology of Soft-Tissue Injury  Dressing & Bandage Materials  Assessment of Soft-Tissue Injuries  Management of Soft-Tissue Injuries  Introduction to Soft Tissue Injury  Anatomy & Physiology of Soft- Tissue Injury  Pathophysiology of Soft-Tissue Injury  Dressing & Bandage Materials  Assessment of Soft-Tissue Injuries  Management of Soft-Tissue Injuries

 Skin is the largest, most important organ  16% of total body weight  Function  Protection  Sensation  Temperature Regulation  AKA: Integumentary System  Skin is the largest, most important organ  16% of total body weight  Function  Protection  Sensation  Temperature Regulation  AKA: Integumentary System Introduction to Soft-Tissue Injury

 Epidemiology  Open Wounds  Over 10 million wounds present to ED Most require simple care and some suturing Up to 6.5% may become infected  Closed Wounds  More Common  Contusions, Sprains, Strains  Epidemiology  Open Wounds  Over 10 million wounds present to ED Most require simple care and some suturing Up to 6.5% may become infected  Closed Wounds  More Common  Contusions, Sprains, Strains Introduction to Soft-Tissue Injury

A&P of Soft Tissue Injuries  Skin Layers  Epidermis  Outermost, avascular layer of dead cells  Helps prevent infection  Sebum Waxy, oily substance that lubricates surface  Dermis  Upper Layer (Papillary Layer) Loose connective tissue, capillaries and nerves  Lower Layer (Reticular Layer) Integrates dermis with SQ layer  Blood vessels, nerve endings, glands Sebaceous & Sudoriferous Glands  Subcutaneous  Adipose tissue  Heat retention  Skin Layers  Epidermis  Outermost, avascular layer of dead cells  Helps prevent infection  Sebum Waxy, oily substance that lubricates surface  Dermis  Upper Layer (Papillary Layer) Loose connective tissue, capillaries and nerves  Lower Layer (Reticular Layer) Integrates dermis with SQ layer  Blood vessels, nerve endings, glands Sebaceous & Sudoriferous Glands  Subcutaneous  Adipose tissue  Heat retention

A&P of Soft Tissue Injuries  Blood Vessels  Arteries  Arterioles  Capillaries  Venules  Veins  Layers  Tunica Intima  Tunica Media  Tunica Adventitia  Blood Vessels  Arteries  Arterioles  Capillaries  Venules  Veins  Layers  Tunica Intima  Tunica Media  Tunica Adventitia

A&P of Soft Tissue Injuries  Muscles  Beneath skin layers  Fascia  Thick, fibrous, inflexible membrane surrounding muscle the aids to bind muscle groups together  Muscles  Beneath skin layers  Fascia  Thick, fibrous, inflexible membrane surrounding muscle the aids to bind muscle groups together

A&P of Soft Tissue Injuries  Tension Lines  Natural patterns in the surface of the skin revealing tension within  Tension Lines  Natural patterns in the surface of the skin revealing tension within

Pathophysiology of Soft-Tissue Injury  Closed Wounds  Contusions  Erythema  Ecchymosis  Hematomas  Crush Injuries  Closed Wounds  Contusions  Erythema  Ecchymosis  Hematomas  Crush Injuries  Open Wounds  Abrasions  Lacerations  Incisions  Punctures  Impaled Objects  Avulsions  Amputations  Open Wounds  Abrasions  Lacerations  Incisions  Punctures  Impaled Objects  Avulsions  Amputations

 Hemorrhag e  Arterial  Capillary  Venous  Hemorrhag e  Arterial  Capillary  Venous Pathophysiology of Soft-Tissue Injury

 Wound Healing Hemostasis  Body’s natural ability to stop bleeding & the ability to clot blood  Begins immediately after injury  Inflammation  Local biochemical process that attracts WBC’s  Epithelialization  Migration of epithelial cells over wound surface  Wound Healing Hemostasis  Body’s natural ability to stop bleeding & the ability to clot blood  Begins immediately after injury  Inflammation  Local biochemical process that attracts WBC’s  Epithelialization  Migration of epithelial cells over wound surface Pathophysiology of Soft-Tissue Injury (continued)

 Neovascularization  New growth of capillaries in response to healing  Collagen Synthesis  Fibroblasts: Cells that form collagen  Collagen: Tough, strong protein that comprises connective tissue  Neovascularization  New growth of capillaries in response to healing  Collagen Synthesis  Fibroblasts: Cells that form collagen  Collagen: Tough, strong protein that comprises connective tissue Pathophysiology of Soft-Tissue Injury

