Download Ready for Review - Paramedic EMS Zone

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The skin is a complex organ that fulfils several crucial roles, including
maintaining homeostasis, protecting tissue from injury, and regulating
temperature.
The main layers of the skin are the epidermis and the dermis. The epidermis, the
outer layer, serves as the principal barrier. The dermis, the inner layer, includes
collagen, elastin, and ground substance, which contribute to the skin’s strength. It
also contains nerve endings, blood vessels, sweat glands, hair follicles, and
sebaceous glands.
The subcutaneous layer lies beneath the dermis and contains adipose tissue.
Below the subcutaneous layer is the deep fascia, which offers support and
protection to underlying structures such as muscle and bone.
The skin is arranged in patterns of tautness known as tension lines. Wounds that
occur parallel to skin tension lines may remain closed. Wounds that run opposite
to tension lines may remain open.
Soft-tissue injuries may be dramatic but are seldom the most serious. Don’t let
them distract you from thorough initial assessment!
The first stage of wound healing is cessation of bleeding. The body uses several
mechanisms to control bleeding, such as constricting the size of vessels and
releasing platelets to form a blood clot.
The second stage of healing is inflammation, in which additional cells enter the
damaged area in an effort to repair it. Epithelialisation (creation of a new layer of
epithelial cells) occurs, followed by neovascularisation (formation of new
vessels).
Wound healing is affected by factors such as the amount of movement the part is
subjected to, medications, and medical conditions. A wound is more likely to
become infected if it is caused by a human or an animal bite or if a foreign body
has been impaled. Pressure injuries can develop when a patient is bedridden or
remains on a backboard for too long.
Signs of infection include redness, pus, warmth, oedema, and local discomfort.
Gangrene, tetanus, and necrotising fasciitis are serious infection-related
conditions that must be recognised early.
In a closed wound, the skin is not broken but soft tissues beneath the skin are
damaged. An example is a bruise. A haematoma (collection of blood beneath the
skin) can also form.
In an open wound, the skin is broken. Such an injury can become infected and can
result in serious blood loss. Open wounds include abrasions, lacerations, puncture
wounds, avulsions, and amputations.
In a crush injury, a body part is crushed between two solid objects, resulting in
damage to soft tissues and bone. The patient’s external appearance may not
adequately represent the level of internal damage.
Crush syndrome may develop after a body part has been trapped for more than 4
hours. Necrosis occurs in crushed muscles, and harmful products are released in a
process called rhabdomyolysis. Freeing the trapped body part can cause these
harmful products to be released into the circulation, which can prove fatal. Kidney
damage, cardiac arrest, and arrhythmias can also result.
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Compartment syndrome results when pressure increases in the injured area.
Tissue necrosis and sepsis may then develop. Patients present with the six Ps:
Pain, Paresthaesia, Paresis, Pressure, Passive stretch pain, and Pulselessness.
Blasts (explosions) can result in soft-tissue injuries. A blast wind from the gases
released can be very forceful, and projectiles can impale victims; both cause
injuries. Falling structures can injure patients, and burns can also occur.
Observe scene safety before assessing patients with soft-tissue injuries; hazards
that caused the injury may still be present. Regardless of the grotesqueness of the
injury, assess the ABCs first.
While taking the history, ask about the event that caused the injury, such as
whether a weapon was used or whether the patient lost consciousness. Find out
when the patient last had a tetanus booster. Pay attention to whether the patient is
taking any medications that may affect haemostasis.
Depending on whether the mechanism of injury is significant or not, complete
your physical examamination en route or at the scene, respectively. Direct your
attention to the chief complaint and area of injury, and perform frequent
reassessments.
Be empathetic to patients with soft-tissue injuries.
Managing soft-tissue injuries includes controlling bleeding. With closed injuries,
follow the RICE mnemonic: Rest, Ice, Compression, and Elevation.
When managing open wounds, control bleeding and keep the wound as clean as
possible by irrigating and using sterile dressings. Try to determine the colour and
type of bleeding and the amount of blood the patient has lost.
Dressings and bandages are used to cover the wound, control bleeding, and limit
motion. Types of dressings include sterile and nonsterile, occlusive and
nonocclusive, adherent and nonadherent, and wet and dry. Types of bandages
include roller and gauze, absorbent gauze sponges, elastic, and triangular
bandages.
Medical tape may be used to secure a bandage in place, except for patients with
thin skin such as older patients because it can cause damage on removal. Do not
apply dressings too tightly.
Methods of bleeding control include direct pressure, elevation, pressure point
control, immobilisation, and tourniquets. Cold compresses may help reduce pain.
IV medications may be administered if basic measures do not relieve pain.
Tourniquets are rarely needed in the civilian setting but may be used as a last
resort. They can damage nerves and blood vessels and lead to loss of an
extremity.
Management of an avulsion includes irrigation, gently folding the flap back onto
the wound, and applying a dry, sterile compression dressing. If the wound is an
amputation, preserve the amputated part and transport it.
Do not remove impaled objects in the prehospital environment. Instead, stabilise
the object in place with a bulky dressing. Control bleeding with direct
compression, but do not apply pressure on the object or on the immediately
adjacent tissues.
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Dressing and bandaging techniques vary for different parts of the body. For
example, the shape of the skull and the presence of hair make dressing the scalp
challenging.
Trapped patients must be managed before being freed from the crushing object
because this approach improves their chances of survival after experiencing crush
syndrome. Aggressive fluid therapy can help prevent kidney failure. Normal
saline should be
infused. Once the patient has been freed, transport him or her as quickly as
possible.
Blast injuries can include pulmonary damage such as tension pneumothorax and
pulmonary contusion, abdominal trauma such as ruptured organs and internal
haemorrhage, damage to the ears, and penetrating wounds. Use the DCAP-BTLS
mnemonic to assess the patient rapidly.
Soft-tissue injuries of the face, neck, thorax, and abdomen deserve special
attention because these areas contain vital structures. Do not underestimate the
seriousness of these injuries, and maintain a high index of suspicion.
Document scene findings, including vehicle damage or the caliber of weapon used
and patient presentation and position; size, location, depth, and complications of
injuries; assessment findings; and interventions.