Chapter 26 Soft Tissue Injuries

Patients who have visible significant bleeding or signs of significant internal bleeding may quickly become unstable.

Stay alert for signs of hypoperfusion (tachycardia; tachypnea; weak pulse; cool, moist skin) Reassess your priority and transport decision if these signs develop.

Stabilizing an Impaled Object

Step 1 Do not attempt to move or remove the object. Stabilize the impaled body part. Step 2 Control bleeding and stabilize the object in place using soft dressings, gauze, and/or tape. Step 3 Tape a rigid item over the stabilized object to prevent it from moving during transport.

Soft-tissue injuries and their related complications can be avoided by using simple protective actions.

Wearing gloves Workplace safety measures Using plastic items (scissors, knives, drinking cups) instead of metal or glass with children Installing smoke alarms Controlling water temperature Enforcing building codes

Which of the following factors will help you to determine the severity of a burn? Depth of the burn Extent of the burn Involvement of any critical body areas (face, upper airway, hands, feet, genitalia) Preexisting medical conditions

All of these factors

Severe Burns

Any full thickness burns Parital thickness burns covering more than 20 percent of the body's totak surface area

Rule of palm:

Compare the size of the burn area to the size of the patient's palm, which is roughly equal to 1% of the patient's total body surface area.

Objects that penetrate the skin but remain in place are referred to as impaled objects.

Concerns include the amount of damage to structures deep inside the body and the presence of foreign materials deep inside the tissue.

There are two dangers specifically associated with electrical burns:

Large amount of deep-tissue injury Electrical burns are always more severe than the external signs indicate. The patient may have only a small burn to the skin but may have massive damage to the deeper tissues, organs, and the nervous system. The force of the electrical energy can also cause fractures or joint dislocations. The patient may go into cardiac or respiratory arrest. Electrical current can cross the chest and cause cardiac arrest or dysrhythmias. Cardiac arrest can also occur after a lightning strike.

Neurologic examination should include assessing for:

Level of consciousness—use AVPU Pupil size and reactivity Motor response Sensory response

Flash burns

Produced by an explosion, which may briefly expose a person to very intense heat. Lightning strikes can also cause a flash burn. These injuries are usually minor compared with the potential for trauma from whatever caused the flash.

Electrical Burns (continued)

f neither CPR nor defibrillation is indicated, give supplemental oxygen and monitor the patient closely for respiratory and cardiac arrest. Treat the soft-tissue injuries by placing dry, sterile dressings on all burn wounds and splinting suspected fractures. Provide prompt transport; all electrical burns are potentially severe injuries that require further treatment in the hospital.

Radiation is measured in units of radiation absorbed dose (rad) or radiation equivalent in man (rem):

100 rad = 1 gray (Gy). Small amounts of everyday background radiation are measured in rad. The amount of radiation released in a major incident may be measured in gray. The average human exposure from background radiation is 0.36 rem per year. Mild radiation sickness can be expected with exposures of 1 to 2 Gy (100 to 200 rad) Moderate sickness = 2 to 5 Gy Severe sickness = 4 to 6 Gy. Exposure to more than 8 Gy is immediately fatal.

Contusion (bruise)

A contusion is an injury that causes bleeding beneath the skin but does not break the skin. Contusions result from blunt forces striking the body. The epidermis remains intact, but cells within the dermis are damaged, and small blood vessels are torn. As fluid and blood leak into the damaged area, the patient may have swelling and pain. The buildup of blood produces ecchymosis, a blue or black discoloration.

Crushing injury

A crushing injury occurs when significant force is applied to the body. The extent of the damage depends on how much force is applied and how long it is applied. In addition to causing direct soft-tissue damage, continued compression of the soft tissues cuts off circulation, producing further tissue destruction.

Flame burns

A flame burn is very often a deep burn, especially if a person's clothing catches fire.

Review your knowledge of the material by answering the following questions. Select whether each statement listed is true or false. A hematoma is an open injury that occurs whenever a large blood vessel is damaged and bleeds rapidly. TrueFalse You should never remove an avulsion skin flap, regardless of its size. TrueFalse When possible, ALS providers should administer IV fluid within 3 minutes after the crushing object is lifted off the body. TrueFalse The goal of the inflammation phase of wound healing is the removal of foreign material, damaged cellular parts, and invading microorganisms from the wound site. TrueFalse

A hematoma is an open injury that occurs whenever a large blood vessel is damaged and bleeds rapidly. TrueFalse Correct. A hematoma does occur whenever a large blood vessel is damaged and bleeds rapidly, but it is a closed injury. You should never remove an avulsion skin flap, regardless of its size. TrueFalse Correct. You should never remove an avulsion skin flap, regardless of its size. Removing the flap could lead to contamination. When possible, ALS providers should administer IV fluid within 3 minutes after the crushing object is lifted off the body. TrueFalse Correct. When possible, ALS providers should administer IV fluid before the crushing object is lifted off the body. The goal of the inflammation phase of wound healing is the removal of foreign material, damaged cellular parts, and invading microorganisms from the wound site. TrueFalse Correct. The goal of the inflammation phase of wound healing is the removal of foreign material, damaged cellular parts, and invading microorganisms from the wound site.

Closed soft-tissue injuries are characterized by:

A history of blunt trauma Pain at the site of injury Swelling beneath the skin Discoloration

Lacerations

A laceration is a jagged cut in the skin caused by a sharp object or a blunt force that tears the tissue. An incision is a sharp, smooth cut. The depth of the injury can vary, extending through the skin and subcutaneous tissue, even into the underlying muscles and adjacent nerves and blood vessels. Lacerations and incisions may appear linear (regular) or stellate (irregular) and may occur along with other types of soft-tissue injury. Lacerations or incisions that involve arteries or large veins may result in severe bleeding

Steam burns

A steam burn can produce a topical (scald) burn. Minor steam burns are common when uncovering the plastic wrap from microwaved food. Steam is also responsible for causing airway burns.

