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Soft-Tissue InjurySoft-Tissue Injury
SectionsSections
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 Introduction to Soft-Tissue InjurySoft-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 Introduction to Soft-Tissue InjurySoft-Tissue Injury
A&P of Soft Tissue A&P of Soft Tissue InjuriesInjuries 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 A&P of Soft Tissue InjuriesInjuries 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 A&P of Soft Tissue InjuriesInjuries 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 A&P of Soft Tissue InjuriesInjuries 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 Pathophysiology of Soft-Tissue InjurySoft-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
Hemorrhage Arterial Capillary Venous
Hemorrhage Arterial Capillary Venous
Pathophysiology of Pathophysiology of Soft-Tissue InjurySoft-Tissue Injury
Wound HealingHemostasis
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 HealingHemostasis
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 Pathophysiology of Soft-Tissue InjurySoft-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 Pathophysiology of Soft-Tissue InjurySoft-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 Pathophysiology of Soft-Tissue InjurySoft-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 Pathophysiology of Soft-Tissue InjurySoft-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 Pathophysiology of Soft-Tissue InjurySoft-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 Pathophysiology of Soft-Tissue InjurySoft-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 Pathophysiology of Soft-Tissue InjurySoft-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 Pathophysiology of Soft-Tissue InjurySoft-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 Dressing & Bandage MaterialsMaterials
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 Dressing & Bandage MaterialsMaterials
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 Assessment of Soft Tissue InjuriesTissue 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 Management of Soft-Tissue InjurySoft-Tissue Injury
Management of Management of Soft-Tissue InjurySoft-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.
TourniquetTourniquet
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 Management of Soft-Tissue InjurySoft-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 Management of Soft-Tissue InjurySoft-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 Anatomical Considerations Considerations for Bandagingfor 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 Anatomical Considerations Considerations for Bandagingfor 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 Anatomical Considerations Considerations for Bandagingfor 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 Anatomical Considerations Considerations for Bandagingfor 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 Anatomical Considerations Considerations for Bandagingfor 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 Anatomical Considerations Considerations for Bandagingfor 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 Anatomical Considerations Considerations
for Bandaging: Specific for Bandaging: Specific WoundsWounds
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 Anatomical Considerations Considerations
for Bandaging: Specific for Bandaging: Specific WoundsWounds
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 Anatomical Considerations Considerations
for Bandaging: Specific for Bandaging: Specific WoundsWounds
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 Anatomical Considerations Considerations
for Bandaging: Specific for Bandaging: Specific WoundsWounds
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 Anatomical Considerations Considerations
for Bandaging: Specific for Bandaging: Specific WoundsWounds
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 Anatomical Considerations Considerations
for Bandaging: Specific for Bandaging: Specific WoundsWounds
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 Anatomical Considerations Considerations for Bandagingfor 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 Anatomical Considerations Considerations for Bandagingfor Bandaging
Abdomen 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.
Abdomen 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.
Anatomical Anatomical Considerations Considerations for Bandagingfor 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 Anatomical Considerations Considerations for Bandagingfor 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 Anatomical Considerations Considerations for Bandagingfor Bandaging