Soft-Tissue Injury

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Soft-Tissue Injury
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Sections

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

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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

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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

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AP of Soft Tissue Injuries

• 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 Sudoriferous Glands
• Subcutaneous
• Adipose tissue
• Heat retention

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AP of Soft Tissue Injuries

• Blood Vessels
• Arteries
• Arterioles
• Capillaries
• Venules
• Veins
• Layers
• Tunica Intima
• Tunica Media
• Tunica Adventitia

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AP of Soft Tissue Injuries

• Muscles
• Beneath skin layers
• Fascia
• Thick, fibrous, inflexible membrane surrounding
  muscle the aids to bind muscle groups together

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AP of Soft Tissue Injuries

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

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Pathophysiology of Soft-Tissue Injury

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

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

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Pathophysiology of Soft-Tissue Injury

• Hemorrhage
• Arterial
• Capillary
• Venous

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Pathophysiology of Soft-Tissue Injury

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

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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

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Pathophysiology of Soft-Tissue Injury

• 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, dead bacteria
• Lymphangitis Visible red streaks
• Fever Malaise
• Localized Fever

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Pathophysiology of Soft-Tissue Injury

• Infection
• Risk Factors
• Hosts health pre-existing illnesses
• Medications (NSAIDs)
• 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

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Pathophysiology of Soft-Tissue Injury

• Other Wound Complications
• Impaired Hemostasis
• Medications
• Anticoagulants
• Aspirin
• Warfarin (Coumadin)
• Heparin
• Antifibrinolytics
• Re-Bleeding
• Delayed Healing
• Compartment Syndrome
• Abnormal Scar Formation
• Pressure Injuries

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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

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Pathophysiology of Soft-Tissue Injury

• 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

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Pathophysiology of Soft-Tissue Injury

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

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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

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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

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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

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Management of Soft-Tissue Injury

• Objectives of Wound Dressing Bandaging
• Hemorrhage Control
• Direct Pressure
• Elevation
• Pressure Points
• Consider
• Ice
• Constricting Band
• Tourniquet
• USE ALL COMPONENTS TOGETHER

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Management of Soft-Tissue Injury
Tourniquet

• Dos
• 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.

• Donts
• Use unless you can not control the bleeding via
  other means
• Use rope or wire.
• Release it once applied.

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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

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Management of Soft-Tissue Injury

• Pain Edema Control
• Cold packs
• Moderate pressure over wound
• Consider analgesic if approved by medical control

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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

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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

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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

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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

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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

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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
• Is dressing size appropriate to injury?

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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

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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

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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.

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Anatomical Considerations for Bandaging
Specific Wounds

• Crush Syndrome
• Management
• 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)

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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 Ps
• Pain
• Paresthesia
• Paresis
• Pressure
• Passive stretching pain
• Pulselessness
• Normal motor and sensory function

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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

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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

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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

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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.

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Anatomical Considerations for Bandaging

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

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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.