DMACC EMT Chapter 28

1. PREHOSPITALPREHOSPITAL
EMERGENCY CAREEMERGENCY CARE
CHAPTER
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Prehospital Emergency Care, 10th
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TENTH EDITION
Part I
Bleeding and Soft
Tissue Trauma
28

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Learning ReadinessLearning Readiness
• EMS Education Standards, text p. 772

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Learning ReadinessLearning Readiness
ObjectivesObjectives
• Please refer to page 772 of your text to
view the objectives for this chapter.

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Learning ReadinessLearning Readiness
Key TermsKey Terms
• Please refer to page 772 of your text to
view the key terms for this chapter.

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Setting the StageSetting the Stage
• Overview of Lesson Topics
 External Bleeding
 Internal Bleeding
 Hemorrhagic Shock

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Case Study IntroductionCase Study Introduction
EMTs Mick Horton and Dave Bowling arrive
at the scene of a MVC, and quickly perform
a scene size-up. They have one patient, a
male in his 30s, who was the unrestrained
driver of a an older model truck that struck
a tree along the roadway. There is an EMR
maintaining spinal stabilization, and another
preparing a long backboard and stretcher.
continued on next slide

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Case Study IntroductionCase Study Introduction
Mick's general impression is that the patient
is awake, but confused, and is pale and
sweating, with blood running from his scalp
down onto his neck and clothing.

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Case StudyCase Study
• From the mechanism of injury and
general impression, what conditions
should the EMTs be suspecting?
• What are the priorities in assessing and
managing this patient?
• What are the consequences of failing to
recognize and manage this patient's
problems?

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IntroductionIntroduction
• Bleeding can be a life-threatening
emergency.
• Severe bleeding is controlled in the
primary assessment.
• Most soft tissue injuries are cared for
after the primary assessment.
• Recognizing shock is an important
element of emergency care.

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External BleedingExternal Bleeding
• Always use Standard Precautions for
patients with external bleeding.
continued on next slide

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External bleeding from a soft tissue injury to the head.
continued on next slide

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External BleedingExternal Bleeding
• The severity of blood loss depends
upon:
 Amount of blood loss
 Rate of blood loss
 Other injuries or existing conditions
 Patient's existing medical problems
 Patient's age
continued on next slide

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External BleedingExternal Bleeding
• The severity of bleeding is relative to
the patient's size.
 A 70 kg adult has 4,900 mL of blood
 A 10 kg infant has 800 mL of blood
• A loss of 15% or more of blood volume
is significant.
 ≥735 mL in a 70 kg adult
 ≥120 mL in a 10 kg infant
continued on next slide

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External BleedingExternal Bleeding
• The best way to estimate blood loss is
by assessing the patient's signs and
symptoms.
continued on next slide

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Table 28-1 Classes of Hemorrhage
continued on next slide

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External BleedingExternal Bleeding
• When injured, blood vessels constrict
and blood clots.
• The type and severity of injury can
interfere with these mechanisms.
continued on next slide

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Types of bleeding.
continued on next slide

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External BleedingExternal Bleeding
• Methods of controlling external
bleeding
 Direct pressure
 Tourniquets
 Elevation
 Splints
 Topical hemostatic agents
continued on next slide

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External BleedingExternal Bleeding
• Direct pressure is the first method for
controlling bleeding.
• A pressure dressing can be used.
• Do not apply pressure to or remove
impaled objects.
continued on next slide

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EMT SKILLS 28-1
Bleeding Control by Direct Pressure

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Bleeding from a wound to the forearm.
continued on next slide

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Apply gloved fingertip pressure over a dressing directly on the point of bleeding.
continued on next slide

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If the bleeding does not stop, remove the dressing and apply direct pressure with gloved fingertips to the point of
bleeding.
continued on next slide

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Pack large, gaping wounds with sterile gauze and apply direct pressure.
continued on next slide

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External BleedingExternal Bleeding
• Tourniquets are used when direct
pressure does not control bleeding.
• There are several types of commercial
tourniquets.
• Tourniquets can be improvised if a
commercial tourniquet is not available.
continued on next slide

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EMT SKILLS 28-2
Application of a Tourniquet

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First attempt to control bleeding by direct pressure.
continued on next slide

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If direct pressure is ineffective, apply direct pressure over a thick dressing while preparing the tourniquet.
continued on next slide

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Apply the tourniquet proximal to the wound but not over a joint.
continued on next slide

