chapter 45ems.jbpub.com/.../docs/ppt_lectures/chapter_045.pdf · · 2014-05-05chapter 45 soft...

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Chapter 45

Soft Tissue Trauma

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Learning Objectives

Describe the incidence, morbidity, and mortality rates of soft tissue injuries

Describe the layers of the skin, specifically the epidermis, dermis (cutaneous), superficial fascia (subcutaneous), and deep fascia

Identify major functions of the integumentary system

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Learning Objectives (Cont’d)

Describe the anatomy and physiology of joints

Discuss the pathophysiology of wound healing, including hemostasis, inflammation, epithelialization, neovascularization, and collagen synthesis

Describe common interruptions in the wound healing process

Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company

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Identify wounds that have a high risk for infection and complications

Discuss the pathophysiology of soft tissue injuries

Distinguish between open and closed soft tissue injuries

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Distinguish between types of closed soft tissue injuries

Describe the etiology, history, and physical findings of closed soft tissue injury

Using the mechanism of injury, patient history, and physical examination findings, develop a treatment plan for closed soft tissue injury

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Distinguish between types of open soft tissue injuries

Describe the etiology, history, and physical findings of open soft tissue injury

Using the mechanism of injury, patient history, and physical examination findings, develop a treatment plan for open soft tissue injury


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Describe the etiology, history, and physical findings of crush injuries

Using the mechanism of injury, patient history, and physical examination findings, develop a treatment plan for crush injury

Discuss the effects of reperfusion and rhabdomyolysis on the body

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Define the following conditions: crush injury, crush syndrome, compartment syndrome

Distinguish between injury types that require use of occlusive dressing and those that require nonocclusive dressing

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Define and discuss following: Dressings Sterile, nonsterile Occlusive, nonocclusive Adherent, nonadherent Absorbent, nonabsorbent Wet, dry Bandages Absorbent, nonabsorbent Adherent, nonadherent


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Define and discuss the following: Tourniquets

Predict possible complications of an improperly applied dressing, bandage, and tourniquet

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Epidemiology of Soft Tissue Trauma

Incidence, mortality, morbidity rates Fifth leading cause of nonfatal injuries

Risk factors Small children and the elderly Industrial settings and some careers Persons with chronic illnesses

Prevention Education

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Standard Precautions Review

Largest concern: blood-borne pathogens

Personal protective equipment

Disposing of soiled material


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Standard Precautions Review (Cont’d)

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Anatomy and Physiology Review

Skin Barrier to prevent

water loss and entrance from infectious organisms

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Anatomy and Physiology Review (Cont’d)

Skin Regulates body temperature Epidermis

• External layer• Constantly developing cells formed in germinativum,

progress to stratum corneum, eventually shed• Cosmetic appearance of skin


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Skin Dermis

• Wound healing• Sebaceous glands• Hair follicles• Capillary vasculature• Nerve fibers• Connective tissues• Mast cells• Fibroblasts• Macrophages• Neutrophils

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Skin Superficial fascia

• Connective tissue surrounds subcutaneous fat Deep fascia

• Thick, dense layer of fibrous connective tissue• Final layer of defense against infection and internal

structures• Support for underlying anatomy

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Joints Synovial joints

• Allow extensive range of motion• Bones’ ends held together with tough, fibrous

ligaments

Tendons• Connect muscle to muscle and muscle to bone• Allow muscle to move bones


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Wound Healing

Normal wound healing Hemostasis Coagulation (platelets and fibrinogen)

• Generates fibrin• Binds platelets, begins forming plug in damaged

vessel• Injured capillaries constrict in response to

epinephrine and norepinephrine


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Wound Healing (Cont’d)

Normal wound healing Histamine release

• Inflammatory phase of healing by dilating capillaries• Increased vascular permeability• Granulocytes• Macrophages• Increased blood flow to injured area• Redness, warmth, swelling onset

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Normal wound healing Epithelialization Neovascularization Capillary buds formed Enables circulation Fibroblasts produce

collagen, strengthen skin

Hydroxylysine strengthens new tissue

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Interruptions in wound healing Anatomic factors

• Poor circulation areas–delay in healing• Foot wounds–high risk for infection• Excellent perfusion wounds–heal well• High tension areas–incur repeated stress, incur

abnormal scars or delayed healing• Skin condition

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Interruptions in wound healing Concurrent drug use

• Drugs inhibiting inflammatory response• Increase healing process• Increase risk of infection

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Interruptions in wound healing Medical conditions and diseases

