Paramedic Soft Tissue Injury

Soft Tissue Injury

Scenario You are caring for a woman who punched out a second-story window and jumped into some bushes to escape a fire. She has a laceration on her hand, with fatty tissue exposed that is bleeding briskly. Her face is badly scraped and is oozing red fluid. A branch punctured her leg and is protruding through the other side. She is developing a “goose-egg”

Discussion 

Which skin layers have been injured?

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How will you control the bleeding?

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What risk factors for wound infection are present?

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How will you manage her injuries?

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What type of dressing will you place on each wound?

Incidence/Morbidity/Mort ality 

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40 million people each year seek medical care for soft tissue trauma Causes:  

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Falls Motor vehicle accidents Blunt trauma Penetrating trauma

Incidence/Morbidity/Mort ality 

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Most soft tissue trauma is not lifethreatening 73,000 died in 2001

Anatomy & Physiology of the Skin 

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Largest Organ – 16% of body weight Layers: 

Epidermis, outer layer 

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Waterproof

Dermis, inner layer Connective tissue Elastic fibers Blood vessels Lymph Vessels Motor & Sensory fibers Hair, nails, sebaceous and sweat glands

Anatomy & Physiology of the Skin 

Role:  

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Protection Temperature maintenance Storage of nutrients Sensory reception Excretion & secretion

Pathophysiology of Wound Healing 

Homeostasis  

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Vasoconstriction Formation of a clot plug Coagulation Fibrous tissue development

Pathophysiology of Wound Healing 

Homeostasis Vasoconstriction Slows blood flow May last as long as 10 minutes

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Formation of a platelet plug 1.

2.

3.

Platelets adhere to collagen Swell, become sticky Secrete chemicals that attract other platelets

Pathophysiology of Wound Healing 

Homeostasis 

Coagulation 

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Occurs within minutes After 30 minutes, clot retracts and vessel is sealed Cascade Event 

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Prothrombin activator Prothrombin → Thrombin Fibrinogen → Fibrin Threads capture platelets, blood

Pathophysiology of Wound Healing 

Homeostasis 

Fibrous tissue development 

As wound is repaired, replaces damaged tissue with new connective tissue 

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Fibroblasts – Collagen synthesis Scar tissue formation

Pathophysiology of Wound Healing 

Homeostasis 

Other points 

Disruption of clotting  

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Genetic diseases Medications

Generally protective Sometimes lifethreatening  

AMI Stroke

Pathophysiology of Wound Healing 

Inflammation – Prepares wound for healing and clears it of foreign and dead tissue 

Capillary dilation 

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Capillary permeability 

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Swelling/pain/tenderne ss Accumulate for up to 72 hours

Attraction of leukocytes 

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Heat/redness

Pus

Systemic response (?)

Pathophysiology of Wound Healing 

Epithelialization and Neovascularization 

Neovascularization 

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New vessel formation

Epithelialization 

Re-establishes the skin layers

Pathophysiology of Wound Healing 

Collagen synthesis 

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Structural protein of most body tissue Deposited at injury site within 48 hours after wound

Alteration of Wound Healing 

Interference of healing or delays 

Medical conditions 

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Advanced age, alcoholism, uremia, diabetes, hypoxia, peripheral vascular disease, malnutrition, advanced cancer, hepatic failure, and C.V. disease

Medications 

Corticosteroids, NSAIDS, PCN and

Alteration of Wound Healing 

High Risk Wounds 

Potential for infection  

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Location Wound cause or force Immunocompromised patients Lots of dead tissue

Alteration of Wound Healing 

Abnormal Scar Formation Keloid – Scar tissue outside the original wound  Hypertrophic – Excessive scar tissue within the original wound 

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Tension lines 

Amount of tension on the skin Vary from body part to body part  Knee wound vs. forearm wound 

Alteration of Wound Healing 

Keloid scar tissue

Alteration of Wound Healing 

Hypertrophic scar tissue

Types of Open Soft Tissue Injuries   

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Abrasions Lacerations Major arterial lacerations Avulsions

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Impaled objects Amputation Incisions Penetrations/punct ures

Types of Open Soft Tissue Injuries 

Abrasions 

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Partial thickness skin injury Caused by scraping or rubbing Painful High for infection

Types of Open Soft Tissue Injuries 

Laceration 

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A tear, split, or incision Can be caused by a knife or other sharp object Vary in depth Can have significant blood loss

Types of Open Soft Tissue Injuries 

Major arterial lacerations Lacerations involving larger arteries  Extensive bleeding possible  If closed, may develop a hematoma 