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Pack large, gaping wounds with sterile gauze and apply direct pressure. Twist the rod to tighten the tourniquet to
the extent necessary to control bleeding and secure the tightening rod. Write the time of tourniquet application
on tape and apply it to the tourniquet, leaving the tourniquet exposed to view, and notify the receiving facility
that a tourniquet has been applied. Continuously reassess the wound for recurrent bleeding. Do not loosen or
remove the tourniquet unless directed to do so by medical direction or local protocol.
continued on next slide

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External BleedingExternal Bleeding
• There is no evidence to support the use
of elevation, but it is not known to be
harmful.
• Do not use elevation as the sole means
of bleeding control.
• Do not elevate an injured extremity
that is not splinted.
continued on next slide

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External BleedingExternal Bleeding
• Splinting is an important way to reduce
bleeding from an injured extremity.
• A traction splint can be helpful for a
fractured femur.
• Do not delay at the scene for splinting
with an unstable patient.
continued on next slide

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External BleedingExternal Bleeding
• Topical hemostatic agents
 Can be used when direct pressure is
ineffective.
 Hemostatic agents promote blood
clotting.
 Use is generally reserved for long
transport times.
 There are some associated
complications.
continued on next slide

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Topical hemostatic agents such as QuikClot can be used with pressure dressings to control bleeding.

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Click on the method that is always used first toClick on the method that is always used first to
control external hemorrhage.control external hemorrhage.
A. Pressure dressing
B. Tourniquet
C. Direct pressure
D. Topical hemostatic agents

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External BleedingExternal Bleeding
• Assessment-based approach
 Ensure that the scene is safe.
 Form a general impression, noting any
signs of shock and presence of
significant bleeding.
 Control significant bleeding immediately.
 Continue with the primary assessment.
continued on next slide

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External BleedingExternal Bleeding
• Assessment-based approach
 Assess the airway and breathing.
 Assess oxygenation and maintain an
SpO2 of 94% or above.
 Assess the pulses and skin.
 Control bleeding, but do not let dramatic
injuries distract you from the primary
assessment.
continued on next slide

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External BleedingExternal Bleeding
• Assessment-based approach
 Perform a rapid secondary assessment
if:
• There is significant bleeding.
• There is altered mental status.
• There are multiple injuries.
• There is a significant mechanism of
injury.
continued on next slide

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External BleedingExternal Bleeding
• Assessment-based approach
 Obtain baseline vital signs.
 Assess for signs of hypoperfusion.
continued on next slide

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External BleedingExternal Bleeding
• Emergency medical care
 Use Standard Precautions.
 Control bleeding with direct pressure.
 If direct pressure is ineffective, apply a
tourniquet.
 Provide care for shock.
 Immobilize injured extremities.
 Reassess.
continued on next slide

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External BleedingExternal Bleeding
• Bleeding from the nose, ears, or mouth
can indicate serious injury.
 Skull injury
 Facial trauma
 Digital trauma to the nose
 Sinusitis
 Hypertension
 Clotting disorders
 Esophageal disease
continued on next slide

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External BleedingExternal Bleeding
• Do not attempt to control bleeding from
the ears or nose if the patient has
experienced a head injury.
• Epistaxis is controlled by direct
pressure.

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EMT SKILLS 28-3
Controlling a Nosebleed

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Have the patient sit and lean forward.
continued on next slide

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Pinch the fleshy part of the nostrils together.

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Internal BleedingInternal Bleeding
• Internal bleeding may result from
trauma or medical problems.
• Internal bleeding may not be obvious,
and can rapidly result in death.
continued on next slide

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Internal BleedingInternal Bleeding
• Common sources of internal bleeding
are injured organs and fractured
extremities.
• A hematoma is a contained collection of
blood that can contain a significant
amount of blood.
• Use signs and symptoms to estimate
severity of blood loss.
continued on next slide

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Internal BleedingInternal Bleeding
• Assessment-based approach
 Perform a scene size-up; look for a
mechanism of injury.
 Form a general impression.
 Immediately control major external
bleeding.
 Pay close attention to the mental status.
continued on next slide

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Internal BleedingInternal Bleeding
• Assessment-based approach
 Assess airway, breathing, and
oxygenation.
 Assess the pulses, skin, and capillary
refill.
 Pay attention to changes in the
respirations, pulse, and skin that can
indicate blood loss.
continued on next slide

