Ch05 soft tissue injury shorter

Paramedic Care:Principles & Practice

Volume 5Trauma Emergencies

Chapter 5Soft-Tissue Trauma

Topics

Introduction to Soft-Tissue InjuriesAnatomy and Physiology of Soft-Tissue InjuriesPathophysiology of Soft-Tissue InjuryDressing and Bandage MaterialsAssessment of Soft-Tissue InjuriesManagement of Soft-Tissue Injury

Introduction to Soft-Tissue Injuries

Introduction to Soft-Tissue Injuries

Skin is the largest organ16% of total body weightFunction:– Protection

Body fluids inBad stuff out (pathogens)

– Sensation– Temperature regulation

Introduction to Soft-Tissue Injury

Epidemiology– Open wounds– Closed wounds

More commonContusions, sprains, strains

– Risk factors for soft-tissue wounds AgeAlcohol and drug abuseOccupation

– Prevention

Anatomy and Physiology of Soft-Tissue Injuries


Layers of the Skin– Epidermis– Dermis– Subcutaneous


Blood Vessels– Arteries– Arterioles– Capillaries– Venules– Veins

Layers– Tunica intima– Tunica media– Tunica adventitia

Click here to view the anatomy of blood vessels.


Muscles– Beneath skin layers– Fascia

Thick, fibrous, inflexible membrane surrounding muscle that aids in binding muscle groups together


Tension LinesLacerations across the tension lines have a tendency to be pulled apart. Lacerations parallel to the tension lines tend to gape very little.

Pathophysiology of Soft-Tissue Injury



Closed Wounds– Contusions

Blunt, nonpenetrating injuries that crush and damage small blood vessels Characterized by erythema and ecchymosis

© Edward T. Dickinson, MD

Closed Wounds

Hematoma – ‘HEMATOMATA’– Blood separates tissue and pool in a pocket

Dangerous in head injuriesSome may cause hypovolemia


Open Wounds– Abrasion

Typically the most minor of injuries Carries the danger of serious infection

– LacerationPenetrates more deeply into the dermis than an abrasion Endangers the deeper and more significant vasculature, nerves, muscles, tendons, ligaments, and organs

© Charles Stewart, MD

Open WoundsIncision– A surgically smooth

laceration Puncture– A small entrance

wound with damage that extends into the body’s interior

– A puncture additionally carries an increased danger of infection

Open Wounds

Impaled Object– A wound

complication often associated with a puncture or laceration

– May cause worsening damage if withdrawn © Charles Stewart, MD

Open Wounds

Avulsion– A flap of skin,

although torn or cut, is not torn completely loose from the body

– Degloving injury Ring injury

Open WoundsAmputations– Partial or complete

severance of a digit or limb

– Hemorrhage associated with the amputation may be limited

– Care is used to ensure that the stump will be as functional as possible © Mark C. Ide


Hemorrhage– Arterial– Venous – Capillary

The nature of the soft-tissue wound may be more important than the size or type of vessel involved– Clean lacerations and amputations generally do

not bleed profusely


Wound Healing– Hemostasis

Vessels have a muscular layer that reflexively constricts the vessel in response to local injury Platelets begin the clotting process

Stick to the vessel wall and to one another forming a plugProteins activate a complicated series of enzyme reactions

Coagulation

Wound Healing

Inflammation– Involves a host of elements

Various kinds of white blood cells Proteins involved in immunity Hormone-like chemicals that signal other cells to mobilize

– Chemotactic factors Recruit cells

Granulocytes and macrophages Phagocytosis

Wound Healing

Inflammation (cont.)– Lymphocytes and immunoglobins– Histamine dilates precapillary blood vessels

Increases blood flow to affected areaBrings much-needed oxygen and more phagocytes to the injured area

Wound Healing

Result of the inflammatory stage– Clearing away of dead and dying tissue – Removal of bacteria and other foreign substances– Preparation of the damaged area for rebuilding

Wound Healing

Epithelialization– Epithelial cells migrate over the surface of the

woundRestores a uniform layer of skin cells along the edges of the healing wound

– The new epithelial layer is not a perfect facsimile of the original, undamaged skin

Usually quite functional and cosmetically similar

Wound Healing

Neovascularization– New growth of capillaries in response to healing– Neovascularized tissue is very fragile and has a

tendency to bleed easily Collagen Synthesis– Fibroblasts: Cells that form collagen– Remodeling

Wound Healing Process


Infection– serious complication of open wounds– Delay healing– Spread to adjacent tissues– Systemic infection: sepsis– Presentation

Pus: WBCs, cellular debris, and dead bacteriaLymphangitis: visible red streaksFever and malaiseLocalized fever

