soft tissue injuries

Depth of burns

- burns are first classified by their depth a. Superficial (first-degree) burns i. Involve only the top layer of skin, the epidermis ii. The skin turns red but does not blister or burn through this top layer. iii. The burn site is often painful. iv. Example: sunburn b. Partial-thickness (second-degree) burns i. Involve the epidermis and some portion of the dermis ii. These burns do not destroy the entire thickness of the skin, nor is the subcutaneous tissue injured. iii. Typically, the skin is moist, mottled, and white to red. iv. Blisters are present. v. Can cause intense pain c. Full-thickness (third-degree) burns i. Extend through all skin layers and may involve subcutaneous layers, muscle, bone, or internal organs ii. The burned area is dry and leathery and may appear white, dark brown, or even charred. iii. If the nerve endings have been destroyed, a severely burned area may have no feeling. iv. The surrounding, less severely burned areas may be extremely painful. d. Significant airway burns are serious. i. May be associated with singed hair within the nostrils, soot around the nose and mouth, hoarseness, and hypoxia ii. These patients should be rapidly transported to an ED or facility capable of advanced airway management - it becomes increasingly more difficult to maintain an airway once swelling begins depth of burns can vary, a full- thickness burn may be surrounded by areas of partial-thickness and superficial burns, so while the full-thickness burn is painless, PT can still experience pain due to the extent of damage to the surrounding tissues Pure full-thickness burn is unusual - severe burns are typically a combination of superficial, partial thickness and full thickness burns Superficial burns heal well without scarring Small partial-thickness burns heal well without scarring Deep partial thickness and all full thickness burns are prone to scarring and may be best manages surgically May be impossible to accurately estimate the depth of a particular burn shortly after surgery

Penetrating wounds (puncture wound)

- injury resulting from a piercing object (knife ice pick, splinter, bullet) If the wound is to the chest or abdomen the injury can cause rapid fatal bleeding such objects leave relatively small entrance wounds, so there may be little external bleeding Impaled objects: penetrate the skin but remain in the body May cause damage to structures deep inside the body - can cause unseen bleeding Damage is difficult to manage and determine b. Presence of foreign materials inside the tissue can lead to infection treat all penetrating wounds of the neck, chest, back and upper abdomen with an occlusive dressing to prevent possible movement of air into the vascular space, thoracic cavity, abdominal cavity Don't waste time trying to figure out if a wound is an entrance or exit wound, just treat the wound 7. Stabbings and shootings often result in multiple penetrating injuries. a. Assess the patient carefully to identify all wounds. b. Count the number of penetrating injuries, especially with gunshot wounds. determining an entrance or exit wound is hard in a prehospital setting, simply count the number of wounds Gunshot wounds have unique characteristics that require special care The amount of energy is directly correlated to the speed of the bullet c. In a shooting, determine the type of gun when possible, do not let this delay patient transport bystanders and witnesses can tell you how many rounds were fired but they may be unreliable due to the stress of the environment It may help hospital personnel to better care for the patient Shotgun wounds create multiple paths of missiles (shot) and create larger surface area and volume of tissue damage Document everything carefully (circumstances surrounding any gunshot injury, condition of patient, and care given) many shooting cases go to court, you may be called to testify 8. Blast injuries may result in multiple penetrating injuries. 9. The mechanism of injury from a blast injury is generally due to three factors: a. Primary blast injury: Damage is caused by the blast wave itself and the sudden pressure changes of the explosion. b. Secondary blast injury: Damage results from flying debris that cause multiple penetrating wounds. c. Tertiary blast injury: The victim is thrown by the explosion, perhaps into an object. -

Secondary assessment

1. A more systematic full-body scan or focused examination of the patient 2. Includes assessing interventions and repeating vital signs, which typically occurs en route to the ED 3. Vital signs a. Obtain a series of vital signs to ensure subtle changes are evident. b. Signs that indicate hypoperfusion and indicate the need for rapid transport: i. Tachycardia ii. Tachypnea Low blood pressure Weak pulse Cool, moist, and pale skin c. Reassessing vital signs will indicate how well the patient is tolerating the injury and the effectiveness of interventions.

Radiation burns

1. Acute radiation exposure has become more than a theoretical issue because the use of radioactive materials has increased in industry and medicine. 2. Potential threats include incidents related to the use and transportation of radioactive isotopes and intentionally released radioactivity in terrorist attacks. 3. First determine if there has been a radiation exposure and then attempt to determine whether ongoing exposure continues to exist. 4. Three types of ionizing radiation: a. Alpha particles i. Have little penetrating energy and are easily stopped by the skin b. Beta particles i. Have greater penetrating power and can travel much farther in air than alpha particles ii. Can penetrate the skin, but can be blocked by simple protective clothing designed for this purpose c. Gamma radiation i. Threat is directly proportional to the wavelength ii. Very penetrating and easily passes through the body and solid materials 5. Most ionizing radiation accidents involve gamma radiation (x-rays). 6. People who have sustained a radiation exposure generally do not pose a risk to others; however, particularly in incidents involving explosions, patients may be contaminated. 7. Management of radiation burns a. Maintain a safe distance and wait for the HazMat team to decontaminate the patient before initiating care. b. Most contaminants can be removed by simply removing the patient's clothes. Call for additional resources. c. Once there is no threat to you, begin treating the ABCs and treat the patient for any burns or trauma. d. Irrigate open wounds. e. Notify the emergency department. f. Identify the radioactive source and the length of the patient's exposure to it. g. Limit your duration of exposure, increase your distance from the source, and attempt to place shielding between yourself and sources of gamma radiation.

