soft tissue injuries chp 26

-Rest -Ice -Compression -Elevation -Splinting

Treat closed soft-tissue injury using the RICES mnemonic

closed injuries opens injuries burns

what are the three types of soft tissue injuries

Signs of developing shock

-Anxiety or agitation -Changes in mental status -Increased heart rate -Increased respiratory rate -Diaphoresis -Cool or clammy skin -Decreased blood pressure

Reassessment

-Flush small wound surfaces with sterile saline prior to applying a dressing. -Do not remove any material stuck in the wound. -Splint extremities that are painful, swollen, or deformed. •Communication and documentation -Description of the MOI -Position in which you found the patient -Amount of blood loss -Location and description of any soft-tissue injuries or other wounds -Size and depth of the injury -How you treated the injuries

Primary Assessment

-Heavy amounts of secretions and frequent coughing may indicate a respiratory burn. -Quickly assess for adequate breathing. -Inspect and palpate the chest wall for DCAP-BTLS.

Scene Size up

-Observe the scene for hazards to your crew, bystanders, and the patient. -Consider the need for additional resources. -Take the necessary standard precautions. -Be careful where you put you hands, place your equipment, and how you package patient. -Focus on controlling the bleeding. •Mechanism of injury -Look for indicators of the MOI as you assess the scene. -The MOI may provide information about potential safety threats. -Evaluate scene safety and consider additional resources.

History Taking

-Regardless of the type of burn injury: •Stop the burning process. •Apply a dressing to prevent contamination. •Treat the patient for shock. •SAMPLE history -Along with the SAMPLE history, ask the following questions: •Are you having any difficulty breathing? •Are you having any difficulty swallowing? •Are you having any pain? -Check whether the patient has an emergency medical identification device.

Impaled objects

-Remove an ______ only when: •The object is in the cheek or mouth and obstructs the airway. •The object is in the chest and interferes with CPR. If the object is very long, secure and then shorten it. 5. Provide rapid transport.

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. -Can result in a serious, spreading infection

Secondary assessment

1. After you evaluate ABCs and identify and treat immediate life threats, a more detailed assessment should follow. 2. _____ is a more systematic full-body scan or focused examination of the patient. 3. ______, which includes assessing interventions and repeating vital signs, typically occurs en route to the ED. -Listen to breath sounds. -Determine the respiratory rate. -Note the pattern and quality of respiratory effort. Assess for asymmetric chest wall movement

Primary Assessment

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.

Thermal Burns

4. A steam burn can produce a topical (scald) burn. a. Minor steam burns are common when microwaving food covered with plastic wrap. 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.

laceration

A ______ is a jagged cut caused by a sharp object or a blunt force that tears the tissue. a. An incision is a sharp, smooth cut. b. The depth of the injury can vary. c. _____ and incisions may appear linear (regular) or stellate (irregular). d. Lacerations or incisions that involve arteries or large veins may result in severe bleeding.

Electrical Burns

A burn injury appears where the electricity enters and exits the body. a. Two dangers specifically associated with electrical burns: i. There may be a large amount of deep tissue injury. ii. The patient may go into cardiac or respiratory arrest from the electric shock. (a) If the patient is not in cardiac arrest on your arrival, he or she is unlikely to experience this problem during transport.

Secondary assessment

Look for DCAP-BTLS. ii. Assess the chest, abdomen, and extremities for hidden bleeding and injuries. iii. Log roll the patient, and assess the posterior torso for injuries. iv. Once the back has been assessed, perform a complete spinal immobilization if indicated.

•Neck injuries

Open _____ can be life threatening. -Open veins may suck in air and cause cardiac arrest. -Cover the wound with an occlusive dressing. -Apply manual pressure but do not compress both carotid arteries at the same time. . 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. 5. Use caution with patients suffering from a neck injury depending on the MOI involved. a. Immobilize the C-spine if indicated, including placing a cervical collar.

Primary Assessment

Open soft-tissue injuries of the face and neck have a potential to interfere with the effectiveness of the airway and breathing. i. Evaluate the patient's voice and speaking ability. ii. If an open injury is found on the chest, evaluate for air movement through the wound that indicate a deep penetrating injury. iii. Assess the patient's back for injuries that might need treatment. •Circulation -Assess the patient's pulse rate and quality. -Determine the skin condition, color, and temperature. -Check the capillary refill time. You may need to treat the patient for shock •Transport decision -Immediately transport in these cases: •Poor initial general impression •Altered level of consciousness •Dyspnea •Abnormal vital signs •Shock Severe pain

skin

The _____ is the body's first line of defense against It is the largest organ in the body. •In all instances, the EMT must: -Control bleeding. -Prevent further contamination to decrease the risk of infection. -Protect wounds from further damage. -Apply dressings and bandages to various parts of the patient's body. •The _____ has two principal layers: the epidermis and the dermis. -Epidermis: tough, external layer -Dermis: inner layer

Stabbings

_____ and shootings often result in multiple penetrating injuries. -Assess the patient carefully to identify all wounds. -Count the number of penetrating injuries. -Determine the type of gun when possible, but do not delay transport. -You may have to testify in court. Sometimes patients or bystanders can tell you how many rounds were fired, but given the stress of the environment, their information may be unreliable. e. You may have to testify in court. i. Carefully document the circumstances surrounding the gunshot injury, the patient's condition, and the treatment you give.