Infection

Risk factors– Host’s health and pre-existing illnesses

Diabetics, the infirm, the elderly, and individuals with serious chronic diseases

– Wound type and locationWell-vascularized areas such as the face and scalp are very resistant to infection Distal areas such as extremities heal more slowly

– Associated contamination– Treatment provided

Infection

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


Other Wound Complications– Impaired hemostasis

Medications can interfere with hemostasis and the clotting process

Aspirin, anticoagulants, fibrinolytics, and penicillins

Abnormalities in proteins involved in the fibrin formation cascade may result in delayed clotting

Hemophilia

Other Wound Complications

Re-bleeding– Re-bleeding is possible from any wound

Movement of underlying structuresHemorrhage continues in large wounds unnoticedPostoperative wounds

Delayed healing– Patients at risk include:

Diabetics, the elderly, the chronically ill, and the malnourished

Main Concepts of this Chapter

Crush InjuryCompartment SyndromeCrush SyndromeRhabdomyalosis

Crush Injury

A body part is compressed, injuring muscles, blood vessels, bones, and other internal structures

© Edward T. Dickinson, MD


Crush Injury– Body tissues subjected to severe compressive

forces– A crush injury disrupts the body’s tissues

Creates an excellent growth medium for bacteria– Tissue hypoxia and acidosis may result in muscle

rigor

Crush Injury

Associated Injury– Additional fractures – Open or closed soft-tissue injuries – Direct injury

Blunt and penetrating – Dehydration and hypothermia

Compartment SyndromeExtremity injury causes significant edema and swelling in the deep tissuesPressure in the compartment will rise

Results in decreased blood flow and ischemia

Care of Specific WoundsCompartment Syndrome– Likely 4–8 hours post-injury– 30 mmHg– Symptom

Severe pain out of proportion with physical exam findings6 Ps

PainParesthesia- numbnessPallorPressureParalysisPulses

Normal motor and sensory function

Care of Specific Wounds

Compartment Syndrome (cont.)– Management

Care of underlying injurySplint and immobilize all suspected fracturesCold packs to severe contusions:

Most effective prehospital managementReduces edemaPrevents ischemia


Crush Syndrome– Body is entrapped for >4 hours– Crushed muscle tissue becomes necrotic

Resultant release of metabolic byproducts traumatic rhabdomyolysis

– By-products of cellular destruction MyoglobinPhosphate and potassium Lactic acid Uric acid

Care of Specific Wounds Crush Syndrome– Anticipate problems– Victims of prolonged entrapment– Ensure that scene is safe– 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 Sydrome

HypovolemiaHyperkalemiaHypocalcemiaAcidosisRenal Failure


Crush Syndrome– Management

IV: 20–30 mL/kg of NS or D51/2 NSAVOID LR or K+ based solutions

After bolus, continuous infusion of 20 mL/kg/hrConsider sodium bicarbonateConsider calcium chloride:

500 mg IVPCounteracts hyperkalemia

Consider diuretics:Mannitol (Osmotrol)Furosemide (Lasix)


Crush Syndrome– Management

IV: 20–30 mL/kg of NS or D51/2 NSAVOID LR or K+ based solutions

After bolus, continuous infusion of 20 mL/kg/hrConsider sodium bicarbonateConsider calcium chloride:

500 mg IVPCounteracts hyperkalemia

Consider diuretics:Mannitol (Osmotrol)Furosemide (Lasix)

Rhabdomyolysis

Breakdown of muscle cellsLiberation of injured muscle into circulation

Rhabdomyolysis

Muscle stretching– Influx of Ca++ and Na+– Cells swell up

IschemiaAnaerobic metabolismMay be due by electrical current


Injection Injury– High-pressure line

bursts– Injects fluid or other

substance into skin and into subcutaneous tissue

Dressing and Bandage Materials


Sterile and Non-sterile Dressings– Sterile: direct wound contact– Non-sterile: bulk dressing above sterile

Occlusive/Non-occlusive DressingsAdherent/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

Self-adherent Roller Bandage– Kerlex/Kling

Multi-ply, stretch: 1–6”Gauze Bandage– Single-ply, non-stretch: 1–3”

Adhesive BandagesElastic (Ace) BandagesTriangular Bandages

Assessment of Soft-Tissue Injuries


Scene Size-up– Rule out or eliminate

any threats to yourself or fellow care providers

– Determine the mechanism of injury

– Standard Precautions


Initial Assessment– Establishing manual cervical in-line immobilization– Form a general impression– Assess the airway, breathing, and circulation – Correct any immediate threats to the patient’s life


Focused History and Physical Exam– Significant MOI

Rapid trauma assessmentPerform a swift evaluation of the patient’s head, neck, chest, abdomen, pelvis, extremities, and posterior body Confirm the decision either to transport the patient immediately with further care provided en route to the hospital


