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Chapter 5 Soft-Tissue Trauma

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Chapter 5 Soft-Tissue Trauma Topics Introduction to Soft Tissue Injury Anatomy and Physiology of Soft-Tissue Injury Pathophysiology of Soft-Tissue Injury Dressing and ... – PowerPoint PPT presentation

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Title: Chapter 5 Soft-Tissue Trauma


1
Chapter 5Soft-Tissue Trauma
2
Topics
  • 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

3
Introduction to Soft-Tissue Trauma
  • Skin is the largest, most important organ.
  • 16 of total body weight.
  • Function
  • Protection
  • Sensation
  • Temperature regulation
  • AKA integumentary system

4
Introduction 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

5
AP 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

6
AP of Soft-Tissue InjuriesThe Skin
7
AP of Soft-Tissue Injuries (3 of 6)
  • Blood Vessels
  • Arteries
  • Arterioles
  • Capillaries
  • Venules
  • Veins
  • Layers
  • Tunica intima
  • Tunica media
  • Tunica adventitia

8
AP of Soft-Tissue InjuriesBlood Vessels
9
AP 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

10
AP of Soft Tissue Injuries (6 of 6)
  • Tension Lines
  • Natural patterns in the surface of the skin
    revealing tension within

11
Pathophysiology 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

12
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13
Pathophysiology of Soft-Tissue Injury (2 of 12)
Soft-Tissue Wounds
14
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15
Pathophysiology of Soft-Tissue Injury (3 of 12)
  • Hemorrhage
  • Arterial
  • Capillary
  • Venous

16
Pathophysiology 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

17
Pathophysiology 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

18
Pathophysiology of Soft-Tissue Injury
Wound Healing
19
Pathophysiology 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

20
Pathophysiology 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

21
Pathophysiology 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

22
Pathophysiology 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

23
Pathophysiology 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

24
Pathophysiology of Soft-Tissue Injury (12 of 12)
  • Injection Injury
  • High-pressure line bursts
  • Injects fluid or other substance into skin and
    into subcutaneous tissue

25
Dressing 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

26
Dressing 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

27
Assessment 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

28
Management 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.

29
Management 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.

30
Management 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.

31
Management 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.

32
Anatomical 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

33
Anatomical 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.

34
Anatomical 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.

35
Anatomical 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.

36
Anatomical 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

37
Anatomical 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?

38
Anatomical 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.

39
Anatomical 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

40
Anatomical 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.

41
Anatomical 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)

42
Anatomical 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

43
Anatomical 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

44
Anatomical 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.

45
Anatomical 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.

46
Anatomical 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.

47
Anatomical 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

48
Anatomical 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.

49
Summary
  • 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
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