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Internal BleedingInternal Bleeding
• Assessment-based approach
 Perform a rapid secondary assessment if
the mechanism of injury and
assessment suggest internal bleeding.
continued on next slide

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Internal BleedingInternal Bleeding
• Assessment-based approach
 Look for external indications that there
is internal bleeding.
• Contusions
• Abrasions
• Deformity
• Impact marks
• Swelling
continued on next slide

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Internal BleedingInternal Bleeding
• Assessment-based approach
 Signs and symptoms of internal bleeding
• Pain, tenderness, swelling, discoloration
• Bleeding from a bodily orifice
• Vomiting; bright red or coffee-ground
material
continued on next slide

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Internal BleedingInternal Bleeding
• Assessment-based approach
 Signs and symptoms of internal bleeding
• Dark tarry stools or stools with bright red
blood
• Tender, rigid, or distended abdomen
continued on next slide

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Internal BleedingInternal Bleeding
• Assessment-based approach
 Signs and symptoms of hemorrhagic
shock
• Anxiety, restlessness, combativeness,
altered mental status
• Weakness, faintness, dizziness
• Thirst
continued on next slide

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Internal BleedingInternal Bleeding
• Assessment-based approach
 Signs and symptoms of hemorrhagic
shock
• Shallow, rapid breathing
• Thirst
• Shallow, rapid breathing
• Rapid, thready pulse
continued on next slide

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Internal BleedingInternal Bleeding
• Assessment-based approach
 Signs and symptoms of hemorrhagic
shock
• Pale, cool, clammy skin
• Delayed capillary refill
• Narrow pulse pressure
• Dropping blood pressure
• Dilated, sluggish pupils
• Nausea, vomiting
continued on next slide

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Internal BleedingInternal Bleeding
• Emergency medical care
 Use Standard Precautions.
 Maintain an open airway and adequate
breathing.
 Administer oxygen if there are signs of
poor perfusion or to maintain an SpO2 of
94% or above.
continued on next slide

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Internal BleedingInternal Bleeding
• Emergency medical care
 Control external bleeding.
 Provide immediate transport.
 Treat for shock.
 Reassess.

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Factors that May IncreaseFactors that May Increase
BleedingBleeding
• Movement
• Low body temperature
• Medications
• Intravenous fluids
• Removal of dressings and bandages

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Hemorrhagic ShockHemorrhagic Shock
• Shock results from inadequate tissue
perfusion.
• Significant hemorrhage leads to
inadequate perfusion.
• Cells are deprived of oxygen and
nutrients, and begin to fail and die.
• Immediate recognition and treatment
are critical.
continued on next slide

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Continuous cycle of shock.
continued on next slide

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Hemorrhagic ShockHemorrhagic Shock
• Assessment-based approach
 Evaluate scene safety and the
mechanism of injury.
 Assess the mental status, airway,
breathing, oxygenation, and circulation.
 Assist breathing and administer oxygen,
as needed.
continued on next slide

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Hemorrhagic ShockHemorrhagic Shock
• Assessment-based approach
 For unstable patients, perform a rapid
secondary assessment.
 Obtain baseline vital signs; loss of
>15% of blood volume will cause
changes in vital signs.
continued on next slide

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Hemorrhagic ShockHemorrhagic Shock
• Signs and symptoms
 Mental status
• Restlessness
• Anxiety
• Altered mental status
continued on next slide

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Hemorrhagic ShockHemorrhagic Shock
• Signs and symptoms
 Peripheral perfusion
• Pale, cool, clammy skin
• Weak thready, or absent peripheral
pulses
• Delayed capillary refill
continued on next slide

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Hemorrhagic ShockHemorrhagic Shock
• Signs and symptoms
 Vital signs
• Increased pulse rate; weak, thready
pulse
• Increased breathing rate; deep, shallow,
labored, or irregular breathing
• Narrow pulse pressure
• Decreased blood pressure
continued on next slide

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Hemorrhagic ShockHemorrhagic Shock
• Signs and symptoms
 Other signs and symptoms
• Dilated pupils
• Thirst
• Nausea, vomiting
• Pallor; cyanosis of the lips
continued on next slide

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Hemorrhagic ShockHemorrhagic Shock
• Emergency medical care
 Use Standard Precautions.
 Maintain an open airway, administer
oxygen, and assist ventilations as
needed.
 Control external bleeding.
 Apply and inflate PASG according to
protocol.
continued on next slide

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Hemorrhagic ShockHemorrhagic Shock
• Emergency medical care
 Place the patient supine.
 Splint bone and joint injuries.
 Keep the patient warm.
 Transport immediately.
continued on next slide

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EMT SKILLS 28-4
Emergency Care for Shock

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Take all necessary Standard Precautions.

