Division 3

Trauma Emergencies

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Chapter 20
Soft-Tissue Trauma

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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

Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

A&P 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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

A&P of Soft-Tissue Injuries (2 of 6)

The Skin

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

A&P of Soft-Tissue Injuries (3 of 6)

Blood Vessels

Arteries
Arterioles
Capillaries
Venules
Veins

Layers
Tunica intima
Tunica media
Tunica adventitia
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

A&P of Soft-Tissue Injuries (4 of 6)

Blood Vessels

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

A&P 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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

A&P of Soft-Tissue Injuries (6 of 6)

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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of
Soft-Tissue Injury (2 of 12)
Soft-Tissue Wounds

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of
Soft-Tissue Injury (3 of 12)
Hemorrhage
Arterial
Capillary
Venous

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of
Soft-Tissue Injury (6 of 12)
The Wound
Healing
Process

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of
Soft-Tissue Injury (7 of 12)
Infection
Most common and most serious complication of open
wounds
1:15 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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of
Soft-Tissue Injury (11 of 12)
Crush Syndrome
Body is entrapped for >4 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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment of
Soft-Tissue Injuries
Scene Size-up
Initial Assessment
Focused H&P
Evaluate MOI and consider IOS
Rapid versus focused assessment

Detailed Physical Exam

Inquiry, inspection, palpation, auscultation

Ongoing Assessment

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

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.

Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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.

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

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.

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

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.
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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.
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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.

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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?

Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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.
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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.
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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)

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

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

Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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.
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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.

Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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.
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ

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.

Bledsoe et al., Essentials of Paramedic Care: Division 1II

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Summary
Introduction to Soft-Tissue Injury
Anatomy and Physiology of SoftTissue Injury
Pathophysiology of Soft-Tissue Injury
Dressing and Bandage Materials
Assessment of Soft-Tissue Injuries
Management of Soft-Tissue Injuries
Bledsoe et al., Essentials of Paramedic Care: Division 1II
2006 by Pearson Education, Inc. Upper Saddle River, NJ