Abrasions

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 An abrasion usually does not penetrate completely through the dermis, but blood may ooze from the injured capillaries in the dermis. Also known as road rash, road burn, strawberry, and rug burn Abrasions can be extremely painful because the nerve endings are located in this area.

There are four types of open soft-tissue wounds that you must be prepared to manage:

Abrasions Lacerations Previous Avulsions Penetrating wounds (or puncture wounds)

There are three types of ionizing radiation:

Alpha Alpha particles have little penetrating energy and are easily stopped by the skin. Beta Beta particles have greater penetrating power and can travel much farther in air than alpha particles. They can penetrate the skin but can be blocked by simple protective clothing designed for this purpose. Gamma The threat from gamma radiation is directly proportional to its wavelength. This type of radiation is very penetrating and easily passes through the body and solid materials.

If indicated, begin CPR on the patient and apply the automated external defibrillator (AED).

Although CPR may need to be prolonged in patients with electrical burns, it has a high success rate if started promptly.

amputation

An injury in which part of the body is completely severed.

avulsion

An injury in which soft tissue is torn completely loose or is hanging as a flap.

Avulsions

An injury that separates various layers of soft tissue (usually between the subcutaneous layer and fascia) so they become either completely detached or hang as a flap. Often, there is significant bleeding. If you can, replace the flat avulsed flap in its original position as long as it is not visibly contaminated with dirt and/or other foreign materials. If an avulsion is complete, wrap the separated tissue in sterile gauze and take it with you to the emergency department (ED). This type of avulsion often poses serious infection concerns. Never remove an avulsion skin flap, regardless of its size. An amputation is an injury in which part of the body is completely severed. You can easily control the bleeding from some amputations, such as the fingers, with direct pressure and pressure dressings. If an amputation involves a large area of muscle mass, there may be massive bleeding, which often requires

Dressing and Bandaging

Any improperly applied bandage that impairs circulation can result in additional tissue damage or even the loss of a limb. Always check a limb distal to a bandage for signs of impaired circulation and loss of sensation. Air splints and vacuum splints are useful in stabilizing broken extremities, and they can be used with dressings to help control bleeding from soft-tissue injuries. If you cannot control bleeding from a major vessel in an extremity, a properly applied tourniquet may save a patient's life.

Primary Assessment

As you approach the patient, important indicators will alert you to the seriousness of the patient's condition, such as: Is the patient awake and interacting with his or her surroundings, or lying still and not making sounds? Is he or she appropriately or inappropriately responding to you? Is the patient's breathing pattern rapid or slow, deep or shallow? What is the color and condition of the patient's skin? Does the patient have any apparent life threats? Closed soft-tissue injuries may appear to be minor; however, they may indicate serious internal injuries. Check for responsiveness. If the patient is alert, ask about the chief complaint to help direct you to any apparent life threats. If the patient is not alert, determine if he or she responds to verbal or painful stimuli or if he or she is unresponsive. Administer high-flow oxygen via a nonrebreathing mask to patients whose LOC is less than alert and oriented. Treat for potential shock. Provide immediate transport to the ED. If significant trauma has likely affected multiple body systems, start with a rapid exam of the patient to be sure you have found all of the problems and injuries. Begin with the head and neck while manually holding the head in place. When you are done, apply a cervical collar if indicated.

Emergency Medical Care for Closed Injuries

Be alert for signs of developing shock. Look for anxiety or agitation and changes in mental status. An increased heart rate, increased respiratory rate, diaphoresis, cool or clammy skin, and eventual decreases in blood pressure may not develop until late in your care of the patient. Any or all of these signs may indicate internal bleeding resulting from injuries to internal organs. If the patient exhibits signs and symptoms of shock, treat accordingly and aggressively.

Small animal bites and rabies

Be sure to consider scene and crew safety prior to entering the environment. Consider all small animal bites to be contaminated and potentially infected wounds that may require debridement (the removal of damaged tissue), antibiotics, and tetanus prophylaxis. All small animal bites should be evaluated by a physician. Place a dry, sterile dressing over the wound and promptly transport the patient to the ED. If an arm or leg was injured, splint that extremity.

Reassessment

Because burn patients are also trauma patients, provide spinal immobilization consistent with your local protocol if you suspect spinal injuries. Oxygen is mandatory for inhalation burns and burns that cover a large surface area. If the patient has signs of hypoperfusion, treat aggressively for shock and provide rapid transport to the appropriate hospital. Cover all burns according to your local protocols. Do not delay transport of a seriously injured patient to complete nonlifesaving treatments in the field, such as splinting extremity fractures. Complete these types of treatment en route to the hospital. Provide hospital personnel with a description of how the burn occurred. Report and document the extent of the burns. This should include: The amount of body surface area involved The depth of the burn The location If special areas are involved (genitalia, feet, hands, face, or circumferential), they should be specifically mentioned and documented.

Hematoma

Blood that has collected within damaged tissue or in a body cavity A hematoma occurs whenever a large blood vessel is damaged and bleeds rapidly. It is usually associated with extensive tissue damage. A hematoma can result from a soft-tissue injury, a fracture, or any injury to a large blood vessel. In severe cases, the hematoma may contain more than a liter of blood.