Abdominal wounds

1. An open wound in the abdominal cavity may expose internal organs. 2. Evisceration: the organs protrude through the wound a. Cover the wound with sterile gauze moistened with sterile saline solution. b. Secure the gauze with an occlusive dressing. c. Keep the organs moist and warm - open abdomen radiates body heat quickly and exposed organs loose fluid quickly don't use an adherent material or a material that falls apart when wet (toilet paper, facial tissues, cotton) Flex their knees if spinal trauma is not suspected and their legs and knees are uninjured 3. Most patients with abdominal wounds require immediate transport to a trauma center.

primary assessment burns

1. Begin with a rapid exam. 2. Form a general impression. a. Look for clues to determine the severity of injuries and the need for rapid treatment. b. Be suspicious of clues that may indicate abuse. c. Consider the need for manual spinal stabilization. d. Check for responsiveness using the AVPU scale. e. 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. 3. Airway and breathing a. Be alert to signs that the patient has inhaled hot gases or vapors: i. Singed facial hair ii. Soot present in or around the airway b. Heavy amounts of secretions and frequent coughing may indicate a respiratory burn. 4. Circulation a. Control significant bleeding. b. If the patient has obvious life-threatening external hemorrhage, control the bleeding first (before airway and breathing), and only then treat the patient for shock as quickly as possible. c. Shock frequently develops in burn patients. 5. Transport decision a. Consider rapid transport for a patient who has: i. An airway or breathing problem ii. Significant burn injuries iii. Significant external bleeding iv. Signs and symptoms of internal bleeding b. Consulting with ALS providers may be appropriate.

Pathophysiology of burns

1. Burns are soft-tissue injuries spread out over a large area created by the transfer of radiation, thermal, or electrical energy. a. Thermal burns can occur when skin is exposed to temperatures higher than 111°F (44°C). b. The severity of a thermal injury correlates directly with: i. Temperature ii. Concentration iii. Amount of heat energy possessed by the object or substance - solids generally have higher heat content than gases (the rack in the oven will produce greater burns that the gases coming from the oven) iv. Duration of exposure c. Burn injuries are progressive—the greater the heat energy, the deeper the wound. 2. Exposure time is another important factor. a. Thermal injury can occur to patients who are unresponsive or paralyzed from heat sources such as heating pads or heat lamps there can be a vast difference in the temperature of a fire from the floor to the ceiling Most people naturally limit their exposure to heat, however a person could be unconscious or trapped extending their exposure time

Thermal burns

1. Caused by heat 2. Most commonly, caused by scalds or an open flame a. A flame burn is very often a deep burn, especially if the person's clothing catches fire. b. A scald burn is most commonly seen in children and handicapped adults but can happen to anyone, particularly while cooking. - scald burns cover a large portion bc liquids spread easily and quickly 3. Coming in contact with hot objects produces a contact burn. a. Contact burns are rarely deep unless the patient was prevented from drawing away from the hot object. 4. A steam burn can produce a topical (scald) burn. a. Minor steam burns are common when microwaving food covered with plastic wrap. - can cause airway burns as well 5. A flash burn is produced by an explosion, which may briefly expose a person to very intense heat. a. Lightning strikes can also cause a flash burn. - injuries are usually minor compared to the potential trauma from whatever caused the flash 6. Management of thermal burns a. Stop the burning source, cool the burned area if appropriate, and remove all jewelry. b. Maintain a high index of suspicion for inhalation injuries. c. Increased exposure time will increase damage to the patient. d. The larger the burn, the more likely the patient is to be susceptible to hypothermia and/or hypovolemia. e. All patients with large surface burns should have a dry sterile dressing applied - maintains body temp, prevents infection, provides comfort

Chemical burns

1. Chemical burns can occur whenever a toxic substance contacts the body. 2. Most chemical burns are caused by strong acids or strong alkalis. 3. The eyes are particularly vulnerable. - fumes alone can cause burns (especially to the respiratory tract) 4. The severity of the burn is directly related to the: a. Type of chemical b. Concentration of the chemical c. Duration of the exposure 5. To prevent exposure to hazardous materials, determine if you can safely approach the patient. In some cases, it may be necessary to wait until a hazardous materials (HazMat) team has decontaminated the patient. 6. Wear appropriate chemical-resistant gloves and eye protection whenever you are caring for a patient with a chemical burn. don't get any of the chemical on yourself May be necessary to gown up 7. Treatment for chemical burns can be specific to the chemical agent. - if available read the container containing said chemical, don't risk exposure 8. Management of chemical burns a. The severity of the burn will depend on the type of chemical, its strength, the duration of exposure, and the area of the body exposed. b. To stop the burning process, remove any chemical from the patient. c. Always brush dry chemicals off the skin and clothing before flushing the patient with water. d. Remove the patient's clothing, including shoes, stockings, gloves, and any jewelry or eyeglasses. e. Take great care to ensure you do not come in contact with the chemical. The patient should be properly decontaminated by properly trained personnel. f. For liquid chemicals, immediately begin to flush the burned area with large amounts of water. - never direct a forceful stream of water on the patient as extreme water pressure may mechanically injure the burned skin g. Continue flooding the area with gallons of water for 15 to 20 minutes after the patient says the burning pain has stopped. h. 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. flush the eyes from the inside corner out U can use a nasal cannula, don't touch prongs to the eye i. As with any substance, once the fluid has been contaminated with the chemical, collect it and properly dispose of it. j. Conduct a proper decontamination prior to loading any patient into the ambulance and again prior to entering a hospital.

