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Ch05 soft tissue injury shorter


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Ch05 soft tissue injury shorter

  1. 1. Paramedic Care: Principles & Practice Volume 5 Trauma Emergencies
  2. 2. Chapter 5 Soft-Tissue Trauma
  3. 3. Topics Introduction to Soft-Tissue Injuries Anatomy and Physiology of Soft-Tissue Injuries Pathophysiology of Soft-Tissue Injury Dressing and Bandage Materials Assessment of Soft-Tissue Injuries Management of Soft-Tissue Injury
  4. 4. Introduction to Soft-Tissue Injuries
  5. 5. Introduction to Soft-Tissue Injuries Skin is the largest organ 16% of total body weight Function: – Protection Body fluids in Bad stuff out (pathogens) – Sensation – Temperature regulation
  6. 6. Introduction to Soft-Tissue Injury Epidemiology – Open wounds – Closed wounds More common Contusions, sprains, strains – Risk factors for soft-tissue wounds Age Alcohol and drug abuse Occupation – Prevention
  7. 7. Anatomy and Physiology of Soft-Tissue Injuries
  8. 8. Anatomy and Physiology of Soft-Tissue Injuries Layers of the Skin – Epidermis – Dermis – Subcutaneous
  9. 9. Anatomy and Physiology of Soft-Tissue Injuries Blood Vessels – Arteries – Arterioles – Capillaries – Venules – Veins Layers – Tunica intima – Tunica media – Tunica adventitia Click here to view the anatomy of blood vessels.
  10. 10. Anatomy and Physiology of Soft-Tissue Injuries Muscles – Beneath skin layers – Fascia Thick, fibrous, inflexible membrane surrounding muscle that aids in binding muscle groups together
  11. 11. Anatomy and Physiology of Soft-Tissue Injuries Tension Lines Lacerations across the tension lines have a tendency to be pulled apart. Lacerations parallel to the tension lines tend to gape very little.
  12. 12. Pathophysiology of Soft-Tissue Injury
  13. 13. Pathophysiology of Soft-Tissue Injury
  14. 14. Pathophysiology of Soft-Tissue Injury Closed Wounds – Contusions Blunt, nonpenetrating injuries that crush and damage small blood vessels Characterized by erythema and ecchymosis © Edward T. Dickinson, MD
  15. 15. Closed Wounds Hematoma – ‘HEMATOMATA’ – Blood separates tissue and pool in a pocket Dangerous in head injuries Some may cause hypovolemia
  16. 16. Pathophysiology of Soft-Tissue Injury Open Wounds – Abrasion Typically the most minor of injuries Carries the danger of serious infection – Laceration Penetrates more deeply into the dermis than an abrasion Endangers the deeper and more significant vasculature, nerves, muscles, tendons, ligaments, and organs © Charles Stewart, MD
  17. 17. Open Wounds Incision – A surgically smooth laceration Puncture – A small entrance wound with damage that extends into the body’s interior – A puncture additionally carries an increased danger of infection
  18. 18. Open Wounds Impaled Object – A wound complication often associated with a puncture or laceration – May cause worsening damage if withdrawn © Charles Stewart, MD
  19. 19. Open Wounds Avulsion – A flap of skin, although torn or cut, is not torn completely loose from the body – Degloving injury Ring injury
  20. 20. Open Wounds Amputations – Partial or complete severance of a digit or limb – Hemorrhage associated with the amputation may be limited – Care is used to ensure that the stump will be as functional as possible © Mark C. Ide
  21. 21. Pathophysiology of Soft-Tissue Injury Hemorrhage – Arterial – Venous – Capillary The nature of the soft-tissue wound may be more important than the size or type of vessel involved – Clean lacerations and amputations generally do not bleed profusely
  22. 22. Pathophysiology of Soft-Tissue Injury Wound Healing – Hemostasis Vessels have a muscular layer that reflexively constricts the vessel in response to local injury Platelets begin the clotting process Stick to the vessel wall and to one another forming a plug Proteins activate a complicated series of enzyme reactions Coagulation
  23. 23. Wound Healing Inflammation – Involves a host of elements Various kinds of white blood cells Proteins involved in immunity Hormone-like chemicals that signal other cells to mobilize – Chemotactic factors Recruit cells Granulocytes and macrophages Phagocytosis
  24. 24. Wound Healing Inflammation (cont.) – Lymphocytes and immunoglobins – Histamine dilates precapillary blood vessels Increases blood flow to affected area Brings much-needed oxygen and more phagocytes to the injured area
  25. 25. Wound Healing Result of the inflammatory stage – Clearing away of dead and dying tissue – Removal of bacteria and other foreign substances – Preparation of the damaged area for rebuilding
  26. 26. Wound Healing Epithelialization – Epithelial cells migrate over the surface of the wound Restores a uniform layer of skin cells along the edges of the healing wound – The new epithelial layer is not a perfect facsimile of the original, undamaged skin Usually quite functional and cosmetically similar