Burns

_____ to the airway are of significant importance. •Circumferential _____ of the chest can compromise breathing. •Circumferential _____ of an extremity can lead to neuromuscular compromise and irreversible damage.

Closed injuries Open injuries Burns

_____Damage is beneath skin or mucous membrane. •Surface is intact. _______Break in surface of skin or mucous membrane •Exposes deeper tissues to contamination ____ is a Damage results from thermal heat, frictional heat, toxic chemicals, electricity, or nuclear radiation

Soft-tissue injuries

______ are common. 1. They can be as simple as a cut or scrape. 2. They can be as serious as a life-threatening internal injury. 3. Do not become distracted by dramatic open wounds. a. Do not make the critical mistake of neglecting other life-threatening conditions such as airway obstruction.

Lymphocytes

______ destroy bacteria and other pathogens.

Abdominal wounds

______ is An open wound in the abdominal cavity may expose internal organs. -In an evisceration, the organs protrude through the wound. -Cover the wound with sterile gauze. -Secure the gauze with an occlusive dressing. -Keep the organs moist and warm.

Compartment syndrome

_______ results from the swelling that occurs whenever tissues are injured. •Severe closed injuries can also damage internal organs. Assess all patients with closed injuries for more serious hidden injuries EMTs 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. a. The greater the amount of energy absorbed from the blunt force, the greater the risk of injury to deeper structures. b. You must assess all patients with closed injuries for more serious hidden injuries.

Primary blast injury: Secondary blast injury: Tertiary blast injury:

_______damage caused by the blast wave and sudden pressure changes ___damage results from flying debris _____ victim is thrown by explosion, perhaps into an object

Soft-tissue injuries

_______of the body can be injured through a variety of mechanisms. 1. A blunt injury occurs when the energy exchange between the patient and an object is more than the tissues can tolerate. 2. A penetrating injury occurs when an object breaks through the skin and enters the body. 3. Barotrauma, commonly seen in blast injury victims, refers to injuries that result from sudden or extreme changes in air pressure. 4. Burns may also result in soft-tissue injuries.

skin

____serves many functions. -Keeps pathogens out -Keeps fluids in -Helps body regulate temperature Nerves in the skin report to the brain on the environment and sensations •Any break in the _____ may allow bacteria to enter and increases the possibilities of: -Infection -Fluid loss -Loss of temperature control

Burn severity

a. Rule of palm: estimates 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: estimates he 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. 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.

Small animal bites

a. This could impair circulation to the brain and cause a stroke. 5. Use caution with patients suffering from a neck injury depending on the MOI involved. a. Immobilize the C-spine if indicated, including placing a cervical collar.

Inhalation Burns

b. Apply cool mist, aerosol therapy, or humidified oxygen to help reduce some minor edema. c. Apply an ice pack to the throat to reduce swelling, provided the tissue in that area does not have burns. 3. 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.

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

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

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

crushing

•A _____ injury occurs when a significant amount of force is applied to the body. •Extent of damage depends on: -Amount of force -Length of time force is applied •When an area of the body is trapped for longer than 4 hours, crush syndrome can develop. 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 also creates the potential for cardiac arrest and renal failure. d. Consider requesting ALS assistance for situations of prolonged entrapment prior to extrication.

contusion hematoma

•A ______ (bruise) causes bleeding beneath the skin but does not break the skin. -Caused by blunt forces -Buildup of blood produces blue or black ecchymosis. A ______is blood collected within damaged tissue or in a body cavity

rabies

•A major concern is the spread of _____. -Acute, potentially fatal viral infection of the central nervous system -Can affect all warm-blooded animals -Transmitted through biting or licking an open wound -Prevented only by a series of special vaccine injections

contaminated

•All open wounds are assumed to be _____ and present a risk of infection. •Control bleeding by splinting the extremity, even if there is no fracture. 3. Small wound surfaces without significant bleeding can be flushed with sterile saline prior to applying a dressing. 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.