Anatomy of the Skin

Blood vessels in the dermis provide the skin with nutrients and oxygen. Small branches reach up to the germinal cells, but blood vessels do not penetrate farther into the epidermis. There are also specialized nerve endings within the dermis. The various openings in the body, including the mouth, nose, anus, and vagina, are lined with mucous membranes. Provide a protective barrier against bacterial invasion Secrete a watery substance that lubricates the openings

Mechanisms of soft-tissue injuries include:

Blunt injury Penetrating injury Barotrauma (injury from changes in air pressure) Burns

Burns

Burns are soft-tissue injuries spread out over a large area created by the transfer of radiation, thermal, or electrical energy. Children, older patients, and patients with chronic illnesses are more likely to experience shock from burn injuries. Thermal burns can occur when skin is exposed to temperatures higher than 111°F (44°C). The severity of the injury directly correlates with temperature; concentration, or amount of heat energy possessed by the object or substance; and the duration of exposure. Burn injuries are progressive—the greater the heat energy, the deeper the wound. Exposure time is another important factor. It may be difficult to evaluate the amount of heat energy or the amount of exposure time in many cases. Life-threatening complications that can result secondary to a burn injury include: Infection Hypothermia Hypovolemia Shock Burns to the airway are of significant importance because the loose mucosa in the hypopharynx can swell and lead to complete airway obstruction. Circumferential burns of the chest can compromise breathing. Circumferential burns of an extremity can lead to compartment syndrome, resulting in neurovascular compromise and irreversible damage if not appropriately treated. If you suspect any complications, call for ALS backup.

A new layer of cells moves into the injury region (third stage).

Cells quickly multiply and redevelop across the edges of the wound.

There are three types of soft-tissue injuries:

Closed injuries, in which soft-tissue damage occurs beneath the skin or mucous membrane but the surface of the skin or mucous membrane remains intact Open injuries, in which there is a break in the surface of the skin or the mucous membrane, exposing deeper tissues to potential contamination Burns, in which the soft-tissue damage occurs as a result of thermal heat, frictional heat, toxic chemicals, electricity, or nuclear radiation

Collagen provides stability to the damaged tissue and joins wound borders, thereby closing the open tissue (last stage).

Collagen cannot restore damaged tissue to its original strength.

Contact burns

Coming in contact with hot objects produces a contact burn. Ordinarily, reflexes protect a person from prolonged exposure to a very hot object, so contact burns are rarely deep unless the patient was prevented from drawing away from the hot object (for example, unconscious, intoxicated, restrained, or impaired).

Closed soft-tissue injuries include:

Contusion (bruise) Hematoma Crushing injury Crush syndrome Compartment syndrome

Heat can be an irritant to the lungs and the airway, causing:

Coughing Wheezing Rapid swelling or edema of the mucosa of the upper airway tissues, often evidenced by stridor

Open Injuries (continued)

Count the number of penetrating injuries, and leave the distinction between entrance and exit wounds to the physician who is working in a more controlled environment. The amount of energy transmitted by a gunshot injury is directly related to the speed of the bullet. When possible, determine the type of gun used, but do not let this delay patient transport. Shotgun wounds create multiple paths of missiles (shot) and create a larger surface area and volume of tissue damage. Many cases involving shootings go to court at some point, and you may be called to testify, so carefully document the circumstances surrounding any gunshot injury, the patient's condition, and the treatment you give.

To control bleeding and prevent the possibility of air embolism:

Cover the wound with an occlusive dressing. Apply manual pressure, but do not compress both carotid vessels at the same time. This impairs circulation to the brain and can cause a stroke. Secure a pressure dressing over the wound by wrapping roller gauze loosely around the neck and then firmly through the opposite axilla.

Compartment syndrome

Develops when edema and swelling result in increased pressure within a closed soft-tissue compartment Because tissues are limited in the amount they can stretch or expand, pressure increases within the compartment, which in turn interferes with circulation. Compartment syndrome commonly develops in the extremities and may occur in conjunction with open or closed injuries or when swelling occurs under restrictive immobilization devices such as a cast. As pressure develops, delivery of nutrients and oxygen is impaired and by-products of normal metabolism accumulate, causing pain, especially on passive movement. Signs of impaired circulation may also be present. The longer this situation persists, the greater the chance for tissue death. Continually reassess skin color, temperature, and pulses distal to the injury site during transport if crush inju

Full-thickness (third-degree) burns

Extend through all skin layers and may involve subcutaneous layers, muscle, bone, or internal organs The burned area is dry and leathery and may appear white, dark brown, or even charred. Some full-thickness burns feel hard to the touch. Clotted blood vessels or subcutaneous tissue may be visible under the burned skin. If the nerve endings have been destroyed, a severely burned area may not have feeling and the surrounding, less severely burned areas may be extremely painful.

Signs and symptoms involve the central nervous, respiratory, and cardiovascular systems of the body and include:

Faintness Anxiety Abnormal vital signs Headache Seizures Paralysis Coma

Thermal burns are caused by heat (as opposed to electricity, chemicals, or radiation). They include:

Flame burns Scald burns Contact burns Steam burns Flash burns

Minor Burns

Full thickness burns covering less than 2 percent of the body's total surface area Partial thickneess burns covering less than 15 percent of the body's total surface area Superficial burns covering less than 50 percent of the body's total surface area .