• Advanced age• Severe alcoholism• Acute uremia• Diabetes• Severe anemia• Peripheral vascular disease• Advanced cancer• Hepatic failure• Cardiovascular disease• Smoking


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High-risk wounds Human bites Dog bites Cat bites Foreign bodies

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High-risk wounds Wounds with significant devitalized tissue

• Farm or agricultural equipment• Industrial equipment• Crushing mechanism of injury• High-velocity missiles• Dragging or sliding at high speeds on pavement• May require debridement to prevent necrosis• Transport

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High-risk wounds Immunocompromised patients

• Any wound at high risk for infection and complications

• Advanced cancer• Rheumatoid arthritis• Autoimmune disorder• Worse if wound is located in are of poor perfusion• Physician evaluation


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High-risk wounds Poor peripheral circulation

• Hypoxic tissue delays healing• Encourages pathogens• Diabetes, deep vein thrombosis, peripheral vascular

disease increases infection risk• Infection

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Abnormal scarring Some wounds develop abnormal levels of scar

formation• Keloid scar

Excessive accumulation of scar tissue Extends beyond original wound borders Darkly pigmented Ears Upper extremities Lower abdomen Sternum Managed through surgical procedures, steroid

injections

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Abnormal scarring Some wounds develop abnormal levels of scar

formation• Hypertrophic scar

More common Excessive amounts of scar tissue Remain within borders of original wound Slightly raised High tissue stress areas

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Abnormal scarring Wound requiring closure

• Cosmetic regions (face, lip, eyebrow)• Gaping wound• Wounds over tension areas• Degloving injuries• Ring injuries• Skin tearing


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Abnormal scarring Wounds that do not require closure

• Superficial wounds• May be able to treat and release• Inquire about tetanus vaccination• Educate patient on how to clean the wound• Careful documentation

Contact medical direction if in doubt

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Pathophysiology and Assessment of Soft Tissue Injuries

Closed soft tissue injuries Contusion

• Rupture of small blood vessels and damage to cells within dermis

• Ecchymosis• Deep muscle tissue

or organs do not always produce external ecchymosis or swelling

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Pathophysiology and Assessment of Soft Tissue Injuries (Cont’d)

Closed soft tissue injuries Hematoma

• “Blood tumor”• Large amounts of tissue

damaged or large veins/arteries ruptured beneath intact skin

• Pocket of blood forms• Blood >1 L or more • Management


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Closed soft tissue injuries Sprain

• Common joint injuries• Stretch/tear ligaments• Often occur during

sports• Difficult to diagnose in

field

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Closed soft tissue injuries Strains

• Muscle or tendon injury• Caused by sudden explosive activity• Athletics• MVCs• Falls• Assaults• Pain, swelling, bruising, warm to touch

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Closed soft tissue injuries Management of sprains, strains, and joint

injuries• Differentiating is impossible in field• Treat as fractures until proven otherwise• Do not allow weight bearing• Assess presence of distal pulse, motor skills,

sensation before and after management• Apply splints• Reassess for nerve or vascular compromise


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Open soft tissue injuries Abrasions

• Outer skin layer damage• Little or no bleeding• Capillary oozing• Painful• Often contaminated• Management

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Lacerations Superficial or deep Linear or stellate Often jagged edges Assess for other trauma

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Incisions Varying depth, bleed extensively Smooth, even edges Knife wounds Management of lacerations and incisions

• Bleeding control• Assessment for life-threatening injuries• Infection control• Follow local protocol

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Avulsions Flap of tissue Degloving injuries Ring injuries Bleed profusely May be major or minor Partial or complete


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Open soft tissue Amputations

• Complete removal of extremity or appendages• Usually involve jagged skin, tissue and bone• May not require a tourniquet• Complete or partial

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Open soft tissue injuries Amputations

• Management of avulsions and amputations Consider possibility of replantation Do not delay transport to find the part Transport to an appropriate facility Place tissue still attached in normal position Dress and bandage Use moist dressing for stump Wrap part in moist, sterile dressing and seal in a

plastic bag/container kept cool, not frozen


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Skill 45-1: Care of Amputated Part

PPE Control hemorrhage Locate amputated part Clean gross contaminate Wrap in sterile dressing

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Open soft tissue injuries Punctures,

penetrations• Potentially life

threatening• Knives, nails, GSWs• Minimal to major

bleeding• May cause internal

injuries

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Open soft tissue injuries Punctures, penetrations

