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Soft-Tissue Injury
Sections
 Introduction to Soft Tissue Injury
 Anatomy & Physiology of SoftTissue Injury
 Pathophysiology of Soft-Tissue
Injury
 Dressing & Bandage Materials
 Assessment of Soft-Tissue Injuries
 Management of Soft-Tissue Injuries
Introduction to
Soft-Tissue Injury
 Skin is the largest, most
important organ
 16% of total body weight
 Function
 Protection
 Sensation
 Temperature Regulation
 AKA: Integumentary System
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
A&P of Soft Tissue
 Skin Layers Injuries
 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 & Sudoriferous Glands
 Subcutaneous
 Adipose tissue
 Heat retention
A&P of Soft Tissue
Injuries
 Blood Vessels
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Arteries
Arterioles
Capillaries
Venules
Veins
 Layers
 Tunica Intima
 Tunica Media
 Tunica Adventitia
A&P of Soft Tissue
Injuries
 Muscles
 Beneath skin layers
 Fascia
 Thick, fibrous, inflexible membrane surrounding
muscle the aids to bind muscle groups together
A&P of Soft Tissue
Injuries
 Tension Lines
 Natural patterns in
the surface of the
skin revealing
tension within
Pathophysiology of
Soft-Tissue Injury
 Closed
Wounds
 Contusions
 Erythema
 Ecchymosis
 Hematomas
 Crush Injuries
 Open Wounds
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Abrasions
Lacerations
Incisions
Punctures
Impaled Objects
Avulsions
Amputations
Pathophysiology of
Soft-Tissue Injury
 Hemorrhag
e
 Arterial
 Capillary
 Venous
Pathophysiology of
Soft-Tissue Injury
 Wound Healing
Hemostasis
 Body’s natural ability to stop bleeding & the ability
to clot blood
 Begins immediately after injury
 Inflammation
 Local biochemical process that attracts WBC’s
 Epithelialization
 Migration of epithelial cells over wound surface
(continued)
Pathophysiology of
Soft-Tissue Injury
 Neovascularization
 New growth of capillaries in response to healing
 Collagen Synthesis
 Fibroblasts: Cells that form collagen
 Collagen: Tough, strong protein that comprises
connective tissue
Pathophysiology of
Soft-Tissue Injury
 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
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Pus: WBC’s, cellular debris, & dead bacteria
Lymphangitis: Visible red streaks
Fever & Malaise
Localized Fever
Pathophysiology of
Soft-Tissue Injury
 Infection
 Risk Factors
 Host’s health & pre-existing illnesses
• Medications (NSAID’s)
 Wound type and location
 Associated contamination
 Treatment provided
 Infection Management
 Antibiotics & keep wound clean
 Gangrene
• Deep space infection of anerobic bacteria
• Bacterial Gas and Odor
 Tetanus
• Lockjaw
Pathophysiology of
Soft-Tissue Injury
 Other Wound Complications
 Impaired Hemostasis
 Medications
• Anticoagulants
 Aspirin
 Warfarin (Coumadin)
 Heparin
 Antifibrinolytics
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Re-Bleeding
Delayed Healing
Compartment Syndrome
Abnormal Scar Formation
Pressure Injuries
Pathophysiology of
Soft-Tissue Injury
 Crush Injury
 Body tissues are subjected to severe
compressive forces
 Tamponading of distal tissue
 Buildup of byproducts of metabolism
 “Wood-like” distal tissue
 Associated Injury
Pathophysiology of
Soft-Tissue Injury
 Crush Syndrome
 Body is entrapped for >4 hours
 Crushed muscle tissue becomes necrotic
 Traumatic Rhabdomyolysis
• Skeletal Muscle Degradation
• Release of toxins
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Myoglobin
Phosphate
Potassium
Lactic Acid
Uric Acid
 When tissue is released, toxins move RAPIDLY into systemic
circulation
• Impacts Cardiac Function
• Impacts Kidney Function
Pathophysiology of
Soft-Tissue Injury
 Injection Injury
 High-pressure line bursts
 Injects fluid or other substance into skin and
into subcutaneous tissue
Dressing & Bandage
Materials
 Sterile & 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
Dressing & Bandage
Materials
 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
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
Management of
Soft-Tissue Injury
 Objectives of Wound Dressing &
Bandaging
 Hemorrhage Control
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Direct Pressure
Elevation
Pressure Points
Consider
• Ice
• Constricting Band
• Tourniquet
 USE ALL COMPONENTS TOGETHER
Management of
Soft-Tissue Injury
Tourniquet
Do’s
 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’ts
 Use unless you can
not control the
bleeding via other
means
 Use rope or wire.
 Release it once
applied.
Management of
Soft-Tissue Injury
 Objectives of Wound Dressing &
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 (continued)
Management of
Soft-Tissue Injury
 Pain & Edema Control
 Cold packs
 Moderate pressure over wound
 Consider analgesic if approved by medical control
Anatomical Considerations
for Bandaging
 Scalp
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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
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
Anatomical Considerations
for Bandaging
 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
Anatomical Considerations
for Bandaging
 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 & Hip
 Bandage by following contours of body
 Movement can increase tightness of bandage
Anatomical Considerations
for Bandaging
 Elbow and Knee
 Circumferential wrap and splint
 Splinting reduces movement
 Position of function
 Half flexion/half extension
 Hand and Finger
 Bulky dressing
 Position of function
 Ankle and Foot
 Circumferential bandage
Anatomical Considerations
for Bandaging
 Complications of Bandaging
 Always assess before and after
 Pulse
 Motor
 Sensation
 Developing ischemia
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Pain
Pallor
Tingling
Loss of pulse
Decreased capillary refill
 Is dressing size appropriate to injury?
Anatomical Considerations
for Bandaging: Specific Wounds
 Amputations
 Patient
 Control bleeding by bulky dressing
 Consider tourniquet proximal to wound
 Do not delay transport to 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
Anatomical Considerations
for Bandaging: 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
Anatomical Considerations
for Bandaging: 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.
Anatomical Considerations
for Bandaging: Specific Wounds
 Crush Syndrome
 Management
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IV: 20-30ml/kg of NS or D51/2NS
AVOID LR or K+ based solutions
After bolus, continuous infusion of 20ml/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)
Anatomical Considerations
for Bandaging: Specific Wounds
 Compartment Syndrome
 Likely 4-8 hours post-injury
 Symptom
 Severe pain out of proportion with physical exam
findings
 6 – P’s
•
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Pain
Paresthesia
Paresis
Pressure
Passive stretching pain
Pulselessness
 Normal motor and sensory function
Anatomical Considerations
for Bandaging: 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
Anatomical Considerations
for Bandaging
 Face & Neck
 Potential for airway obstruction or
compromise
 Aggressive suctioning and oxygenation
 Consider intubation
 If excessive swelling or damage
• Needle or surgical cricothyroidotomy
Anatomical Considerations
for Bandaging
 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
Anatomical Considerations
for Bandaging
 Abdomen
 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.
Anatomical Considerations
for Bandaging
 Wounds Requiring Transport
 Any wound that involves
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Nerves
Blood vessels
Ligaments
Tendons
Muscles
Significantly contaminated
Impaled object
Likely cosmetic injury
Anatomical Considerations
for Bandaging
 Soft-Tissue Treatment and Refer
or Release
 Typically requires online medical control
 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.