chapter 24 soft tissue injuries. © 2005 by thomson delmar learning,a part of the thomson...

Chapter 24Soft Tissue Injuries

Overview

Anatomy Review Bleeding Types of Wounds Wound Management Bruising Crush Injury Burns Chemical Burns Electrical Burns

Anatomy Review

Skin’s cells and tissues constitute the integumentary system

Skin protects the internal organs, regulates the internal environment, and allows us to sense external environment

Anatomy Review

Injury to the skin– First and immediate sensation is pain– Inflammation helps the body prevent infection and

begin healing

Bleeding

Loss depends on how much skin is damaged and amount of force behind the bleeding– Arterial bleeding—bright red, tends to spurt– Capillary bleeding—low pressure, tends to ooze– Venous bleeding—darker red, tends to flow

Bleeding

Assessment– Prepare for large amounts of blood to be present – Wear applicable PPE– Bring bleeding control supplies to scene

Bleeding

Scene size-up– Assess and render harmless the mechanism of

injury– Establish perimeter to contain onlookers

Bleeding

Initial assessment– Constantly consider the patient’s ABCs– Focus attention on the important facts– Expose the entire length of the limb

Bleeding

Management – Once the scene is safe, the EMT’s first concern is

to control the bleeding– Begin with the easiest and safest techniques

Bleeding

Principles of bleeding control– Ask “Can this bleeding lead to shock and possibly

death?”• If not immediately life threatening, continue with the initial

assessment of the patient• If life threatening, bleeding must be dealt with

immediately

Bleeding

Principles of bleeding control– Allow coagulation to occur– Apply direct pressure– Elevate the wound above the heart– Apply a dressing– Apply manual pressure at a pressure point

Bleeding

Principles of bleeding control– Apply an arterial-constricting band called a

tourniquet to the entire limb– May result in loss of the limb– Should not be removed without a physician’s order– Note exact time that tourniquet is applied

Bleeding

Dressings– Once bleeding is controlled, apply dressing– Dressing protects wound from further injury, while

supporting clotting activity – Apply the cleanest dressing possible

Bleeding

Types of dressings– Gauze – Trauma– Nonadherent– Self-adherent– Occlusive– Universal

Bleeding

Pressure dressing– Used when bleeding continues despite direct

pressure, dressing, and elevation– Maintains pressure over the wound edges and

compresses surrounding blood vessels

Bleeding

Transportation– Priority is dictated by the presence or absence of

hypoperfusion– Complete set of vital signs

Stop and Review

Identify the different types of bleeding Describe two principles of bleeding control

Types of Wounds

A break in the skin is called a wound Results from blunt forces like a baseball bat

or sharp edges like a knife

Types of Wounds

Abrasions– Upper layer of skin is scraped away, exposing

nerve endings– Usually the result of skin being rubbed against a

rough surface

Types of Wounds

Lacerations– A full-thickness skin tear– Can be linear or stellate in appearance– Can involve veins, arteries, and bones

Types of Wounds

Incisions– A full-thickness injury of the skin– Usually made by a knife– Wound edges are straight

Types of Wounds

Punctures– An incision made by a sharp, pointed object– Severity depends upon depth and location– Gunshot wounds are considered puncture wounds

Types of Wounds

Amputation– The clean removal of a limb from the body

Avulsion– A forceful separation of a limb from the body

because of trauma– Can be either partial or complete

Wound Management

Assessment– A cut implies that some sort of violence occurred– The source of violence should be identified and

neutralized whenever possible

Wound Management

Scene size-up– Mechanism of injury can cause the EMT injury– Identify and render harmless the mechanism of

injury– Take standard precautions against blood

Wound Management

Initial assessment– The external appearance of the wound can be

deceiving– Focus on signs of hypoperfusion such as

tachycardia and tachypnea

Rapid trauma assessment– Proceed with a head-to-toe rapid trauma

assessment

Wound Management

Bandages– Primary purpose is to hold dressing in place– Roller bandage– Military compress– Elastic bandage– Triangular bandage– Cravat– Binder bandage

Wound Management

Principles of wound bandaging– Wounds are dressed differently depending on

where they occur– Several fundamental bandaging techniques exist;

use individually or in combination– Practice is the key to success

Wound Management

Principles of wound bandaging– Recurrent bandage

• Bandage holds dressing down over a large area

– Spiral bandage• Bandage in which successive turns overlap preceding

– Figure-of-eight• Bandage turns across itself like a figure eight

Wound Management

Principles of wound bandaging– Special bandages

• Neck wound– Occlusive dressing must be applied– A gloved hand is often sufficient temporarily

• Sucking chest wound– Occlusive dressing is applied – Tape only three sides, while fourth is left unattached

Wound Management

• Evisceration– Cover the wound with a large trauma dressing– Follow local protocols

• Straddle injury– Cover the wound with a dressing– Create belt and tie around waist– Secure triangular bandage to belt– Bandage holds dressing in place, helps control bleeding

Wound Management

• Impaled objects– Stabilize object in the position found– Secure with a large, bulky dressing – If an object like a pencil is impaled in the eye, a paper

cup maybe used to stabilize the object

Wound Management

• Avulsions and amputations– Reaffix partial amputations to natural position– Control bleeding by elevation of stump– Wrap stump with triangular bandage– Administer oxygen and monitor for signs of shock– When the amputated part is found, wrap in moistened

gauze and place in a plastic bag

Wound Management

• Degloving avulsion– Treat the same as any large wound– Take great care in handling the extremity, since bone

fractures often accompany these wounds

Wound Management

Transportation– Focus on caring for and comforting the patient,

including driving carefully to the hospital– Ongoing assessment

• Monitor bandages• Check PMS

Stop and Review

When should a tourniquet be used? Describe the field care for an amputation.

