Soft Tissue Injury

April Morgenroth RN, MNDavid Peck MSN, ARNP

Soft TissueDefined

Soft tissues are structures of the body that connect,

envelope, provide support, or move the structures

surrounding it.Examples: skin, muscle, fat

The Integumentary SystemIncludes all external coverings of the body

HairSkin Exocrine Glands

Protects body from infectionThermoregulationHelps to maintain fluid

balanceHelps to maintain electrolyte

balance

Function:

Skin

Hair

Skin is composed of three layers:

Epidermis: outermost layer of cells, contains melanin, gives skin pigment

Dermis: bottom layer of skin, contains blood vessels, connective tissue, nervesSubcutaneous layer: fatty tissue, stores nutrients

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Soft Tissue Trauma

Fat/Adipose Tissue

The most vulnerable soft tissue to trauma and infection.

Adipose soft tissue heals more slowly Poor vascularity Limited capacity to form collagen

and tensile bonds.

ages.com

Soft Tissue Trauma Open vs. Closed

Open Soft Tissue Trauma: Outermost layer of skin is open. Damage may be only on the surface or it may be deep past the skin and fatty tissues.

Closed Soft Tissue Trauma: Inner layers of soft tissue are damaged but the outermost layer remains intact .

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Classification of Soft Tissue InjuryAbrasion: epidermal and dermal layers are affected. The injury is caused by friction.

Avulsion: skin flap, the edges cannot be approximated

Laceration: Tearing or splitting of the skin, can involve the fatty tissues as well

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Degloving: large amounts of skin are torn away from the vascular supply

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Classification of Soft Tissue Injury

Contusion: damage to small blood vessels causes bleeding into the tissue, skin remains intact

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Puncture: an open wound that tears through skin and damages underlying tissues. These wounds can be shallow or deep and some may even have an entry point and an exit point.

Soft Tissue Trauma Gunshot Wound Vocabulary

Wounds by projectiles are determined by size of the projectile, the force/velocity at entry, the density of the tissue and shape and design of the missile

Tumble & Yaw - how the bullet turns while inside tissue

Cavitation - the internal size of the wound tract

Speed – contributes to severity and extent of wounds(example: Lead bullet cores melt when propelled above a velocity of 2000ft/sec. causing internal burns as well as cavitation on entry)

Cavitation tracts from various projectiles

Soft Tissue Trauma Gunshot Wound Vocabulary

Entry & Exit wounds- Two holes may indicate two separate gunshot wounds or the path that one bullet took through and out of tissue. Observing and documenting these wounds is an important trauma function.

Gunshot crepitis- Gasses injected into the tissues on bullet impact may become lodged there and cause a popping crepitis on palpation

Gunpowder tattoos- Residual gunpowder may burn the tattoo the skin surrounding the entry and exit wounds. Washing powder off during wound care may lessen this deformity

Wound Healing

“Golden Window for wounds” - 12 hours

Wounds closed/sutured open more than 12 hours following trauma display profound increases in

infection failed closure significant cosmetic deformity

• nevamwiti.com

Stages of Wound HealingPhase I Inflammatory Response- Day 1-5

A.D.A.M.

1. Plasma protein, blood cells, fibrin & antibodies flow into the wound.

2. Within 4 hours leukocytes cause localized edema, pain, & erythema.

3. Leukocytes and macrophages ingest & remove debris.

4. Skin margin basal cells begin migration over incision to close the wound.

5. Connective tissue fibroblasts begin reconstruction of non-epithelial tissue.

Stages of Wound HealingPhase II Migration/Proliferation- Day 5-14

1. Collagen, fibrin & fibronectin contract wound margins & initiate scar formation.

2. Tensile strength of the affected tissue increases, sutures are not needed for wound closure.

3. Lymphatics, blood vasculature and granulation tissues regenerate.

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Stages of Wound HealingPhase III Maturation/Remodeling Day 14- complete healing

1. Tensile strength increases up to one year. Skin tissue regains 70-90% of it’s original strength Intestinal tissue may regain 100% of original strength within one

week!

2. Fibrous connective tissue stratifies to increase pliability 3. Scar structure remodels and retracts. A.D.A.M

Stages of Wound HealingDelayed Closure-

Some wounds are not able to be sutured closed because of extensive trauma, infection, tissue loss, or imprecise initial closure of wound.

These wounds are kept open to allow for drainage &prevent closed (anaerobic) pockets from forming, as in puncture wounds.