Burn severity

1. Five factors help determine the severity of a burn (the first two factors are the most important): seriousness of a burn may determine treatment facility a. What is the depth of the burn? b. What is the extent of the burn? c. Are any critical areas involved? i. Face, upper airway, hands, feet, genitalia, and circumferential burns? d. Does the patient have any preexisting medical conditions or other injuries? e. Is the patient younger than 5 years or older than 55 years? - if the answer to any of these 3 questions is yes, upgrade the burn classification 2. Burns to the face are of particular importance due to the potential for airway involvement. 3. Burns to the hands or feet or over joints are considered serious because of the potential for loss of function as the result of scarring. be aware for signs of abuse Pediatric, geriatric or disabled patient Various injuries in multiple stages of healing Injuries inconsistent with the caregiver story Burns in "patterns" - small round burns may be cigarette scars. Fully examine a patient you suspect is being abused

Primary assessment

1. Focus on identifying and managing life-threatening concerns and identifying the transport priority. 2. Form a general impression. a. Important indicators will alert you to the seriousness of the patient's condition. i. Is the patient awake and interacting with his or her surroundings, or is the patient lying still, making no sounds? ii. Is the patient responding to you appropriately or inappropriately? iii. Is the patient's breathing pattern rapid or slow, deep or shallow? iv. What is the color and condition of the patient's skin? v. Does the patient have any apparent life threats? b. Closed soft-tissue injuries may appear to be minor, but could indicate serious internal injuries. i. Do not be distracted from looking for more serious hidden injuries. c. Check for responsiveness. 3. Airway and breathing a. Providing high-flow oxygen may help reduce the effects of shock and assist in perfusion of damaged tissues, particularly in crush injuries. b. Open soft-tissue injuries of the face and neck have a potential to interfere with the effectiveness of the airway and breathing. 4. Circulation a. Assessment of the pulse and skin provides an indication as to how aggressively you need to treat the patient for shock. 5. Transport decision a. Consider whether transport to the closest hospital is appropriate or whether the patient would be better served by transport to a trauma center. b. Types of patients who need immediate transportation: i. Poor initial general impression ii. Altered level of consciousness iii. Dyspnea iv. Abnormal vital signs v. Shock vi. Severe pain

Pathophysiology of Closed and Open Injuries

1. Healing of wounds is a natural process that involves several overlapping stages, all directed toward the larger goal of maintaining homeostasis (balance). - ultimately the body's goal is to return to its functional state, although the area may never be restored to its pre-injury state 2. Cessation of bleeding is the primary concern - loss of blood internal or external, hinders the provision of vital nutrients and oxygen to the affected area, it also impairs the tissues ability to eliminate wastes, end result is abnormal or absent function, which interferes with homeostasis - to stop the bleeding, vessels, platelets, and clotting cascade must work in unison 3. During inflammation, the next stage of healing: a. Additional cells move into the damaged area to begin repair. b. White blood cells migrate to the area to combat pathogens that have invaded the exposed tissue - foreign products and bacteria are also removed from the body c. Lymphocytes (type of white blood cells) destroy bacteria and other pathogens. d. Mast cells release histamine as a part of the body response in the early stages of inflammation - histamine dilates blood vessels, increasing blood flow to the injured area and resulting in a reddened warm area immediately around the site, histamines makes capillaries more permeable and swelling may occur as fluid seeps put of these leaky capillaries e. Inflammation ultimately leads to the removal of: i. Foreign material ii. Damaged cellular parts iii. Invading microorganisms 4. In the outer layer of skin, cells are stacked in layers, to replace the area damaged in a soft-tissue injury, a new layer of cells must be moved into this region - next stage of wound healing cells quickly multiply and redevelop across the edges of the wound Except in cases of clean incisions, the appearance of the restructured area seldom returns to the pre-injury state Large wounds or injuries that result in significant disruption of the skin will often not complete the process Ppl with lighter skin might see a pink scar, signaling the presence of collagen - structural protein that has reinforced the damaged tissue, despite the changed appearance the function will be normal 5. In the next stage of wound healing, new blood vessels form as the body attempts to bring oxygen and nutrients to the injured tissue, new capillaries bud from the intact capillaries that lie adjacent to the damages skin, these vessels provide a channel for oxygen and nutrients and serve as a pathway to waste removal Bc they are new and delicate bleeding might result from a very minor injury, may take weeks or months for the new capillaries to be as stable as the preexisting vessels 6. In the last stage of wound healing, collagen provides stability to the damaged tissue and joins wound borders, thereby closing the open tissue. a. Collagen is a tough, fibrous protein found in scar tissue, hair, bones, and connective tissue. b. Collagen cannot restore the damaged tissue to its original strength. - healing doesn't always follow this pattern, infection or an abnormal scar may develop, excessive bleeding may occur or healing may be slow

Taser injuries

1. In recent years, law enforcement has increased its use of Tasers. 2. These weapons fire two small darts (electrodes) that puncture the patient's skin. a. Barbs are generally treated as impaled objects and removed by a physician. b. In some jurisdictions, depending on local protocol, EMTs are permitted to remove these barbs from patients. - these barbs are 13mm in length 3. There are potential complications for the patient when these devices have been used, particularly when the patient is experiencing certain underlying disorders. a. Excited delirium is commonly associated with illegal drug ingestion. b. It is considered a true emergency and warrants assisted ALS response. c. Using a Taser device in patients with true excited delirium has been associated with dysrhythmias and sudden cardiac arrest. 4. Make sure you have access to an AED when you respond to patients who have been exposed to Taser shots.