• Chest cavity punctures can cause: Pneumothorax Hemothorax Sucking chest wound Pericardial tamponade Laceration of aorta Subclavian arteries Injuries can also cause esophageal, diaphragmatic,

bronchus laceration Determine size of project


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• Abdominal laceration Solid and hollow organ laceration or rupture Digestive system contents released into abdomen

result in bacterial infection of peritoneum Intestines exit cavity, create evisceration where they

protrude from wound ED evaluation

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• Management of punctures and penetrations Control hemorrhage Assess for life threats Identify object that caused injury Notify police if necessary

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Open soft tissue injuries High-pressure injections

• May appear benign• Often require amputation• Management • Rapid transport


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Open soft tissue injuries Impaled objects

• If still in place, do not remove

• Stabilize• Remove only to

protect airway per medical direction

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Skill 45-2:Care of Impaled Object

PPE Control hemorrhage Stabilize object Bulky dressings Assess bandaging

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Open soft tissue injuries Major arterial lacerations

• Bright red blood• Spurts or flows rapidly• Shock• Death• Management


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Crush injuries Destruction or damage of large areas of tissue Increased infection risk High pressure within muscle compartments,

prevent capillary refilling Rhabdomyolysis

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Crush injuries Traumatic asphyxia External bleeding minimal, internal organ

damage severe Prolonged crushing impairs normal metabolic

function

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Crush injuries Restoration of blood flow brings O2 in contact

with cells and brings O2 free radical–O2

superoxide• Attacks cell membrane through lipid peroxidation• Membrane permeable to ions and water• Further stretches cell• Influx of Ca2+ into cell and mitochondria• Causes mitochondrial swelling and cellular death• Water, Na+ and Ca2+ influx into cells causes swelling


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Crush injuries Rhabdomyolysis

• Myoglobinemia results in rhabdomyolysis• Increased K+ and decreased Ca2+ with hypovolemia

cause cardiac irritability• Toxins in the blood lead to renal failure• DIC causes thrombi to form in glomeruli• Catecholamines also decrease kidney blood flow• Myoglobinemia has nephrotoxic effect• Renal failure results

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Crush injuries Compartment syndrome

• Increased pressure within muscle compartment• Muscle fascia is fibrous, does not stretch• Results from decreased size of space or increased

contents

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• Mechanisms Limb compression Constriction from dressings or casts Circumferential burns, thermal injuries, frostbite Snake bites Hemorrhage, orthopedic injuries IV infiltration, anticoagulation

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• The “six Ps” Pain out of proportion to injury Paresthesia Paralysis Puffiness Pallor Pulselessness (late or nonexistent sign)

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• Limb May appear normal initially Paralysis and sensory loss possible

• Joint distal and involved muscles may have rigor• Skin may be taut “wood-like”• Pain, swelling, sensory changes, weakness,

increased pain with passive stretching


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• Voluntary muscle contraction may be absent• Progression will involve “six Ps”• Fasciotomy is used to relieve pressure• Surgery is only definitive treatment

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Crush injuries Management of crush syndrome

• Goals Prevent sudden death Prevent renal failure Salvage limbs Initiate care early

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• ABCs• Maintain renal function• IV bolus 1-1.5 L• Alkalinization of urine


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• Management of crush injuries Open injury risks crush syndrome and infection Gross decontamination Sterile dressings and bandaging ED evaluation Hyperbaric therapy may be used (local SOPs)

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Blast injuries Damage due to pressure field or wave

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Common Soft Tissue Infections

Bacterial skin infections Folliculitis

• Infected hair follicle

Furuncles• Folliculitis that

spread Carbuncles

• Several furuncles• Typically caused by

Staphylococcus aureus


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Common Soft Tissue Infections (Cont’d)

Bacterial skin infections Cellulitis

• Local infection common in DM or immunosuppressed• Systemic involves lymph nodes and/or bacteremia

Necrotizing cellulitis• Skin and SQ tissues after recent trauma or surgery• May also develop spontaneously in patients with DM

Necrotizing fasciitis• Typically polymicrobial following trauma, surgery,

bite

Gas gangrene• Life threatening Clostridium infection

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Bacterial skin infection Gas gangrene

• Life threatening Clostridium infection• Immunocompromised at greater risk• Incubation: 3 days• Initial presentation

Heaviness of affected extremity Brawny edema Pain out of proportion to injury

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• Progression Toxins released cause cellular destruction Systemic toxicity Cardiodepression Extremity develops bronze/brown discoloration, has

malodorous seroanguineous discharge Blisters Low-grade fever Tachycardia Disoriented