(note granulation of tissue margins)

Care of Open Soft Tissue Injury

Ensure a patient airway

Evaluate patients respiratory status

Note respiratory rate

Note work of breathing (labored, use of accessory muscles)

Care of Open Soft Tissue Injuries

Evaluate for signs of circulation and major bleeding

Control bleeding using appropriate method, stabilize impaled objects

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Ensure fluid and electrolyte balanceCheck hematocrit and

electrolytes in the presence of any major injury

Open Wound Management Wound Assessment

following stabilization of patient

Observe for foreign objects in wound Note debris & cues to trauma source (glass

shards/dirt/bite marks) Assess for parasthesia/paralysis Monitor for pallor/pulselessness distal to

wound Observe deformity, contusion, other

ruptures of skin integrity, swelling Assess & manage pain (analgesics or local

block) Document wound depth, size, location &

appearance

Open Wound Management

The following categories can be used to describe & document wound characteristics based on a clinical estimation of microbial contamination

& risk for subsequent infection.

Clean Mechanism of injury relatively clean- knife/glass/plastic/milled wood

Clean/Contaminated Appears clean, but known contact with soil, stagnant water, feces

Contaminated (“dirty”) Visible debris in wound, possible foreign body

Contaminated and Infected Foul odor, signs of infection, visible debris or foreign body

Wound Cleansing & Care

Use normal saline if available, avoid tap water

Antimicrobial surgical scrub- Betadine

Scrub with soft brush or gauze, from the center of the wound out

Irrigate wound liberally and frequently

Consider antibiotics

The Solution to Pollution is Dilution! isips.org

Care of Open Soft Tissue Injuries

Evaluate the need for suturesWound is a deep and/or gaping

laceration, avulsion, or incision where the edges can be approximated

Skin grafts may be needed for major degloving injuries or major burns.

Tetanus (lockjaw)-

Non-immunized trauma victims with open wounds face a significant risk for tetanus.

A spore forming anaerobic bacteria Found in soil and the feces of domesticated animals Endemic in developing areas

(In Mexico, tetanus immunization is inconsistent. Rates of infections are unreported.

CDC, 2009).

Cedarcrest.edu

Tetanus Immunization

Tetanus can be prevented in trauma patients through prophylactic treatment

Trauma victims with high-risk wounds may be given tetanus immune globulin (TIG) in addition to tetanus toxoid if their immunization status is unknown or not current

Tetanus toxoid ‘booster’ at least every 10 years, every 5 years in cases of tetanus-prone exposures

Assessment and documentation of immunization status and tetanus-prone wounds is a vital component of trauma care

Tetanus Prone WoundsClinical Features Non-Tetanus Prone

WoundsTetanus-Prone Wounds

Age of Wound ≤ 6 hours > 6 hours

Configuration Linear, abrasions Stellate wound, avulsions

Depth ≤ 1 cm > 1cm

Mechanism of injury Sharp surface (knife, glass)

Missile, crush, burn, frostbite

Sign of infection Absent Present

Contaminants (dirt/feces/soil/saliva)

Absent Present

Denervated/ischemic tissue

Absent Present

Soft Tissue Trauma- Respiratory

Types of Pneumothorax-Simple pneumothorax- a portion of the inflated lung pulls away from the pleural wall causing a partial collapse

Treatment- Chest tube (small pneumothorax may be allowed to

reinflate spontaneously)

Hemothorax- blood fills a portion of space between lung tissue & the pleural wall. Blood loss into the pleural cavity can be up to 1/3 total blood volume

Treatment- Chest tube If large volume of blood is retrieved, auto

transfusion is performed to return the patient blood volume. Surgical thoracotomy may be required to stop hemorrhage resolve accompanying tamponade

Tension PneumothoraxA Medical Emergency Air is forced through a

“one way valve” through the lung tissue into the pleural space

Intrapleural pressure causes-

• the lung to collapse • Mediastinal shift• Limits cardiac circulation • Applies pressure on the

remaining lung with risk of complete respiratory collapseTreatment- Needle Decompression:

large bore needle is inserted into the second intercostal space at the midclavicular line- converting the defect to a simple pneumothorax. Then a chest tube is inserted.

Chest trauma can sometimes result in blood or other fluids collecting in the pericardium

Pressure builds and restricts movement of the heart

Signs and symptoms: anxiety, chest pain, shortness of breath, narrowing pulse pressure, signs of poor perfusion, death

This an emergency, call the physician immediately

Monitor closely, obtain IV access, give supplemental oxygen

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The physician will need to perform a pericardiocentesis.

Tamponade

Sucking Chest Wound

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A puncture to the thoracic wall that communicates with the pleural space may cause a sucking chest wound

When the patient inhales, intrathoracic pressure drops below atmospheric pressure creating a vacuum which sucks air into the pleural space. (Air will also escape the pleural space to some degree following pressures)

Pressure in the pleural space builds and the lung begins to collapse. The patient now has a pneumothorax.

