Title: Chapter 5 Soft-Tissue Trauma
1Chapter 5Soft-Tissue Trauma
2Topics
- Introduction to Soft Tissue Injury
- Anatomy and Physiology of Soft-Tissue Injury
- Pathophysiology of Soft-Tissue Injury
- Dressing and Bandage Materials
- Assessment of Soft-Tissue Injuries
- Management of Soft-Tissue Injuries
3Introduction to Soft-Tissue Trauma
- Skin is the largest, most important organ.
- 16 of total body weight.
- Function
- Protection
- Sensation
- Temperature regulation
- AKA integumentary system
4Introduction to Soft-Tissue Injury
- Epidemiology
- Open wounds
- Over 10 million wounds present to ED
- Most require simple care and some suturing.
- Up to 6.5 may become infected.
- Closed wounds
- More common
- Contusions, sprains, strains
5AP of Soft-Tissue Injuries (1 of 6)
- Skin Layers
- Epidermis
- Outermost, avascular layer of dead cells
- Helps prevent infection
- Sebum
- Waxy, oily substance that lubricates surface
- Dermis
- Upper layer (papillary layer)
- Loose connective tissue, capillaries, and nerves
- Lower layer (reticular layer)
- Integrates dermis with SQ layer
- Blood vessels, nerve endings, glands
- Sebaceous and sudoriferous glands
- Subcutaneous
- Adipose tissue
- Heat retention
6AP of Soft-Tissue InjuriesThe Skin
7AP of Soft-Tissue Injuries (3 of 6)
- Blood Vessels
- Arteries
- Arterioles
- Capillaries
- Venules
- Veins
- Layers
- Tunica intima
- Tunica media
- Tunica adventitia
8AP of Soft-Tissue InjuriesBlood Vessels
9AP of Soft-Tissue Injuries (5 of 6)
- Muscles
- Beneath skin layers
- Fascia
- Thick, fibrous, inflexible membrane surrounding
muscle that aids in binding muscle groups together
10AP of Soft Tissue Injuries (6 of 6)
- Tension Lines
- Natural patterns in the surface of the skin
revealing tension within
11Pathophysiology of Soft-Tissue Injury (1 of 12)
- Closed Wounds
- Contusions
- Erythema
- Ecchymosis
- Hematomas
- Crush injuries
- Open Wounds
- Abrasions
- Lacerations
- Incisions
- Punctures
- Impaled objects
- Avulsions
- Amputations
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13Pathophysiology of Soft-Tissue Injury (2 of 12)
Soft-Tissue Wounds
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15Pathophysiology of Soft-Tissue Injury (3 of 12)
- Hemorrhage
- Arterial
- Capillary
- Venous
16Pathophysiology of Soft-Tissue Injury (4 of 12)
- Wound Healing
- Hemostasis
- Bodys natural ability to stop bleeding and the
ability to clot blood - Begins immediately after injury
- Inflammation
- Local biochemical process that attracts WBCs
- Epithelialization
- Migration of epithelial cells over wound surface
17Pathophysiology of Soft-Tissue Injury (5 of 12)
- Neovascularization
- New growth of capillaries in response to healing
- Collagen Synthesis
- Fibroblasts Cells that form collagen
- Collagen Tough, strong protein that comprises
connective tissue
18Pathophysiology of Soft-Tissue Injury
Wound Healing
19Pathophysiology of Soft-Tissue Injury (7 of 12)
- Infection
- Most common and most serious complication of open
wounds - 115 wounds seen in ED result in infection
- Delay healing
- Spread to adjacent tissues
- Systemic infection sepsis
- Presentation
- Pus WBCs, cellular debris, and dead bacteria
- Lymphangitis visible red streaks
- Fever and malaise
- Localized fever
20Pathophysiology of Soft-Tissue Injury (8 of 12)
- Infection
- Risk factors
- Hosts health and pre-existing illnesses
- Medications (NSAIDs)
- Wound type and location
- Associated contamination
- Treatment provided
- Infection management
- Antibiotics and keep wound clean
- Gangrene
- Deep space infection of anaerobic bacteria
- Bacterial gas and odor
- Tetanus
- Lockjaw
- Uncommon with the exception of third-world
country immigrants
21Pathophysiology of Soft-Tissue Injury (9 of 12)
- Other Wound Complications
- Impaired hemostasis
- Medications
- Anticoagulants
- Aspirin
- Warfarin (Coumadin)
- Heparin
- Antifibrinolytics
- Re-bleeding
- Delayed healing
- Compartment syndrome
- Abnormal scar formation
- Pressure injuries
22Pathophysiology of Soft-Tissue Injury (10 of 12)
- Crush Injury
- Body tissues subjected to severe compressive
forces - Tamponading of distal tissue
- Buildup of byproducts of metabolism
- Wood-like distal tissue
- Associated injury
23Pathophysiology of Soft-Tissue Injury (11 of 12)
- Crush Syndrome
- Body is entrapped for gt4 hours.