  27. 27. Wound Healing Neovascularization – New growth of capillaries in response to healing – Neovascularized tissue is very fragile and has a tendency to bleed easily Collagen Synthesis – Fibroblasts: Cells that form collagen – Remodeling
  28. 28. Wound Healing Process
  29. 29. Pathophysiology of Soft-Tissue Injury Infection – serious complication of open wounds – 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
  30. 30. Infection Risk factors – Host’s health and pre-existing illnesses Diabetics, the infirm, the elderly, and individuals with serious chronic diseases – Wound type and location Well-vascularized areas such as the face and scalp are very resistant to infection Distal areas such as extremities heal more slowly – Associated contamination – Treatment provided
  31. 31. Infection 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
  32. 32. Pathophysiology of Soft-Tissue Injury Other Wound Complications – Impaired hemostasis Medications can interfere with hemostasis and the clotting process Aspirin, anticoagulants, fibrinolytics, and penicillins Abnormalities in proteins involved in the fibrin formation cascade may result in delayed clotting Hemophilia
  33. 33. Other Wound Complications Re-bleeding – Re-bleeding is possible from any wound Movement of underlying structures Hemorrhage continues in large wounds unnoticed Postoperative wounds Delayed healing – Patients at risk include: Diabetics, the elderly, the chronically ill, and the malnourished
  34. 34. Main Concepts of this Chapter Crush Injury Compartment Syndrome Crush Syndrome Rhabdomyalosis
  35. 35. Crush Injury A body part is compressed, injuring muscles, blood vessels, bones, and other internal structures © Edward T. Dickinson, MD
  36. 36. Pathophysiology of Soft-Tissue Injury Crush Injury – Body tissues subjected to severe compressive forces – A crush injury disrupts the body’s tissues Creates an excellent growth medium for bacteria – Tissue hypoxia and acidosis may result in muscle rigor
  37. 37. Crush Injury Associated Injury – Additional fractures – Open or closed soft-tissue injuries – Direct injury Blunt and penetrating – Dehydration and hypothermia
  38. 38. Compartment Syndrome Extremity injury causes significant edema and swelling in the deep tissues Pressure in the compartment will rise Results in decreased blood flow and ischemia
  39. 39. Care of Specific Wounds Compartment Syndrome – Likely 4–8 hours post-injury – 30 mmHg – Symptom Severe pain out of proportion with physical exam findings 6 Ps Pain Paresthesia- numbness Pallor Pressure Paralysis Pulses Normal motor and sensory function
  40. 40. Care of Specific Wounds Compartment Syndrome (cont.) – Management Care of underlying injury Splint and immobilize all suspected fractures Cold packs to severe contusions: Most effective prehospital management Reduces edema Prevents ischemia
  41. 41. Pathophysiology of Soft-Tissue Injury Crush Syndrome – Body is entrapped for >4 hours – Crushed muscle tissue becomes necrotic Resultant release of metabolic byproducts traumatic rhabdomyolysis – By-products of cellular destruction Myoglobin Phosphate and potassium Lactic acid Uric acid
  42. 42. Care of Specific Wounds Crush Syndrome – Anticipate problems – Victims of prolonged entrapment – Ensure that scene is safe – 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
  43. 43. Crush Sydrome Hypovolemia Hyperkalemia Hypocalcemia Acidosis Renal Failure
  44. 44. Care of Specific Wounds Crush Syndrome – Management IV: 20–30 mL/kg of NS or D51/2 NS AVOID LR or K+ based solutions After bolus, continuous infusion of 20 mL/kg/hr Consider sodium bicarbonate Consider calcium chloride: 500 mg IVP Counteracts hyperkalemia Consider diuretics: Mannitol (Osmotrol) Furosemide (Lasix)
  45. 45. Care of Specific Wounds Crush Syndrome – Management IV: 20–30 mL/kg of NS or D51/2 NS AVOID LR or K+ based solutions After bolus, continuous infusion of 20 mL/kg/hr Consider sodium bicarbonate Consider calcium chloride: 500 mg IVP Counteracts hyperkalemia Consider diuretics: Mannitol (Osmotrol) Furosemide (Lasix)
  46. 46. Rhabdomyolysis Breakdown of muscle cells Liberation of injured muscle into circulation
  47. 47. Rhabdomyolysis Muscle stretching – Influx of Ca++ and Na+ – Cells swell up Ischemia Anaerobic metabolism May be due by electrical current
  48. 48. Pathophysiology of Soft-Tissue Injury Injection Injury – High-pressure line bursts – Injects fluid or other substance into skin and into subcutaneous tissue
  49. 49. Dressing and Bandage Materials
  50. 50. Dressing and Bandage Materials 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
  51. 51. Dressing and Bandage Materials Wet/Dry Dressings – Wet: burns, postoperative wounds (sterile NS) – Dry: most common 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
  52. 52. Assessment of Soft-Tissue Injuries
  53. 53. Assessment of Soft-Tissue Injuries Scene Size-up – Rule out or eliminate any threats to yourself or fellow care providers – Determine the mechanism of injury – Standard Precautions
