Chapter 26: Soft-Tissue Issues Notes

Epidermis

1. tough, external layer that forms a watertight covering for the body a. composed of several layers

Death is often related to hemorrhage or infection

1. uncontrolled hemorrhage can lead to shock and death 2. when the skin barrier is breached, invading pathogens can cause local or systemic infection 3. 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

Blunt injury

*Trauma that results in deep tissue injury without rupture of the skin *Occurs when the energy exchange between the patient and an object is more than the tissues can tolerate

Taser injuries

-2 small electrodes that puncture skin Treatment: -usually treated as impaled objects & removed by doctor -pay attention for excited delirium *agitation, reduced pain sensitivity, hallucinations, persistent struggling, & elevated temp. -make sure you have an AEDS Alpha < Beta < Gamma

The soft tissues of the body can be injured through a variety of mechanisms

-Blunt injury -Penetrating injury -Barotrauma -Burns

Open injuries

-Differ from closed injuries in that the protective layer of the skin is damaged -Can produce extensive bleeding -A break in the protective skin layer or mucous membrane means that the wound is contaminated and may become infected

Tx

-If the patient has obvious life-threatening external bleeding, control the bleeding first (even before airway and breathing), then assess and treat the ABCs and provide treatment for shock -Administer high flow oxygen via NRM to help reduce the effects of shock and assist in perfusion of damaged tissues, particularly crush injuries

Contamination

-The presence of infectious organisms or foreign bodies such as dirt, gravel or metal in the wound -Address both excessive bleeding and contamination in your treatment of open soft-tissue wounds

Hematoma

1. Blood that is collected within damaged tissue or in a body cavity a. It occurs whenever a large blood vessel is damaged and bleeds rapidly b. It is usually associated with extensive tissue damage

Contusion (bruise)

1. An injury that causes bleeding beneath the skin but does not break the skin a. Contusions 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 c. The buildup of blood produces a characteristic blue or black discoloration called ecchymosis

Abdominal wounds

1. An open wound in the abdominal cavity may expose internal organs 2. In an 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 3. Most patient with abdominal wounds require immediate transport to a trauma center

Be alert for signs of developing shock:

1. Anxiety or agitation 2. Changes in mental status 3. Increased HR 4. Increased RR 5. Diaphoresis 6. Cool or clammy skin 7. Decreased BP

It is more difficult to assess a closed injury than an open injury

1. Anytime you observe bruising, swelling, deformity, or if the patient is reporting pain, the possibility of a closed injury should be considered 2. An open injury is easier to assess because you can see the injury

Pathophysiology of burns

1. Burns are soft-tissue injuries that are spread out over a large area and are created by the transfer of radiating, thermal or electrical energy a. Thermal burns can occur when skin is exposed to temperatures higher than 111F (44C) 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 iv. Duration of exposure c. Burn injuries are progressive-- the greater the heat energy, the deeper the wound 2. People naturally limit the amount of time they are exposed time to such heat a. If clothing is on fire or the person is trapped or unconscious, exposure time can be extended

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 of the burn is directly related to three factors: a. Type of chemical b. Concentration of the chemical c. Duration of the exposure

In all instances, the EMT 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 patient's body

Soft tissue injuries and their complications can often be prevented by using simple protective actions

1. Effective strategies to reduce injury and death from burns: a. Smoke alarms b. Controlling the temperature of hot water heaters c. Enforcing building codes that regulate electrical and construction practices

Electrical burns

1. Electrical burns may be the result of contact with high- or low- voltage electricity a. High-voltage burns may occur when utility workers may 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, and voltage have effects on the seriousness of burns 4. A burn injury appears where the electricity enters and exits the body 5. Note that the patient may go into cardiac or respiratory arrest from the electric shock

Burn severity

1. Five factors to help determine the severity of a burn (the first two factors are the most important): 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 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?

Bites

1. 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. Regard any human bite that has penetrated the skin as a very serious injury c. Any laceration caused by a human tooth can result in a serious, spreading infection d. Emergency tx consists of the following steps: 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 abx therapy

Inhalation burns

1. Inhalation injuries can occur when burning takes place in enclosed spaces without ventilation a. When the upper airway is exposed to excessive heat, the patient can experience rapid and serious airway compromise b. Upper airway damage is often associated with the inhalation of superheated gases c. Lower airway damage is often associated with the inhalation chemicals and particulate matter

Dermis

1. inner layer of the skin a. it contains hair follicles, sweat glands and sebaceous glands b. blood vessels in the dermis provide the skin with nutrients and oxygen

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 a. Injuries range from simple bruises and abrasions to serious lacerations and amputations b. Injuries may expose blood vessels, nerves and bones

Significant airway burns are serious

1. May be associated with singed hair within the nostrils, soot around the nose and mouth, hoarseness, and hypoxia 2. These patients should be rapidly transported to an ED or facility capable of advanced airway management

Sterile dressings

1. Most wounds will be covered by: a. universal dressings b. conventional 4x4 and 4x8 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 appropriated 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, alumni foil, or plastic b. Used to cover sucking chest wounds, abdominal eviscerations, penetrating back wounds, and neck injuries