Inhalation burns

1. Inhalation injuries can occur when burning takes place in enclosed spaces without ventilation. when the upper airway is exposed to excessive heat, pt can experience rapid and serious airway compromise Heat can be an irritant to the lungs and airway - causes coughing, wheezing, rapid swelling, edema of mucosa of upper airway tissues (stridor) a. Upper airway damage is often associated with the inhalation of superheated gases b. Lower airway damage is often associated with the inhalation of chemicals and particulate matter. 2. When treating a patient for inhalation injuries, you may encounter severe upper airway swelling, requiring immediate intervention. a. Consider requesting ALS backup if the patient has signs and symptoms of edema. i. Stridor ii. Hoarse voice iii. Singed nasal hairs iv. Burns of the face v. Carbon particles in the sputum b. Apply cool mist, aerosol therapy, or humidified oxygen to help reduce minor edema. c. Apply an ice pack to the throat to reduce swelling, provided the tissue in that area does not have burns.

History taking of burns

1. Investigate the chief complaint. a. Be alert for signs or symptoms of other injuries due to the MOI. b. If the patient was burned in a confined space, suspect an inhalation injury. c. When burns result from explosive forces, be alert for other internal injuries and fractures. d. Obtain a medical history and be alert for injury-specific signs and symptoms and pertinent negatives. 2. SAMPLE history a. Along with the SAMPLE history, ask the following questions: i. Are you having any difficulty breathing? ii. Are you having any difficulty swallowing? iii. Are you having any pain? b. Check whether the patient has an emergency medical identification device.

History taking

1. Investigate the chief complaint. a. Chronic medical conditions such as anemia and hemophilia as well as a host of other medical conditions can complicate open soft-tissue injuries.

Electrical burns

1. May be the result of contact with high- or low-voltage electricity a. High-voltage burns may occur when utility workers make direct contact with power lines. b. Ordinary household current can cause severe burns and cardiac arrhythmias. 2. For electricity to flow, there must be a complete circuit between the electrical source and the ground. a. Insulator: any substance that prevents this circuit from being completed b. Conductor: any substance that allows a current to flow through it c. The human body is a good conductor. d. Electrical burns occur when the body, or a part of it, completes a circuit connecting a power source to the ground. 3. The type of electric current, magnitude of current (amperage), and voltage influence the seriousness of burns. when an electrical current enters the body, the skin is burned at the entrance wound as well as everywhere along the path until the current grounds and exits the body In addition to tissues damaged by heat, significant changes chemical changes take place in the nervous, cardiovascular and muscular systems of the body - causes disruptions of the body's normal functions, can even cause system failure 4. Your safety is of particular importance when you are called to the scene of an emergency involving electricity. you can be fatally injured by coming into contact with a patient still touching a power line Never attempt to remove someone from an electrical source unless trained to do so Never move a downed power line unless trained to do so Make sure the power is off before approaching the patient 5. A burn injury appears where the electricity enters (entrance wound) and exits (exit wound) the body. entrance wound is small Exit wound is usually large, deep and extensive in comparison a. Two dangers specifically associated with electrical burns: i. A large amount of deep tissue injury damage may be more severe than external signs indicate Force of current can cause Fxs and joint dislocations ii. Cardiac or respiratory arrest from the electric shock if the patient isn't in arrest upon ur arrival it is unlikely they will go into arrest while in transport Current can cross the chest and cause cardiac arrest and dysrhythmias Cardiac arrest can also happen after lightening strikes 6. Management of electrical burns a. Electrical current can cross the chest and cause cardiac arrest or arrhythmias. b. If indicated, begin CPR on the patient and apply the automated external defibrillator (AED). c. Be prepared to defibrillate if necessary. d. Give supplemental oxygen and monitor the patient closely for respiratory and cardiac arrest. e. Treat soft-tissue injuries by applying dry, sterile dressing on all burn wounds and splinting suspected fractures. f. Provide prompt transport.

Sterile dressings

1. Most wounds will be covered by: a. Universal dressings b. Conventional 4″ ◊ 4″ and 4″ ◊ 8″ gauze pads c. Assorted small adhesive-type dressings and soft self-adherent roller dressings 2. The universal dressing is ideal for covering large open wounds. 3. Gauze pads are appropriate for smaller wounds. 4. Adhesive-type dressings are useful for minor wounds. 5. Occlusive dressings prevent air and liquids from entering (or exiting) the wound. a. Made of Vaseline gauze, aluminum foil, or plastic b. Used to cover sucking chest wounds, abdominal eviscerations, penetrating back wounds, and neck injuries

Neck injuries

1. Open neck injuries can be life threatening. 2. If the veins of the neck are open to the environment, they may suck in air. a. If enough air is sucked into a blood vessel, it can block the flow of blood in the lungs and cause cardiac arrest. b. This condition is called air embolism. 3. Cover the wound with an occlusive dressing. 4. Apply manual pressure but do not compress both carotid arteries at the same time. a. This could impair circulation to the brain and cause a stroke. - wrap with dressing loosely around the neck and securely around the axilla 5. Use caution with patients suffering from a neck injury depending on the MOI involved. Immobilize the C-spine if indicated, including placing a cervical collar. Cervical collar can hold dressings and gauze in place

secondary assessment of burns

1. Physical examination a. Perform an exam of the entire body. b. Assess the patient from head to toe looking for DCAP-BTLS. c. Make a rough estimate, using the rule of nines, of the extent of the burned area. d. Determine which classification of burns the victim has sustained. e. Determine the severity of the burns. f. Package the patient for transport based on your findings. 2. Vital signs a. Obtaining an early set of vital signs will indicate how the patient is tolerating his or her injuries. b. Monitoring devices i. Oxygen saturation monitor ii. Carbon monoxide monitor

reassessment of burns

1. Reassess the patient and reevaluate interventions and treatments. 2. Communication and documentation a. Provide hospital personnel with a description of how the burn occurred. b. Describe the extent of the burns: i. Amount of body surface area involved ii. Depth of the burn iii. Location of the burn c. If special areas are involved, they should be specifically mentioned and documented.

