Chapter 31 Soft-Tissue Trauma.

Chapter 31 Soft-Tissue Trauma

National EMS Education Standard Competencies
Trauma Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient.

Soft-Tissue Trauma Recognition and management of Wounds Burns Electrical Chemical Thermal Chemicals in the eye and on the skin

Pathophysiology, assessment, and management of Wounds Avulsions Bite wounds Lacerations Puncture wounds Incisions

Pathophysiology, assessment, and management of (cont’d) Burns Electrical Chemical Thermal Radiation High-pressure injection Crush syndrome

Introduction The skin is the largest organ of the body.
Injuries are common. Wound: any injury to soft tissue Always search for other injuries or conditions before treating soft-tissue trauma.

Incidence, Mortality, and Morbidity
Soft tissue can be injured by: Blunt injury Penetrating injury Burns Soft-tissue trauma is the leading form of injury.

Incidence, Mortality, and Morbidity
Death from soft-tissue injury is rare. Uncontrolled bleeding Local or systemic infections Prevention involves simple actions.

Structure and Function of the Skin
Skin: complex organ with crucial role in homeostasis Protects underlying tissue from injury Aids in temperature regulation Prevents excessive water loss Acts as sense organ

Structure and Function of the Skin
Significant damage may make the patient vulnerable to: Bacterial invasion Temperature instability Fluid balance disturbances

Epidermis First line of defense Consists of five layers
Stratum corneum (outermost layer) Four inner layers of living cells

Epidermis

Dermis Tough, highly elastic connective tissue Composed of:
Collagen and elastic fibers Mucopolysaccharide gel Fibroblasts Subdivided into: Papillary dermis and reticular layer

Dermis Macrophages and lymphocytes Part of the inflammatory process
Responsible for combating micro-organisms Results in increased blood flow, causing redness and warmth

Dermis Specialized structures Nerve endings Blood vessels Sweat glands
Hair follicles Sebaceous gland

Subcutaneous Tissues Layer beneath the dermis Mostly adipose tissue
Insulates underlying tissues Provides a cushion for underlying structures Provides an energy reserve for the body

Deep Fascia Thick, dense layer of fibrous tissue below subcutaneous tissue Composed of tough tissue bands Supports and protects underlying structures

Skin Tension Lines Static tension develops over areas with limited movement. Lacerations parallel to lines may remain closed. Larger wounds may be pulled open. Smaller lacerations perpendicular to tension lines will remain open.

Skin Tension Lines Dynamic tension found over muscle
Open injuries interfere with healing: Disrupt clotting process Disrupt tissue repair cycle An abnormal scar may prompt scar revision surgery.

Closed Wounds Soft tissue is damaged but skin is not broken
Characteristic closed wound is a contusion.

Courtesy of Rhonda Beck
Closed Wounds If small blood vessels are damaged, ecchymosis will cover the area. If large blood vessels are torn, a hematoma will appear. Courtesy of Rhonda Beck

Open Wounds Characterized by disruption in the skin
Potentially more serious than closed wounds Vulnerable to infection Greater potential for serious blood loss

Open Wounds

Crush Injuries An injury to the underlying soft tissues and bones
Caused by a body part being crushed between two solid objects © Mark C. Ide

Crush Injuries May lead to compartment syndrome
May lead to rupture of internal organs External appearance may not represent level of internal damage. Grotesque injuries may not be primary problem.

Crush Injuries Body’s first responses to vessel injury is localized vasoconstriction. If vessels are damaged, they may not be able to constrict. Crush injuries often result in difficult-to-control hemorrhage.

Blast Injury Explosions can result in: Assess the scene for hazards.
Soft-tissue trauma Abdominal trauma Skeletal trauma Blast lung Assess the scene for hazards.

The Process of Wound Healing
Hemostasis Vessels, platelets, and clotting cascade must work together to stop bleeding. The release of chemicals: Constricts the blood vessels Activates platelets

Inflammation Additional cells enter area for repair. White blood cells combat pathogens. Chemotactic factors are released. Lymphocytes destroy bacteria and pathogens. Mast cells release histamine.

