Soft Tissue Trauma.

Name: Soft Tissue Trauma.
Uploaded: 2017-12-16T18:55:24+00:00
Duration: PTM31S35
Channel: Gillian Adams
Description: Soft Tissue Trauma.

Soft Tissue Trauma

Introduction to Soft-Tissue Trauma
Skin is the largest, most important organ. 16% of total body weight. Function: Protection Sensation Temperature regulation AKA: integumentary system Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

A&P of Soft-Tissue Injuries (1 of 6)
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 and sudoriferous glands Subcutaneous Adipose tissue Heat retention Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

A&P of Soft-Tissue Injuries (2 of 6) The Skin
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Blood Vessels Arteries Arterioles Capillaries Venules Veins Layers Tunica intima Tunica media Tunica adventitia Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

A&P of Soft-Tissue Injuries (4 of 6) Blood Vessels

Muscles Beneath skin layers Fascia Thick, fibrous, inflexible membrane surrounding muscle that aids in binding muscle groups together Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

A&P of Soft Tissue Injuries (6 of 6)
Tension Lines Natural patterns in the surface of the skin revealing tension within Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of Soft-Tissue Injury (1 of 12)
Closed Wounds Contusions Erythema Ecchymosis Hematomas Crush injuries Open Wounds Abrasions Lacerations Incisions Punctures Impaled objects Avulsions Amputations Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of Soft-Tissue Injury (2 of 12) Soft-Tissue Wounds

Wound Healing Hemostasis Body’s natural ability to stop bleeding and the ability to clot blood Begins immediately after injury Inflammation Local biochemical process that attracts WBCs Epithelialization Migration of epithelial cells over wound surface Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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: WBCs, cellular debris, and dead bacteria Lymphangitis: visible red streaks Fever and malaise Localized fever Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Infection Risk factors Host’s health and pre-existing illnesses Medications (NSAIDs) Wound type and location Associated contamination Treatment provided Infection management Antibiotics and keep wound clean Gangrene Deep space infection of anaerobic bacteria Bacterial gas and odor Tetanus Lockjaw Uncommon with the exception of third-world country immigrants Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Other Wound Complications Impaired hemostasis Medications Anticoagulants Aspirin Warfarin (Coumadin) Heparin Antifibrinolytics Re-bleeding Delayed healing Compartment syndrome Abnormal scar formation Pressure injuries Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Crush Injury Body tissues subjected to severe compressive forces Tamponading of distal tissue Buildup of byproducts of metabolism “Wood-like” distal tissue Associated injury Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Injection Injury High-pressure line bursts Injects fluid or other substance into skin and into subcutaneous tissue Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Dressing and Bandage Materials (1 of 2)
Sterile and 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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Dressing and Bandage Materials (2 of 2)
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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment of Soft-Tissue Injuries
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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Management of Soft-Tissue Injury (1 of 4)
Objectives of Wound Dressing and Bandaging Hemorrhage control Direct pressure Elevation Pressure points Consider Ice Constricting band Tourniquet USE ALL COMPONENTS TOGETHER. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Management of Soft-Tissue Injury (2 of 4) Tourniquet
Do 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’t Use unless you cannot control the bleeding via other means.?????? Use rope or wire. Release it once applied. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Objectives of Wound Dressing and 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. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hemostatic Bandages Adjunct to direct pressure
Concentrate clotting factors and aid clot formation QuikClot HemCon Celox New Fibrin-based sealants Adjunct= used in conjunction with direct pressure tourniquets and other bandages.All of them are bulky and serve to fill the space of large wounds. Most of the agents absorb water in some capacity, acting to concentrate the clotting factors in the blood and aid clot formation. Some of the most advanced dressings are engineered with human coagulation factors implanted into the dressing to promote fibrin formation, the last step in clot formation. The variation among available products lies in their substance (granular or solid), size and flexibility. The ideal hemostatic agent would require little to no training, be in a pre-mixed, non-perishable state and have the ability to effectively control hemorrhage from any source. In addition, advantages would include being inexpensive, posing no risk to life or limb, and remaining stable and functional at extreme temperatures. Currently, no single product meets all of these ideals review of products= When QuikClot comes in contact with blood, it preferentially takes in smaller molecules (i.e., water), leaving the larger clotting factors and platelets behind in the wound (3). This results in a highly concentrated form that promotes coagulation. QuikClot has been FDA approved under a few different formulations to be externally used to stop moderate to severe bleeding. The initial product showed reasonable promise for hemorrhage control, but several factors limited its application for day-to-day use. The most significant of these problems was an exothermic (heat-producing) reaction that occurred with its application. The temperature rise was significant enough to result in a burn-like injury to surrounding tissue about 2% of the time. Additionally, the original formulation was a granular powder that was difficult to handle and remove surgically once hemostasis was achieved. In 2005 and 2006, Z-Medica re-engineered the product and introduced new formulations that addressed these problems. The new QuikClot 1st Response and QuikClot ACS+ are no longer associated with any significant exothermic reaction and allow for easier application and removal. One published study demonstrated the efficacy of the new formulations (4). he advantage of the new QuikClot ACS+ formulation is its ability to fill large wounds and cover large surface areas. It doesn_t work well for small, deep wounds, such as small-entry penetrating wounds. In the personal experience of the authors, the products have been easy to use and remove during surgery and showed no heat production. Hemcon= Chitosan has been shown to have mucoadhesive properties that make it an ideal hemostatic agent. The HemCon dressing is a freeze-dried chitosan dressing, designed to optimize the mucoadhesive surface density and structural integrity of chitosan at the site of the injury. Essentially, the bandage works by becoming extremely sticky when in contact with blood. The adhesive-like action seals the wound and controls the bleeding. The chemical makeup of the dressing, with its positive charges, attracts negatively charged red-blood cells. These cells create a seal as they_re drawn into the bandage, forming a tight adherent clot (5). The bandage is intended as a topical dressing for local management of bleeding but can be used temporarily for severe bleeding of surgical wounds and traumatic injury. The dressing shouldn_t be left in place longer than 24 hours. The bandage appears to be stable at extremes of temperature and doesn_t require special preparation or significant amounts of training for its use. There have been no known allergic reactions attributed to the dressing. One of the authors has had significant experience with the product in combat care and feels it provides good hemorrhage control in large, open wounds. The material is inflexible, and thus the main disadvantage is difficulty using it in deep, narrow wounds. Celox= Celox is another chitosan product that_s one of the newer hemostatics on the market. There have been no published reports to date on human use, but a live-tissue study and animal trials reported by company literature show promise. The material appears to control major arterial bleeding, doesn_t generate heat, can work at temperature extremes, is lightweight, portable and easy to administer without specialized training. The product comes in granular form that_s poured over the bleeding site where it gels and can then be removed easily. Celox can be applied to deep, narrow wounds because of its granular form. And the Celox-A applicator and plunger delivery system helps the agent reach even deeper inside a penetrating wound. In addition, it can be spread over large areas of open surface wounds. The granules coalesce into a coagulum that_s reported to lift off the wound easily during surgery.