Types of Open Soft Tissue Injuries 

Avulsions 

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Flap of skin is torn or cut, not completely loose Tissue may not be viable Examples: 

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Ear lobe, nose tip, finger tips, degloving, and scalp wounds

Seriousness depends on: 

Types of Open Soft Tissue Injuries 

Impaled object 

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Instrument that causes injury remains imbedded in wound Knives, tree branches…

Types of Open Soft Tissue Injuries 

Amputation 

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Complete or partial loss of a limb by a mechanical force Digits, lower leg, hand, forearm, and foot Fatal bleeding may result 

Partial amputation have more severe bleeding than a complete amputation

Types of Open Soft Tissue Injuries 

Incisions 

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Similar to a laceration – wound edges are smooth and not jagged Caused by a knife, razor, glass, or sharp metal Heal better Bleed freely

Types of Open Soft Tissue Injuries 

Penetrations and punctures 

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Caused by a pointed or sharp object Can cause deep damage to underlying tissue Hard to assess in the field Stab wound, GSW

Blast Injuries 

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Is caused by a blast or explosion Injuries are due to 3 forces:   

Primary Secondary Tertiary

Blast Injuries 

Assessment   

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Scene Survey Initial Assessment Rapid Trauma Assessment Detailed Assessment On-Going Assessment

Blast Injuries 

Management 

Same principles apply for trauma management: 

ABCs 

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Rapid transport 

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Oxygenation and ventilation Stabilize impaled objects, PRN Fix life threats onscene

Trauma center routing Maintain adequate

Crush Injuries  

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Crush Injury Compartment Syndrome Crush Syndrome

Crush Injuries 

Crush Injury Occurs when tissue is exposed to a compressive force  Interferes with normal tissue structure and metabolic function 

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Massive crush injury to vital organs = Immediate death

Severity depends on: Amount of pressure applied  Amount if time the pressure stays in place  Body region affected 

Crush Injuries 

Crush Injury 

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Usually involves upper/lower extremities, torso, or pelvis Common situations:   

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Structural collapse Earth collapse Motor vehicle crashes Warfare incidents/Terrorism Industrial accidents

Crush Injuries 

Compartment Syndrome 

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A result of a crush injury (compressive forces) Muscle groups are confined within their tough fibrous sheaths and not allowed to stretch 

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Usually below the knee or above the elbow  Tibial fracture common Associated hemorrhage and edema increase the pressure within the closed fascial space  Result in ischemia – More swelling and more

Crush Injuries 

Compartment Syndrome 

S/S 

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5 Ps – Pain, Paresis, Parathesia, Pallor, Pulselessness Pain is out of proportion of the injury and with passive stretch Swelling Tenderness Weakness in affected muscle groups

Diagnosis – History, MOI and Index of Suspicion

Crush Injuries 

Crush Syndrome Life-threatening condition  Caused by prolonged immobilization or compression  Destruction and necrosis of tissue  Rare – Occur when extrication or rescue is prolonged > 4-6 hours 

Crush Injuries 

Crush Syndrome 

Pathophysiology    

Vascular integrity disturbed Loss of cell structure and membrane Survival until compressive force is removed Harmful processes: 

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Oxygen rich blood returns to damaged (ischemic) tissue (Reperfusion)  Results in pooling of blood and shock Toxic substances and waste picked up from damaged site  Returns to systemic circulation – Metabolic acidosis and electrolyte imbalance Rhabdomyolysis – Myoglobin from damaged muscle filtered by kidneys  Renal failure

Crush Injuries 

Crush Syndrome Treatment 

Difficult to diagnose and treat 

Variables 

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Extent of tissue damage Duration and force of crush Patient’s general health Other injures?

Crush Injuries 

Crush Syndrome Treatment    

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Oxygenation and Ventilation Maintain body temperature Aggressive hydration Sodium bicarbonate - Hyperkalemia and acidosis Insulin and dextrose – Hyperkalemia Mannitol – Kidney hydration Arterial tourniquets (?) before releasing compressive force Amputation (?) Consider hospitals with hyperbaric oxygenation

Hemorrhage Control Techniques   

Direct pressure Elevation Pressure dressing

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Pressure point Tourniquet application Splinting

Hemorrhage Control Techniques

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Arterial bleed – Bright red, spurting Venous bleed – Dark reddish-blue, oozing Capillary bleed – Bright red, oozing

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Apply PPE and take BSI precautions

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Hemorrhage Control Techniques 

Direct pressure Hemorrhage control by apply direct pressure at the injury site  Applied for 4-6 minutes 

Manual or via bandage  Never remove pressure 

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Continued bleeding? 

