Transcript RefresherTrauma-7SoftTissueInj

Soft -Tissue
Injuries
Beyond the Objectives
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Anatomy & Physiology Review
• Layers of soft tissue
– Cutaneous layer
• Epidermis
• Dermis
– Subcutaneous layer
• Loose connective tissue
• Fat
– Deep Fascia
• Fibrous tissue
• Supportive & protective
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Anatomy & Physiology Review
• Functions of Soft Tissue
– Protection from Trauma
– Thermoregulation
– Sensory functions
• Pain, Touch, Temperature
– Protection from infection
– Fluid maintenance
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Soft Tissue Injuries Review
• Abrasion
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superficial injury
outermost skin damaged by shearing forces
painful in proportion to degree of injury
no bleeding or minor bleeding
contamination is primary concern
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Soft Tissue Injuries Review
• Laceration
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Skin disruption with greater depth than abrasion
jagged wound ends bleed easily
may involve other soft tissue injuries
caused by forceful impact with sharp object
bleeding may be severe
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Soft Tissue Injuries Review
• Incisions
– Skin disruption with greater depth than abrasion
– similar to laceration except wound ends are
smooth and even
– tend to heal better than lacerations
– caused by very sharp objects
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Soft Tissue Injuries Review
• Avulsion
– flap of skin or tissue torn loose or pulled
completely off
– avulsed tissue may or may not be viable
• Amputation
– involves extremities or body parts
– jagged skin and/or bone edges at site
– three types
• complete, partial, degloving
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Compartment Syndrome
• Crush Injuries
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caused by a crushing (compressive) force
may result in organ injury
often associated with severe fractures
overlying skin may be intact
causes
• collapse of structure onto body area
• compressive trauma to body area
• prolonged compression in a chronic situation
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Compartment Syndrome
• Crush Injuries & Crush Syndrome
– Injury sustained from a compressive force
sufficient to interfere with the normal
metabolic function of the injured tissue
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rhabdomyolysis
electrolyte abnormalities
acid-base abnormalities
hypovolemia
acute renal failure
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Compartment Syndrome
• Compartment Syndrome
– local evidence of muscle ischemia
– results from compressive forces in a closed space
• e.g. within fascia
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Compartment Syndrome
• Crush Syndrome
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may be painful, swollen, deformed
little or no external bleeding
internal bleeding may be severe
reperfusion phenomenon
• systemic effects occur after the issue is reperfused
• oxygen free radicals result in muscle injury
• high intracellular calcium
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Compartment Syndrome
• Rhabdomyolysis - Pathophysiology
– muscle destroyed
– extracellular fluid moves into muscle cells
• increased H20, NaCl, Calcium
– Fluid from muscle move into extracellular fluid
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Lactic acid
Myoglobin
Potassium, Phosphate
Thromboplastin, Creatine kinase & Creatinine
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Compartment Syndrome
• Rhabdomyolysis - Potential Complications
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Hypovolemia
Hypocalcemia
Hyperkalemia
Metabolic acidosis
Hyperuricemia
Hyperphosphatemia
Possible DIC
 Cardiotoxicity
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Compartment Syndrome
• Compartment Syndrome
– Tissue pressure > capillary hydrostatic pressure
• Results in ischemia to muscle
• Muscle cell edema begins
– Prolonged ischemia (>6-8 hrs) leads to tissue
hypoxia and cell death
– Direct soft tissue trauma also adds to edema and
ischemia
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Compartment Syndrome
• Compartment Syndrome
– Renal failure
• hypovolemia
• renal tubules become obstructed
• nephrotoxic agents present
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Compartment Syndrome
• Compartment Syndrome
– Early signs of crush syndrome
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paralysis and sensory loss to injured area
rigor of joint distal to the injured muscles
pain, swelling, sensory changes, weakness
may have pulses present and warm skin
– Later signs indicating compartment syndrome
• 5 Ps
– pain, paresthesia, pallor, pressure, pulselessness
– some include “polar”
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Hemorrhage Control
• Direct pressure
– use
• dressing
• gloved hand or patient’s hand
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quickest and most efficient method
promotes localized clotting
avoid removing initial dressing
