Chapter 5 Soft-Tissue Trauma

1
Chapter 5Soft-Tissue Trauma
2
Topics

• Introduction to Soft Tissue Injury
• Anatomy and Physiology of Soft-Tissue Injury
• Pathophysiology of Soft-Tissue Injury
• Dressing and Bandage Materials
• Assessment of Soft-Tissue Injuries
• Management of Soft-Tissue Injuries

3
Introduction to Soft-Tissue Trauma

• Skin is the largest, most important organ.
• 16 of total body weight.
• Function
• Protection
• Sensation
• Temperature regulation
• AKA integumentary system

4
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

5
AP of Soft-Tissue Injuries (1 of 6)

• Skin Layers
• 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 and sudoriferous glands
• Subcutaneous
• Adipose tissue
• Heat retention

6
AP of Soft-Tissue InjuriesThe Skin
7
AP of Soft-Tissue Injuries (3 of 6)

• Blood Vessels
• Arteries
• Arterioles
• Capillaries
• Venules
• Veins
• Layers
• Tunica intima
• Tunica media
• Tunica adventitia

8
AP of Soft-Tissue InjuriesBlood Vessels
9
AP of Soft-Tissue Injuries (5 of 6)

• Muscles
• Beneath skin layers
• Fascia
• Thick, fibrous, inflexible membrane surrounding
  muscle that aids in binding muscle groups together

10
AP of Soft Tissue Injuries (6 of 6)

• Tension Lines
• Natural patterns in the surface of the skin
  revealing tension within

11
Pathophysiology of Soft-Tissue Injury (1 of 12)

• Closed Wounds
• Contusions
• Erythema
• Ecchymosis
• Hematomas
• Crush injuries

• Open Wounds
• Abrasions
• Lacerations
• Incisions
• Punctures
• Impaled objects
• Avulsions
• Amputations

12
(No Transcript)
13
Pathophysiology of Soft-Tissue Injury (2 of 12)
Soft-Tissue Wounds
14
(No Transcript)
15
Pathophysiology of Soft-Tissue Injury (3 of 12)

• Hemorrhage
• Arterial
• Capillary
• Venous

16
Pathophysiology of Soft-Tissue Injury (4 of 12)

• Wound Healing
• Hemostasis
• Bodys natural ability to stop bleeding and the
  ability to clot blood
• Begins immediately after injury
• Inflammation
• Local biochemical process that attracts WBCs
• Epithelialization
• Migration of epithelial cells over wound surface

17
Pathophysiology of Soft-Tissue Injury (5 of 12)

• Neovascularization
• New growth of capillaries in response to healing
• Collagen Synthesis
• Fibroblasts Cells that form collagen
• Collagen Tough, strong protein that comprises
  connective tissue

18
Pathophysiology of Soft-Tissue Injury
Wound Healing
19
Pathophysiology of Soft-Tissue Injury (7 of 12)

• Infection
• Most common and most serious complication of open
  wounds
• 115 wounds seen in ED result in infection
• 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

20
Pathophysiology of Soft-Tissue Injury (8 of 12)

• Infection
• Risk factors
• Hosts health and pre-existing illnesses
• Medications (NSAIDs)
• Wound type and location
• Associated contamination
• Treatment provided
• 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

21
Pathophysiology of Soft-Tissue Injury (9 of 12)

• Other Wound Complications
• Impaired hemostasis
• Medications
• Anticoagulants
• Aspirin
• Warfarin (Coumadin)
• Heparin
• Antifibrinolytics
• Re-bleeding
• Delayed healing
• Compartment syndrome
• Abnormal scar formation
• Pressure injuries

22
Pathophysiology of Soft-Tissue Injury (10 of 12)

• Crush Injury
• Body tissues subjected to severe compressive
  forces
• Tamponading of distal tissue
• Buildup of byproducts of metabolism
• Wood-like distal tissue
• Associated injury

23
Pathophysiology of Soft-Tissue Injury (11 of 12)

• Crush Syndrome
• Body is entrapped for gt4 hours.
• Crushed muscle tissue becomes necrotic.
• Traumatic rhabdomyolysis
• Skeletal muscle degradation
• Release of toxins
• Myoglobin
• Phosphate
• Potassium
• Lactic acid
• Uric acid
• When tissue is released, toxins move RAPIDLY into
  systemic circulation.
• Impacts cardiac function
• Impacts kidney function

24
Pathophysiology of Soft-Tissue Injury (12 of 12)

• Injection Injury
• High-pressure line bursts
• Injects fluid or other substance into skin and
  into subcutaneous tissue