Tx of Impaled objects

1. Occasionally, a patient will have an object, such as a knife, fishhook, wood splinter or piece of glass impaled in his or her body 2. See drill 26-1 3. Remove an impaled object only in two circumstances: a. The object is in the cheek or mouth and obstructs the airway b. The object 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

Crushing injury

1. Occurs when significant force is applied to the body a. The extend of the damage depends on: -How much force is applied -The amount of time that the force is applied b. Continues compression of the soft tissues will cut off circulation, producing further tissue destruction

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

Soft tissue trauma is a common form of injury

1. Open wounds accounted for approximately 4.1 million emergency department visits 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: a. Wound injuries b. Dressing c. Bandaging d. Limited suturing

The mechanism of injury from a blast injury is generally due to three factors:

1. Primary blast injury: Damage is caused by the blast wave itself and the sudden pressure change of the explosion 2. Secondary blast injury: Damage results from flying debris that causes multiple penetrating wounds 3. Tertiary blast injury: The victim is thrown by the explosion, perhaps into an object

Treat a closed soft-tissue injury using the RICES mnemonic:

1. Rest 2. Ice 3. Compression 4. Elevate 5. Splinting

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 they eyelids, lips, and ears than on the scalp, back and soles of the feet 3. Thin skin is more easily damaged than thick skin

Bites

1. Small animal bites and rabies a. Consider the scene and crew safety prior to entering the enviro 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 d. Tx may require: i. Debridement (removal of damaged tissue) ii. Antibiotics iii. Tetanus prophylaxis iv. Surgical repair e. All small animal bites should be evaluated by a physician f. A major concern is the spread of rabies, an acute potentially fatal viral infection of the CNS that can affect all warm blooded animals i. The virus is in the saliva of a rabid, or infected animal and is transmitted through biting or licking an open wound ii. Infection can be prevented only by a series of special vaccine injections g. 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

All wounds require bandaging

1. Splints can help control bleeding and provide firm support for dressing 2. Many different types of dressings and bandages exist 3. 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

Complications of burns

1. The skin serves as a barrier between the environment a. When a person is burned, this barrier is destroyed b. Burns create a 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 complications, call for ALS backup

Thermal burns

1. Thermal burns are caused by heat. 2. Most commonly, they are caused by scalds or an open flame. a. A flame burn is very often a deep burn, especially if a 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. i. Hot liquids produce scald injuries. ii. Scald burns often cover large surface areas of the body because liquids can spread quickly.

Soft-tissue injuries are common

1. They can be 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 obstructions

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 4. Do not use elastic bandages to secure dressings. a. 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 wound continues to bleed despite the use of direct pressure, quickly proceed to use of a tourniquet.

Laceration

A. 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. Lacerations and incisions may appear linear (regular) or stellate (irregular) d. Lacerations or incisions that involve arteries or large veins may result in severe bleeding

2. The next wound healing stage is inflammation.

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 exposed tissue. C. Lymphocytes destroy bacteria and other pathogens. D. Mast cells release histamine. E. Inflammation ultimately leads to the removal of: i. Foreign material ii. Damaged cellular parts iii. Invading microorganisms

Abrasion

A. An abrasion is a wound of the superficial layer of the skin, caused by friction when a body part rubs or scraped across a rough or hard surface i. An abrasion usually does not penetrate completely through the dermis, but blood may ooze from the injures capillaries in the dermis ii. Example: Road rash, road burn, strawberry, rug burn iii. Abrasions can be extremely painful because the nerve endings are located in this area

Penetrating wound

A. An injury resulting from a piercing object, such as a knife, ice pick, splinter or bullet a. These objects can damage structures deep within the body and cause unseen bleeding b. If the wound is to the chest or abdomen, the injury can cause rapid, fatal bleeding

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 body part, receives more radiant energy that 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, you should always perform a complete assessment to determine whether other serious injuries are present 3. Children, older patients, and patients with chronic illnesses are most likely to experience shock from burn injuries

The combustion process produces a variety toxic gases including

A. Carbon monoxide (CO) intoxication should be considered whenever a group of people in the same place all report a headache or nausea **Cherry red skin, lips and nail beds are commonly observed in patients who have died from CO exposure B. Hydrogen cyanide (HCN) **Signs and symptoms involve the CNS, Respiratory system, and cardiovascular systems: i. Faintness ii. Anxiety iii. Abnormal vital signs iv. Headache vi. Seizures vii. Paralysis viii. Coma

Impaled objects

A. Objects that penetrate the skin but remain in place B. Concerns with this type of injury: i. Damage to structures deep inside the body ii. Presence of foreign material inside the tissue that can lead to infection

Stabbings and shootings

A. Often result in multiple penetrating injuries i. Assess the patient carefully to identify all wounds ii. Count the number of penetrating injuries, especially with GSWs a. Leave the distinction between entrance and exit to the physician iii. In a shooting, determine the type of gun when possible, but do not let this delay patient transport iv. Sometimes patients or bystanders can tell you how many round were fired, but give the stress of the environment, their information may be unreliable v. You may have to testify in court a. Carefully document the circumstances surrounding the gunshot injury, the patient's condition and the treatment you give