Reassessment

1. Reassessment should be conducted regularly during transport. 2. Repeat the primary assessment and pay extra attention to areas of concern identified in the initial assessment. 3. Assess the effectiveness of prior treatments. 4. Reassess vital signs and the chief complaint. 5. Identify and treat changes in the patient's condition. 6. Communication and documentation a. Communication and documentation must include a description of the MOI and the position in which you found the patient when you arrived on scene. b. Report blood loss using terms that you are comfortable with and that will be easily understood by other personnel. c. Include the location and description of any soft-tissue injuries or other wounds you have located and treated. d. Describe the size and depth of the injury. e. Provide an accurate account of how you treated these injuries.

Scene size up burns

1. Scene safety b. Ensure that the factors that led to the patient's burn injury do not pose a hazard to you and your crew. 2. Mechanism of injury a. Attempt to determine the type of burn that has been sustained and the MOI. b. What the patient reports will often provide some important information about the extent of the injury. c. Assess the scene for any environmental hazards. d. Determine the number of patients. e. Call for additional resources early, if necessary. f. Consider the potential for spinal injuries, broken bones, inhalation injuries, and other injuries.

Physiology

1. Skin serves many functions: a. Barrier against infection b. Helps maintain fluid balance c. Assists with the regulation of body temperature - body major organ for temp regulation, blood vessels constrict in a cold environment, deviating blood away from the skin decreasing heat radiation, in hot environments blood vessels dilate - skin becomes flushed or red, heat radiates from the body surface, as sweat evaporates the body cools down d. Sensory organ - nerves in the skin report to the brain on the environment and many sensations, this nerve pathway connection that allows the body to adapt to environments through responses in the skin and surrounding tissues 2. Any break in the skin may allow bacteria to enter and increases the potential for infection, fluid loss, and loss of temperature control, any one of these conditions can cause serious injury or even death, soft tissues are often injured due to environmental exposure 3. Three types of soft-tissue injuries: a. Closed injuries - injuries occur beneath skin/mucous membranes, skin or mucous membranes remain intact b. Open injuries - break in skin or mucous membranes exposing deeper tissues to possible contamination c. Burns - soft tissue damage which occurs as a result of thermal heat, frictional heat, toxic chemicals, electricity, or nuclear radiation

Bites

1. Small-animal bites and rabies a. Consider the scene and crew safety prior to entering the environment. b. A small animal's mouth is heavily contaminated with virulent bacteria. c. Consider all small-animal bites to be contaminated and potentially infected wounds and in need of debridement (removal of damaged tissue), antibiotics and tetanus prophylaxis d. All small-animal bites should be evaluated by a physician - they can result in small complex wounds that need surgical repair - cover the wound in dry sterile dressings, splint and offer reassurance e. A major concern is the spread of rabies, an acute, potentially fatal viral infection of the central nervous system that can affect all warm-blooded animals - transmitted through saliva by bitting or licking an open wound it can be prevented with a serious of vaccinations - painful Try to bring the animal since rabid may take time to manifest f. Children, particularly young ones, may be seriously injured or even killed by dogs. i. The animal may turn and attack you as well. ii. Do not enter the scene until the animal has been secured by the police or an animal control officer. 2. Human bites a. The human mouth, more so than even the small animal's mouth, contains an exceptionally wide range of bacteria and viruses. b. Consider any human bite that has penetrated the skin to be a very serious injury. c. Any laceration caused by a human tooth can result in a serious, spreading infection. d. Emergency treatment: i. Apply a dry, sterile dressing. ii. Promptly immobilize the area with a splint or bandage. iii. Provide transport to the ED for surgical cleansing of the wound and antibiotic therapy.

Anatomy

1. The skin has two principal layers: the epidermis and the dermis. a. Epidermis: the tough, external layer that forms a watertight covering for the body i. The epidermis is itself composed of several layers. cells on the surface layers are constantly worn away They are replaced by cells pushed to the surface when new cells form in the germinal layer at the base of the epidermis Deeper cells in the germinal layer contain pigment granules (melanocytes) that produce the skin color along with blood vessels in the dermis b. Dermis: the inner layer of the skin - lies below the germinal cells of the epidermis i. Contains the hair follicles, sweat glands, and sebaceous glands - gives skin its characteristic appearance sweat glands sweat through small pores or ducts that pass through the epidermis to cool the body Sebaceous glands produce sebum - an oily material that keeps the skin waterproof and supple Sebum travels to the skin surface along the shaft of adjacent hair follicles Hair follicles are are small organs that produce hair, for every hair there is one follicle, each connected with a sebaceous gland and tiny muscle This tiny muscle pulls the hair erect in flight or fight or if the person is cold ii. Blood vessels in the dermis provide the skin with nutrients and oxygen. small branches may reach up to the germinal cells but blood vessels do not penetrate farther into the dermis There are special nerve endings in the dermis 2. Skin covers all the external surfaces of the body. 3. The various openings in the body (mouth, nose, anus, vagina) are lined with mucous membranes. protective barrier against bacterial invasion Secretes a water substance that lubricates the openings Mucous membranes are moist Skin is dry (generally)