25
Dressing and Bandage Materials (1 of 2)

• 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
• Wet/Dry Dressings
• Wet burns, postoperative wounds (sterile NS)
• Dry most common

26
Dressing and Bandage Materials (2 of 2)

• Self-adherent Roller Bandage
• Kerlex/Kling
• Multi-ply, stretch 16
• Gauze Bandage
• Single-ply, non-stretch 13
• Adhesive Bandages
• Elastic (Ace) Bandages
• Triangular Bandages

27
Assessment of Soft-Tissue Injuries

• Scene Size-up
• Initial Assessment
• Focused HP
• Evaluate MOI and consider IOS
• Rapid versus focused assessment
• Detailed Physical Exam
• Inquiry, inspection, palpation, auscultation
• Ongoing Assessment

28
Management of Soft-Tissue Injury (1 of 4)

• Objectives of Wound Dressing and Bandaging
• Hemorrhage control
• Direct pressure
• Elevation
• Pressure points
• Consider
• Ice
• Constricting band
• Tourniquet
• USE ALL COMPONENTS TOGETHER.

29
Management of Soft-Tissue Injury (2 of 4)
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 patients forehead.

• Dont
• Use unless you cannot control the bleeding via
  other means.
• Use rope or wire.
• Release it once applied.

30
Management of Soft-Tissue Injury (3 of 4)

• 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.

31
Management of Soft-Tissue Injury (4 of 4)

• Pain and Edema Control
• Cold packs
• Moderate pressure over wound
• Consider analgesic if approved by medical
  direction
• Morphine sulfate
• 2 mg SIVP every 5 minutes up to a total of 10 mg
  given.
• Fentanyl (Sublimaze)
• 2550 mcg SIVP followed by an additional 25 mcg
  as needed.
• If given too rapidly, chest wall rigidity may
  ensue leading to respiratory compromise.

32
Anatomical Considerations for Bandaging (1 of
17)

• 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

33
Anatomical Considerations for Bandaging (2 of
17)

• 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.

34
Anatomical Considerations for Bandaging (3 of
17)

• 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.

35
Anatomical Considerations for Bandaging (4 of
17)

• 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 and Hip
• Bandage by following contours of body.
• Movement can increase tightness of bandage.

36
Anatomical Considerations for Bandaging (5 of
17)

• 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

37
Anatomical Considerations for Bandaging (6 of
17)

• Complications of Bandaging
• Always assess before and after
• Pulse
• Motor
• Sensation
• Developing ischemia
• Pain
• Pallor
• Tingling
• Loss of pulse
• Decreased capillary refill
• Is dressing size appropriate to injury?

38
Anatomical Considerations for Bandaging (7 of
17) Specific Wounds

• Amputations
• Patient
• Control bleeding by bulky dressing.
• Consider tourniquet proximal to wound.
• Do not delay transport 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.

39
Anatomical Considerations for Bandaging (8 of
17) 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

40
Anatomical Considerations for Bandaging (9 of
17) 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.

41
Anatomical Considerations for Bandaging (10 of
17) Specific Wounds

• Crush Syndrome
• Management
• IV 2030 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
• 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)

42
Anatomical Considerations for Bandaging (11 of
17) Specific Wounds

• Compartment Syndrome
• Likely 48 hours post-injury
• Symptom
• Severe pain out of proportion with physical exam
  findings
• 6 Ps
• Pain
• Paresthesia
• Paresis
• Pressure
• Passive stretching pain
• Pulselessness
• Normal motor and sensory function

43
Anatomical Considerations for Bandaging (12 of
17) 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

44
Anatomical Considerations for Bandaging (13 of
17)

• 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.

45
Anatomical Considerations for Bandaging (14 of
17)

• 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.

46
Anatomical Considerations for Bandaging (15 of
17)

• 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.

47
Anatomical Considerations for Bandaging (16 of
17)

• Wounds Requiring Transport
• Any wound that involves
• Nerves
• Blood vessels
• Ligaments
• Tendons
• Muscles
• Significantly contaminated
• Impaled object
• Likely cosmetic injury

48
Anatomical Considerations for Bandaging (17 of
17)

• Soft-Tissue Treatment and Refer or 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.

49
Summary

• Introduction to Soft Tissue Injury
• Anatomy and Physiology of Soft-Tissue Injury
• Pathophysiology of Soft-Tissue Injury
• Dressing and Bandage Materials
• Assessment of Soft-Tissue Injuries
• Management of Soft-Tissue Injuries