continue pressure by securing dressing and
applying additional dressings
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Hemorrhage Control
• Elevation
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Useful in extremity
Used WITH direct pressure
Elevate above level of heart
Gravity used to slow hemorrhage & promote
clotting
– Not always useful with extremity fracture
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Hemorrhage Control
• Pressure Points
– Site where artery lies near surface
– Direct compression applied
– Most common are
• brachial artery
• femoral artery
– Used when direct pressure, elevation and
continued pressure fail
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Hemorrhage Control
• Tourniquets
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Last resort method when all others fail
Placed within 2 inches of wound
Useful only on extremities
Never apply directly over a joint
Once in place, avoid loosening
• risk of emboli or continued hemorrhage
– Use wide material
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Management
• General Principles
– Control Bleeding
– Apply Dressing
• Method dependent on location of injury
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Immobilization
Bandaging
Antibacterial ointment
Consider need for further Evaluation
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Management
• Need for Further Evaluation
– Treat and Release
– Treat and Refer
– Treat and Transport
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Management
• Wounds Requiring Transport for Evaluation
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Neural compromise
Vascular compromise
Muscular compromise
Tendon/Ligament compromise
Heavy contamination or High Risk Wounds
Cosmetic complications
Foreign body complications
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Soft Tissue Injury Management
• Other Considerations
– Tetanus vaccine
• Caused by Clostridium tetani
– anaerobic bacteria
• Initial vaccine
• Booster
– q 10 years
– q 5 years for high risk persons
• Potential for allergic reaction
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Soft Tissue Injury Management
• Other Considerations
– Potential Risk of Infection
• Common complication
• Risk factors
– Microflora common on skin surface
– Source on wound mechanism
– Patient immunocompromised
• Infection Minimization
– minimize contamination
– clean wound soon after injury
– protect
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Soft Tissue Injury Management
• Management of Specific Injuries
– Avulsion
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ABCs
Control bleeding
Dress and Bandage
Package avulsed tissue for transport
– Wrap in sterile gauze
– Place in plastic bag
– Place plastic bag in bag of ice
• Transport to appropriate facility
– Consider surgery & plastic surgery capabilities
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Soft Tissue Injury Management
• Management of Specific Injuries
– Amputation
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ABCs
Control bleeding
Do not complete partial amputations
Dress and Bandage
Package amputated part for transport
Transport to appropriate facility
– Consider surgery & plastic surgery capabilities
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Soft Tissue Injury Management
• Management of Specific Injuries
– Crush Injuries
• Goals
– Prevent sudden death
– Prevent renal failure
– Salvage limb
• Treat early -- Before arrival at ED
• Fluid for hypovolemia
– Consider bolus of 1 - 1.5 liters in 250 ml increments
– No IV sites distal to crush injury!!
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Soft Tissue Injury Management
• Management of Specific Injuries
– Crush Injuries
• Alkalinize urine
– Consider NaHCO3: Add 50 mEq to 1 liter bag of fluid
– Goal: Urine pH > 6.5
– Controls hyperkalemia and acidosis to prevent acute
myoglobinuria renal failure by changing structure of
myoglobin so it passes thru renal tubules
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Soft Tissue Injury Management
• Management of Specific Injuries
– Crush Injuries
• Maintain urine output
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Diuresis of at least 300 cc/hr
Consider Mannitol
Avoid loop diuretics (may acidify urine)
Ideal fluid is D5 1/2 normal saline with 50 mEq NaHCO3 and
Mannitol
– Treat hypovolemia
– Correct acidosis
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Soft Tissue Injury Management
• Management of Specific Injuries
– Crush Injuries
• Other possible therapies
– Consider insulin/glucose for severe hyperkalemia (12.5 g D50
followed by 10 units regular insulin IV)
– Amiloride
» potassium sparing diuretic
– Hemodialysis (if needed)
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Soft Tissue Injury Management
• Management of Specific Injuries
– Compartment Syndrome
• Clinical signs and symptoms may indicate need for
emergency fasciotomy
• Early fasciotomy can preserve limb, avoid Volkmann’s
contracture and preserve sensation
• Seldom but occasionally performed in out of hospital
setting
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QUESTIONS
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