 Infection  Most common and most serious complication of open wounds  1:15 wounds seen in ED result in infection  Delay healing  Spread to adjacent tissues  Systemic infection: Sepsis  Presentation  Pus: WBC’s, cellular debris, & dead bacteria  Lymphangitis: Visible red streaks  Fever & Malaise  Localized Fever  Infection  Most common and most serious complication of open wounds  1:15 wounds seen in ED result in infection  Delay healing  Spread to adjacent tissues  Systemic infection: Sepsis  Presentation  Pus: WBC’s, cellular debris, & dead bacteria  Lymphangitis: Visible red streaks  Fever & Malaise  Localized Fever Pathophysiology of Soft-Tissue Injury

 Infection  Risk Factors  Host’s health & pre-existing illnesses Medications (NSAID’s)  Wound type and location  Associated contamination  Treatment provided  Infection Management  Antibiotics & keep wound clean  Gangrene Deep space infection of anerobic bacteria Bacterial Gas and Odor  Tetanus Lockjaw  Infection  Risk Factors  Host’s health & pre-existing illnesses Medications (NSAID’s)  Wound type and location  Associated contamination  Treatment provided  Infection Management  Antibiotics & keep wound clean  Gangrene Deep space infection of anerobic bacteria Bacterial Gas and Odor  Tetanus Lockjaw Pathophysiology of Soft-Tissue Injury

 Other Wound Complications  Impaired Hemostasis  Medications Anticoagulants  Aspirin  Warfarin (Coumadin)  Heparin  Antifibrinolytics  Re-Bleeding  Delayed Healing  Compartment Syndrome  Abnormal Scar Formation  Pressure Injuries  Other Wound Complications  Impaired Hemostasis  Medications Anticoagulants  Aspirin  Warfarin (Coumadin)  Heparin  Antifibrinolytics  Re-Bleeding  Delayed Healing  Compartment Syndrome  Abnormal Scar Formation  Pressure Injuries Pathophysiology of Soft-Tissue Injury

 Crush Injury  Body tissues are subjected to severe compressive forces  Tamponading of distal tissue  Buildup of byproducts of metabolism  “Wood-like” distal tissue  Associated Injury  Crush Injury  Body tissues are subjected to severe compressive forces  Tamponading of distal tissue  Buildup of byproducts of metabolism  “Wood-like” distal tissue  Associated Injury Pathophysiology of Soft-Tissue Injury

 Crush Syndrome  Body is entrapped for >4 hours  Crushed muscle tissue becomes necrotic  Traumatic Rhabdomyolysis Skeletal Muscle Degradation Release of toxins  Myoglobin  Phosphate  Potassium  Lactic Acid  Uric Acid  When tissue is released, toxins move RAPIDLY into systemic circulation Impacts Cardiac Function Impacts Kidney Function  Crush Syndrome  Body is entrapped for >4 hours  Crushed muscle tissue becomes necrotic  Traumatic Rhabdomyolysis Skeletal Muscle Degradation Release of toxins  Myoglobin  Phosphate  Potassium  Lactic Acid  Uric Acid  When tissue is released, toxins move RAPIDLY into systemic circulation Impacts Cardiac Function Impacts Kidney Function Pathophysiology of Soft-Tissue Injury

 Injection Injury  High-pressure line bursts  Injects fluid or other substance into skin and into subcutaneous tissue  Injection Injury  High-pressure line bursts  Injects fluid or other substance into skin and into subcutaneous tissue Pathophysiology of Soft-Tissue Injury

 Sterile & Non-sterile Dressings  Sterile: Direct wound contact  Non-sterile: Bulk dressing above sterile  Occlusive/Non-occlusive Dressings  Adherent/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  Sterile & Non-sterile Dressings  Sterile: Direct wound contact  Non-sterile: Bulk dressing above sterile  Occlusive/Non-occlusive Dressings  Adherent/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 Dressing & Bandage Materials

 Self-adherent roller bandage  Kerlex/Kling  Multi-ply, stretch; 1-6”  Gauze bandage  Single ply, non-stretch: 1-3”  Adhesive bandages  Elastic (Ace) Bandages  Triangular Bandages  Self-adherent roller bandage  Kerlex/Kling  Multi-ply, stretch; 1-6”  Gauze bandage  Single ply, non-stretch: 1-3”  Adhesive bandages  Elastic (Ace) Bandages  Triangular Bandages Dressing & Bandage Materials

 Scene Size-up  Initial Assessment  Focused H&P  Evaluate MOI and consider IOS  Rapid versus Focused Assessment  Detailed Physical Exam  Inquiry, Inspection, Palpation, Auscultation  Ongoing Assessment  Scene Size-up  Initial Assessment  Focused H&P  Evaluate MOI and consider IOS  Rapid versus Focused Assessment  Detailed Physical Exam  Inquiry, Inspection, Palpation, Auscultation  Ongoing Assessment Assessment of Soft Tissue Injuries