Burns

•Always perform a complete assessment to determine whether other serious injuries are present. •Children, older patients, and patients with chronic illnesses are more likely to experience shock from ______injuries. -______ are soft-tissue injuries that are created by the transfer of radiation, thermal, or electrical energy. -Thermal _____ occur when the skin is exposed to temperatures higher than 111ºF.

abrasion

•An ____ is 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 _______ usually does not penetrate completely through the dermis, but blood may ooze from the injured capillaries in the dermis

avulsion

•An avulsion separates various layers of soft tissue so that they become either completely detached or hang as a flap. Often there is significant bleeding

member

•Before caring for the patient, follow standard precautions. •If life-threatening bleeding is observed, assign a team _____ to apply direct pressure. •Cover wounds of the chest, upper abdomen, or upper back with an occlusive dressing.

Inhalation Burns

•Can occur when burning takes place in enclosed spaces without ventilation -Upper airway damage is often associated with the inhalation of superheated gases. -Lower airway damage is often associated with the inhalation of chemicals and particulate matter. 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

Chemical Burns

•Can occur whenever a toxic substance contacts the body •Generally caused by strong acids or strong alkalis •The eyes are particularly vulnerable. •Management -Remove any chemical from the patient. -Always brush dry chemicals off the skin and clothing before flushing with water. -Remove the patient's clothing. -For liquid chemicals, immediately begin to flush the burned area with lots of water. -Continue flooding the area 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 while flooding the eye. -Conduct proper decontamination prior to loading the patient.

Inhalation Burns

•Carbon monoxide intoxication should be considered whenever a group of people in the same place all report a headache or nausea. •Management -First ensure your own safety and the safety of your coworkers. -Prehospital treatment of a patient with suspected hydrogen cyanide poisoning includes decontamination and supportive care. -Care for any toxic gas exposure includes: •Recognition •Identification •Supportive treatment

Thermal Burns

•Caused by heat •Most commonly, they are caused by scalds or an open flame. -A flame burn is very often a deep burn. -Hot liquids produce scald injuries. •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.

cardiac arrest

•In recent years, law enforcement has increased its use of Tasers. -Potential complications for patients with underlying disorders. -Use of a Taser has been associated with dysrhythmias and sudden _____. -Make sure you have access to an AED when responding to patients who have been exposed to Taser shots.

Thermal Burns

•Management -Stop the burning source, cool the burned area, and remove all jewelry. -Increased exposure time will increase damage to the patient. -All patients should have a dry dressing applied to: •Maintain body temperature •Prevent infection Provide comfort

Electrical Burns

•May be the result of contact with high- or low-voltage electricity •For electricity to flow, there must be a complete circuit between the source and the ground. -Insulator: any substance that prevents this circuit -Conductor: any substance that allows a current to flow Never attempt to remove someone from an electrical source unless you are specially trained to do so.

closed

•More difficult to assess a ____ injury than an open injury -You can see an open injury. •Consider the possibility of a closed injury when you observe: -Bruising -Swelling -Deformity The patient reporting pain

Radiation Burns

•Most ionizing radiation accidents involve gamma radiation (x-rays). •Management -Maintain a safe distance and wait for the HazMat team to decontaminate the patient. -Call for additional resources to remove the patient's clothes. -Begin ABCs and treat burns or trauma. -Irrigate open wounds. •Management (cont'd) -Notify the emergency department. -Identify the radioactive source and the length of the patient's exposure to it. -Limit your duration of exposure. -Increase your distance from the source. -Attempt to place shielding between yourself and the sources of gamma radiation.

Sterile Dressings

•Most wounds will be covered by: -Universal dressings -Conventional 4″ ´ 4″ and 4″ ´ 8″ gauze pads -Assorted small adhesive-type dressings and soft self-adherent roller dressings •Universal dressings are ideal for covering large open wounds. •Gauze pads are appropriate for smaller wounds. •Adhesive-type dressings are useful for minor wounds. •Occlusive dressings prevent air and liquids from entering (or exiting) the wound.

Bandages

•Splints are useful in stabilizing broken extremities. -Can be used with dressings to help control bleeding from soft-tissue injuries •If a wound continues to bleed despite the use of direct pressure, quickly proceed to the use of a tourniquet.

Radiation Burns

•Three types of ionizing radiation: -Alpha •Little penetrating energy' easily stopped by the skin -Beta •Greater penetrating power, but blocked by simple protective clothing -Gamma •Very penetrating; easily passes through the body and solid materials

Bandages

•To keep dressings in place during transport, you can use: -Soft roller bandages -Rolls of gauze -Triangular bandages -Adhesive tape •The self-adherent, soft roller bandages are easiest to use. •Adhesive tape holds small dressings in place and helps to secure larger dressings. •Do not use elastic bandages to secure dressings. -The bandage may become a tourniquet and cause further damage.

Patient Assessment of Burns

•When you are assessing a burn, it is important to classify the victim's burns. •Classification of burns is based on: -Source of the burn -Depth of the burn -Severity of the burn