Transcript Paramedic Care: Principles & Practice Volume 4

Paramedic Care:
Principles & Practice
Volume 4
Trauma Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 5
Soft-Tissue Trauma
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Introduction to Soft-Tissue Injuries
Anatomy and Physiology of
Soft-Tissue Injuries
Pathophysiology of Soft-Tissue Injury
Dressing and Bandage Materials
Assessment of Soft-Tissue Injuries
Management of Soft-Tissue Injury
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to
Soft-Tissue Injuries
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to
Soft-Tissue Injuries
Skin is the largest organ
16% of total body weight
Function:
– Protection
Keeps invading pathogens out while containing body
substances and fluids
– Sensation
– Temperature regulation
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to
Soft-Tissue Injury
Epidemiology
– Open wounds
Over 10 million wounds present to emergency
departments
– Closed wounds
More common
Contusions, sprains, strains
– Risk factors for soft-tissue wounds
Age
Alcohol and drug abuse
Occupation
– Prevention
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology of
Soft-Tissue Injuries
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology of
Soft-Tissue Injuries
Layers of the
Skin
– Epidermis
A layer of cells
just above the
dermis
– Dermis
Connective
tissue that helps
contain the body
– Subcutaneous
Is rich in fatty or
adipose tissue
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology of
Soft-Tissue Injuries
Blood Vessels
–
–
–
–
–
Arteries
Arterioles
Capillaries
Venules
Veins
Layers
– Tunica intima
– Tunica media
– Tunica adventitia
Click here to view the anatomy of blood
vessels.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology of
Soft-Tissue Injuries
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology of
Soft-Tissue Injuries
Tension Lines
– Natural patterns in the
surface of the skin
revealing tension
within.
Lacerations across the
tension lines have a
tendency to be pulled
apart.
Lacerations parallel to
the tension lines tend
to gape very little.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury
Closed Wounds
– Contusions
Blunt, nonpenetrating
injuries that crush and
damage small blood
vessels
Characterized by
erythema and
ecchymosis
© Edward T. Dickinson, MD
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Closed Wounds
Hematoma
– Blood separates tissue and pool in a pocket
Dangerous in head injuries
Some may cause hypovolemia
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Closed Wounds
Crush Injuries
– A body part is
compressed,
injuring muscles,
blood vessels,
bones, and other
internal structures
– Crush Syndrome
Used to describe the
systemic effects of a
large crush injury
© Edward T. Dickinson, MD
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury
Open Wounds
– Abrasion
Typically the most minor
of injuries
Carries the danger of
serious infection
– Laceration
© Charles Stewart, MD
Penetrates more deeply
into the dermis than an
abrasion
Endangers the deeper
and more significant
vasculature, nerves,
muscles, tendons,
ligaments, and organs
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Open Wounds
Incision
– A surgically smooth
laceration
Puncture
– A small entrance
wound with damage
that extends into the
body’s interior
– A puncture
additionally carries
an increased danger
of infection
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Open Wounds
Impaled Object
– A wound
complication often
associated with a
puncture or
laceration
– May cause
worsening damage
if withdrawn
© Charles Stewart, MD
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Open Wounds
Avulsion
– A flap of skin,
although torn or cut,
is not torn
completely loose
from the body
– Degloving injury
Ring injury
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Open Wounds
Amputations
– Partial or complete
severance of a digit
or limb
– Hemorrhage
associated with the
amputation may be
limited
– Care is used to
ensure that the stump
will be as functional
as possible
© Mark C. Ide
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury
Hemorrhage
– Arterial
– Venous
– Capillary
The nature of the soft-tissue wound may be
more important than the size or type of vessel
involved
– Clean lacerations and amputations generally do
not bleed profusely
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury
Wound Healing
– Hemostasis
Vessels have a muscular layer that reflexively constricts
the vessel in response to local injury
Platelets begin the clotting process
Stick to the vessel wall and to one another forming a plug
Proteins activate a complicated series of enzyme
reactions
Coagulation
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Wound Healing
Inflammation
– Involves a host of elements
Various kinds of white blood cells
Proteins involved in immunity
Hormone-like chemicals that signal other cells to
mobilize
– Chemotactic factors
Recruit cells
Granulocytes and macrophages
Phagocytosis
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Wound Healing
Inflammation (cont.)