 Objectives of Wound Dressing & Bandaging  Hemorrhage Control  Direct Pressure  Elevation  Pressure Points  Consider Ice Constricting Band Tourniquet  USE ALL COMPONENTS TOGETHER  Objectives of Wound Dressing & Bandaging  Hemorrhage Control  Direct Pressure  Elevation  Pressure Points  Consider Ice Constricting Band Tourniquet  USE ALL COMPONENTS TOGETHER Management of Soft-Tissue Injury

Do’s  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. Do’s  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’ts  Use unless you can not control the bleeding via other means  Use rope or wire.  Release it once applied. Don’ts  Use unless you can not control the bleeding via other means  Use rope or wire.  Release it once applied. Tourniquet

 Objectives of Wound Dressing & Bandaging  Sterility  Keep the wound as clean as possible  If wound is grossly contaminated consider cleansing  Immobilization  Prevents movement and aggravation of wound  Do not use an elastic bandage: TQ effect  Monitor distal pulse, motor, and sensation  Objectives of Wound Dressing & Bandaging  Sterility  Keep the wound as clean as possible  If wound is grossly contaminated consider cleansing  Immobilization  Prevents movement and aggravation of wound  Do not use an elastic bandage: TQ effect  Monitor distal pulse, motor, and sensation Management of Soft-Tissue Injury (continued)

 Pain & Edema Control  Cold packs  Moderate pressure over wound  Consider analgesic if approved by medical control  Pain & Edema Control  Cold packs  Moderate pressure over wound  Consider analgesic if approved by medical control Management of Soft-Tissue Injury

 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 wound  Pressure on local arteries  Without Skull Fracture  Direct pressure  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 wound  Pressure on local arteries  Without Skull Fracture  Direct pressure Anatomical Considerations for Bandaging

 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  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 Anatomical Considerations for Bandaging

 Neck  Consider circumferential bandage  Protect trachea and carotids  C-Collar and dressing  Occlusive dressing if lacerated vessel  Shoulder  Care to avoid pressure  Axillary artery  Trachea  Anterior neck  Neck  Consider circumferential bandage  Protect trachea and carotids  C-Collar and dressing  Occlusive dressing if lacerated vessel  Shoulder  Care to avoid pressure  Axillary artery  Trachea  Anterior neck Anatomical Considerations for Bandaging

 Trunk  Minor wounds: Dressing and tape  Major wounds: Circumferential wrap  Ladder splint behind back and wrap gauze over it Prevents worsening of respiratory status  Groin & Hip  Bandage by following contours of body  Movement can increase tightness of bandage  Trunk  Minor wounds: Dressing and tape  Major wounds: Circumferential wrap  Ladder splint behind back and wrap gauze over it Prevents worsening of respiratory status  Groin & Hip  Bandage by following contours of body  Movement can increase tightness of bandage Anatomical Considerations for Bandaging

 Elbow and Knee  Circumferential wrap and splint  Splinting reduces movement  Position of function  Half flexion/half extension  Hand and Finger  Bulky dressing  Position of function  Ankle and Foot  Circumferential bandage  Elbow and Knee  Circumferential wrap and splint  Splinting reduces movement  Position of function  Half flexion/half extension  Hand and Finger  Bulky dressing  Position of function  Ankle and Foot  Circumferential bandage Anatomical Considerations for Bandaging

 Complications of Bandaging  Always assess before and after  Pulse  Motor  Sensation  Developing ischemia  Pain  Pallor  Tingling  Loss of pulse  Decreased capillary refill  Is dressing size appropriate to injury?  Complications of Bandaging  Always assess before and after  Pulse  Motor  Sensation  Developing ischemia  Pain  Pallor  Tingling  Loss of pulse  Decreased capillary refill  Is dressing size appropriate to injury? Anatomical Considerations for Bandaging

 Amputations  Patient  Control bleeding by bulky dressing  Consider tourniquet proximal to wound  Do not delay transport to to locate amputated part Have a second unit transport the part  Amputated Part  Dry cooling and rapid transport Part in plastic bag (Double bag) Immerse in cold water Avoid direct contact between tissue and cold water  Amputations  Patient  Control bleeding by bulky dressing  Consider tourniquet proximal to wound  Do not delay transport to to locate amputated part Have a second unit transport the part  Amputated Part  Dry cooling and rapid transport Part in plastic bag (Double bag) Immerse in cold water Avoid direct contact between tissue and cold water Anatomical Considerations for Bandaging: Specific Wounds

 Impaled Objects  Stabilize with bulky dressing in place  Prevent movement of object  Consider cutting or shortening LARGE impaled objects  Prevent gross movement  Reduce heat to patient if cutting torch used  REMOVE ONLY IF  In cheek and interferes with airway  Interferes with CPR Poor outcome  Impaled Objects  Stabilize with bulky dressing in place  Prevent movement of object  Consider cutting or shortening LARGE impaled objects  Prevent gross movement  Reduce heat to patient if cutting torch used  REMOVE ONLY IF  In cheek and interferes with airway  Interferes with CPR Poor outcome Anatomical Considerations for Bandaging: Specific Wounds