Bruising

Contusions can signify damage to deeper tissues and organs

Bleeding that forms a swelling under the skin is called a hematoma

Crush Injury

Sustained pressure results in a crush injury Toxic chemicals are released into circulation Acidosis can irritate the heart, causing

sudden cardiac death

Crush Injury

Compartment syndrome– Increasing pressure in muscle compartments

(fascia) compresses nerves and blood vessels– Results in

• Paresthesia—loss of feeling• Paralysis—loss of motion• Pulselessness—loss of circulation

– Field treatment is splinting and transport

Crush Injury

Assessment– Other signs of injury predict contusion

• Abrasion marks• Swelling• Tissue that is firm to the touch

– An ecchymosis will turn blue and then black

Crush Injury

Scene size-up– Confined space rescue is potentially lethal to

an EMT– Technical rescue requires specialized equipment

and training– Set up stage nearby, observe the rescue, and

maintain the perimeter

Crush Injury

Initial assessment– Priorities are the same as in other trauma cases

• Spinal immobilization• Rapid initial assessment• Observe for hyperthermia• Assess for life threatening injuries

Crush Injury

Rapid trauma assessment– Complete assessment of patient– Assess entire skin surface– Note every minor defect

Crush Injury

Management– ABCs– Provide ALS backup– Promptly package for transport– Splint patient on a backboard

Crush Injury

Transport– Transport to a trauma center

Ongoing assessment– Prepare for the possibility of the patient going into

shock– Assess vital signs at least every 5–10 minutes– Assess for hypoperfusion

Two million Americans suffer burn injuries annually, with 100,000 hospitalizations and 8,000 deaths

Four sources of burns– Flame– Electrical burns– Chemical burns– Radiation burns

Classification of burn injury– Skin has three layers

• Epidermis (top layer)• Dermis (middle layer)• Subcutaneous (bottom layer)

Classification of burn injury– Superficial– Partial thickness– Full-thickness

Superficial Partial thickness Full- thickness

Burn severity– Rule of nines calculates the percentage of the

burn area• Each arm—9%• Each leg—18%• Upper back and lower back—18%• Chest and abdomen—18%• Genitals—1%

Burn severity– Palmar method calculates small burns or

widespread burns– Palm of hand used to estimate total percent

Critical burns– Those with critical burns should be transferred to a

burn center– Critical burn—a full-thickness or partial thickness

burn that is 10% or greater– Burns to the face, airway, hands or feet, and

genitals are all considered critical

Assessment– Identical to that of any other trauma patient

– CO2 poisoning makes providing oxygen a problem

Scene size-up– The fire scene is inherently dangerous– The EMT must carefully assess the scene

Initial assessment– Assess facial burns for airway involvement– Examine inside of mouth for swelling– Listen for stridor– Auscultate apices of lungs

Rapid trauma assessment– Conduct head-to-toe assessment– Be aware that burn injury is a distracting injury

Management– Burn field dressing

• Universal dressings for large areas; roller gauze for extremities

• No ointments or antiseptic lotions• Less than 10% of BSA: can apply wet dressing• More than 10% of BSA: apply only dry dressings• Minimize heat loss and hypothermia

Transportation– Transport critically burned patients to the closest

specialized burn center– Consider air medical transport

Chemical Burns

Result from direct contact or exposure to fumes

Frequent causes—mishandling of chemicals and failure to wear protective apparel

Depth of burn depends on the amount of chemical spilled and the length of contact with the skin

Chemical Burns

Scene size-up– Chemical spill is a hazmat incident– Special team must respond to spill– Allow the hazmat team to deliver the patient– Wear eye protection and gloves

Chemical Burns

Initial assessment– Focus on airway and breathing

Management– Identify the chemical– Refer to MSDS for guidance on treatment– Consult the Emergency Response Guidebook

or CHEMTREC

Chemical Burns

Dry chemicals – Wear a dust/mist mask to prevent inhalation– Flush chemicals off the patient with water only if

this is the correct procedure– Assess for the presence of other injuries– Cover burned areas with a dressing and keep the

patient warm

Chemical Burns

Wet chemicals – Wear a gown and eye protection – Flush the chemicals off the patient with copious

amounts of water, per instructions in the MSDS or ERG

Chemical Burns

Eye injury– Begin irrigation of the eyes as soon as possible– Keep eyelids open– Ensure drainage is running away from unaffected

eye– If both eyes need drainage, use a nasal cannula

hooked up to an IV setup

Electrical Burns

Water is an excellent conductor; skin and bones are excellent insulators

When electricity meets insulator, heat results Electricity enters the body through an

entrance wound and creates an exit wound

Electrical Burns

Scene size-up– Utility poles are a serious hazard to EMTs– All downed power lines are dangerous

– Never touch a downed power line!

Electrical Burns

Assessment– Internal damage may be substantial– Degree of electrical burn is determined by duration

of contact– Let go energy threshold

Electrical Burns

Management– Check ABCs; start CPR and defibrillation– Administer oxygen– Rapid trauma assessment– Cover entrance and exit wounds

Electrical Burns

Transportation – All patients require rapid transportation– Transport to a regional burn or trauma center per

local protocols

Ongoing assessment– Monitor vitals, particularly pulse– Follow standard cardiac arrest protocols

Stop and Review

Describe the classification of burn injuries. Explain how to manage a chemical burn

involving a dry chemical. Describe the injuries that can occur from an

electrical shock.

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