1. CHAPTER 24: SOFT TISSUE INJURIES
PATIENT ASSESSMENT & CARE II
EMS 246
Dr.Bushra Bilal

2. The Anatomy and Physiology of the Skin
Skin has two principal layers: the epidermis and the dermis.
Functions:
Keeps pathogens out
Assists in temperature regulation
Nerves in skin report to brain on environment and sensations.

3. Pathophysiology Three types of soft-tissue injuries: Closed injuries
Open injuries
Burns

4. Closed Injuries (1 of 2) Characteristics of closed injuries
History of blunt trauma
Pain
Swelling
Discoloration

5. Closed Injuries (2 of 2)
A contusion (bruise) causes bleeding beneath the skin but does not break the skin.
A hematoma is blood collected within damaged tissue or in a body cavity.
A crushing injury occurs when a great amount of force is applied to the body
Compartment syndrome results from the swelling that occurs whenever tissues are injured.

6. Open Injuries (1 of 5) Four types: Abrasions Lacerations Avulsions
Penetrating wounds

7. Open Injuries (2 of 5)
An abrasion is a wound of the superficial layer of the skin.
Caused by friction when a body part rubs or scrapes across a rough or hard surface

8. Open Injuries (3 of 5) A laceration is a jagged cut.
Caused by a sharp object or blunt force that tears the tissue
An incision is a sharp, smooth cut.

9. Open Injuries (4 of 5)
An avulsion separates various layers of soft tissue so that they become either completely detached or hang as a flap.
Often there is significant bleeding.
An amputation is an injury in which part of the body is completely severed.

10. Open Injuries (5 of 5)
A penetrating wound is an injury resulting from a sharp, pointed object.

11. Patient Assessment of Closed and Open Injuries
Patient assessment steps
Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment

12. Scene Size-up Scene safety
Observe the scene for hazards and the potential for violence.
Take standard precautions.
Mechanism of injury/nature of illness
Look for indicators of the MOI as you assess the scene.

13. Primary Assessment Form a general impression.
Check for responsiveness using the AVPU scale.
Airway and breathing
Ensure that the patient has a clear and patent airway.
Inspect and palpate the chest for DCAP-BTLS.
Circulation
Assess the patient’s pulse rate and quality.
Determine the skin condition, color, and temperature, and the capillary refill time.
Transport decision

14. History Taking Investigate the chief complaint.
Obtain a medical/ SAMPLE history.
Typical signs of an open injury include:
Bleeding
Break(s) in the skin
Shock
Hemorrhage
Disfigurement or loss of a body part

15. Secondary Assessment Physical examinations
Check the skin’s color and condition
Check for any signs of increased respiratory efforts
Retractions, Nasal flaring, Pursed lip breathing
Use of accessory muscles
Listen for breath sounds.
Assess pulse rate, quality, capillary refill time
Determine the skin condition, color, and temperature.
Assess the neurologic and musculoskeletal system
Vital signs

16. Reassessment Repeat the primary assessment.
Reassess vital signs and the chief complaint.
Interventions
Assess the patients’ ABCs, control bleeding.
Communication and documentation
Description of the MOI/Position in which you found the patient
Amount of blood loss
Location and description of any soft-tissue injuries or other wounds

17. Emergency Medical Care for Closed Injuries
Treat closed soft-tissue injury using the RICES mnemonic:
Rest
Ice
Compression
Elevation
Splinting

18. Emergency Medical Care for Open Injuries (1 of 4)
Follow standard precautions.
Make sure the airway is open and administer high-flow oxygen.
Control life-threatening bleeding using:
Direct, even pressure and elevation
Pressure dressings and/or splints
Tourniquets

19. Emergency Medical Care for Open Injuries (2 of 4)
Abdominal wounds
An open wound in the abdominal cavity may expose internal organs.
The organs may even protrude through the wound, an injury called evisceration.
Cover the wound with sterile gauze.
Secure with an occlusive dressing.
Keep the organs moist and warm.

20. Emergency Medical Care for Open Injuries (3 of 4)
Impaled objects
Only remove an impaled object when:
The object is in the cheek and obstructs breathing.
The object is in the chest and interferes with CPR.
Neck injuries
Open veins may suck in air and cause cardiac arrest.
Cover the wound with an occlusive dressing.
Apply pressure but do not compress both carotid arteries at the same time.

21. Emergency Medical Care for Open Injuries (4 of 4)
Small-animal bites
Wounds may require:
Antibiotics
Tetanus prophylaxis
Suturing
A major concern is the spread of rabies.
Acute, potentially fatal viral infection of the central nervous system
Can affect all warm-blooded animals
Transmitted through biting or licking an open wound

22. Burns
A burn occurs when the body receives more radiant energy than it can absorb.
Sources of this energy include heat, toxic chemicals, and electricity.
Complications :
Infection
Hypothermia
Hypovolemia
Shock

23. Burn Severity (1 of 5) Burn severity depends on: Depth of burn
Extent of burn
Critical areas involved
(Face, upper airway, hands, feet, genitalia)
Patient younger than 5 or older than 55

24. Burn Severity (2 of 5) Depth Superficial (first-degree) burns
Only the top layer of skin
Partial-thickness (second-degree) burns
Epidermis and some portion of the dermis
Blisters are present.
Full-thickness (third-degree) burns
Extend through all skin layers.