 Crush Syndrome  Anticipate Problems  Victims of prolonged entrapment  Ensure that scene is safe  Initial assessment  Control any initial problems  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.  Crush Syndrome  Anticipate Problems  Victims of prolonged entrapment  Ensure that scene is safe  Initial assessment  Control any initial problems  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. Anatomical Considerations for Bandaging: Specific Wounds

 Crush Syndrome  Management  IV: 20-30ml/kg of NS or D51/2NS  AVOID LR or K + based solutions  After bolus, continuous infusion of 20ml/kg/hr  Consider Sodium Bicarbonate 1 mEq/kg initial bolus 0.25 mEq/kg/hr infusion Corrects systemic acidosis  Consider Calcium Chloride 500 mg IVP Counteracts hyperkalemia  Consider Diuretics Mannitol (Osmotrol) Furosemide (Lasix)  Crush Syndrome  Management  IV: 20-30ml/kg of NS or D51/2NS  AVOID LR or K + based solutions  After bolus, continuous infusion of 20ml/kg/hr  Consider Sodium Bicarbonate 1 mEq/kg initial bolus 0.25 mEq/kg/hr infusion Corrects systemic acidosis  Consider Calcium Chloride 500 mg IVP Counteracts hyperkalemia  Consider Diuretics Mannitol (Osmotrol) Furosemide (Lasix) Anatomical Considerations for Bandaging: Specific Wounds

 Compartment Syndrome  Likely 4-8 hours post-injury  Symptom  Severe pain out of proportion with physical exam findings  6 – P’s Pain Paresthesia Paresis Pressure Passive stretching pain Pulselessness  Normal motor and sensory function  Compartment Syndrome  Likely 4-8 hours post-injury  Symptom  Severe pain out of proportion with physical exam findings  6 – P’s Pain Paresthesia Paresis Pressure Passive stretching pain Pulselessness  Normal motor and sensory function Anatomical Considerations for Bandaging: Specific Wounds

 Compartment Syndrome  Management  Care of underlying injury  Splint and immobilize all suspected fractures  Cold packs to severe contusions Most effective prehospital management Reduces edema Prevents ischemia  Compartment Syndrome  Management  Care of underlying injury  Splint and immobilize all suspected fractures  Cold packs to severe contusions Most effective prehospital management Reduces edema Prevents ischemia Anatomical Considerations for Bandaging: Specific Wounds

 Face & Neck  Potential for airway obstruction or compromise  Aggressive suctioning and oxygenation  Consider intubation  If excessive swelling or damage Needle or surgical cricothyroidotomy  Face & Neck  Potential for airway obstruction or compromise  Aggressive suctioning and oxygenation  Consider intubation  If excessive swelling or damage Needle or surgical cricothyroidotomy Anatomical Considerations for Bandaging

 Thorax  Superficial injury can be deep  Always suspect the worst due to underlying organs  NEVER explore a wound internally  Alert for  Subcutaneous emphysema  Pneumothorax or Hemothorax  Tension pneumothorax  Consider occlusive dressing sealed on 3 sides  Thorax  Superficial injury can be deep  Always suspect the worst due to underlying organs  NEVER explore a wound internally  Alert for  Subcutaneous emphysema  Pneumothorax or Hemothorax  Tension pneumothorax  Consider occlusive dressing sealed on 3 sides Anatomical Considerations for Bandaging

 Abdomen  Always suspect injury to ribs or thoracic organs if between the level of the 5 th and 9 th 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.  Abdomen  Always suspect injury to ribs or thoracic organs if between the level of the 5 th and 9 th 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. Anatomical Considerations for Bandaging

 Wounds Requiring Transport  Any wound that involves  Nerves  Blood vessels  Ligaments  Tendons  Muscles  Significantly contaminated  Impaled object  Likely cosmetic injury  Wounds Requiring Transport  Any wound that involves  Nerves  Blood vessels  Ligaments  Tendons  Muscles  Significantly contaminated  Impaled object  Likely cosmetic injury Anatomical Considerations for Bandaging

 Soft-Tissue Treatment and Refer or Release  Typically requires online medical control  Evaluate and dress wound  Inform the patient about  Preventing infection  Follow-up care with a physician  Inquire about tetanus and inform of risks  Document treatment, referral and teaching.  Soft-Tissue Treatment and Refer or Release  Typically requires online medical control  Evaluate and dress wound  Inform the patient about  Preventing infection  Follow-up care with a physician  Inquire about tetanus and inform of risks  Document treatment, referral and teaching. Anatomical Considerations for Bandaging