Mdoerate Burns

Full thickness burns involving 2 to 10 percent of the body's total surface area Partial thickness burns covering 15 ot 30 percent of the body's totla surface area Suprficial burns covering more than 50 percent of the body's total surface area

Severe Burns

Full-thickness burns uinvolving the hands, feet, face, upper airway, or genetalia or circumferential burns of other areas Full thickness burns covering more than 10% of the bdy's total surface areas Partial-thickness burns covering more than 30% of the body's total surface area Burns associated with respiratroy injury Burns complicated by fractures Burns on patients younger than 5 yrs old or older than 55 years old that would be classified as moderate on young adults

Due to unique differences associated with their ages and anatomy, children are more likely to:

Go into shock Develop hypothermia Experience airway difficulties

Electrical Burns

High-voltage burns may occur when utility workers make direct contact with power lines. Ordinary household current is still powerful enough to cause severe burns as well as cardiac dysrhythmias. Any substance that prevents the circuit from being completed, such as rubber, is called an insulator. Any substance that allows a current to flow through it is called a conductor. The human body, which is primarily water, is a good conductor. The type of electric current, magnitude of current (amperage), and voltage have effects on the seriousness of burns. Never attempt to remove someone from an electrical source unless you are specially trained to do so. Never move a downed power line unless you have the special training and equipment necessary for the job. Before approaching someone who may still be in contact with a power line or an electrical appliance, make certain the power is turned off. Always assume that any downed power line is live. A burn injury appears where the electricity enters (an entrance wound) and exits (an exit wound) the body. The entrance wound may be small, but the exit wound can be extensive and deep. Always look for both entrance and exit wounds.

Scald burns

Hot liquids produce scald injuries. A scald burn is most commonly seen in children and handicapped adults but can happen to anyone, particularly while cooking. Scald burns often cover large surface areas of the body because liquids can spread quickly.

Inhalation of Toxic Gases (continued)

Hydrogen cyanide (HCN) is generated by the combustion of commonly encountered substances such as paper, cotton, and wool.

Treating Chemical Burns

If available, read all of the labels of the chemical agent. To stop the burning process, remove any chemical from the patient. Brush off dry chemicals from the skin and clothing before flushing the patient with water. Remove the patient's clothing, including shoes, stockings, gloves, and any jewelry or eyeglasses. Do not come in contact with the chemical. The patient should be properly decontaminated by properly trained personnel. For liquid chemicals, immediately flush the burned area with large amounts of water. Do not contaminate uninjured areas or make the patient hypothermic. Never direct a forceful stream of water from a hose at the patient; the extreme water pressure may mechanically injure the burned skin. Continue flooding the area with gallons of water for 15 to 20 minutes after the patient says the burning pain has stopped. If the patient's eye has been burned, hold the eyelid open (without applying pressure over the globe of the eye) while flooding the eye with a gentle stream of water. Continue flushing the contaminated area en route to the hospital.

Flush the eyes from the inside corners to the outside to prevent cross contamination.

If only one eye has been affected, turn the patient's head to that side and flush. If both eyes are affected, hook up a nasal cannula to a bag of saline to flush both eyes simultaneously. The prongs can be placed on the bridge of the nose to flush from the inside corners of the eyes to the outside corners. Be careful not to touch the prongs to the eye or surrounding tissue.

Do not use elastic bandages to secure dressings.

If the injury swells, the bandage may become a tourniquet and cause further damage.

Primary Assessment (continued)

If the patient has signs of hypoperfusion, treat aggressively for shock: Place the patient supine. Prevent heat loss with a blanket. Provide rapid transport to the hospital. Request ALS as necessary to assist with more aggressive shock management. Protect the patient from further spinal injury as you manage the airway by preventing the head and torso from moving. If the patient is unresponsive or has a significantly altered level of consciousness (LOC), consider inserting an oropharyngeal airway or nasopharyngeal airway and suction the airway as needed. Inspect and palpate the chest wall for DCAP-BTLS (Deformities, Contusions, Abrasions, Punctures/penetrations, Burns, Tenderness, Lacerations, Swelling). If a soft-tissue injury is discovered on the chest or abdomen, auscultate for clear and symmetric breath sounds and look at the structure of the chest wall to ensure equal expansion and rise and fall of the chest. Provide high-flow oxygen or assisted ventilations using a bag-valve mask (BVM) as needed. Evaluate the patient's voice and ability to speak to identify throat injuries. If an open injury is found on the chest, evaluate for air movement through the wound in the form of bubbling or sucking sounds, which indicate a deep penetrating injury. Assess the patient's back for injuries. Place an occlusive dressing over the wound. Monitor the patient for signs of increasing respiratory distress that may require you to relieve pressure built up under the dressing (caused by a pneumothorax). Assess the patient's pulse rate, rhythm, and quality; determine the skin condition, color, and temperature; and check the capillary refill time.

History Taking

If the patient was burned in a confined space, suspect an inhalation injury. When burns result from explosive forces, be alert for other internal injuries and fractures. Obtain a medical history. Be alert for injury-specific signs and symptoms as well as any pertinent negatives such as no pain. Typical signs of a burn are pain, redness, swelling, blisters, or charring. Typically, symptoms include pain and/or burning at the injury site. It is important to stop the burning process, apply dressings to prevent contamination, and treat the patient for shock. Obtain a SAMPLE history. Ask the following questions of a burn patient: Are you having any difficulty breathing? Are you having any difficulty swallowing? Are you having any pain? Check for an emergency medical identification device, or ask the patient or a family member about preexisting conditions.

Abdominal Wounds

In some cases, organs may even protrude through the wound (called an evisceration). Do not touch or move the exposed organs. Cover the wound with sterile gauze moistened with sterile saline solution and secure with an occlusive dressing. Because the open abdomen radiates body heat quickly, and because exposed organs lose fluid rapidly, keep the organs moist and warm. If you do not have gauze compresses, you may use moist sterile dressings, covered and secured in place with a bandage and tape. Do not use any material that is adherent or loses its substance when wet (eg, toilet paper, facial tissue, paper towels, or absorbent cotton). If the patient's legs and knees are uninjured and spinal injury is not suspected, flex the legs to relieve pressure on the abdomen. Most patients with abdominal wounds require immediate transport to a trauma center, depending on the local protocol.