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Administer supplemental oxygen or positive pressure ventilation as indicated.

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Cover the patient to prevent loss of body heat.

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Hemorrhagic ShockHemorrhagic Shock
• Pneumatic antishock garment (PASG)
 Controversial device used in some cases
of hemorrhagic shock
 Follow protocols.
continued on next slide

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A pneumatic antishock garment (PASG).
continued on next slide

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Hemorrhagic ShockHemorrhagic Shock
• PASG indications
 Suspected pelvic fracture with SBP <90
mmHg
 Suspected intraperitoneal hemorrhage
with hypotension
 Suspected retroperitoneal hemorrhage
with hypotension
continued on next slide

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Hemorrhagic ShockHemorrhagic Shock
• PASG contraindications
 Penetrating thoracic trauma
 Splinting of lower extremity fractures
 Eviscerated abdominal organs
 Impaled object in the abdomen
continued on next slide

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Hemorrhagic ShockHemorrhagic Shock
• PASG contraindications
 Pregnancy
 Cardiopulmonary arrest
 Congestive heart failure
 Pulmonary edema
continued on next slide

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Hemorrhagic ShockHemorrhagic Shock
• Do not deflate PASG once it has been
inflated unless ordered to do so by
medical direction.
• Contact medical direction about
deflation if:
 You suspect ruptured diaphragm.
 The patient experiences respiratory
distress after inflation.

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EMT SKILLS 28-5
Applying the PASG

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Place the PASG on the spine board, then the patient on the PASG. Position so the top of the garment is three
finger-widths below the bottom of the rib cage.
continued on next slide

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Apply the garment.
continued on next slide

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Inflate the garment.
continued on next slide

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Monitor and record vital signs every 5 minutes. If the garment loses pressure, add air as needed.

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Case Study ConclusionCase Study Conclusion
Mick ensures that the patient has an open
airway and adequate breathing as Dave applies
direct pressure to the scalp wound. Mick
detects a weak, thready, rapid radial pulse. He
performs a rapid secondary assessment, noting
tenderness to the chest and abdomen.
Breath sounds are present on both sides, but
seem to be deceased on the right side. There
are swelling, deformity, and tenderness of the
right femur and right lower leg.
continued on next slide

86. Prehospital Emergency Care, 10th
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Mistovich | Karren
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Case Study ConclusionCase Study Conclusion
The EMTs recognize indications of significant
internal bleeding, and rapidly extricate the
patient, securing him to a long backboard. They
begin transport immediately, applying oxygen
by nonrebreather mask, assessing baseline vital
signs, and performing a head-to-toe secondary
assessment.
continued on next slide

87. Prehospital Emergency Care, 10th
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Case Study ConclusionCase Study Conclusion
At the emergency department, the patient
receives a chest tube for a right pneumothorax,
then is quickly prepared for surgery to repair
damage to his liver and right leg.

88. Prehospital Emergency Care, 10th
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Lesson SummaryLesson Summary
• Hypoperfusion and shock can result
from blood loss.
• Bleeding can be arterial, venous, or
capillary.
• Bleeding can be external or internal.
• The first method of controlling external
bleeding is direct pressure.
continued on next slide

89. Prehospital Emergency Care, 10th
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Lesson SummaryLesson Summary
• Tourniquets and hemostatic agents are
only used if direct pressure is not
effective for on-going significant
bleeding.

90. PREHOSPITALPREHOSPITAL
EMERGENCY CAREEMERGENCY CARE
CHAPTER
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Prehospital Emergency Care, 10th
edition
Mistovich | Karren
TENTH EDITION
Part II
Bleeding and Soft
Tissue Trauma
28

91. Prehospital Emergency Care, 10th
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Learning ReadinessLearning Readiness
• EMS Education Standards, text p. 772

92. Prehospital Emergency Care, 10th
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Learning ReadinessLearning Readiness
ObjectivesObjectives
• Please refer to page 772 of your text to
view the objectives for this chapter.

93. Prehospital Emergency Care, 10th
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Learning ReadinessLearning Readiness
Key TermsKey Terms
• Please refer to page 772 of your text to
view the key terms for this chapter.