Inflammation (cont’d) Leads to the removal of: Foreign material Damaged cellular parts Invading micro-organisms

Epithelialization New epithelial cells move to outer layer of skin to replace those lost in injury. Area seldom regains previous look. Function of area may be restored.

Neovascularization New blood vessels form to bring oxygen and nutrients to injured tissue. New capillaries form from intact capillaries.

Collagen synthesis Collagen: Tough, fibrous protein in scar tissue, hair, bones, connective tissue Repair unit is synthesized by fibroblasts. Cannot restore damaged tissue to former strength

Alterations of Wound Healing
Healing does not always follow pattern because there may be: Infection or abnormal scarring Excessive bleeding Slow healing

Anatomic factors Body areas with repeated motion Relationship of open wound to skin tension lines Medications Medical conditions

High-risk wounds Human and animal bites High risk of infection Injuries from foreign bodies or organic matter Do not remove an impaled object in the field.

Abnormal scar formation Excessive collagen formation can occur if healing phases are not balanced, leading to: Hypertrophic scar Keloid scar

Pressure injuries Occur from: Being bedridden Pressure applied for prolonged periods Involved tissues are deprived of oxygen.

Wounds requiring closure Include: Open injuries affecting cosmetic areas Gaping wounds and wounds over tension lines Degloving injuries Ring injuries and skin tears

Wounds requiring closure (cont’d) Open injuries should be closed within 24 hours. Three types of wound closure: Primary closure Secondary intention Delayed primary closure

Pathophysiology of Wound Healing
Infection Pathogens grow and multiply once they reach body tissues. Clinical signs may not appear for days.

Infection (cont’d) Visible signs Pus Warmth Edema Local discomfort Red streaks

Infection (cont’d) Systemic signs Fever Shaking Chills Joint pain Hypotension

Gangrene Caused by Clostridium perfringens Causes foul-smelling gas If untreated: Skin will become necrotic. Infection may lead to sepsis.

Tetanus Caused by infection from Clostridium tetani Causes a potent toxin, resulting in: Painful muscle contractions Muscle stiffness Rare because of vaccine

Necrotizing fasciitis Involves tissue death from bacterial infection Rare, but with high mortality Treatment includes: Antibiotic therapy Surgical debridement

Patient Assessment Skin trauma is rarely life-threatening.
Stay focused on assessment process. Identify threats to EMS crew. Identify threats to patient.

Scene Size-Up Address safety first. Evaluate MOI.
If significant, keep a high index of suspicion. Determine the number of patients involved. Protect yourself and patient from bodily fluid.

Primary Assessment Form a general impression.
Determine any life threats. Check patient and immediate surroundings. Check for potential injuries to neck and spine. Evaluate level of consciousness.

Primary Assessment Airway and breathing Assess immediately.
Correct anything that interferes with airway. Assess the patient’s breathing. Take prompt action for compromised breathing.

Primary Assessment Circulation Assess circulation by:
Palpating a pulse Palpating and inspecting the skin using CTC Control of severe hemorrhage with a tourniquet takes precedence.

Primary Assessment Transport decision
Transport patients with significant trauma. Patients with isolated injuries can often be treated at the scene.

Primary Assessment Significant MOI Serious trauma indicated by:
Altered level of consciousness Lack or airway protection or patency Inadequate breathing Uncontrolled bleeding

Primary Assessment Significant MOI (cont’d)
If possibility of serious injury, perform a rapid exam, assessing: Head and neck Chest Abdomen Pelvis Lower and upper extremities Posterior

Identify need for attention using DCAP-BTLS: Deformities Contusions Abrasions Punctures or penetrations Burns Tenderness Lacerations Swelling

Primary Assessment Significant MOI (cont’d) Assess areas with:
Alteration in sensation Uneven temperature Abnormal muscle tone Note blood from hidden injuries. Address any life threats.

