Ch. 26: Soft Tissue Injuries

13. Explain how the seriousness of a burn is related to its depth and extent. (pp 924-925)

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. Burns to the airway are of significant importance because the loose mucosa in the hypopharynx can swell and lead to complete airway obstruction. Five factors will help you to determine the severity of a burn. 1. What is the depth of the burn? 2. What is the extent of the burn? -These first two factors are the most important. After gauging these, ask yourself the following questions. 3. 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. 4. Does the patient have any preexisting medical conditions or other injuries? 5. Is the patient younger than 5 years or older than 55 years?

Skills Objectives 1. Demonstrate the emergency medical care of an open chest wound. (pp 911, 914-915, 918)

-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. -Place an occlusive dressing over the wound.

3. Demonstrate how to control bleeding from an open soft-tissue injury. (pp 918-919)

-direct even pressure and elevation -pressure dressings and/or splints -tourniquets do not bother doing these things with a wound that is hemorrhaging profusely. Apply a tourniquet early when these is massive hemorrhage to rapidly stop bleeding.

3. Name the three types of soft-tissue injuries. (p 907)

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

11. Explain the emergency medical care for neck injuries. (pp 921-922)

If the veins of the neck are open to the environment, they may suck in air, leading to an air embolism. try to prevent an air embolism by sealing the open wound: -Cover the wound with an occlusive dressing. -Apply manual pressure, but do not compress both carotid vessels at the same time. -Secure a pressure dressing over the wound by wrapping roller gauze loosely around the neck and then firmly through the opposite axilla.

2. Know the major functions of the skin. (p 906)

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. In hot environments, the vessels in the skin dilate. Stages of wound healing: 1. vessels, platelets and clotting cascade must work in unison to stop blood flow 2. inflammation- additional cells moves to damaged area 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 3. new layer of cells moves into the damaged area 4. new blood vessels form 5. collagen provides stability to the damaged tissue and joins wound borders, closing the open tissue

Rule of palm/ Rule of nines

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

1. Describe the anatomy of the skin; include the layers of the skin. (pp 905-906)

Two principal layers: epidermis and dermis 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 The dermis is the inner layer of the skin. -Contains the structures that give the skin its characteristic appearance: -Hair follicles -sweat glands -sebaceous glands 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.

7. Explain patient assessment of closed and open injuries in relation to airway management. (pp 914-915)

treat for bleeding before managing airway and breathing. -ensure airway is patent and clear. - if not, fix it -protect pt from further spinal injury as you manage the airway by preventing the head and torso from moving -consider inserting an airway, if indicated

4. Demonstrate the emergency medical care of an open abdominal wound. (pp 919-920)

-Cover the wound with sterile gauze moistened with sterile saline solution and secure with an occlusive dressing. -keep the organs moist and warm. -If the patient's legs and knees are uninjured and spinal injury is not suspected, flex the legs to relieve pressure on the abdomen.

18. Know the functions of sterile dressings and bandages. (pp 938-939)

-Dressings and bandages have three primary functions: -To control bleeding -To protect the wound from further damage -To prevent further contamination and infection -The universal dressing measures 9 inches × 36 inches; is made of thick, absorbent material; and is ideal for covering large open wounds. -occlusive dressings Airtight dressings that protect a wound from air and bacteria -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.

12. Describe the steps of the emergency treatment of small animal bites, human bites, and rabies. (pp 922-923)

-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. -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. 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

15. Explain the primary assessment of a burn patient. (pp 928-929)

-The presence of stridor means your patient's airway is significantly swollen and can signal impending complete airway obstruction. -consider need for spinal immobilization -AVPU scale -administer O2 to all pts with altered mental status -Assess for adequate breathing. -Inspect and palpate the chest wall for DCAP-BTLS. -treat the shock by preventing heat loss (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.)

9. Explain the emergency medical care for an open wound to the abdomen. (pp 919-920)

-evisceration: the displacement of organs outside of the body. -Cover the wound with sterile gauze moistened with sterile saline solution and secure with an occlusive dressing. -keep the organs moist and warm. -If the patient's legs and knees are uninjured and spinal injury is not suspected, flex the legs to relieve pressure on the abdomen.

5. Describe the types of open soft-tissue injuries. (pp 909-912)

1. Abrasions Loss or damage of the superficial layer of skin as a result of a body part rubbing or scraping across a rough or hard surface. -does not penetrate completely through the dermis, but blood may ooze from injured capillaries in the dermis 2. 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. 3. 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. 4. Penetrating wounds (or puncture wounds) A penetrating wound is an injury resulting from a piercing object, such as a knife, ice pick, splinter, or bullet. Treat all penetrating wounds of the neck, chest, back, and upper abdomen with an occlusive dressing to prevent the possible movement of air into the vascular space, thoracic cavity, and/or abdominal cavity.