Assess the musculoskeletal system by performing a detailed full-body scan. Specifically look for the following:

In the head, check for singed nasal or facial hair, burns or swelling of the face or ears, or burns or swelling in the mouth. If the patient sustained electrical injury, examine the scalp for signs of entrance or exit wounds. In the neck, check for burns, especially if they encircle the entire neck, which can impair circulation. In the chest, check for burns that encircle the entire chest, which can impair normal chest rise. In the abdomen and pelvis, feel all four quadrants for tenderness or rigidity. If the abdomen is tender, expect internal bleeding. Look for burns of the genitalia, as burns to this area are considered high risk. Look for burns that encircle an extremity, as they can impair circulation. If the patient sustained an electrical injury, assess thoroughly for entry or exit burn wounds. This should include the axilla and the area between digits. Record pulse and motor and sensory function. Examine the posterior surface of the body, as large burns or electrical exit burns may be located in this body area.

Superficial (first-degree) burns

Involve only the epidermis The skin turns red but does not blister or burn through this top layer. The burn site is often painful. Sunburn is a good example of a superficial burn.

Partial-thickness (second-degree) burns

Involve the epidermis and some portion of the dermis These burns do not destroy the entire thickness of the skin nor is the subcutaneous tissue injured. Typically, the skin is moist, mottled, and white to red. Blisters are present. Partial-thickness burns cause intense pain.

The universal dressing measures 9 inches × 36 inches; is made of thick, absorbent material; and is ideal for covering large open wounds.

It also makes an efficient pad for rigid splints. These dressings are available in compact, commercially sterilized packages.

These patients should be rapidly transported to an ED or facility capable of advanced airway management.

It becomes increasingly difficult to achieve airway control once swelling begins.

Secondary Assessment

Listen to breath sounds with a stethoscope. Breath sounds should be clear and equal bilaterally, anteriorly, and posteriorly. Determine the patient's respiratory rate and note the pattern and quality of the respiratory effort. Assess for asymmetric chest wall movement. Assess the neurologic system to gather baseline data, including: LOC Pupil size and reactivity Motor and sensory response Assess the musculoskeletal system by performing a detailed exam of the entire body. Look for DCAP-BTLS. Assess the chest, abdomen, and extremities for hidden bleeding and injuries. Log roll the patient and assess the posterior torso for injuries. Once the back has been assessed, the patient can be log rolled back down onto a backboard, followed by complete spinal immobilization if indicated. Assess all anatomic regions, looking for the following signs/symptoms: Check the neck for jugular vein distention and tracheal deviation. Be alert for patients with a stoma or tracheostomy. Check the pelvis for stability. Check the abdomen; feel all four quadrants for tenderness/rigidity and inspect for bruising. If the abdomen is tender, expect internal bleeding. Check the extremities and record pulse, motor, and sensory function. Patients who have hidden internal injuries under a closed soft-tissue injury may have internal bleeding and may rapidly become unstable. Make sure you obtain a series of vital signs to ensure subtle changes are evident as soon as possible. Signs that indicate hypoperfusion and imply the need for rapid transport and treatment at the hospital include: Tachycardia Tachypnea Low blood pressure Weak pulse Cool, moist, and pale skin Soft-tissue injuries, even without a significant MOI, can cause shock.

Radiation Burns (continued)

Maintain a safe distance and wait for the HazMat team to decontaminate the patient before initiating care. Most contaminants can be removed by simply removing the patient's clothes. Call for additional resources to manage this situation. Once the patient is decontaminated and there is no threat to you, begin treating the ABCs and treat the patient for any burns or trauma. Irrigate open wounds. Washing should be gentle to avoid further damage to the skin, which could result in additional internal radiation absorption. Irrigate the head and scalp the same way. Notify the ED as soon as practical if you are transporting a potentially contaminated patient. Radioactive particulate matter poses a relatively small risk to the provider. Consider providing basic care to the patient before decontamination if you are wearing protective clothing. Identify the radioactive source and the length of the patient's exposure to it, if this information is available. If not readily available, rely on the HazMat team to obtain this information. Limit your duration of exposure, increase your distance from the source, and attempt to place shielding between yourself and sources of gamma radiation. With contact radiation burns, decontaminate the wound as if it were a chemical burn to remove any radioactive particulate matter, then treat it as a burn. Antidotes may help bind an isotope, enhance its elimination from the body, or reduce the toxic effects on other organs. Antidotal therapy should be considered only under the guidance of a knowledgeable physician or public health agency.

History Taking

Make every attempt to obtain a SAMPLE history from your patient. When you use SAMPLE, OPQRST, and DCAP-BTLS together, your assessment will be well rounded and provide significant insight into the patient's condition. If the patient is not responsive, attempt to obtain the history from other sources. Medical identification jewelry and cards in wallets may also provide information about the patient's medical history or alert you to the presence of implanted medical devices. Typical signs of an open injury include: Bleeding A break in the skin Shock Hemorrhage Disfigurement or loss of a body part Typically, symptoms include pain and/or burning at the injury site. Chronic medical conditions such as anemia and hemophilia can complicate open soft-tissue injuries. Medications, such as aspirin or others that impair the blood's ability to clot, are frequently taken by older patients and may make it more difficult to control bleeding.

Chemical Burns

Most chemical burns are caused by strong acids or strong alkalis. The eyes are particularly vulnerable to chemical burns. The severity of the burn is directly related to: The type of chemical The concentration of the chemical The duration of the exposure You must wear the appropriate chemical-resistant gloves and eye protection whenever you are caring for a patient with a chemical burn. Consider wearing a protective gown. Exposure risk is also present when you are cleaning up after a call.

New blood vessels form as the body attempts to bring oxygen and nutrients to the injured tissue.

