Transcript Document
Soft-Tissue Injury
Sections
Introduction to Soft Tissue Injury
Anatomy & Physiology of SoftTissue Injury
Pathophysiology of Soft-Tissue
Injury
Dressing & Bandage Materials
Assessment of Soft-Tissue Injuries
Management of Soft-Tissue Injuries
Introduction to
Soft-Tissue Injury
Skin is the largest, most
important organ
16% of total body weight
Function
Protection
Sensation
Temperature Regulation
AKA: Integumentary System
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
A&P of Soft Tissue
Skin Layers Injuries
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 & Sudoriferous Glands
Subcutaneous
Adipose tissue
Heat retention
A&P of Soft Tissue
Injuries
Blood Vessels
Arteries
Arterioles
Capillaries
Venules
Veins
Layers
Tunica Intima
Tunica Media
Tunica Adventitia
A&P of Soft Tissue
Injuries
Muscles
Beneath skin layers
Fascia
Thick, fibrous, inflexible membrane surrounding
muscle the aids to bind muscle groups together
A&P of Soft Tissue
Injuries
Tension Lines
Natural patterns in
the surface of the
skin revealing
tension within
Pathophysiology of
Soft-Tissue Injury
Closed
Wounds
Contusions
Erythema
Ecchymosis
Hematomas
Crush Injuries
Open Wounds
Abrasions
Lacerations
Incisions
Punctures
Impaled Objects
Avulsions
Amputations
Pathophysiology of
Soft-Tissue Injury
Hemorrhag
e
Arterial
Capillary
Venous
Pathophysiology of
Soft-Tissue Injury
Wound Healing
Hemostasis
Body’s natural ability to stop bleeding & the ability
to clot blood
Begins immediately after injury
Inflammation
Local biochemical process that attracts WBC’s
Epithelialization
Migration of epithelial cells over wound surface
(continued)
Pathophysiology of
Soft-Tissue Injury
Neovascularization
New growth of capillaries in response to healing
Collagen Synthesis
Fibroblasts: Cells that form collagen
Collagen: Tough, strong protein that comprises
connective tissue
Pathophysiology of
Soft-Tissue Injury
Infection
Most common and most serious complication of open
wounds
1:15 wounds seen in ED result in infection
Delay healing
Spread to adjacent tissues
Systemic infection: Sepsis
Presentation
Pus: WBC’s, cellular debris, & dead bacteria
Lymphangitis: Visible red streaks
Fever & Malaise
Localized Fever
Pathophysiology of
Soft-Tissue Injury
Infection
Risk Factors
Host’s health & pre-existing illnesses
• Medications (NSAID’s)
Wound type and location
Associated contamination
Treatment provided
Infection Management
Antibiotics & keep wound clean
Gangrene
• Deep space infection of anerobic bacteria
• Bacterial Gas and Odor
Tetanus
• Lockjaw
Pathophysiology of
Soft-Tissue Injury
Other Wound Complications
Impaired Hemostasis
Medications
• Anticoagulants
Aspirin
Warfarin (Coumadin)
Heparin
Antifibrinolytics
Re-Bleeding
Delayed Healing
Compartment Syndrome
Abnormal Scar Formation
Pressure Injuries
Pathophysiology of
Soft-Tissue Injury
Crush Injury
Body tissues are subjected to severe
compressive forces
Tamponading of distal tissue
Buildup of byproducts of metabolism
“Wood-like” distal tissue
Associated Injury
Pathophysiology of
Soft-Tissue Injury
Crush Syndrome
Body is entrapped for >4 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
Pathophysiology of
Soft-Tissue Injury
Injection Injury
High-pressure line bursts
Injects fluid or other substance into skin and
into subcutaneous tissue
Dressing & Bandage
Materials
Sterile & 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
Dressing & Bandage
Materials
Self-adherent roller bandage
Kerlex/Kling
Multi-ply, stretch; 1-6”
Gauze bandage
Single ply, non-stretch: 1-3”
Adhesive bandages
Elastic (Ace) Bandages
Triangular Bandages
Assessment of Soft
Tissue Injuries
Scene Size-up
Initial Assessment
Focused H&P
Evaluate MOI and consider IOS
Rapid versus Focused Assessment
Detailed Physical Exam
Inquiry, Inspection, Palpation, Auscultation
Ongoing Assessment
Management of
Soft-Tissue Injury
Objectives of Wound Dressing &
Bandaging
Hemorrhage Control
Direct Pressure
Elevation
Pressure Points
Consider
• Ice
• Constricting Band
• Tourniquet
USE ALL COMPONENTS TOGETHER
Management of
Soft-Tissue Injury
Tourniquet
Do’s
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 patient’s
forehead.
Don’ts
Use unless you can
not control the
bleeding via other
means
Use rope or wire.
Release it once
applied.
Management of
Soft-Tissue Injury
Objectives of Wound Dressing &
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 (continued)
Management of
Soft-Tissue Injury
Pain & Edema Control
Cold packs
Moderate pressure over wound
Consider analgesic if approved by medical control
Anatomical Considerations
for Bandaging
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
Anatomical Considerations
for Bandaging
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
Anatomical Considerations
for Bandaging
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
Anatomical Considerations
for Bandaging
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 & Hip
Bandage by following contours of body
Movement can increase tightness of bandage
Anatomical Considerations
for Bandaging
Elbow and Knee
Circumferential wrap and splint
Splinting reduces movement
Position of function
Half flexion/half extension
Hand and Finger
Bulky dressing
Position of function
Ankle and Foot
Circumferential bandage
Anatomical Considerations
for Bandaging
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?
Anatomical Considerations
for Bandaging: Specific Wounds
Amputations
Patient
Control bleeding by bulky dressing
Consider tourniquet proximal to wound
Do not delay transport to 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
Anatomical Considerations
for Bandaging: 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
Anatomical Considerations
for Bandaging: 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.
Anatomical Considerations
for Bandaging: Specific Wounds
Crush Syndrome
Management
IV: 20-30ml/kg of NS or D51/2NS
AVOID LR or K+ based solutions
After bolus, continuous infusion of 20ml/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)
Anatomical Considerations
for Bandaging: Specific Wounds
Compartment Syndrome
Likely 4-8 hours post-injury
Symptom
Severe pain out of proportion with physical exam
findings
6 – P’s
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Pain
Paresthesia
Paresis
Pressure
Passive stretching pain
Pulselessness
Normal motor and sensory function
Anatomical Considerations
for Bandaging: 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
Anatomical Considerations
for Bandaging
Face & Neck
Potential for airway obstruction or
compromise
Aggressive suctioning and oxygenation
Consider intubation
If excessive swelling or damage
• Needle or surgical cricothyroidotomy
Anatomical Considerations
for Bandaging
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
Anatomical Considerations
for Bandaging
Abdomen
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.
Anatomical Considerations
for Bandaging
Wounds Requiring Transport
Any wound that involves
Nerves
Blood vessels
Ligaments
Tendons
Muscles
Significantly contaminated
Impaled object
Likely cosmetic injury
Anatomical Considerations
for Bandaging
Soft-Tissue Treatment and Refer
or Release
Typically requires online medical control
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.