- Crushed muscle tissue becomes necrotic.
- Traumatic rhabdomyolysis
- Skeletal muscle degradation
- Release of toxins
- Myoglobin
- Phosphate
- Potassium
- Lactic acid
- Uric acid
- When tissue is released, toxins move RAPIDLY into
systemic circulation. - Impacts cardiac function
- Impacts kidney function
24Pathophysiology of Soft-Tissue Injury (12 of 12)
- Injection Injury
- High-pressure line bursts
- Injects fluid or other substance into skin and
into subcutaneous tissue
25Dressing and Bandage Materials (1 of 2)
- Sterile and Non-sterile Dressings
- Sterile direct wound contact
- Non-sterile bulk dressing above sterile
- Occlusive/Non-occlusive Dressings
- Adherent/Non-adherent Dressings
- Adherent stick to blood or fluid
- Absorbent/Non-absorbent
- Absorbent soak up blood or fluids
- Wet/Dry Dressings
- Wet burns, postoperative wounds (sterile NS)
- Dry most common
26Dressing and Bandage Materials (2 of 2)
- Self-adherent Roller Bandage
- Kerlex/Kling
- Multi-ply, stretch 16
- Gauze Bandage
- Single-ply, non-stretch 13
- Adhesive Bandages
- Elastic (Ace) Bandages
- Triangular Bandages
27Assessment of Soft-Tissue Injuries
- Scene Size-up
- Initial Assessment
- Focused HP
- Evaluate MOI and consider IOS
- Rapid versus focused assessment
- Detailed Physical Exam
- Inquiry, inspection, palpation, auscultation
- Ongoing Assessment
28Management of Soft-Tissue Injury (1 of 4)
- Objectives of Wound Dressing and Bandaging
- Hemorrhage control
- Direct pressure
- Elevation
- Pressure points
- Consider
- Ice
- Constricting band
- Tourniquet
- USE ALL COMPONENTS TOGETHER.
29Management of Soft-Tissue Injury (2 of 4)
Tourniquet
- Do
- Apply in a way that will not injure tissue
beneath it. - Use something at least 2 wide.
- Consider using a blood pressure cuff.
- Write TQ and time placed on patients forehead.
- Dont
- Use unless you cannot control the bleeding via
other means. - Use rope or wire.
- Release it once applied.
30Management of Soft-Tissue Injury (3 of 4)
- Objectives of Wound Dressing and Bandaging
- Sterility
- Keep the wound as clean as possible.
- If wound is grossly contaminated, consider
cleansing. - Immobilization
- Prevents movement and aggravation of wound.
- Do not use an elastic bandage TQ effect.
- Monitor distal pulse, motor, and sensation.
31Management of Soft-Tissue Injury (4 of 4)
- Pain and Edema Control
- Cold packs
- Moderate pressure over wound
- Consider analgesic if approved by medical
direction - Morphine sulfate
- 2 mg SIVP every 5 minutes up to a total of 10 mg
given. - Fentanyl (Sublimaze)
- 2550 mcg SIVP followed by an additional 25 mcg
as needed. - If given too rapidly, chest wall rigidity may
ensue leading to respiratory compromise.
32Anatomical Considerations for Bandaging (1 of
17)
- Scalp
- Rich supply of blood vessels
- Rarely account for shock
- Can be severe and difficult to control
- With skull fracture
- Gentle digital pressure around the wound
- Pressure on local arteries
- Without skull fracture
- Direct pressure
33Anatomical Considerations for Bandaging (2 of
17)
- Face
- Heavy bleeding.
- Assess and protect the airway.
- Blood is a gastric irritant.
- Be alert for nausea and vomiting.
- Ear or Mastoid
- Cover and collect bleeding.
- DO NOT STOP.
- CSF.
34Anatomical Considerations for Bandaging (3 of
17)
- Neck
- Consider circumferential bandage.
- Protect trachea and carotids.
- C-collar and dressing.
- Occlusive dressing if lacerated vessel.
- Shoulder
- Care to avoid pressure.
- Axillary artery.
- Trachea.
- Anterior neck.
35Anatomical Considerations for Bandaging (4 of
17)
- Trunk
- Minor wounds Dressing and tape.
- Major wounds Circumferential wrap.
- Ladder splint behind back and wrap gauze over it.
- Prevents worsening of respiratory status.
- Groin and Hip
- Bandage by following contours of body.
- Movement can increase tightness of bandage.
36Anatomical Considerations for Bandaging (5 of
17)
- Elbow and Knee
- Circumferential wrap and splint
- Splinting reduces movement
- Position of function
- Half flexion/half extension
- Hand and Finger
- Remove jewelry from wrist and fingers
- Bulky dressing
- Position of function
- Ankle and Foot
- Circumferential bandage
37Anatomical Considerations for Bandaging (6 of
17)
- Complications of Bandaging
- Always assess before and after
- Pulse
- Motor
- Sensation
- Developing ischemia
- Pain
- Pallor
- Tingling
- Loss of pulse
- Decreased capillary refill
- Is dressing size appropriate to injury?