New capillaries budding from intact capillaries provide a channel for oxygen and nutrients and serve as a pathway for waste removal. It may take weeks to months for the new capillaries to be as stable as preexisting vessels.

Scene Size-up

Observe the scene for hazards and threats. Assess the impact of hazards on patient care and address the hazards. Ensure the scene is safe and consider the need for additional resources. Take standard precautions—a minimum of gloves and eye protection. Eye protection is required when managing open injuries to avoid potential splashing. Place several pairs of gloves in your pocket for easy access in case your gloves tear or there are multiple patients with bleeding. Do not spend time trying to estimate blood loss; focus on controlling the bleeding. Look for indicators of the MOI. Consider how the MOI produced the injuries expected. The MOI may also provide information about potential safety threats.

Scene Size-up

Observe the scene for hazards and threats. Ensure that the factors that led to the patient's burn injury do not pose a hazard to you and your crew. Determine if the patient has been decontaminated, if needed. When possible, determine the type of burn that has been sustained and the MOI. Assess the scene for any environmental hazards. Wear gloves and eye protection when treating any burn patient and gowns when serious injuries are expected. Determine the number of patients. The possibility for multiple patients grows if you are responding to a lightning strike or a vehicle crash. At vehicle crashes, ensure the scene is safe from energized electrical lines or leaking fuel in the area where you will be working. Call for additional resources early. Consider the potential for spinal injuries, broken bones, inhalation injuries, and other

For which injury would you use an occlusive dressing directly on the wound? Avulsion Evisceration Impaled object Open neck injury

Open Neck Injury injury Correct. If the veins of the neck are open to the environment, they may suck in air, leading to an air embolism. To control bleeding and prevent the possibility of air embolism, cover the wound with an occlusive dressing.

Moderate Burns

Partial thickness burnas covring 10 to 20 percent of the body's total surface area

A major concern with small animal bites is the spread of rabies, an acute, potentially fatal viral infection of the central nervous system that can affect all warm-blooded animals.

Potentially rabid animals include stray dogs that have not been vaccinated, squirrels, bats, foxes, skunks, and raccoons. The virus is transmitted through biting or by licking an open wound. Infection can be prevented only by a series of special vaccine injections that must be started soon after the bite. A person's only chance to avoid the vaccine is to find the animal and turn it over to the health department for observation and/or testing.

Blast injuries may also result in multiple penetrating injuries. The mechanism of injury (MOI) is generally due to three factors:

Primary blast injury: Injuries to the body caused by the blast wave itself; damage to the body is caused by the sudden pressure changes generated by the explosion. Secondary blast injury: Injuries caused to the body from being struck by flying debris, propelled by the force of the blast. These small objects may cause multiple penetrating wounds. Tertiary blast injury: Injuries to the body from being thrown or hurled by the force of the explosion into an object or onto the ground.

Secondary Assessment

Quickly assess the patient from head to toe looking for DCAP-BTLS to ensure you have found all of the problems and injuries. Make a rough estimate, using the rule of nines, of the extent of the burned area to report to medical control. Determine what classification of burns the victim has sustained. Follow your local protocols for criteria for transport to a burn center. Ask the patient to cough and assess for black sputum, which indicates smoke inhalation. Listen to breath sounds with a stethoscope. Breath sounds should be clear and equal bilaterally, anteriorly, and posteriorly. Determine the patient's rate and quality of respiration. Assess the chest for DCAP-BTLS and asymmetrical chest wall movement. Assess pulse rate and quality. Determine skin condition, color, and temperature, and check the capillary refill time. Control any bleeding.

Reassessment

Reassess vital signs and the chief complaint. Recheck patient interventions. Reassess the effectiveness of the bandaging. If blood continues to soak through bandages, use additional methods to control bleeding. Identify and treat changes in the patient's condition. Closed soft-tissues injuries can be life threatening if not appropriately treated. Assess and manage all threats to the patient's airway, breathing, and circulation. Supplemental oxygen via a nonrebreathing mask is commonly given to all patients with traumatic injuries impacting airway or ventilation or those with a potential for shock. Consider flushing small wound surfaces without significant bleeding with sterile saline prior to applying a dressing. If any material is "stuck" in the wound, do not remove it, as this may worsen bleeding and shock. Splint extremities that are painful, swollen, or deformed. If done correctly, splinting can assist with pain management and bleeding control, but if done poorly it may cause greater harm. Assess the patient's pulse, motor, and sensory functions distal to the injury zone both before and after applying the splint. Your documentation must include: A description of the MOI The position in which you found the patient when you arrived on scene Report of blood loss using terms that you are comfortable with and that will be easily understood by other personnel The location and description of any soft-tissue injuries or other wounds you have located and treated The size and depth of the injury An accurate account of how you treated these injuries

Patients with CO intoxication may:

Report headache or nausea Have cherry-red skin, lips, and nail beds Have an oxygen saturation level that is normal

Treat a closed soft-tissue injury by applying the mnemonic RICES:

Rest. Keep the patient as quiet and comfortable as possible. Ice. Use ice or cold packs to slow bleeding by causing blood vessels to constrict, and also to reduce pain. Compression: Apply pressure over the injury site to slow bleeding by compressing the blood vessels. Elevation: Raise the injured part just above the level of the patient's heart to decrease swelling. Splinting: Immobilize a soft-tissue injury or an injured extremity to decrease bleeding and reduce pain.