– Lymphocytes and immunoglobins
– Histamine dilates precapillary blood vessels
Increases blood flow to affected area
Brings much-needed oxygen and more phagocytes to
the injured area
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Wound Healing
Result of the inflammatory stage
– Clearing away of dead and dying tissue
– Removal of bacteria and other foreign substances
– Preparation of the damaged area for rebuilding
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Wound Healing
Epithelialization
– Epithelial cells migrate over the surface of the
wound
Restores a uniform layer of skin cells along the edges of
the healing wound
– The new epithelial layer is not a perfect facsimile
of the original, undamaged skin
Usually quite functional and cosmetically similar
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Wound Healing
Neovascularization
– New growth of capillaries in response to healing
– Neovascularized tissue is very fragile and has a
tendency to bleed easily
Collagen Synthesis
– Fibroblasts: Cells that form collagen
– Remodeling
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Wound Healing Process
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury
Infection
– Most common and most serious complication of
open wounds
– 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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Infection
Risk factors
– Host’s health and pre-existing illnesses
Diabetics, the infirm, the elderly, and individuals with
serious chronic diseases
– Wound type and location
Well-vascularized areas such as the face and scalp are
very resistant to infection
Distal areas such as extremities heal more slowly
– Associated contamination
– Treatment provided
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Infection
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury
Other Wound Complications
– Impaired hemostasis
Medications can interfere with hemostasis and the
clotting process
Aspirin, anticoagulants, fibrinolytics, and penicillins
Abnormalities in proteins involved in the fibrin formation
cascade may result in delayed clotting
Hemophilia
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Other Wound Complications
Re-bleeding
– Re-bleeding is possible from any wound
Movement of underlying structures
Hemorrhage continues in large wounds unnoticed
Postoperative wounds
Delayed healing
– Patients at risk include:
Diabetics, the elderly, the chronically ill, and the
malnourished
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Other Wound Complications
Compartment
Syndrome
– Extremity injury
causes significant
edema and swelling
in the deep tissues
– Pressure in the
compartment will
rise
Results in decreased
blood flow and
ischemia
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Other Wound Complications
Abnormal Scar Formation
– Keloid
– Hypertrophic scar formation
Associated with dynamic skin tension lines
Flexion joints
Pressure Injuries
– Caused by prolonged compression of the skin and
tissues beneath
– Compressed tissue induces hypoxic injury
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury
Crush Injury
– Body tissues subjected to severe compressive
forces
– A crush injury disrupts the body’s tissues
Creates an excellent growth medium for bacteria
– Tissue hypoxia and acidosis may result in muscle
rigor
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Crush Injury
Associated Injury
– Additional fractures
– Open or closed soft-tissue injuries
– Direct injury
Blunt and penetrating
– Dehydration and hypothermia
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury
Crush Syndrome
– Body is entrapped for >4 hours
– Crushed muscle tissue becomes necrotic
Resultant release of metabolic byproducts
traumatic rhabdomyolysis
– By-products of cellular destruction
Myoglobin
Phosphate and potassium
Lactic acid
Uric acid
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of
Soft-Tissue Injury
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Dressing and
Bandage Materials
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Dressing and
Bandage Materials
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
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Dressing and
Bandage Materials
Wet/Dry Dressings
– Wet: burns, postoperative wounds (sterile NS)
– Dry: most common
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of
Soft-Tissue Injuries
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of
Soft-Tissue Injuries
Scene Size-up
– Rule out or eliminate
any threats to yourself
or fellow care providers
– Determine the
mechanism of injury
– Standard Precautions
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of
Soft-Tissue Injuries
Initial Assessment
–
–
–
–
Establishing manual cervical in-line immobilization
Form a general impression
Assess the airway, breathing, and circulation
Correct any immediate threats to the patient’s life
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of
Soft-Tissue Injuries
Focused History and Physical Exam
– Significant MOI
Rapid trauma assessment
Perform a swift evaluation of the patient’s head, neck,
chest, abdomen, pelvis, extremities, and posterior body
Confirm the decision either to transport the patient
immediately with further care provided en route to the
hospital
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of