38Anatomical Considerations for Bandaging (7 of
17) Specific Wounds
- Amputations
- Patient
- Control bleeding by bulky dressing.
- Consider tourniquet proximal to wound.
- Do not delay transport to locate amputated part.
- Have a second unit transport the part.
- Amputated Part
- Dry cooling and rapid transport.
- Part in plastic bag (double bag).
- Immerse in cold water.
- Avoid direct contact between tissue and cold
water.
39Anatomical Considerations for Bandaging (8 of
17) Specific Wounds
- Impaled Objects
- Stabilize with bulky dressing in place.
- Prevent movement of object.
- Consider cutting or shortening LARGE impaled
objects. - Prevent gross movement.
- Reduce heat to patient if cutting torch used.
- REMOVE ONLY IF
- In cheek and interferes with airway
- Interferes with CPR
- Poor outcome
40Anatomical Considerations for Bandaging (9 of
17) Specific Wounds
- Crush Syndrome
- Anticipate problems.
- Victims of prolonged entrapment.
- Ensure that scene is safe.
- Initial assessment.
- Control any initial problems.
- Greater the body area compressed, the longer the
entrapment, the greater the risk of crush
syndrome. - Once body part is freed, toxic by-products of
crush injury are released into systemic
circulation. - General management for soft tissue and
musculoskeletal injury.
41Anatomical Considerations for Bandaging (10 of
17) Specific Wounds
- Crush Syndrome
- Management
- IV 2030 mL/kg of NS or D51/2 NS.
- AVOID LR or K based solutions.
- After bolus, continuous infusion of 20 mL/kg/hr.
- Consider sodium bicarbonate
- 1 mEq/kg initial bolus
- 0.25 mEq/kg/hr infusion
- Corrects systemic acidosis
- Consider calcium chloride
- 500 mg IVP
- Counteracts hyperkalemia
- Consider diuretics
- Mannitol (Osmotrol)
- Furosemide (Lasix)
42Anatomical Considerations for Bandaging (11 of
17) Specific Wounds
- Compartment Syndrome
- Likely 48 hours post-injury
- Symptom
- Severe pain out of proportion with physical exam
findings - 6 Ps
- Pain
- Paresthesia
- Paresis
- Pressure
- Passive stretching pain
- Pulselessness
- Normal motor and sensory function
43Anatomical Considerations for Bandaging (12 of
17) Specific Wounds
- Compartment Syndrome
- Management
- Care of underlying injury.
- Splint and immobilize all suspected fractures.
- Cold packs to severe contusions
- Most effective prehospital management
- Reduces edema
- Prevents ischemia
44Anatomical Considerations for Bandaging (13 of
17)
- Face and Neck
- Potential for airway obstruction or compromise
- Aggressive suctioning and oxygenation
- Consider intubation
- Verify ET tube placement.
- Ensure tube remains in the airway by using
continuous waveform capnography. - If excessive swelling or damage
- Needle or surgical cricothyroidotomy.
45Anatomical Considerations for Bandaging (14 of
17)
- Thorax
- Superficial injury can be deep.
- Always suspect the worst due to underlying
organs. - NEVER explore a wound internally.
- Alert for
- Subcutaneous emphysema
- Pneumothorax or hemothorax
- Tension pneumothorax
- Consider occlusive dressing sealed on 3 sides.
46Anatomical Considerations for Bandaging (15 of
17)
- Abdominal Region
- Always suspect injury to ribs or thoracic organs
if between the level of the 5th and 9th rib. - Damage to hollow or solid organs from blunt or
penetrating trauma. - Signs of symptoms of internal injury may be
subtle and slow to progress. - Supportive treatment unless aggressive care is
warranted.
47Anatomical Considerations for Bandaging (16 of
17)
- Wounds Requiring Transport
- Any wound that involves
- Nerves
- Blood vessels
- Ligaments
- Tendons
- Muscles
- Significantly contaminated
- Impaled object
- Likely cosmetic injury
48Anatomical Considerations for Bandaging (17 of
17)
- Soft-Tissue Treatment and Refer or Release
- Typically requires on-line medical direction.
- Evaluate and dress wound.
- Inform the patient about
- Preventing infection.
- Follow-up care with a physician.
- Inquire about tetanus and inform of risks.
- Document treatment, referral, and teaching.
49Summary
- Introduction to Soft Tissue Injury
- Anatomy and Physiology of Soft-Tissue Injury
- Pathophysiology of Soft-Tissue Injury
- Dressing and Bandage Materials
- Assessment of Soft-Tissue Injuries
- Management of Soft-Tissue Injuries