Emergency Medical Care for Open Injuries

Several methods are available to control open injuries or external bleeding. Start with the most commonly used: Direct, even pressure and elevation Pressure dressings and/or splints Tourniquets It will often be useful to combine these methods. If the wound is in the chest, upper abdomen, or upper back, cover it with an occlusive dressing. Do not remove material from an open wound, no matter how dirty the wound is. Rubbing, brushing, or washing an open wound can cause additional bleeding Small wound surfaces without significant bleeding can be flushed with sterile saline prior to applying a dressing. Flush chemical burns and contamination to remove remaining chemicals. To prevent a wound from drying, apply sterile dressings moistened with sterile saline solution and cover the moist dressing with a dry, sterile dressing. In some cases, you can better control bleeding by splinting the extremity, even if there is no fracture. Splinting: Can help you keep the patient calm and quiet because it typically reduces pain Keeps sterile dressings in place Minimizes damage to an already injured extremity Makes it easier to move the patient

Significant airway burns are serious. They may be associated with:

Singed hair within the nostrils Soot around the nose and mouth Hoarseness Hypoxia

Bite injuries include:

Small animal bites and rabies Human bites

When you assess the respiratory system of a burn patient, look specifically for:

Soot around the mouth Soot around the nose Singed nasal hairs If any of these findings are present, open the patient's mouth and examine for burns or swelling of the tongue.

Emergency Medical Care for Burns

Step 1 Follow standard precautions to help prevent infection. If safe to do so, remove the patient from the burning area; extinguish or remove hot clothing and jewelry as necessary. If the wound is still burning or hot, immerse the hot area in cool, sterile water, or cover with a wet, cool dressing Step 2 Provide high-flow oxygen and continue to assess the airway. Step 3 Estimate the severity of the burn, and then cover the area with a dry, sterile dressing or clean sheet. Assess and treat the patient for any other injuries. Step 4 Prepare for transport. Treat for shock. Cover the patient with blankets to prevent loss of body heat. Transport promptly.

The goals in treating patients with burns are to:

Stop the burning process Assess and treat breathing Support circulation Provide rapid transport

To manage thermal burns:

Stop the burning source. Cool the burned area if appropriate. Remove all jewelry. Maintain a high index of suspicion for inhalation injuries. Increased exposure time will increase damage to the patient. The larger the burn, the more likely the patient will be susceptible to hypothermia and/or hypovolemia. All patients with large surface burns should have a dry, sterile dressing applied to help maintain body temperature, prevent infection, and provide comfort.

Which of the following patients is likely to have injuries with entrance and exit wounds? A technician who has been exposed to gamma radiation A do-it-yourselfer who touched a live wire while repairing a light fixture A 19-year old who has been hit by high-caliber gunfire A drug user who has been TASERed

Submit Correct. Electrical burns and high-caliber gunshots leave entrance and exit wounds.

Immobilize the C-spine if indicated, including placing a cervical collar.

The cervical collar may assist with holding a dressing in place over a neck wound.

Open wounds caused by crushing may involve damaged internal organs or broken bones as well as extensive soft-tissue damage.

The crushing force damages soft tissues as well as vessels and nerves. This frequently results in a painful, swollen, deformed area.

evisceration

The displacement of organs outside of the body.

Pathophysiology of Closed and Open Injuries

To stop the flow of blood, the vessels, platelets, and clotting cascade must work in unison (first stage).

The skin has two principal layers:

The epidermis is the tough, external layer that forms a watertight covering for the body. The cells on the surface layer of the epidermis are constantly worn away and replaced when new cells form in the germinal layer at the base of the epidermis. Deeper cells in the germinal layer contain pigment granules that produce skin color. The dermis is the inner layer of the skin. Contains the structures that give the skin its characteristic appearance: Hair follicles Small organs that produce hair Sweat glands Cool the body Sebaceous glands Produce sebum, the oily material that waterproofs the skin and keeps it supple Sebum travels to the skin's surface along the shaft of adjacent hair follicles.

fascia

The fiberlike connective tissue that covers arteries, veins, tendons, and ligaments.

Extent of Burns

The head of an infant or child is relatively larger than the head of an adult, and the legs are smaller. When you calculate the extent of burn injury, include only partial-thickness (second-degree) and full-thickness (third-degree) burns. Document superficial (first-degree) burns, but do not include them in the body surface area estimation of extent of burn injury.

Human bites

The human mouth contains an exceptionally wide range of bacteria and viruses. Regard any human bite that has penetrated the skin as a very serious injury. Any laceration caused by a human tooth can result in a serious, spreading infection. The emergency treatment of bites consists of: Applying a dry, sterile dressing Promptly immobilizing the area with a splint or bandage Providing transport to the ED for surgical cleansing of the wound and antibiotic therapy

dermis

The inner layer of the skin, containing hair follicles, sweat glands, nerve endings, and blood vessels.

Inhalation of Toxic Gases

The less efficient the combustion process, the more toxic the gases—such as carbon monoxide (CO) and carbon dioxide (CO2)— created. Because CO binds to receptor sites on hemoglobin 250 times more easily than oxygen, the patient's hemoglobin may become saturated with the wrong chemical. Being exposed to relatively small concentrations of CO (such as in cigarette smoke) will result in progressively higher blood levels of CO. Most people have approximately 2% CO attached to their hemoglobin, but these levels may be as high as 4% to 8% in heavy smokers. Levels of 50% or higher may be fatal.

epidermis

The outer layer of skin, which is made up of cells that are sealed together to form a watertight protective covering for the body.