Sucking Chest Wound Evaluation and Treatment

Make a three way occlusive dressing Tape down three sides This makes a one way valve Patient will need a chest tube May use the sterile side of plastic

packaging, Plastic bag or specifically designed ‘flutter valve’

Soft Tissue Trauma- Respriatory

Cardiac Tamponade TensionPneumothorax

Breath sounds

Equal on both sides

Decreased or absent on affected side

Trachea Midline Deviated away from affected side

Percussion Normal resonance

Tympanic (Hyperresonant)

Pulse Affected by breathing

Normal

Tension Pneumothorax & Cardiac Tamponade are: Two very different medical emergencies that present with very similar symptoms-

The diagnosis of each is determined by clinical evaluation that You could make in a trauma care setting!

Abdominal Trauma Evaluate for internal bleeding Note any external bleeding Treat for shock If the wound is open and

intestines are exposed (eviscerated organs) use sterile saline on sterile gauze, then cover with plastic (an occlusive dressing)

Impaled ObjectsDo not attempt to remove the object

UNLESS: it is in the cheek and is obstrubstructing the airway

If an object in the cheek needs to be removed, gently pull it the rest of the way through

Control bleeding using appropriate methods

Minimize damage to internal organs by stabilizing the object to minimize movement and vibration

Treat patient for shock

Prepare for emergent surgical interventionwww.cprpgh.fanspace.com/images/pencil.jpg

Burns

Three Mechanisms Thermal: caused by heat Chemical: caused by

caustic chemicals Electrical: caused by

electicity (ex. Electical shock)

Burn ClassificationFirst Degree/Shallow Thickness: involves just the outer layer of skin, the skin is

reddened, hot, painful but overall the skin is intact

Sunburn, minor scald burns

Treatment: may use aloe on the skin to restore skin moisture and sooth the burn

Prevention is key: protect from intense sun

Images from A.D.A.M.

Burn Classification Continued

Second Degree/Partial Thickness: The damage is deeper and involves more layers.

The area may be blistered, red, and painful

Example: hand on a hot stove

Stop the burning!

Lance the blisters

Do Not put ointments on it (this keeps the heat in)

Images from A.D.A.M.

Burn ClassificationContinued

Third Degree/Full Thickness: The burn is full thickness, open, weepy, there

may be nerve damage Keep it clean Dress with dry gauze Protect patient from hypothermia If the burn involves fingers or toes, they will

need to be separated when bandaging

Burn ClassificationEstimation of the

percentage of body area affected by the burns is important as it helps us to make clinical decisions.

Estimate the extent of a burn by using the rule of nines

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Burns and Breathing Sometimes burns can affect breathing

and the airway (smoke inhalation, swelling)

Inhalation of chemicals and smoke can cause burns and/or damage to the airway and lungs

Protect the airway through: positioning, placement of an artificial airway if needed

Provide supplemental oxygen

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Soft Tissue Burns

Thermal injuries/Smoke inhalation:

Clinical indications of inhalation injury Face/neck burns “ Sooty” sputumCarbon deposits and inflammation of oropharynx Singeing of eyebrows and nasal passageHoarseness Impaired mentation after confinement in burning

environmentExplosion with burns to head and torsoThe presence of any of these findings suggests acute inhalation injury

allergyconsumerreview.com

Soft Tissue BurnsThermal injuries/Smoke inhalation:Assessment-

History of burn injury is vital to management

Obtain information from witnesses & victim

Inhalation injury may not appear for 24 hours

Length of exposure to fumes/thermal assault affects severity of injury

Consider internal and orthopedic injuries from explosions, falling debris

Soft Tissue BurnsCarbon Monoxide (CO) Exposure (poisoning): Always assume CO exposure for patients burned in enclosed

areasCO levels- < 20% rarely result in symptoms

> 20% headache & nausea> 30% confusion> 40% coma> 60% death

Patients with CO exposure need 100% O2 because of CO’s ability to bind oxyhemoglobin and cause decreased O2 absorption in the blood

Soft Tissue Burns

Escharotomy –

Incisions through the skin layers in circumferential burns to avoid compartment syndrome

A surgical procedure used to maintain circulation & relieve pressure from massive edema and rigid/non-elastic burned skin (eschar)

Not usually needed within the first 6 hours following burn trauma

Soft Tissue Burns

Fasciotomy -A rare surgical ‘limb saving’ procedure where fascia is removed to relieve pressure and prevent compartment syndrome

In addition to use in deep burns, fasciotomy is also used in the following conditions

Skeletal traumaCrush injuriesHigh voltage electrical injury

Fluid Resuscitation for BurnsIn the case of severe burns the

body looses fluids due to the impaired skin integrity and fluid shifts that naturally occur during inflammation.

The blood may become “sludgy” as fluids are lost but cells are retained, this is sometimes called burn shock

Fluid Resuscitation for Burns

Patients weightX

% body burnedX

4 ml lactated ringers=

Volume needed

Give 50% total amount over the first 8 hours.

Give 25% total amount during hours 8 to 16.

Give the remaining 25% of total volume during hours 16-24

Time for fluid resuscitation begins at the time of the injury.

Use this formula for all patients with airway trauma and patients who have 20% body surface area burned.