Soft-Tissue Injuries
Focused History and Physical Exam
– No significant MOI
Focused trauma assessment
Use the examination techniques of inquiry, inspection,
and palpation to evaluate the injury and the surrounding
area
Check the distal extremity for pulses, capillary refill, color, and
temperature
Transport Decision
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of
Soft-Tissue Injuries
Detailed Physical Exam
– Detailed exam should follow a planned and
comprehensive process
– The detailed physical exam is usually performed
during transport
Never delay transport to perform it
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of
Soft-Tissue Injuries
Assessment Techniques
– Inquiry
The mechanism of injury, any pain, pain on touch or
movement, and any loss of function or sensation specific
to an area
– Inspection
Carefully observing a particular body region
– Palpation
Palpate the body’s entire surface
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment of
Soft-Tissue Injuries
Ongoing Assessment
– Reassess the patient’s mental status, airway,
breathing, and circulation
– Inspect any interventions you have performed
– Perform at least every 5 minutes with unstable
patients
– Perform at least every 15 minutes with stable
patients
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of
Soft-Tissue Injury
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of
Soft-Tissue Injury
Objectives of Wound Dressing and
Bandaging
– Hemorrhage control
Direct pressure
Elevation
Pressure points
Consider
Ice
Constricting band
Tourniquet
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of Soft-Tissue
Injury - Tourniquet
Don’t
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
– 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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of
Soft-Tissue Injury
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Management of
Soft-Tissue Injury
Pain and Edema Control
– Cold packs
– Moderate pressure over wound
– Consider analgesic if approved by medical
direction:
Morphine sulfate
2 mg IVP every 5 minutes up to a total of 10 mg given.
Fentanyl (Sublimaze)
25–50 mcg IVP 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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
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 from ears or nose
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical Considerations
for Bandaging
Neck
– Consider circumferential bandage
Protect trachea and carotids
C-collar and dressing
– Occlusive dressing if lacerated vessel
Shoulder
– Take care to avoid pressure
Axillary artery
Trachea
Anterior neck
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical Considerations
for Bandaging
Trunk
– Minor wounds: Dressing
and tape
– Major wounds:
Circumferential wrap
Ladder splint behind back
and wrap gauze over it
Groin and Hip
– Bandage by following
contours of body
– Movement can increase
tightness of bandage
© Ray Kemp/911 Imaging
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomical Considerations
for Bandaging
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Care of Specific Wounds
Amputations
– Patient
Control bleeding
Consider tourniquet
Do not delay transport
– 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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Care of Specific Wounds
Impaled Objects
– Stabilize with bulky dressing in place
– Prevent movement of object
– Consider cutting or shortening large impaled
objects
– Consider removal if:
In cheek and interferes with airway
Interferes with CPR
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Care of Specific Wounds
Crush Syndrome
–
–
–
–
Anticipate problems
Victims of prolonged entrapment
Ensure that scene is safe
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Care of 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
Consider calcium chloride:
500 mg IVP
Counteracts hyperkalemia
Consider diuretics:
Mannitol (Osmotrol)
Furosemide (Lasix)
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Care of 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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Care of Specific Wounds
Compartment Syndrome (cont.)
– 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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Special Anatomical Sites
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Special Anatomical Sites
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Special Anatomical Sites
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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Wounds Requiring Transport
Any wound that involves
–
–
–
–
–
–
–
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Nerves
Blood vessels
Ligaments
Tendons
Muscles
Significantly contaminated
Impaled object
Likely cosmetic injury
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Soft-Tissue Treatment and
Refer/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 Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Introduction to Soft-Tissue Injuries
Anatomy and Physiology of Soft-Tissue
Injuries
Pathophysiology of Soft-Tissue Injury
Dressing and Bandage Materials
Assessment of Soft-Tissue Injuries
Management of Soft-Tissue Injury
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