After assessment, apply a cervical collar. Decide whether to rapidly transport. Perform a complete set of vital signs and a SAMPLE history.

Primary Assessment No significant MOI
Isolated extremity trauma does not warrant a fully body exam. If protocols allow, some patients can be released after treatment on the scene.

History Taking Ask about events leading to injury.
Ask about the last tetanus booster. Ask about over-the-counter medicines. Use the mnemonic SAMPLE.

Secondary Assessment Conduct a more thorough examination en route if there is: A significant MOI Adequate time Patient in stable condition

Reassessment Do frequent reassessments en route.
Stable patient—every 15 minutes Serious condition—every 5 minutes minimum Obtain and evaluate vital signs. Check interventions and monitor patient.

Reassessment Complete written documentation.
Note specific injuries, describing wounds. Note assessment findings for: Distal neurovascular status Range of motion Presence or absence of infection

Reassessment Obtain patient demographic information.
Record any interventions performed, documenting: Patient’s response Patient’s understanding Which provider attended the patient

Emergency Medical Care
Basic management principles: Attend to clinical issues and patient’s feelings. Control bleeding with direct pressure, elevation, or a tourniquet if necessary. Document any care provided.

Treatment of Closed Wounds
Minimize bleeding and swelling (ICES): Apply Ice or cold packs. Apply firm Compression. Elevate the injured part higher than the heart. Apply a Splint.

Treatment of Closed Wounds
Edema is the body’s way of dealing with injury to soft or connective tissues. Using ice as early as possible may speed up healing time.

Treatment of Open Wounds: General Principles
Control bleeding by most effective method. Keep wound as clean as possible. Determine injury magnitude, and relay information to the receiving facility.

Treatment of Open Wounds: General Principles
If wound is already in healing stage: Examine edges to see if the wound is closing properly. Check for signs of infection.

Bandaging and Dressing Wounds
Used to: Cover wound Control bleeding Limit motion Variety of materials used

Complications of Improperly Applied Dressings
Always use as sterile technique as possible. Irrigate open wounds with normal saline. Apply antibiotic ointment to smaller wounds. Do not use ointment on larger wounds.

Hemodynamic complications may include continued bleeding. Apply additional dressings in conjunction with other interventions. Perform frequent assessments.

Structural elements can be damaged if dressings are too tight. Assess and readjust if necessary. When extremity dressings are in place, assess: Distal pulses Motor function Sensation

Control of External Bleeding
Bleeding can be characterized by type of blood vessel damaged. Capillary bleeding—slow flow, bright or dark red Venous bleeding—slow, steady, darker color Arterial bleeding—spurts, bright red color

Direct pressure Allows platelets to form blood clots Steps for management: Follow standard precautions. Maintain airway. Apply direct pressure with a dry, sterile dressing. Apply a pressure dressing and gauze.

Direct pressure (cont’d) If bleeding is not controlled, apply a tourniquet. Apply high-flow oxygen as necessary. Monitor serial vital signs, and watch for shock. If signs of shock arise, transport rapidly. Assess circulation before and after application.

Elevation Can substantially slow venous bleeding Immobilization Motion disrupts clotting process. Limit injured extremity movement. If necessary, apply a splint.

Tourniquet Especially useful if: Extremity injury below the axilla or groin is severely bleeding. Other bleeding control methods are ineffective. Courtesy of Steven Kasser

Tourniquet (cont’d) Follow standard precautions. Hold direct pressure over bleeding site. Place tourniquet above the bleeding site. Click the buckle into place. Turn the tightening dial clockwise until pulses are no longer palpable distal to the tourniquet.

Tourniquet (cont’d) To release the tourniquet, push the release button and pull the strap back. If a commercial tourniquet is not available, use a triangular bandage and a stick or rod. A blood pressure cuff can also be used.

Tourniquet (cont’d) Take the following precautions: Do not apply over a joint. Use the widest bandage possible. Never use material that could cut into the skin. If possible, use wide padding under the tourniquet.