Consider rapid transport to the hospital for treatment or request ALS support if:

The patient has: An airway or breathing problem Poor initial general impression Altered level of consciousness Dyspnea Abnormal vital signs Shock Severe pain Signs and symptoms of internal bleeding You identify conditions that have the potential to become unstable, such as a distended abdomen or femur fracture

Primary Assessment

The presence of stridor means your patient's airway is significantly swollen and can signal impending complete airway obstruction. If the patient has singed facial hair, eyebrows, or nasal hair, your initial general impression might be that the patient has a potential airway and/or breathing problem. Always consider the need for manual spinal stabilization. Check for responsiveness using the AVPU scale. Assess a patient's mental status by asking the patient about his or her chief complaint. In all patients whose level of consciousness is less than alert and oriented, administer high-flow oxygen via a nonrebreathing mask and provide immediate transport to the ED. Ensure the patient has a clear and patent airway. If the patient is unresponsive or has a significantly altered LOC, consider inserting a properly sized oropharyngeal or nasopharyngeal airway. Heavy amounts of secretions and frequent coughing may indicate a respiratory burn. Assess for adequate breathing. Inspect and palpate the chest wall for DCAP-BTLS. Evaluate and treat for spinal injuries and airway problems concurrently. Assess the pulse rate and quality and determine perfusion based on the patient's skin condition, color, temperature, and capillary refill time. If the patient has obvious life-threatening external hemorrhage, control the bleeding first (before airway and breathing), then treat the patient for shock as quickly as possible. Treat the shock by preventing heat loss.

In hot environments, the vessels in the skin dilate.

The skin becomes flushed or red, and heat radiates from the body's surface. Sweat glands secrete sweat to help cool the body. As the sweat evaporates from the skin's surface, the body temperature drops, and the person begins to cool down.

Classifying burns involves determining:

The source of the burn The depth of the burn The severity of the burn

Self-adherent, soft roller bandages are easy to use to keep dressings in place.

They are slightly elastic and the layers adhere somewhat but sho

Occlusive dressings, made of petroleum (Vaseline) gauze, aluminum foil, or plastic, prevent air and liquids from entering (or exiting) the wound.

They are used to cover sucking chest wounds, abdominal eviscerations, penetrating back wounds, and neck injuries.

Excited delirium is characterized by extreme agitation, reduced pain sensitivity, hallucinations, persistent struggling, and elevated temperature.

This condition is commonly associated with illegal drug ingestion. Excited delirium is a true emergency and warrants assisted ALS response. Some studies found that using a TASER in patients with true excited delirium was associated with dysrhythmias and sudden cardiac arrest. Other studies have found that the risk of sudden death is related to the excited delirium condition and is not associated with TASER use.

Dressings and bandages have three primary functions:

To control bleeding To protect the wound from further damage To prevent further contamination and infection

Inhalation Burns

Upper airway damage is often associated with the inhalation of superheated gases. Lower airway damage is more often associated with the inhalation of chemicals (eg, acids, aldehydes) and particulate matter. When treating a patient for inhalation injuries, you may encounter severe upper airway swelling, which requires immediate intervention. Sometimes airway swelling and compromise will develop more slowly and not manifest until transport. Consider requesting ALS backup if the patient has signs or symptoms of edema, such as stridor, a hoarse voice, singed nasal hairs, singed facial hairs, burns of the face, or carbon particles in the sputum. Apply cool mist, aerosol therapy, or humidified oxygen to help reduce some minor edema. Because most ambulances do not carry misters, apply an ice pack to the throat to help reduce the swelling, provided the tissue in that area does not have burns.

Severity is calculated by considering:

What caused the burn The body region that is burned The depth and extent of the burn The patient's age Preexisting illness or injuries

Five factors will help you to determine the severity of a burn.

What is the depth of the burn? What is the extent of the burn? These first two factors are the most important. After gauging these, ask yourself the following questions. Are any critical areas (face, upper airway, hands, feet, genitalia) involved? Also included in critical areas are any circumferential burns, which are burns that go completely around a body part such as an arm, foot, or chest. Does the patient have any preexisting medical conditions or other injuries? Is the patient younger than 5 years or older than 55 years? If the answer to any of these three questions is yes, you should upgrade the classification.

Crush syndrome

When an area of the body is trapped for longer than 4 hours and arterial blood flow is compromised, crush syndrome can develop. When a patient's tissues are crushed beyond repair, muscle cells die and release harmful substances into the surrounding tissues. The oppressing force prevents blood from returning to the injured body part, so these harmful substances are released into the body's circulation after the limb is freed and blood flow is returned. When possible, advanced life support (ALS) providers should administer IV fluid before the crushing object is lifted off the body. Freeing the limb or other body part from entrapment not only results in the release of the by-products of metabolism and harmful products of tissue destruction, but it also creates the potential for cardiac arrest and renal failure. Consider requesting ALS assistance for situations of prolonged entrapment prior to extrication.

During inflammation (the next stage of wound healing), additional cells move into the damaged area to begin repair.

White blood cells migrate to the area to combat pathogens that have invaded exposed tissue. Lymphocytes destroy bacteria and other pathogens. Mast cells release histamine as part of the body's response in the early stages of inflammation, which: Dilates blood vessels, increasing blood flow to the injured area and resulting in a reddened, warm area immediately around the site Makes capillaries more permeable, and swelling may occur as fluid seeps out of these "leaky" capillaries. Inflammation ultimately leads to the removal of foreign material, damaged cellular parts, and invading microorganisms from the wound site.

Rule of nines

divides the body into sections, each of which is approximately 9% of the total surface area.

A penetrating wound

is an injury resulting from a piercing object, such as a knife, ice pick, splinter, or bullet. Such objects leave relatively small entrance wounds, so there may be little external bleeding. These objects can damage structures deep within the body and cause unseen bleeding.

Contamination

is the presence of infectious organisms (pathogens) or foreign bodies, such as dirt, gravel, or metal, in the wound.

Minor Burns

partial-thickness burns covering less than 10 percent of the body's total surface area

In a cold environment,

the blood vessels in the skin constrict, diverting blood away from the skin and decreasing the amount of heat that radiates from the body's surface.