  54. 54. Assessment of Soft-Tissue Injuries Initial Assessment – Establishing manual cervical in-line immobilization – Form a general impression – Assess the airway, breathing, and circulation – Correct any immediate threats to the patient’s life
  55. 55. Assessment of Soft-Tissue Injuries Focused History and Physical Exam – Significant MOI Rapid trauma assessment Perform a swift evaluation of the patient’s head, neck, chest, abdomen, pelvis, extremities, and posterior body Confirm the decision either to transport the patient immediately with further care provided en route to the hospital
  56. 56. Assessment of Soft-Tissue Injuries Focused History and Physical Exam – No significant MOI Focused trauma assessment Use the examination techniques of inquiry, inspection, and palpation to evaluate the injury and the surrounding area Check the distal extremity for pulses, capillary refill, color, and temperature Transport Decision
  57. 57. Assessment of Soft-Tissue Injuries Detailed Physical Exam – Detailed exam should follow a planned and comprehensive process – The detailed physical exam is usually performed during transport Never delay transport to perform it
  58. 58. Assessment of Soft-Tissue Injuries Assessment Techniques – Inquiry The mechanism of injury, any pain, pain on touch or movement, and any loss of function or sensation specific to an area – Inspection Carefully observing a particular body region – Palpation Palpate the body’s entire surface
  59. 59. Assessment of Soft-Tissue Injuries Ongoing Assessment – Reassess the patient’s mental status, airway, breathing, and circulation – Inspect any interventions you have performed – Perform at least every 5 minutes with unstable patients – Perform at least every 15 minutes with stable patients
  60. 60. Management of Soft-Tissue Injury
  61. 61. Management of Soft-Tissue Injury Objectives of Wound Dressing and Bandaging – Hemorrhage control Direct pressure Elevation Pressure points Consider Ice Constricting band Tourniquet
  62. 62. Management of Soft-Tissue Injury - 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
  63. 63. Management of Soft-Tissue Injury 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
  64. 64. Management of Soft-Tissue Injury Pain and Edema Control – Cold packs – Moderate pressure over wound – Consider analgesic : Morphine sulfate 2 mg IVP every 5 minutes up to a total of 10 mg given. Fentanyl (Sublimaze) 25–50 mcg IVP followed by an additional 25 mcg as needed. If given too rapidly, chest wall rigidity may ensue leading to respiratory compromise
  65. 65. Anatomical Considerations for Bandaging 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
  66. 66. 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 from ears or nose
  67. 67. Anatomical Considerations for Bandaging Neck – Consider circumferential bandage Protect trachea and carotids C-collar and dressing – Occlusive dressing if lacerated vessel Shoulder – Take care to avoid pressure Axillary artery Trachea Anterior neck
  68. 68. Anatomical Considerations for Bandaging Trunk – Minor wounds: Dressing and tape – Major wounds: Circumferential wrap Ladder splint behind back and wrap gauze over it Groin and Hip – Bandage by following contours of body – Movement can increase tightness of bandage © Ray Kemp/911 Imaging
  69. 69. Anatomical Considerations for Bandaging Elbow and Knee – Circumferential wrap and splint Splinting reduces movement Position of function Half flexion/half extension Hand and Finger – Remove jewelry from wrist and fingers – Bulky dressing – Position of function Ankle and Foot – Circumferential bandage
  70. 70. Anatomical Considerations for Bandaging Complications of Bandaging – Always assess before and after: Pulse Motor Sensation – Developing ischemia: Pain Pallor Tingling Loss of pulse Decreased capillary refill
  71. 71. Care of Specific Wounds Amputations – Patient Control bleeding Consider tourniquet Do not delay transport – 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
  72. 72. Care of Specific Wounds Impaled Objects – Stabilize with bulky dressing in place – Prevent movement of object – Consider cutting or shortening large impaled objects – Consider removal if: In cheek and interferes with airway Interferes with CPR
  73. 73. Special Anatomical Sites 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
  74. 74. Special Anatomical Sites 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
  75. 75. Special Anatomical Sites Abdominal Region – 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
  76. 76. Wounds Requiring Transport Any wound that involves – Nerves – Blood vessels – Ligaments – Tendons – Muscles – Significantly contaminated – Impaled object – Likely cosmetic injury
  77. 77. Soft-Tissue Treatment and Refer/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
  78. 78. Summary Introduction to Soft-Tissue Injuries Anatomy and Physiology of Soft-Tissue Injuries Pathophysiology of Soft-Tissue Injury Dressing and Bandage Materials Assessment of Soft-Tissue Injuries Management of Soft-Tissue Injury