Tourniquet (cont’d) Take the following precautions (cont’d): Never cover with a bandage. Inform the hospital. Do not loosen after it is applied.

Pain Control May include: Cold compress Pressure dressing
Morphine sulfate or other pain medication

Managing Wound Healing and Infection
Basic measures should be used in the prehospital setting. Wounds that look infected or are not healing properly should be dressed and bandaged. Pain control management may be indicated.

Dressing Specific Anatomic Sites
Scalp dressings Direct pressure is usually effective. Determine the extent of injury. Balance bleeding control needs against the possibility of causing further damage. If skull has been damaged, apply pressure to areas around the break.

Facial dressings Reassure patient. Direct pressure is effective to control bleeding. If avulsed tissue is present, attempt to place it as close to its previous position as possible. Assess for airway compromise.

Ear or mastoid dressings Do not place a dressing in the ear canal. Use gauze sponges to aid in stopping blood loss. Do not try to directly stop blood flow from the ear canal. Place a bulky dressing over the external ear.

Neck dressings Minor injuries can become major. Use occlusive dressings. Make sure dressings do not interfere with blood flow or movement of air through the trachea. © E. M. Singletary, MD. Used with permission

Truncal dressings Cover open wounds with occlusive dressing, taping only three sides. Assess breath sounds. Use medical tape to secure dressing.

Groin and hip dressings Combined with direct pressure Genitalia injuries should be managed by someone of the same gender. Remain professional, and protect the patient’s privacy.

Hand, wrist, and finger dressings Place the hand in a position of function. The hand and wrist can be splinted. Leave fingers exposed.

Elbow and knee dressings Movement may cause dressings to shift. For larger wounds, immobilize joint. Assess distal neurovascular status.

Ankle and foot dressings Control bleeding with direct pressure. If bleeding is arterial and not controlled, consider a tourniquet proximal to injury. Always assess distal neurovascular function before and after caring for a wound.

Abrasions Superficial wound
Occurs when part of epidermis is lost from being rubbed or scraped over a rough surface

Abrasions Assessment and management Oozes small amounts of blood
May be painful and prone to infection Do not clean in the field. Cover lightly with sterile dressing.

Courtesy of Rhonda Beck
Lacerations Cut from a sharp instrument that produces a clean or jagged incision Can injure structures beneath skin Courtesy of Rhonda Beck

Lacerations Assessment and management Seriousness depends on:
Depth Structures damaged First priority is to control bleeding.

Puncture Wounds Caused by a stab from a pointed object
Can result in injury to underlying tissues and organs

Puncture Wounds Assessment and management
Consider potential depth of wound. Treatment is similar to other wounds: Look for entrance and exit wounds. Take steps to prevent infection.

Puncture Wounds Assessment and management (cont’d)
Air may be injected under the skin with certain puncture wounds. Monitor for edema. Treat swelling with ice.

© Custom Medical Stock Photo
Puncture Wounds Assessment and management (cont’d) If the object is still embedded in the wound: Immobilize the object. Transport the patient. © Custom Medical Stock Photo

Basic management points for impaled objects: Do not try to remove an impaled object. Use direct compression, but not on the impaled object or adjacent tissues. Do not try to shorten the object. Stabilize the object with bulky dressing, and immobilize the extremity.

Prehospital care goal—limit movement as soon as possible. Secure the object as best as possible. Provide reassurance. Constantly assess for risks to life.

Removal of impaled object may be necessary: If object directly interferes with airway control If object interferes with chest compression If patient is impaled on an immovable object

Avulsions Occurs when a flap of skin is partially or completely torn loose Amount of bleeding is dependent on the depth of injury.

Avulsions Assessment and management
Principle danger is loss of blood supply to the avulsed skin flap. If wound is contaminated, provide irrigation. Gently fold and align the skin flap back as close to its normal position as possible. Cover it with a dry, sterile compression dressing.

Avulsions Assessment and management (cont’d)
Ice packs on the surrounding area may: Decrease pain and swelling Increase the length of time the underlying tissue remains viable If patient is unstable, do not delay transport.

