Soft Tissue Trauma Bledsoe et al Paramedic Care

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

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

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

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 (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

Hemostatic Bandages Adjunct to direct pressure Concentrate clotting factors and aid clot formation Quik. Clot Hem. Con Celox New Fibrin-based sealants

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 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 m. L/kg of NS or D 51/2 NS. AVOID LR or K+ based solutions. After bolus, continuous infusion of 20 m. L/kg/hr. Consider sodium bicarbonate: 1 m. Eq/kg initial bolus 0. 25 m. Eq/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 5 th and 9 th 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