94. Prehospital Emergency Care, 10th
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Setting the StageSetting the Stage
• Overview of Lesson Topics
 Open Soft Tissue Trauma
 Closed Soft Tissue Trauma
 Dressings and Bandages

95. Prehospital Emergency Care, 10th
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Mistovich | Karren
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Case Study IntroductionCase Study Introduction
Seven-year-old Tara Lambert shrieks as her
older brother, Denny, chases her through the
living room. She is taken by surprise as she
slips on a rug in the entryway. Losing her
balance, she falls hands-first into the panes of
glass in the door. The glass shatters as Tara's
left hand and forearm break through it. She sits
down, stunned, as blood begins pouring out
from a long laceration below the crease of her
elbow.
"Mom!" Denny screams. "Come quick!"

96. Prehospital Emergency Care, 10th
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Case StudyCase Study
• What will be the EMTs' first steps as
they arrive at the scene?
• What methods do EMTs have to control
bleeding?
• Once bleeding is controlled, what other
treatment should EMTs perform?

97. Prehospital Emergency Care, 10th
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IntroductionIntroduction
• Soft tissue injuries may be closed or
open.
• The appearance of soft tissue injuries
can be dramatic, but don't be distracted
from the priorities of care.
• Dressings and bandages are used to
help control bleeding and prevent
further wound contamination.

98. Prehospital Emergency Care, 10th
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Soft Tissue TraumaSoft Tissue Trauma
• Skin functions
 Protects the body from the environment
and organisms
 Helps regulate body temperature
 Senses heat, cold, touch, pressure, pain
 Assists in elimination of water and salts
continued on next slide

99. Prehospital Emergency Care, 10th
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Soft Tissue TraumaSoft Tissue Trauma
• Skin layers
 Epidermis
 Dermis
 Subcutaneous layer
continued on next slide

100. Prehospital Emergency Care, 10th
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Soft Tissue TraumaSoft Tissue Trauma
• Soft tissue injuries can be open or
closed.

101. Prehospital Emergency Care, 10th
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EMT SKILLS 28-6
Soft Tissue Injuries

102. Prehospital Emergency Care, 10th
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During a street altercation, one participant struck the other with a tire iron—blunt trauma resulting in an open
soft tissue injury to the arm.

103. Prehospital Emergency Care, 10th
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This patient, a salesman in a sporting goods store, was demonstrating a bow with a carbon fiber arrow. During
the demonstration, the apparatus broke, releasing the arrow that penetrated the patient's hand. (© Charles
Stewart, MD, FACEP)

104. Prehospital Emergency Care, 10th
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This patient, a salesman in a sporting goods store, was demonstrating a bow with a carbon fiber arrow. During
the demonstration, the apparatus broke, releasing the arrow that penetrated the patient's hand. (© Charles
Stewart, MD, FACEP)

105. Prehospital Emergency Care, 10th
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Closed Soft Tissue InjuryClosed Soft Tissue Injury
• In closed injuries, there is no break in
the skin.
• Three types of closed injury
 Contusions
 Hematomas
 Crush injuries
continued on next slide

106. Prehospital Emergency Care, 10th
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Closed Soft Tissue InjuryClosed Soft Tissue Injury
• Contusions
 A bruise
 Injury to blood vessels in the dermis
 Swelling, discoloration (ecchymosis)
continued on next slide

107. Prehospital Emergency Care, 10th
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Contusions.
continued on next slide

108. Prehospital Emergency Care, 10th
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Closed Soft Tissue InjuryClosed Soft Tissue Injury
• Hematoma
 Involves larger blood vessels and areas
of tissue than a contusion
 A pocket of blood forms beneath the
skin, and can separate the tissues.
 Presents as a lump with discoloration
continued on next slide

109. Prehospital Emergency Care, 10th
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Closed Soft Tissue InjuryClosed Soft Tissue Injury
• Crush injury
 Results from significant blunt trauma or
crushing force
 May be open or closed
 Serious damage to underlying tissues
 Internal bleeding
continued on next slide

110. Prehospital Emergency Care, 10th
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Closed Soft Tissue InjuryClosed Soft Tissue Injury
• Assessment-based approach
 Perform a scene size-up; look for
mechanism of injury.
 Perform spinal stabilization, if indicated.
 Primary assessment
 Secondary assessment
continued on next slide

111. Prehospital Emergency Care, 10th
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Closed Soft Tissue InjuryClosed Soft Tissue Injury
• Emergency medical care
 Standard Precautions
 Ensure an open airway, adequate
breathing, and maintain oxygenation.
 Treat for shock, if indicated.
 Splint suspected fractures.
 Reassess.

112. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• In open injuries, the continuity of the
skin is broken.
• Open injuries are at risk for external
bleeding and contamination.
• An open injury may be a sign of a
deeper underlying injury.
continued on next slide

113. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Six types of open injuries
 Abrasions
 Lacerations
 Avulsions
 Amputations
 Penetrations/punctures
 Crush injuries
continued on next slide

114. Prehospital Emergency Care, 10th
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Classification of open injuries.
continued on next slide

115. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Abrasion
 Caused by scraping or rubbing way the
epidermis
 Superficial, but painful
 Bleeding is easily controlled
 If large areas of the body are involved,
infection is a concern.
continued on next slide

116. Prehospital Emergency Care, 10th
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Abrasions.
continued on next slide

117. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Laceration
 A break in the skin
 Depth may vary
 May be linear or stellate
 Bleeding can be significant
continued on next slide

118. Prehospital Emergency Care, 10th
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Lacerations and deep abrasions.
continued on next slide

119. Prehospital Emergency Care, 10th
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Lacerations to the leg.
continued on next slide

120. Prehospital Emergency Care, 10th
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Lacerations to the face.
continued on next slide

121. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Avulsion
 A flap of skin is torn loose or pulled off
completely.
 Bleeding can be severe.
 Healing can be prolonged and scarring
may be extensive.
continued on next slide

122. Prehospital Emergency Care, 10th
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Forearm avulsion.
continued on next slide

123. Prehospital Emergency Care, 10th
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Ring avulsion.
continued on next slide

124. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Amputations
 Disruption in the continuity of an
extremity or other body part
 Result from ripping or tearing forces
 Bleeding can be minimal or massive.
 May be partial or complete
continued on next slide

125. Prehospital Emergency Care, 10th
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Finger amputation.
continued on next slide

126. Prehospital Emergency Care, 10th
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Finger amputations.
continued on next slide

127. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Penetrations/punctures
 Result from a sharp, pointed object
pushed or driven into the soft tissues
 The entry wound may be small, but
underlying damage and be severe.
continued on next slide

128. Prehospital Emergency Care, 10th
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Penetration/puncture wound to the chest. (© Edward T. Dickinson, MD)
continued on next slide

129. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Gunshot wounds are a type of
penetrating/puncture wound.
 There may be entrance and exit
wounds.
 Always assess for the possibility of
multiple gunshot wounds.
continued on next slide

130. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Stab wounds can be hidden.
 Expose the patient for assessment.
 Assess for underlying injuries and
hemorrhagic shock.
continued on next slide

131. Prehospital Emergency Care, 10th
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EMT SKILLS 28-7
Gunshot Wounds
continued on next slide

132. Prehospital Emergency Care, 10th
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Powder burns from gunshot. (© Edward T. Dickinson, MD)
continued on next slide

133. Prehospital Emergency Care, 10th
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Gunshot entrance wound to the chest. (© Edward T. Dickinson, MD)
continued on next slide

134. Prehospital Emergency Care, 10th
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Gunshot exit wound from the shoulder. (© Edward T. Dickinson, MD)
continued on next slide

135. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Crush injuries
 The affected part may be painful,
swollen, and deformed; bleeding can be
minimal or absence.
 Suspect internal injuries and bleeding.
 Shock can develop rapidly when the
crushing object is lifted from the
patient.
continued on next slide

136. Prehospital Emergency Care, 10th
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Crush injury, open wound. (© Edward T. Dickinson, MD)
continued on next slide

137. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Other soft tissue injuries
 Dog bites can be complicated by
infection, cellulitis, septicemia, and
concerns of rabies and tetanus.
 Human bites can result in infection and
hepatitis.
continued on next slide

138. Prehospital Emergency Care, 10th
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Dog bite to a child’s face.
continued on next slide

139. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Clamping injuries
 A body part is caught or strangled in
machinery.
 Often include a finger or hand.
 Removal becomes more difficult with
time because of swelling.
continued on next slide

140. Prehospital Emergency Care, 10th
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Clamping injury.
continued on next slide