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• Treatment Surgical debridement Often amputation Aggressive fluid resuscitation Transport

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Viral infections Herpes simplex virus (HSV-1, HSV-2)

• HSV-1–infections of mouth• HSV-2–infections of genitals• Causes

Stress Ultraviolet light exposure Skin irritation Fever Fatigue

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Viral infections Herpes simplex virus (HSV-1, HSV-2)

• Presentation Rash Paresthesia Increased sensitivity Mild burning Viral shedding

• No cure• Topical or antiviral agents

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Viral infections Herpes zoster and varicella

• Caused by same virus• Initial infection, chickenpox

Lies dormant in trigeminal and dorsal root ganglia Later reactivates, causes shingles

• Treatment Control skin irritation Compresses, calamine lotion, baking soda

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Hand infections Most result from

Staphylococcus or Streptococcus

Gross wound contamination

IV drug abuse Human/animal bites Splint to position

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Hand infections Paronychia

• Infection of lateral nail fold; may involve cuticle• Nail biting, manicures, hangnails• Staphylococcus aureus, Streptococcus,

Pseudomonas• Treatment

Warm soaks Elevation Topical antibiotics

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Hand infections Felon

• SQ infection of pulp space• Throbbing pain• Red, tense finger pad• Surgical incision to drain

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Hand infections Flexor tenosynovitis

• Involves tendon sheath• Tenderness• Symmetric swelling• Pain with passive extension• Flexed posture of finger at rest• Surgical emergency• Requires hand surgeon• Treatment


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Deep space infections Dorsal edema Tenderness Induration Fluctuance Pain with ROM Immobilize, elevate Transport for

surgical consult

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Infection prevention Good hygiene (handwashing) Good wound care

• Clean gloves• Aseptic technique• Removal of debris• Proper dressing and bandaging


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General Management of Soft Tissue Trauma

Scene size-up Treat underlying life-threatening injuries

before superficial wounds Control hemorrhage Treat for shock

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General Management of Soft Tissue Trauma (Cont’d)

Dressings, bandages Sterile dressings Nonsterile dressings Occlusive dressings Adherent dressings Nonadherent dressings Wet dressings

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Dressings, bandages Sterile dressings

• Chemically or radiologically rendered free of bacteria• Used with direct pressure for bleeding control

Nonsterile dressings• Clean, not completely free of bacteria• Used to provide bulk for bleeding control• Cleaning dirt/debris from intact skin


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Dressings, bandages Occlusive dressings

• Prevent free flow of air• Large artery neck wounds• Seal chest wounds• Plastic sheeting• Minimize air entrance into pleural space and

development of pneumothorax with chest trauma• Minimize risk of air emboli• Can contribute to tension pneumothorax

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Dressings, bandages Adherent dressings

• Become incorporated into clot• Scab forms over wound• Control hemorrhage

Nonadherent dressings• Burn patients• Allow wound exudates to pass through• Prevent gross contamination of wound

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Dressings, bandages Wet dressings

• Used with organs exposed to air• Abdominal evisceration• Soaked in sterile saline• Enhance healing process• Supports movement of cells across wound


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Complications Too little or too much pressure Check bandages often Too loose may hemorrhage further Too tight may restrict circulation or damage

underlying structures

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Irrigate gross contamination

Bandaging Head Face Neck Arm

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Bandaging Shoulder Trunk Groin Leg Foot Hand


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Documentation of Soft Tissue Injuries

Crucial part of care Careful description of injuries Patient’s response to treatment Vital signs throughout care

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Chapter Summary

Skin and structures serve key roles in maintaining body temperature and moisture and protecting body from disease Any disruption caused by trauma can result in

significant threats to the patient’s life Soft tissue injuries encompass all types of

injuries, from superficial to life threatening

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Chapter Summary (Cont’d)

Carefully assess the patient’s injuries, apply appropriate knowledge to distinguish superficial from life-threatening soft tissue injuries, and provide proper care

Soft tissue injuries can be classified as open or closed, depending on whether the skin remains intact Both injuries have the potential for

complications when not identified and properly managed


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Control hemorrhage by applying direct pressure; check local protocols

Wound healing can be complicated by: Age Unrelated medical conditions Wound contamination Location of injury Severity of injury

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Wound management of open soft tissue injuries should focus on control of hemorrhage and protection of the wound from contamination

Prioritize care of injuries; ensure that the most life-threatening ones receive most attention first

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Take special care when treating amputations, avulsions, chest injuries, abdominal injuries, and crush injuries


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Questions?


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