Complications of burns

1. The skin serves as a barrier between the environment and the body. a. When a person is burned, this barrier is destroyed. b. Burn victims are at high risk for: i. Infection ii. Hypothermia iii. Hypovolemia iv. Shock 2. Burns to the airway are of significant importance because the loose mucosa in the hypopharynx can swell and lead to complete airway obstruction. 3. Circumferential burns of the chest can compromise breathing. 4. Circumferential burns of an extremity can lead to compartment syndrome, resulting in neurovascular compromise and irreversible damage if not appropriately treated. 5. If you suspect any complications, call for ALS backup. burns can cause hypothermia, acidosis and prevent blood from clotting effectively - increases the likelihood of death (keep PT warm and give O2) Consult local protocols on treating burns

Bandages

1. To keep dressings in place during transport, you can use: a. Soft roller bandages b. Rolls of gauze c. Triangular bandages d. Adhesive tape 2. The self-adherent, soft roller bandages are easiest to use. 3. Adhesive tape holds small dressings in place and helps to secure larger dressings. a. Some people are allergic to adhesive tape; with these individuals, use paper or plastic tape instead. 4. Do not use elastic bandages to secure dressings. a. If the injury swells, the bandage may become a tourniquet and cause further damage. b. Always check a limb distal to a bandage for signs of impaired circulation and loss of sensation. c. Air splints and vacuum splints are useful in stabilizing broken extremities and can be used with dressings to help control bleeding from soft-tissue injuries. 5. If a wound continues to bleed despite the use of direct pressure, quickly proceed to the use of a tourniquet.

Dressing and Bandaging

A. All wounds require bandaging. 1. Dressings and bandages have three functions: a. To control bleeding b. To protect the wound from further damage c. To prevent further contamination and infection

Emergency Medical Care for Open Injuries

A. Before you begin to care for a patient with an open wound, follow standard precautions. 1. If life-threatening bleeding is observed, assign a team member to apply direct pressure over the wound to control the bleeding. 2. If the wound is in the chest, upper abdomen, or upper back, cover it with an occlusive dressing. 3. Control bleeding using: a. Direct, even pressure and elevation b. Pressure dressings and/or splints c. Tourniquets - for severe hemorrhaging don't waste time apply a tourniquet early B. All open wounds should be assumed to be contaminated and to present a risk of infection. 1. Apply a sterile dressing to reduce the risk of further contamination. 2. Do not remove material from an open wound, no matter how dirty the wound is. Brushing, rubbing or washing can cause additional bleeding 3. Small wound surfaces without significant bleeding can be flushed with sterile saline prior to applying a dressing. chemical burns and contamination should be flushed to remove remaining chemicals To prevent a wound from drying you may apply moist sterile dressings covered with dry dressings 4. In most circumstances, hospital personnel, rather than EMTs, will clean open wounds. C. In some cases, you can better control bleeding from open soft-tissue wounds by splinting the extremity, even if there is no fracture. splinting the extremity can better control bleeding and lessen pain Splinting also keeps sterile dressing in place, minimized damage and makes patients easier to move

Burns

A. Burns account for approximately 3,400 deaths per year. B. Burns are among the most serious and painful of all injuries. 1. A burn occurs when the body, or a body part, receives more radiant energy than it can absorb, resulting in an injury. a. Potential sources of this energy: i. Heat ii. Toxic chemicals iii. Electricity 2. Although a burn may be the patient's most obvious injury, perform a complete assessment to determine whether the patient has other serious injuries. 3. Children, older patients, and patients with chronic illnesses are more likely to experience shock from burn injuries. - many fires generate toxic compounds such as cyanides - a result of combustion of synthetic materials, don't enter a scene unless u are trained to do so

Patient Assessment of Closed and Open Injuries

A. It is more difficult to assess a closed injury than to assess an open injury. B. Scene size-up 1. Scene safety 2. Mechanism of injury (MOI) a. Look for indicators of the MOI as you assess the scene. i. Helps develop an early index of suspicion for underlying injuries. ii. Interactions with the patient and your assessment will provide you with additional information about the extent of the injuries. b. The MOI may provide information about potential safety threats. c. Use all available information to evaluate scene safety and consider whether additional resources may be necessary.

Emergency Medical Care for Closed Injuries

A. Small contusions generally require no special emergency medical care, but you should note their presence to determine the extent of the patient's injuries. B. More extensive closed injuries may involve significant swelling and bleeding beneath the skin, which could lead to hypovolemic shock. C. The injuries might not have had time to cause swelling or bruising. D. Closely watch any area of injury throughout the time you are caring for the patient, no matter how minor it may look upon initial assessment. E. Treat a closed soft-tissue injury using the RICES mnemonic: 1. Rest 2. Ice 3. Compression 4. Elevation 5. Splinting F. Be alert for signs of developing shock: 1. Anxiety or agitation 2. Changes in mental status 3. Increased heart rate 4. Increased respiratory rate 5. Diaphoresis 6. Cool or clammy skin 7. Decreased blood pressure G. If the patient exhibits signs and symptoms of shock, treat accordingly and aggressively.