© E. M. Singletary, MD. Used with permission.
Amputations An avulsion involving the complete loss of a body part © E. M. Singletary, MD. Used with permission.

Amputations Assessment and management
Be aware of sharp bone protrusions. The body part may be completely detached or soft tissues may remain attached. Degloving injury: unraveling of skin from the hand

Amputations Assessment and management (cont’d)
If a body part is completed amputated, try to preserve it in optimal condition. Rinse off any debris. Wrap it loosely in saline-moistened sterile gauze. Seal it in a plastic bag; place it in a cool container. Never warm it or place it in water. Never place it directly on ice or use dry ice.

Amputations Assessment and management (cont’d)
Transport as soon as possible. If the amputated part is a limb or part of one, notify ED staff of: Type of amputation Estimated arrival time

Courtesy of Moose Jaw Police Service
Bite Wounds Animals bites can be serious. Cat and dog mouths are contaminated with virulent bacteria. Courtesy of Moose Jaw Police Service © Chuck Stewart, MD

Bite Wounds Human bites usually occur on the hand.
Human mouths contain a wide variety of virulent pathogens.

Bite Wounds Assessment and management
Place a sterile dressing and transport promptly. Splint an arm or leg if it is injured. Determine and document: When the bite occurred Type of animal What led to the biting incident

Bite Wounds Assessment and management (cont’d)
Rabies is a major concern with dog bites. Once signs appear, it is almost always fatal. Spread by bites or licking an open wound Can be prevented by a series of vaccine injections Do not enter until the scene is secured.

Bite Wounds Assessment and management (cont’d)
Emergency treatment for human bites includes: Control all bleeding and apply a sterile dressing. Immobilize the area with splint or bandage. Provide transport.

Crush Syndrome Can develop if a body area is trapped for longer than 4 hours and arterial blood flow is compromised If muscles are crushed beyond repair, tissue necrosis leads to rhabdomyolysis.

Crush Syndrome Freeing the body part from entrapment may result in release of harmful products. “Smiling death” may occur. Other significant complications include: Renal failure Life-threatening dysrhythmias

Crush Syndrome Assessment and management
Scene safety is the first consideration. Complete primary assessment as possible. Obtain IV access before removing the object. Infuse normal saline. Add sodium bicarbonate as part of the IV fluid.

Crush Syndrome Assessment and management (cont’d)
If pretreatment not possible, apply a tourniquet. Will reduce some of the reperfusion damage Treat severe hyperkalemia with 25 mL of D50W, followed by 10 units of regular IV insulin. Rapidly transport once the patient is freed.

Manage other injuries once en route. Handle open injuries with dressing and bandages. Splint fractures. Prepare to administer fluids as needed. Take vital signs every 5 minutes at minimum. Get an ECG reading to detect dysrhythmias.

When transporting, consult with medical control about using a hyperbaric chamber.

Compartment Syndrome Develops when edema and swelling cause increased pressure within a closed soft-tissue compartment Leads to compromised circulation Commonly develops in extremities Can cause tissue necrosis

Compartment Syndrome Assessment and management Presents with six Ps:
Pain Paresthesia Paresis Pressure Passive stretch pain Pulselessness

Compartment Syndrome Assessment and management (cont’d)
Many signs may be delayed or nonspecific. Can cause death of local tissues Risk of sepsis In-hospital intervention includes fasciotomy.

High-Pressure Injection Injuries
Occurs when a foreign material is forcefully injected into soft tissue, causing: Acute and chronic inflammation Damage from: Direct insult Chemical inflammation Ischemia from compressed blood vessels Secondary infection

Assessment and management Question patient about nature of injury. Inspect injury for extent of visibly damaged tissue. Palpate affected area for signs of edema. Check for crepitus at injury site.

Assessment and management (cont’d) Gently irrigate open wounds with normal saline. Dress and bandage open injuries. Manage pain if necessary. Injury may require emergent surgery.