141. Prehospital Emergency Care, 10th
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Click on the type of injury that occurs when a flapClick on the type of injury that occurs when a flap
of skin is partially or completely torn away fromof skin is partially or completely torn away from
the body.the body.
A. Laceration
B. Avulsion
C. Abrasion
D. Amputation

142. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Assessment-based approach
 Ensure scene safety and evaluate the
mechanism of injury.
 Perform spinal stabilization, if indicated.
 Form a general impression.
 Ensure adequate airway, breathing, and
oxygenation.
continued on next slide

143. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Assessment-based approach
 Secondary assessment
• For an unstable patient or significant
mechanism of injury, perform a rapid
secondary assessment.
• For a stable patient without significant
mechanism of injury, perform a modified
secondary assessment.
continued on next slide

144. Prehospital Emergency Care, 10th
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Copyright © 2014, 2010, 2008 by Pearson Education, Inc.
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Emergency medical care
 Use Standard Precautions.
 Ensure an open airway and adequate
breathing and oxygenation.
 Expose the wound.
 Control bleeding with direct pressure.
 Prevent further contamination.
continued on next slide

145. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Emergency medical care
 Dress and bandage the wound.
 Keep the patient calm and quiet.
 Treat for hemorrhagic shock, if
appropriate.
 Transport.
 Reassess.
continued on next slide

146. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Penetrating chest wounds
 Use an occlusive dressing to prevent air
from entering through the wound.
 Secure the dressing with tape on three
sides.
 Position the patient according to his
condition and comfort.
continued on next slide

147. Prehospital Emergency Care, 10th
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Open chest injury with occlusive dressing taped on three sides. (© Shout Picture Library)

148. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Abdominal evisceration
 Do not touch or try to replace the
organs.
continued on next slide

149. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Abdominal evisceration
 Cover the exposed organs with a sterile
dressing moistened with sterile water or
saline.
• Do not use absorbent materials.
• Cover the moist dressing with an
occlusive dressing taped on four sides.
• Maintain the temperature of the affected
area.
continued on next slide

150. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Abdominal evisceration
 Flex the patient's hips and knees if not
contraindicated by other injuries.
continued on next slide

151. Prehospital Emergency Care, 10th
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Cover the abdominal organs with a moist sterile dressing and an occlusive covering.

152. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Impaled object
 Do not remove unless it is in the cheek
or neck and obstructing airflow through
the airway.
 Stabilize the object in place.
continued on next slide

153. Prehospital Emergency Care, 10th
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An impaled object in the cheek may be removed. Dress outside of wound and inside between cheek and teeth.
continued on next slide

154. Prehospital Emergency Care, 10th
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EMT SKILLS 28-8
Stabilizing an Impaled Object
continued on next slide

155. Prehospital Emergency Care, 10th
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An impaled kitchen knife.
continued on next slide

156. Prehospital Emergency Care, 10th
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Cut away clothing.
continued on next slide

157. Prehospital Emergency Care, 10th
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Stabilize and bandage the object in place.
continued on next slide

158. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Amputations
 Care for the patient and the amputated
part.
 Some amputated parts can be
reattached, if cared for properly.
continued on next slide

159. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Caring for amputated parts
 Remove gross contamination by flushing
with sterile water or saline.
 Wrap the part in dry, sterile gauze.
 Wrap or bag the part in plastic.
 Keep the amputated part cool.
 Transport the part with the patient, if
possible.
 Never complete a partial amputation.
continued on next slide

160. Prehospital Emergency Care, 10th
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Emergency care for amputated part. Follow local protocol.
continued on next slide

161. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Open neck wounds
 Bleeding may be severe.
 Air can be sucked into damaged veins,
causing an air embolism.
continued on next slide

162. Prehospital Emergency Care, 10th
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Open wound to the neck.

163. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Caring for open neck wounds
 Use a gloved hand to control bleeding.
 Apply an occlusive dressing, taped on
four sides.
 Cover the occlusive dressing with a
regular dressing.
continued on next slide

164. Prehospital Emergency Care, 10th
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Open Soft Tissue InjuryOpen Soft Tissue Injury
• Caring for open neck wounds
 Apply only enough pressure to control
bleeding.
 Once bleeding is controlled, apply a
pressure dressing; do not use a
circumferential dressing.
 Provide spinal immobilization if
appropriate.