Pain and Edema Control Cold packs Moderate pressure over wound Consider analgesic if approved by medical direction: Morphine sulfate 2 mg SIVP every 5 minutes up to a total of 10 mg given. Fentanyl (Sublimaze) 25–50 mcg SIVP followed by an additional 25 mcg as needed. If given too rapidly, chest wall rigidity may ensue leading to respiratory compromise. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomical Considerations for Bandaging (1 of 17)
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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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 and Hip Bandage by following contours of body. Movement can increase tightness of bandage. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Elbow and Knee Circumferential wrap and splint Splinting reduces movement Position of function Half flexion/half extension Hand and Finger Remove jewelry from wrist and fingers Bulky dressing Ankle and Foot Circumferential bandage Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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? Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomical Considerations for Bandaging (7 of 17) Specific Wounds
Amputations Patient Control bleeding by bulky dressing. Consider tourniquet proximal to wound. Do not delay transport 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. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Crush Syndrome Management IV: 20–30 mL/kg of NS or D51/2 NS. AVOID LR or K+ based solutions. After bolus, continuous infusion of 20 mL/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) Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Compartment Syndrome Likely 4–8 hours post-injury Symptom Severe pain out of proportion with physical exam findings 6 Ps Pain Paresthesia Paresis Pressure Passive stretching pain Pulselessness Normal motor and sensory function Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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 Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Face and Neck Potential for airway obstruction or compromise Aggressive suctioning and oxygenation Consider intubation: Verify ET tube placement. Ensure tube remains in the airway by using continuous waveform capnography. If excessive swelling or damage: Needle or surgical cricothyroidotomy. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Abdominal Region Always suspect injury to ribs or thoracic organs if between the level of the 5th and 9th 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. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Wounds Requiring Transport Any wound that involves Nerves Blood vessels Ligaments Tendons Muscles Significantly contaminated Impaled object Likely cosmetic injury Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Soft-Tissue Treatment and Refer or Release Typically requires on-line medical direction. 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. Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ

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