Second pressure dressing on top of first

Hemorrhage Control Techniques 

Elevation Elevate injury site above the heart, as possible  A supplement to direct pressure 

Hemorrhage Control Techniques 

Pressure Point 

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Used when direct pressure and elevation does not get the job done Compression of an artery (over a bone) proximal to the injury site Pressure should be maintained for about 10 minutes

Hemorrhage Control Techniques 

Tourniquet application 

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Has little or no indication in the emergency management of hemorrhage Associated with nerve, vessel, and eventual limb loss Last resort only

Hemorrhage Control Techniques 

Tourniquet application 

Guidelines: Select site – Need a 2 inch wide site  Place tourniquet over artery to be compressed, use wide material (BP cuff?) 

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Place pad over artery to be compressed

If using a bandage, encircle extremity twice (pad), tie knot over pad  Tie a windlass with a square knot  Tighten windlass until bleeding stops. Secure it  Document tourniquet – Mark forehead – Never loosen 

Hemorrhage Control Techniques 

Splinting/Pneumatic Pressure Devices Uniform direct pressure  Over a dressed would only after bleeding is controlled 

Types of Bandages and Dressings 

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Bandage – Any material used to secure a dressing Dressing – A sterile or non-sterile cover that aids in hemorrhage control and prevents further damage or contamination.

Types of Bandages and Dressings     

Sterile Non-sterile Occlusive Non-occlusive Adherent Nonadherent

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Complications of Improperly Applied Dressings and Bandages

Discomfort Too loose - Do not control bleeding Too tight – Can cause ischemia, structural damage to vessels, nerves, tendons, muscles, and skin Unclean - Infection

Wound Infection 

Common complication of soft tissue injury 

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Can cause systemic infection sepsis

Causes:        

Time (Should be cleaned and repaired within 812 hours) Mechanism (GSW, knife, crush injury) Location (foot, hand, perineum) Severity (More tissue damage = more infection) Contamination (Soil, saliva, and/or feces) Preparation (Cleanliness) Cleansing (Normal saline and high-pressure syringe) Technique of repair (Some need to be left open, other closed)

Wound Infection 

S/S of infection 

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Pain, swelling, and redness at the site Purulent discharge (yellow or green) Foul odor Red streaks from wound – directed towards the heart Fever, chills, sweats

Related Protocols

Amputation Pain management

PAIN MANAGEMENT PROTOCOL

PAIN MANAGEMENT PROTOCOL Pain Management Inclusion Criteria: This guideline applies to patients suffering from severe pain or discomfort, including isolated extremity injuries, musculoskeletal or soft tissue injuries, flank pain due to suspected kidney stone, sickle cell crisis, labor, and other causes.  

Basic Level Assess and support ABCs. Offer comfort and reassurance. Patient positioning:

Initiate patient positioning and spinal movement restrictions, as needed. If no spinal injury suspected, place the patient in a position of comfort. If evidence of shock, place the patient supine with the feet elevated and monitor airway closely. Treat shock according to the Shock Guidelines. Guidelines.

Administer oxygen, as needed to maintain an SpO2 of at least 96%. Splint injured extremities and apply cold packs. Once advanced level care arrives on scene, give report and transfer care. Advanced Level 6. If the patient can cooperate, have the patient self-administer nitrous oxide.

PAIN MANAGEMENT PROTOCOL

Amputation Inclusion Criteria: Patients with isolated amputation of any extremity. EMS personnel may also need to refer to Shock Guidelines.

Basic Level Assess and support ABCs. If the initial assessment is abnormal, minimize scene time. Continue treatment guidelines enroute. Initiate spinal movement restrictions, as needed. If no spinal injury is suspected, place the patient in a position of comfort. If evidence of shock, place the patient supine with the feet elevated and monitor airway closely. Treat shock according to the Shock Treatment Guidelines. Administer oxygen as needed to maintain an SpO2 of at least 96%. 

Control any obvious external bleeding with any combination of direct pressure, pressure points or elevation. EMS personnel may apply a tourniquet only as a last resort. Care of the amputated part: Remove gross contaminants by rinsing with saline. Wrap in moistened saline gauze and place in plastic bag or container (sterile, if available). Seal the container tightly and place in solution of ice water, if available. All parts should be brought to the hospital, regardless of the condition of the part. If the part cannot be located immediately, transport the patient and instruct other field

Amputation Begin transport as soon as possible. Advanced Level Consider establishing IV access at a TKO rate or use a saline lock. Consider ECG and ETCO2 monitor. Follow Pain Management Guidelines .