25. Burn Severity (3 of 5)

26. Burn Severity (4 of 5) Extent Can be estimated using the rule of nines
Divides the body into sections, each representing approximately 9% of the total body surface area
Proportions differ for infants, children, and adults

27. Burn Severity (5 of 5)

28. Chemical Burns
Can occur whenever a toxic substance contacts the body e.g. strong acids or strong alkalis
Management
Remove any chemical from the patient.
Remove the patient’s clothing.
For liquid chemicals, immediately begin to flush the burned area with lots of water.
Continue flooding the area for 15 to 20 minutes after the patient says the burning pain has stopped.

29. Electrical Burns
May be the result of contact with high- or low-voltage electricity
Your safety is of particular importance.
Never attempt to remove someone from an electrical source unless you are specially trained to do so.
Management
If indicated, begin CPR on the patient and apply an AED.
Give supplemental oxygen and monitor.
Provide prompt transport.

30. Thermal Burns Caused by heat Management
Stop the burning source, cool the burned area, and remove all jewelry.
A dry dressing applied to
Maintain body temperature
Prevent infection

31. Inhalation Burns
Can occur when burning takes place in enclosed spaces without ventilation
Carbon monoxide intoxication should be considered whenever a group of people in the same place all report a headache or nausea.

32. Radiation Burns (1 of 2) Three types of ionizing radiation: Alpha Beta
Gamma
Very penetrating, easily passes through the body and solid materials

33. Radiation Burns (2 of 2) Management Irrigate open wounds.
Notify the emergency department.
Identify the radioactive source and the length of the patient’s exposure to it.
Limit your duration of exposure.
Increase your distance from the source.

34. Patient Assessment of Burns
Patient assessment steps
Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment

35. Scene Size-up Scene safety
Observe the scene for hazards and safety threats.
Mechanism of injury/nature of illness
Determine the type of burn that has been sustained and the MOI.

36. Primary Assessment (1 of 2)
Form a general impression.
Be suspicious of clues that may indicate abuse.
Check for responsiveness using the AVPU scale.
Airway and breathing
Ensure that the patient has a clear and patent airway.
Inspect and palpate the chest wall for DCAP-BTLS

37. Primary Assessment (2 of 2)
Circulation
Assess the pulse rate and quality.
Observe the patient’s skin condition, color, temperature, and capillary refill time.
Control significant bleeding.
Assess for shock.
Transport decision
Consider quickly transporting a patient who has:
An airway or breathing problem
Significant burn injuries/ external bleeding
Signs and symptoms of internal bleeding

38. History Taking
Investigate the chief complaint.
SAMPLE history

39. Secondary Assessment Physical examinations Perform a full-body scan.
Make a rough estimate, using the rule of nines, of the extent of the burned area.
Determine the severity of the burn.
Package the patient for transport.
Assess the patient’s neurologic, respiratory and musculoskeletal system.

40. Reassessment
Repeat the primary assessment and reassess the patient’s vital signs.
Reassess the chief complaint.
Reevaluate interventions
Assess and treat breathing.
Support circulation.
Provide rapid transport.
Communication and documentation
Provide hospital personnel with a description of how the burn occurred.

41. Dressing and Bandaging (1 of 2)
All wounds require bandaging.
Sometimes splints can help control bleeding and provide firm support for dressing.

42. Dressing and Bandaging (2 of 2)
Dressings and bandages have three functions:
To control bleeding
To protect the wound from further damage
To prevent further contamination and infection

43. Sterile Dressings Most wounds will be covered by: Universal dressings
Conventional gauze pads
Universal dressings are ideal for covering large open wounds.
Gauze pads are appropriate for smaller wounds.
Adhesive-type dressings are useful for minor wounds.
Occlusive dressings prevent air and liquids from entering (or exiting) the wound.

44. SUMMARY
There are three types of soft-tissue injuries: closed injuries, open injuries, and burns.
Closed soft-tissue injuries are characterized by a history of blunt trauma, pain at the site of injury, swelling beneath the skin, and discoloration. Contusions, hematomas, and crushing injuries are classified as closed injuries.
Treat a closed soft-tissue injury by applying the mnemonic RICES: Rest, Ice, Compression, Elevation, and Splinting.

45. SUMMARY
Open injuries differ from closed injuries in that the protective layer of skin is damaged. Abrasions, lacerations, avulsions, and penetrating wounds are classified as open injuries.
Treat an open soft-tissue injury by applying direct pressure with a sterile bandage using a roller bandage, and splint the extremity.
Burns are considered to be superficial, partial-thickness, or full-thickness based on the depth involved.

46. SUMMARY When providing emergency care for burns:
Use standard precautions.
Cool burned area to prevent further damage.
Remove jewelry and constrictive clothing.
Ensure an open and clear airway, provide high-flow oxygen,
Place sterile dressings over the burned area, cover patient with a blanket, and transport promptly.
Dressings and bandages are designed to control bleeding, protect the wound from further damage, prevent further contamination, and prevent infection.

47. UNIT ASSESSMENT What does the acronym RICES stand for?
Describe the steps used to control bleeding from an open soft-tissue injury.
When would it be appropriate to remove an impaled object?
 What are the critical areas of the body relating to burns?