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A. Soft-tissue injuries are common. 1. They can be as serious as a life-threatening internal injury or a simple cut or scrape. 2. Do not become distracted by dramatic open wounds, don't ignore larger life threats, focus on the ABC's. B. The soft tissues of the body can be injured through a variety of mechanisms: 1. Blunt injury - energy exchange between the patient and object is more than the tissues can tolerate, does not penetrate the skin 2. Penetrating injury - an object (such as bullet or knife) breaks through the skin into the body 3. Barotrauma - injuries that result from sudden or extreme changed in air pressure (commonly seen in blast injury victims) 4. Burns C. Soft-tissue trauma is a common form of injury. 1. Open wounds accounted for approximately 4.1 million emergency department (ED) visits in 2011. 2. Wound care is one of the most frequently performed procedures in EDs across the United States. 3. Most of these injuries require basic interventions - wound irrigation, dressing, bandaging, limited suturing D. Death is often related to hemorrhage or infection. uncontrolled hemorrhage can quickly lead to shock or death When the skin barrier is breached, invading pathogens - fungi, bacteria and viruses - can cause local or systemic infection 1. Infection can be life or limb threatening, especially in children, older adults, and people with diabetes or other conditions that may compromise the immune system. E. Soft-tissue injuries and their complications can often be prevented by using simple protective actions. wearing gloves Safety measures in the workplace Plastic cookware for children Smoke alarms, heater regulation and building codes

The Anatomy and Physiology of the Skin

A. The skin is the body's first line of defense against external forces and infection. 1. It is the largest organ in the body. 2. It is relatively tough, but still susceptible to injury. - injuries range from cuts and bruises to amputations and lacerations a. Injuries may expose blood vessels, nerves, and bones. B. In all instances, you must: 1. Control bleeding. 2. Prevent further contamination to decrease the risk of infection. 3. Protect wounds from further damage. 4. Apply dressings and bandages to various parts of the body. C. Skin varies in thickness, depending on the person's age and the skin's location. 1. Skin is thinner in the very young and the very old. 2. Skin is thinner on the eyelids, lips, and ears (thin skin is more easily damaged) - scalp, back, and soles of the feet skin is the thickest

Patient Assessment of Burns

A. When you are assessing a burn, it is important to classify the patient's burns. 1. Classification of burns involves determining: a. Source of the burn b. Depth of the burn c. Severity of the burn

Emergency Medical Care for Burns

A. Your first responsibility in caring for a patient with a burn is to stop the burning process and prevent additional injury. B. Refer to Skill Drill 26-2. follow standard precautions, burn destroys PTs skin, wear gloves and eye protection Move pt away from burning area, is clothing is on fire smother it with a fire blanket, follow protocols, remove jewelry (If protocol allows) immerse area in cool sterile water or saline or cover skin with cool, clean, wet dressings - relives pain and stops burning, no longer than 10 mins bc of hypothermia and infection risk, don't immerse if burning has stooped, you can also irrigate Cover with a dry sterile dressings, don't apply saline to a larger burn surface since its for the purpose of stopping the burn process Provide oxygen (inhalation kills more than burns) Rapidly estimate burn severity, cover with dry sterile dressings, you can use sheets or gauze, no ointments lotions or antiseptics, don't break blisters Check for traumatic injuries and other medical conditions that may be life threatening Treat for shock Prevent further heat loss Transpot Key to initial burn treatment is to stop the burning process not to "cool" the skin, cold/ice water can cause further injury

Management of inhalation burns

a. First ensure your own safety and the safety of your coworkers. b. Prehospital treatment of a patient with suspected hydrogen cyanide poisoning includes decontamination and supportive care until an antidote can be administered by ALS providers. - exposure to other toxic gases can also cause damages to organs and systems leading to death c. Care for any toxic gas exposure: i. Recognition ii. Identification iii. Supportive treatment

Extent of burns

a. Rule of palm: Estimate the surface area that has been burned by comparing it to the size of the patient's palm, which is roughly equal to 1% of the patient's total body surface area. b. Rule of nines: Estimate the extent of a burn by dividing the body into sections, each representing approximately 9% of the total body surface area. c. The proportions differ for infants, children, and adults. head of an infant or child is relatively larger than an adult, the legs are relatively smaller Burns to children are considered more serious Infants/children have more surface area relative to total body mass - greater fluid/heat loss Children do not tolerate burns well More likely to go into shock, have hypothermia, airway difficulties bc of unique anatomy differences Watch for signs of abuse d. When you calculate the extent of burn injury, include only partial- and full-thickness burns. Document superficial burns, but do not include them in the body surface area estimation of extent of burn injury.

The combustion process produces a variety of toxic gases.

a. The less efficient the combustion process, the more toxic the gases that may be created. when furnaces, kerosene heaters, and other heating devices may be in poor repair, they may emit toxic gases Internal combustion gases may emit toxins 4. Carbon monoxide (CO) intoxication should be considered whenever a group of people in the same place all report a headache or nausea. should also be considered if people complain about being sick at home but not at work or school CO can displace O2 from the alveolar air and from its attachment sites on hemoglobin molecules contained in circulating red blood cells CO bonds to receptor sites on hemoglobin at least 250x more easily than O2 - its hemoglobin may become saturated with the wrong chemical Being exposed regularly to small concentrations of CO (from cig smoke) can take CO levels from 2% to 4%-8% Levels of 50% are usually fatal 5. Cherry red skin, lips, and nail beds are commonly observed in patients who have died from CO exposure Do not rule out CO exposure simply because the patient's skin is not cherry red. pts with a severe CO intoxication usually have a O2 saturation level that is normal Be suspicious of pulse oximetry readings in suspected CO poisonings 6. Hydrogen cyanide (HCN) is generated by combustion of common materials (paper, cotton, wool) colorless, smell of burnt almonds Prehospital diagnosis is difficult because lab tests or necessary Difficult to detect at the scene of a fire a. Signs and symptoms of HCN poisoning involve the central nervous, respiratory, and cardiovascular systems of the body: i. Faintness ii. Anxiety iii. Abnormal vital signs iv. Headache vi. Seizures vii. Paralysis viii. Coma