Focused History and Physical Exam– No significant MOI

Focused trauma assessmentUse the examination techniques of inquiry, inspection, and palpation to evaluate the injury and the surrounding area

Check the distal extremity for pulses, capillary refill, color, and temperature

Transport Decision


Detailed Physical Exam– Detailed exam should follow a planned and

comprehensive process – The detailed physical exam is usually performed

during transport Never delay transport to perform it


Assessment Techniques– Inquiry

The mechanism of injury, any pain, pain on touch or movement, and any loss of function or sensation specific to an area

– InspectionCarefully observing a particular body region

– PalpationPalpate the body’s entire surface


Ongoing Assessment– Reassess the patient’s mental status, airway,

breathing, and circulation – Inspect any interventions you have performed – Perform at least every 5 minutes with unstable

patients – Perform at least every 15 minutes with stable

patients

Management of Soft-Tissue Injury


Objectives of Wound Dressing and Bandaging– Hemorrhage control

Direct pressureElevationPressure pointsConsider

IceConstricting bandTourniquet

Management of Soft-Tissue Injury - 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


Objectives of Wound Dressing and Bandaging– Sterility

Keep the wound as clean as possibleIf wound is grossly contaminated, consider cleansing

– ImmobilizationPrevents movement and aggravation of woundDo not use an elastic bandage: TQ effectMonitor distal pulse, motor, and sensation


Pain and Edema Control– Cold packs– Moderate pressure over wound– Consider analgesic :

Morphine sulfate2 mg IVP every 5 minutes up to a total of 10 mg given.

Fentanyl (Sublimaze)25–50 mcg IVP followed by an additional 25 mcg as needed.If given too rapidly, chest wall rigidity may ensue leading to respiratory compromise

Anatomical Considerations for Bandaging

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 woundPressure on local arteries

– Without skull fracture:Direct pressure


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 from ears or nose


Neck– Consider circumferential bandage

Protect trachea and carotidsC-collar and dressing

– Occlusive dressing if lacerated vesselShoulder– Take care to avoid pressure

Axillary arteryTracheaAnterior neck


Trunk– Minor wounds: Dressing

and tape– Major wounds:

Circumferential wrapLadder splint behind back and wrap gauze over it

Groin and Hip– Bandage by following

contours of body– Movement can increase

tightness of bandage© Ray Kemp/911 Imaging


Elbow and Knee– Circumferential wrap and splint

Splinting reduces movementPosition of functionHalf flexion/half extension

Hand and Finger– Remove jewelry from wrist and fingers– Bulky dressing– Position of function

Ankle and Foot– Circumferential bandage


Complications of Bandaging– Always assess before and after:

PulseMotorSensation

– Developing ischemia:PainPallorTinglingLoss of pulseDecreased capillary refill

Care of Specific WoundsAmputations– Patient

Control bleeding Consider tourniquet Do not delay transport

– Amputated PartDry cooling and rapid transportPart in plastic bag (double bag)Immerse in cold waterAvoid direct contact between tissue and cold water

Care of Specific WoundsImpaled Objects– Stabilize with bulky dressing in place– Prevent movement of object– Consider cutting or shortening large impaled

objects– Consider removal if:

In cheek and interferes with airwayInterferes with CPR

Special Anatomical SitesFace and Neck– Potential for airway obstruction or compromise– Aggressive suctioning and oxygenation– Consider intubation:

Verify ET tube placementEnsure tube remains in the airway by using continuous waveform capnographyIf excessive swelling or damage:

Needle or surgical cricothyroidotomy

Special Anatomical Sites

Thorax– Superficial injury can be deep– Always suspect the worst due to underlying

organs– NEVER explore a wound internally– Alert for:

Subcutaneous emphysemaPneumothorax or hemothoraxTension pneumothorax

– Consider occlusive dressing sealed on 3 sides

Special Anatomical Sites

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

Wounds Requiring Transport

Any wound that involves– Nerves– Blood vessels– Ligaments– Tendons– Muscles– Significantly contaminated– Impaled object– Likely cosmetic injury

Soft-Tissue Treatment and Refer/Release

Typically requires on-line medical direction– Evaluate and dress wound– Inform the patient about:

Preventing infectionFollow-up care with a physician Inquire about tetanus and inform of risks

– Document treatment, referral, and teaching

Summary

Introduction to Soft-Tissue InjuriesAnatomy and Physiology of Soft-Tissue InjuriesPathophysiology of Soft-Tissue InjuryDressing and Bandage MaterialsAssessment of Soft-Tissue InjuriesManagement of Soft-Tissue Injury

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