Avulsion

A. 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 b. Never remove an avulsion skin flap, regardless of its size c. An amputation is an injury in which part of the body is completely severed i. You can easily control the bleeding from some amputations, such as the fingers, with direct pressure and pressure dressings ii. If there is massive bleeding, you should stop the bleeding, which often requires a tourniquet, and treat the patient for hypovolemic shock

Emergency medical care for burns

A. Your first responsibility in caring for a patient is to stop the burning process and prevent additional injury B. When caring for a burn patient, follow the steps in Skill Drill 26-2

Tx for life threatening bleeding

Apply direct pressure over the wound to control the bleeding

Tx of wounds in the chest, upper abdomen or upper back:

Cover it with occlusive dressing

Burns

Damage results from: a. thermal heat b. frictional heat c. toxic chemicals d. electricity e. nuclear radiation

Blast injuries

Often result in multiple penetrating injuries

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.

Classification of burns is based on

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

Skin covers all the external surfaces of the body

The various openings in the body are lined with mucous membranes i. Mucous membranes provide a protective barrier against bacterial invasion ii. They secrete a watery substance that lubricates the openings iii. They are moist, whereas skin is generally dry

Tx of inhalation burns

When treating a patient for inhalation injuries, you may encounter severe upper airway swelling, which requires 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 some minor edema c. Apply an ice pack to the throat to reduce swelling, provided the tissue in that area does not have burns

Healing of wounds

a natural process that involves several overlapping stages, all directed toward the larger goal of maintaining homeostasis (balance)

Any break in the skin may allow bacteria to enter and increases the possibility of infection, fluid loss and loss of temperature control

a. Any one of these conditions can cause serious illness and even death

3. To replace the area damaged in a soft tissue injury, a new layer of cells must be moved into this region

a. Cells quickly multiply and redevelop across the edges of the wound b. Except in cases of clean incisions, the appearance of the restructured area seldom returns to the preinjury state c. Despite the changed appearance, the function of the area may be restored to near normal

Three types of soft tissue injuries

a. Closed injuries b. Open injuries c. Burns

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. Collage cannot restore the damaged tissue to its original strength

Control bleeding using

a. Direct, even pressure and elevation b. Pressure dressings and/or splints c. Tourniquets

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. 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

Skin serves many functions

a. Keep pathogens out b. Keep fluids in c. Help regulate body temperature d. The nerves in the skin report to the brain on the environment and many sensations e. The nerves pathway connection allows the body to adapt to the environment responses in the skin and surrounding tissues

1. Cessation of blood is the primary concern

a. Loss of blood hinders the provision of vital nutrients and oxygen to the affected area b. It also impairs the tissue's ability to eliminate wastes c. The end result is abnormal or absent function, which interferes with homeostasis

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

a. New capillaries bud from intact capillaries that lie adjacent to the damaged skin b. These vessels provide a channel for oxygen and nutrients and serve as a pathway for waste removal

Types of patients who need immediate transportation:

a. Poor initial general impressions b. ALOC c. Dyspnea d. Abnormal vital signs e. Shock f. Severe pain

Compartment syndrome develops when edema and swelling result in increased pressure within a closed soft tissue compartment

a. Pressure increases within the compartment, which interferes with circulation b. Delivery of nutrients and oxygen is impaired and by-products of normal metabolism accumulate c. There is no pain, especially on passive movement d. The longer this situation persists, the greater the chance for tissue death e. EMTs must continually reassess skin color, temperature, and pulses distal to the injury site if crush injury persists

Extent of burns

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 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 d. When you calculate the extent of the 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

Management of thermal burnsn

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 will be susceptible to hypothermia and/or hypovolemia e. All patient with large surface burns should have a dry sterile dressing applied to help: i. Maintain body temp ii. Prevent infection iii. Provide comfort

Signs that indicate hypoperfusion and indicate need for rapid transport:

a. Tachycardia b. Tachypnea, c. Low BP d. Weak pulse e. Cool, moist and pale skin

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

Closed soft tissue injuries are characterized by

a. history of blunt trauma b. pain at the site of injury c. swelling beneath the skin d. discoloration

Barotrauma

commonly seen in blast injury victims, refers to injuries that result from sudden or extreme changes in air pressure

Four types of open soft-tissue wounds

i. Abrasions ii. Lacerations iii. Avulsions iv. Penetrating wounds

Closed injuries

i. Damage occurs beneath the skin or mucous membrane ii. The surface of the skin or mucous membrane remains intact

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

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 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 injures iii. Typically, the skin is moist, mottled, and white to red iv. Blisters are present v. Can cause intense pain

Open injuries

i. There is a break in the surface of the skin or mucous membrane ii. Exposes deeper tissues to contamination

The skin has two principal layers:

the epidermis the dermis

Penetrating injury

when an object, such as a bullet or knife, breaks through the skin and enters the body