Transcript Bledsoe_V4_ch05

Chapter 5
Soft-Tissue Trauma
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
A&P 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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
A&P of Soft-Tissue Injuries (2 of 6)
The Skin
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
A&P of Soft-Tissue Injuries (3 of 6)
Blood Vessels
–
–
–
–
–
Arteries
Arterioles
Capillaries
Venules
Veins
Layers
– Tunica intima
– Tunica media
– Tunica adventitia
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
A&P of Soft-Tissue Injuries (4 of 6)
Blood Vessels
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
A&P 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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
A&P of Soft Tissue Injuries (6 of 6)
Tension Lines
– Natural patterns in
the surface of the
skin revealing
tension within
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury (2 of 12)
Soft-Tissue Wounds
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury (3 of 12)
Hemorrhage
– Arterial
– Capillary
– Venous
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury (4 of 12)
Wound Healing
– Hemostasis
Body’s 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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury (6 of 12)
Wound
Healing
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury (7 of 12)
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: WBCs, cellular debris, and dead bacteria
Lymphangitis: visible red streaks
Fever and malaise
Localized fever
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury (8 of 12)
Infection
– Risk factors
Host’s 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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury (11 of 12)
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Dressing and Bandage
Materials (2 of 2)
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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 patient’s
forehead.
Don’t
– Use unless you
cannot control the
bleeding via other
means.
– Use rope or wire.
– Release it once
applied.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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)
25–50 mcg SIVP followed by an additional 25 mcg as
needed.
If given too rapidly, chest wall rigidity may ensue leading
to respiratory compromise.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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?
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical Considerations
for Bandaging (10 of 17)
Specific Wounds
Crush Syndrome
– Management
IV: 20–30 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)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical Considerations
for Bandaging (11 of 17)
Specific Wounds
Compartment Syndrome
– Likely 4–8 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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Introduction to Soft Tissue Injury
Anatomy and Physiology of SoftTissue Injury
Pathophysiology of Soft-Tissue Injury
Dressing and Bandage Materials
Assessment of Soft-Tissue Injuries
Management of Soft-Tissue Injuries
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