165. Prehospital Emergency Care, 10th
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Case StudyCase Study
EMTs arrive to find a pale and sobbing Tara
sitting on the floor. Her mother is kneeling next
to her, holding a blood-soaked hand towel
around her arm.
"Please help," her mother says. "I can't seem to
get the bleeding to stop."
"Okay. We're here to help," says one of the
EMTs as he removes the towel and uses his
gloved fingertips to firmly apply pressure to the
laceration. His partner pulls out packages of
sterile gauze to help with bleeding control.
continued on next slide

166. Prehospital Emergency Care, 10th
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Case StudyCase Study
• Once bleeding is under control, what
guidelines should the EMTs follow in
applying dressings and bandages?

167. Prehospital Emergency Care, 10th
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Dressing and BandagesDressing and Bandages
• Dressings
 Cover the wound to help control
bleeding and prevent further
contamination.
 Should be sterile
 Various types of dressings are available.
continued on next slide

168. Prehospital Emergency Care, 10th
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Sterile gauze pads.
continued on next slide

169. Prehospital Emergency Care, 10th
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Multitrauma dressings.
continued on next slide

170. Prehospital Emergency Care, 10th
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Materials that can be used as occlusive dressings.
continued on next slide

171. Prehospital Emergency Care, 10th
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Dressing and BandagesDressing and Bandages
• Bandages
 Used to secure dressings
 Should be clean and free of debris
 Various types are available.
continued on next slide

172. Prehospital Emergency Care, 10th
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Nonelastic, self-adhering dressing and roller bandages.
continued on next slide

173. Prehospital Emergency Care, 10th
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EMT SKILLS 28-9
Bandaging
continued on next slide

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Head and/or eye bandage.
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175. Prehospital Emergency Care, 10th
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Head and/or ear bandage.
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Cheek bandage (be sure the mouth will open).
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Hand bandage.
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Shoulder bandage.
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Foot and/or ankle bandage.
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180. Prehospital Emergency Care, 10th
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Knee bandage.
continued on next slide

181. Prehospital Emergency Care, 10th
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Dressing and BandagesDressing and Bandages
• Applying a pressure dressing
 Cover the wound with sterile dressings.
 Apply direct pressure over the wound to
control bleeding.
 Bandage firmly to maintain bleeding
control; reassess pulses.
 If blood soaks through, remove the
dressings and apply fingertip pressure.
continued on next slide

182. Prehospital Emergency Care, 10th
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Triangular bandage as cravat.
continued on next slide

183. Prehospital Emergency Care, 10th
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Dressing and BandagesDressing and Bandages
• General principles
 Sterile materials are preferred.
 Do not apply a bandage until bleeding is
controlled.
 A dressing should cover the entire
wound.
 Remove all jewelry from the injured
part.
 Do not bandage too loosely.
continued on next slide

184. Prehospital Emergency Care, 10th
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Dressing and BandagesDressing and Bandages
• General principles
 Bandage snugly, but not too tightly.
 If the wound is small, use a wider
bandage to avoid creating a pressure
point.
 Position the part before bandaging.
 If bleeding is not controlled with direct
pressure, apply a tourniquet.

185. Prehospital Emergency Care, 10th
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Case Study ConclusionCase Study Conclusion
After several minutes of direct pressure, the
bleeding from the laceration is under
control. Meanwhile, the EMTs have assessed
Tara for other injuries and obtained a
baseline set of vital signs.
Tara's color has improved, and her sobs
have diminished to occasional sniffles. Her
heart rate is 96, respirations 20, and BP
94/74. Her skin is warm and moist, and her
SpO2 is 100%.
continued on next slide

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Case Study ConclusionCase Study Conclusion
The EMTs apply a snug pressure dressing
and splint the arm, then recheck Tara's
pulse, motor, and sensory function below the
injury.
The EMTs transport Tara to the emergency
department, where she receives 22 stitches
to close the wound in her arm. Fortunately,
there was no damage to the arteries,
nerves, or tendons, and the wound is
expected to heal without complications.

187. Prehospital Emergency Care, 10th
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Lesson SummaryLesson Summary
• Soft tissue injuries can be closed or
open.
• Closed injuries include contusions,
hematomas, and crush injuries.
• Open injuries include abrasions,
avulsions, amputations, lacerations,
punctures/penetrations, and crush
injuries.
continued on next slide

188. Prehospital Emergency Care, 10th
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Lesson SummaryLesson Summary
• Do not let the appearance of soft tissue
injuries distract you from the priorities
of patient care.
• Dressings and bandages are used to
help control bleeding and prevent
further contamination of wounds.