Closed injuries

characterized by a history of blunt trauma, pain at the site of injury, swelling beneath the skin, and discoloration, injuries can very from minor to severe 1. Contusions (or bruise) - injury that causes bleeding beneath the skin but does not break the skin a. Result from blunt forces striking the body b. The epidermis remains intact, but cells within the dermis are damaged, and small blood vessels are usually torn. - depth of injury varies, depending on the amount of energy absorbed c. Fluid and blood leak into the damages area, patient may have swelling and pain, the buildup of blood produces a characteristic blue or black discoloration called ecchymosis. 2. Hematoma a. A collection of blood within damaged tissue or in a body cavity b. Occurs whenever a large blood vessel is damaged and bleeds rapidly c. Usually associated with extensive tissue damage can result from a soft tissue injury, fracture or any injury to a larger blood vessel In severe cases a hematoma may contain up to a liter of blood 4. Crush injuries - significant force is applied to the body a. The extent of the damage depends on: i. How much force is applied ii. How long the force is applied b. Continued compression of the soft tissues will cut off circulation, producing further tissue destruction - if a person is trapped under rocks damage will continue until the rocks are removed 5. When an area of the body is trapped for longer than 4 hours and arterial blood flow is compromised, crush syndrome can develop. 6. When a patient's tissues are crushed beyond repair, muscle cells die and release harmful substances into the surrounding tissues. a. Harmful substances are released into the body's circulation after the limb is freed and blood flow is returned. b. Advanced life support (ALS) providers should administer IV fluid before the crushing object is lifted off the body. c. Freeing the body part from entrapment creates the potential for cardiac arrest and renal failure - bc of the release of byproducts from metabolism and the harmful products of tissue destruction d. Consider requesting ALS assistance for situations of prolonged entrapment prior to extrication. 7. Compartment syndrome develops when edema and swelling result in increased pressure within a closed soft-tissue compartment. Tissues are limited with the amount they can stretch, pressure increases within the compartment, which interferes with circulation. 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 b. As pressure develops, delivery of nutrients and oxygen is impaired and by-products of normal metabolism accumulate. c. There is pain, especially on passive movement. d. The longer this situation persists, the greater the chance for tissue death. e. The EMT must continually reassess skin color, temperature, and pulses distal to the injury site if crush injury is suspected. 8. Severe closed injuries can damage internal organs. the greater the amount of energy is absorbed the greater the chance of internal injuries in deeper structures You must assess all patients with closed injuries for more signs of serious hidden injuries Remain alert for signs and symptoms of shock or internal bleeding

Open injuries

differ from closed injuries because the protective layer of skin is damaged This can produce extensive bleeding A break means the wound is contaminated and may become infected Contamination is the presence of infectious organisms (pathogens) or foreign bodies, such as dirt, gravel, or metal in the wound You must address excessive bleeding and contamination in your treatment of open soft-tissue wounds 1. Four types of open soft-tissue wounds: a. Abrasions b. Lacerations c. Avulsions d. Penetrating wounds 2. Abrasion: 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 usually does not penetrate completely through the dermis, but blood may ooze from the injured capillaries in the dermis Known as road rash, mad burn, strawberry and rug burn Can be extremely painful because nerve endings are located in the dermis 3. Laceration: a jagged cut caused by a sharp object or a blunt force that tears the tissue incision - sharp, smooth cut Depth of the injury may vary, extending through the skin and subcutaneous tissues, even into the underlying muscles and adjacent nerves and blood vessels May appear linear (regular) or stellate (irregular) and may occur alongside other soft-tissue injuries If they involve arteries or large veins severe bleeding may occur 4. Avulsion: a wound that separates various layers of soft tissue (usually between the subcutaneous layer and fascia) so that they become either completely detached or hang as a flap a. Often there is significant bleeding. if the avulsion is attached by a small piece of skin, circulation may be compromised If you can place the avulsion over the skin its removed from unless its not visibly contamination If its fully off wrap the separate skin in sterile gauze and transport This type produces serious infection concerns b. Never remove an avulsion skin flap, regardless of its size. c. Amputation: an injury in which part of the body is completely severed control the bleedings with dressings, pressure and tourniquets if needed Treat for hypovolemic shock

Impaled objects

do not attempt to move or remove the object unless its in the mouth or chest (airway obstruction) or interfere with AED Remove any clothing covering the injury Control bleeding with direct pressure Apply a bulky dressing to stabilize the object Use an occlusive dressing in the injury is in the chest neck or back Secure the object in the gauze Protect the object by placing a plastic bottle, cup or container over the object and secure it 2. Remove an impaled object only when the object: a. Is in the cheek or mouth and obstructs the airway b. Is in the chest and directly interferes with CPR 4. If the object is very long, secure and then shorten it. 5. Provide rapid transport.

Classification of burns in adults

severe burns Full thickness burns involving hands, feet, face, upper airway, genitalia, circumferential burns Full thickness burns covering more than 10% of the body's total surface area Partial thickness burns covering more than 30% Burns associated with respiratory injury (smoke inhalation) Burns complicated by FXs Burns on ppl younger than 5 or older than 55 that would be moderate burns in a young adult Moderate burns Full thickness burns involving 2-10% of the body's total surface area (excluding hands, feet, face, genitalia, upper airway) Partial-thickness burns covering 15-30% of the body's total surface area Superficial burns covering more than 50% of the body's total surface area Minor burns Full thickness burns covering less than 2% Partial thickness burns covering less than 15% Superficial burns covering less than 50%