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Soft Tissue Injuries Temple College EMS Professions ECA Skin Anatomy and Physiology Body’s largest organ Layers Epidermis Dermis Subcutaneous tissue Skin Anatomy and Physiology Functions Sensation Control of water loss Protection against microbes Temperature control Soft Tissue Injuries Closed Open Closed Injury Associated with blunt trauma Skin remains intact Damage occurs below surface Types Contusions Hematomas Contusion Produced when blunt force damages dermal structures Blood, fluid leak into damage area causing swelling, pain Presence of blood causes skin discoloration called ecchymosis (bruise) Hematoma “Blood lump” Larger blood vessel damaged Causes mass of blood to collect in the injured area Fist-sized hematoma = 10% volume loss Closed Tissue Injury Considerations How much blood is tied up in that injury rather than circulating in the vessels? What could the force the caused the soft tissue trauma have done to underlying organs? Closed Injury Management Rest Ice Compression Elevate Splint When in doubt assume underlying fractures are present Open Injury Skin broken Protective function lost External bleeding, infection become problems Open Injury Types Abrasions Lacerations Punctures Avulsions Amputations Abrasion Loss of portions of epidermis, upper dermis by rubbing or scraping force. Usually associated with capillary oozing, leaking of fluid “Road rash” Laceration Cut by sharp object or blunt trauma Typically longer than it is deep May be associated with severe blood loss, damage to underlying tissues Types Linear Stellate Punctures Result from stabbing force Wound is deeper than it is long Difficult to assess injury extent Object producing puncture may remain impaled in wound Avulsions Piece of skin torn loose as a flap or completely torn from body Result from accidents with machinery and motor vehicles Replace flap into normal position before bandaging Treat completely avulsed tissue like amputated part Amputations Disruption of continuity of extremity or other body part Part should be wrapped in sterile gauze, placed in plastic bag, transported on top of cold pack Do NOT pack part directly in ice Do NOT let part freeze Open Wound Management BSI Manage ABCs first Control bleeding Prevent further contamination, but do not worry about trying to clean wound Immobilize injured part Mange hypoperfusion if present Dressing and Bandaging Function Stop bleeding. Protect the wound from further damage. Prevent further contamination and infection. Dressings Universal dressing 4 X 4 inch gauze pads Adhesive-type Occlusive Bandages Purpose - holds dressing in place Types Self-adherent bandages Gauze rolls Triangular bandages Adhesive tape Air splint Special Considerations Impaled objects Eviscerations Open chest wounds Neck wounds Gunshot wounds Impaled Objects Do NOT remove Stabilize in place Impaled objects in the eye Cover both eyes Exception Object in cheek Remove, dress inside and outside mouth Eviscerations Internal organs exposed through wound Cover organs with large moistened dressing, then with aluminum foil or dry multitrauma dressing Do NOT use individual 4 x 4’s Do NOT attempt to replace organs Open Chest Wound May prevent adequate ventilation Cover with 3 sided occlusive dressing Monitor patient for signs of air becoming trapped under pressure in chest (tension pneumothorax) If tension pneumothorax develops lift dressing corner to relieve pressure Neck Wounds Risk of severe bleeding from large vessels Risk of air entering vein and moving through heart to lungs Cover with occlusive dressing Do NOT occlude airway or blood flow to brain Suspect presence of spinal injury Gunshot Wound Special type of puncture wound Transmitted energy can cause injury remote from bullet track Bullets change direction, tumble Impossible to assess severity in field or ER Patient must go to OR Burns Critical Factors Burn Depth Superficial (1st Degree) Partial Thickness (2nd Degree) Full Thickness (3rd Degree) Extent % of body that is damaged Burn Depth First Degree (Superficial) Involves only epidermis Red Painful Tender Blanches under pressure Possible swelling, no blisters Heal in ~7 days Burn Depth Second Degree (Partial Thickness) Extends through epidermis into dermis Salmon pink Moist, shiny Painful Blisters may be present Heal in ~7 to 21 days Burn Depth Burns that blister are second degree. But all second degree burns don’t blister. Burn Depth Third Degree (Full Thickness) Through epidermis, dermis into underlying structures Thick, dry Pearly gray or charred black May bleed from vessel damage Painless Require grafting Burn Depth Often cannot be accurately determined in acute stage Infection may convert to higher degree When in doubt, over-estimate Burn Extent Rule of Nines Adult Rule of Nines Pediatric Rule of Nines For each year over 1 year of age, subtract 1% from head, add equally to legs. Burn Extent Rule of Palm Patient’s palm equals 1% of his body surface area Burn Severity Based on Depth Extent Location Cause Patient Age Associated Factors Critical Burns (Require Burn Center) 3rd Degree >10% BSA 2nd Degree > 25% BSA (20% pediatric) Face, Feet, Hands, Perineum, Joints Airway/Respiratory Involvement Associated Trauma Associated Medical Disease Electrical Burns Deep Chemical Burns Moderate Burns 3rd Degree 2 to 10% 2nd Degree 15 to 25% (10 to 20% pediatric) Minor Burns 3rd Degree <2% 2nd Degree <15% (<10% pediatric) Associated Factors Patient Age < 5 years old > 55 years old Burn Location Circumferential burns of chest or extremities MANAGEMENT Stop Burning Process Remove patient from source of injury Remove clothing unless stuck to burn Cut around clothing stuck to burn, leave in place Assess Airway/Breathing Start oxygen if: Moderate or critical burn Decreased level of consciousness Signs of respiratory involvement Burn occurred in closed space History of CO or smoke exposure Assist ventilations as needed Assess Circulation Check for shock signs /symptoms Early shock seldom results from effects of burn itself. Early shock = Another injury until proven otherwise Obtain History How long ago? What has been done? What caused burn? Burned in closed space? Loss of consciousness? Allergies/medications? Past medical history? Rapid Physical Exam Check for other injuries Rapidly estimate burned, unburned areas Remove constricting bands Treat Burn Wound Cover with DRY, CLEAN SHEETS Do NOT rupture blisters Do NOT put oil based products on burn Special Considerations Pediatrics Geriatrics Pediatrics Thin skin, increased severity Large surface to volume ratio Poor immune response Small airways, limited respiratory reserve capacity Consider possibility of abuse Geriatrics Thin skin Poor Circulation Underlying disease processes Pulmonary Peripheral vascular Decreased cardiac reserve Decreased immune response Chemical Burns Concerns Damage to skin Absorption of chemical; systemic toxic effects Avoiding EMS personnel exposure Management Remove chemical from skin Liquids Flush with water Dry chemicals Brush away Flush what remains with water Chemical in Eyes Flush with NS or Ringers No other chemicals in eye Flush out contacts Electrical Burns Electrical Burns Conductive injuries “Tip of Iceberg” Entrance/exit wounds may be small Massive tissue damage between entrance/exit “Tip of the Iceberg” Management Make sure current is off! Check ABCs Assess carefully for other injuries Patient needs hospital evaluation, observation