Facial and Neck Injuries
May involve airway or large blood vessels Airway compromise may arise. Suctioning and positioning may be necessary. Open injuries to the jugular or carotid vessels can result in exsanguinations.

Assessment and management Assess airway patency, protection, and oxygen. May require more invasive management: Endotracheal tube A Combitube Laryngeal mask airway

Assessment and management (cont’d) Bleeding control can be started while airway control is underway. If only one EMS provider is available, address bleeding after airway is secured.

Thoracic Injuries May appear minor but produce deadly internal damage
Determine MOI during primary assessment to detect life threats.

Thoracic Injuries Assessment and management Four steps to assessment:
Inspection Palpation Auscultation Percussion

Abdominal Injuries Range from minor abrasions to evisceration
Inspect abdomen and palpate area. During inspiration, the size of thoracic and abdominal cavities change. Increases risk of drawing air into pleural space

Abdominal Injuries Assessment and management
Focus on injury to underlying organs and blood vessels. Could quickly lead to serious complications

Summary The skin fulfills crucial roles, including maintaining homeostasis, protecting tissue, and regulating temperature. The skin’s main layers are the epidermis and dermis. The layer beneath the dermis is the subcutaneous layer. Below that is the deep fascia.

Summary Tension lines are patterns of tautness in the skin. If a wound is parallel to skin tension, it may remain closed, while a wound that runs perpendicular may remain open. Soft-tissue injuries are seldom the most serious injuries, although they may look dramatic. In a closed wound, soft tissues beneath the skin are damaged but the skin is not broken.

Summary In an open wound, the skin is broken, and the wound can become infected and result in serious blood loss. In a crush injury, a body part is crushed between two solid objects, causing damage to soft tissues and bone. Cessation of bleeding is the first stage of wound healing. Inflammation is the second stage of healing.

Summary Factors that affect wound healing include the amount of movement the part is subjected to, medications, and medical conditions. Infection signs include redness, pus, warmth, edema, and local discomfort. Observe scene safety first. Then assess the ABCs.

Summary During the history intake, ask about the event causing the injury. Ask about the patient’s last tetanus booster, and if they are taking mediations that may affect hemostasis. Complete the physical exam either en route or at the scene, depending on mechanism of injury. Document scene findings.

Summary Be empathetic. Controlling bleeding is a part of soft-tissue injury management. Follow the ICES mnemonic for closed injuries. When managing open wounds, control bleeding and keep wound clean by irrigating and sterile dressings. Dressings and bandages cover wounds, control bleeding, and limit motion.

Summary Medical tape may secure a bandage in place. Dressings should not be applied too tightly. Bleeding control methods include direct pressure, elevation, immobilization, and tourniquets. Dressing and bandaging techniques vary for different areas of the body.

Summary Avulsion management includes irrigation; gently folding the flap back onto the wound; and applying a dry, sterile compression dressing. Do not remove impaled objects. Animal and human bites can cause serious infection. Dogs and cats can carry rabies. Crush syndrome may develop after a body part has been trapped more than 4 hours.

Summary Patients trapped for prolonged periods of time must be managed before being freed to improve survival chances. Compartment syndrome results from pressure increase in a closed soft-tissue compartment. Presentation includes some or all of the six Ps. Blasts can result in soft-tissue injuries. Use the DCAP-BTLS guideline for assessment.

Summary High-pressure injection injuries involve foreign material injection into soft tissue. Special attention should be paid to soft-tissue injuries of the face, neck, thorax, and abdomen because they contain vital structures.

Credits Chapter opener: © Mark C. Ide
Backgrounds: Orange—© Keith Brofsky/Photodisc/ Getty Images; Blue—Jones & Bartlett Learning. Courtesy of MIEMSS; Purple—Jones & Bartlett Learning. Courtesy of MIEMSS; Green—Courtesy of Rhonda Beck. Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.

Chapter 31 Soft-Tissue Trauma.

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Chapter 31 Soft-Tissue Trauma.

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