10. Explain the emergency medical care for an impaled object. (pp 920-921)

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

5. Demonstrate how to stabilize an impaled object. (pp 920-921, Skill Drill 26-1)

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

8. Explain the emergency medical care for closed and open injuries. (pp 918-919)

Closed 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. -look for signs of shock Open 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. -Do not remove material from an open wound, no matter how dirty the wound is. -Flush chemical burns and contamination to remove remaining chemicals. -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

4. Describe the types of closed soft-tissue injuries. (pp 907-909)

Closed soft-tissue injuries are characterized by: A history of blunt trauma Pain at the site of injury Swelling beneath the skin Discoloration Include: Contusion (bruise)- bleeding beneath the skin, but no break in the skin. caused by blunt trauma Hematoma Blood that has collected within damaged tissue or in a body cavity Crushing injury An injury that occurs when a great amount of force is applied to the body. Crush syndrome Significant metabolic derangement that develops when crushed extremities or body parts remain trapped for prolonged periods. This can lead to renal failure and death. 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. 1. Establish A, B, C's 2. Provide high concentration oxygen if the patient is hypoxic. Use caution if cutting torches are in close proximity to the patient. 3. Assess the patient for crush injury, noting entrapment time. 4. Establish intravenous or intraosseous access. Compartment syndrome Swelling within a confined anatomic compartment that produces dangerous pressure, characterized by extreme pain, decreased pain sensation, pain on stretching of affected muscles, and decreased power; frequently seen in fractures below the elbow or knee in children.

2. Demonstrate the emergency medical care of closed soft-tissue injuries. (p 918)

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. -look for signs of shock

6. Explain patient assessment of closed and open injuries. (pp 912-918)

Scene size up Take standard precautions—a minimum of gloves and eye protection. Do not spend time trying to estimate blood loss; focus on controlling the bleeding. Look for indicators of the MOI. Primary Assessment -look for life threats and treat as you find them. -Life threatening bleeding must be controlled first-- even before airway and breathing -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. -Rapid exam: exam whole body starting with head and neck. Apply cervical collar if indicated If there's signs of hypoperfusion, treat for shock -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. -Place an occlusive dressing over the wound. -Rapid transport qualifiers: --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 History Taking -injury specific signs and symptoms -SAMPLE -chronic med cond's that could complicate bleeding (anemia, hemophilia) -medications that could complicate bleeding (aspirin) Secondary Assessment -Listen to breath sounds with a stethoscope. assess neurologic system -Look for DCAP-BTLS. -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. -vitals reassessment -repeat vitals -repeat primary assess -reassess effectiveness of bandaging -Splint extremities that are painful, swollen, or deformed. -estimate blood loss

14. Define superficial, partial-thickness, and full-thickness burns; include the characteristics of each burn. (pp 925-926)

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. 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.

17. Describe the emergency management of chemical, electrical, thermal, inhalation, and radiation burns. (pp 931-938)

Thermal burns types include: flame burns, scald burns, contact burns, steam burns, and flash burns 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 Inhalation burns 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. 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 treatment: -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. -Continue flooding the area with gallons of water for 15 to 20 minutes after the patient says the burning pain has stopped. Electrical burns There are two dangers specifically associated with electrical burns: Large amount of deep-tissue injury The patient may go into cardiac or respiratory arrest. -CPR if indicated -give O2 -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 burns 3 types: alpha, beta, gamma Most ionizing radiation accidents involve gamma radiation, or X-rays 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. 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. Identify the radioactive source and the length of the patient's exposure to it, if this information is available.

16. Explain the emergency medical care for burn injuries. (p 931)

stop burning process, and prevent additional injury 1. follow standard precautions to help prevent infection. If safe to do so, remove the pt from the burning area; extinguish or remove hot clothing and jewelry as necessary. If the wound is still burning or hot, immerse the hot are in cool, sterile water, or cover with a wet, cool dressing 2. provide high-flow O2 and continue to assess the airway 3. Estimate the severity of the burn, and then cover the area with a dry, sterile dressing or clean sheet. Assess and treat the pt for any other injuries 4. Prepare for transport. Treat for shock. Cover the pt with blankets to prevent loss of body heat. Transport promptly.

6. Demonstrate how to care for a burn. (pp 931-932, Skill Drill 26-2)

stop burning process, and prevent additional injury 1. follow standard precautions to help prevent infection. If safe to do so, remove the pt from the burning area; extinguish or remove hot clothing and jewelry as necessary. If the wound is still burning or hot, immerse the hot are in cool, sterile water, or cover with a wet, cool dressing 2. provide high-flow O2 and continue to assess the airway 3. Estimate the severity of the burn, and then cover the area with a dry, sterile dressing or clean sheet. Assess and treat the pt for any other injuries 4. Prepare for transport. Treat for shock. Cover the pt with blankets to prevent loss of body heat. Transport promptly.