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SOFT TISSUE INJURY

L. ARIES FAHROZI
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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
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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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A&P 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 Free Powerpoint Templates

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Skin Layers

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Structure and Function of the Skin


Skin: complex organ with crucial role in homeostasis
Protects underlying tissue from injury Aids in temperature regulation Prevents excessive water loss Acts as sense organ

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Structure and Function of the Skin


Significant damage may make the patient vulnerable to:
Bacterial invasion Temperature instability Fluid balance disturbances

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

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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
(continued)
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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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Complication of Soft-Tissue Injury


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, & dead bacteria Lymphangitis: Visible red streaks Fever & Malaise Localized Fever Free Powerpoint Templates Page 15

Complication 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
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Lockjaw

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Complication 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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Classification of Soft-Tissue Injury


Closed Wounds
Contusions
Erythema Ecchymosis

Open Wounds
Abrasions Lacerations Incisions Punctures Avulsions Amputations

Hematomas Crush Injuries

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Closed Injuries/wound
In which soft tissue damage occurs beneath the skin, but the surface remains intact.
Typically caused by blunt trauma or crushing injury Examples: contusion (bruise), hematoma

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Closed Wounds
If small blood vessels are damaged, ecchymosis will cover the area. If large blood vessels are torn, a hematoma will appear.
Courtesy of Rhonda Beck

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Open Injuries
There is a break in the surface of the skin exposing deeper tissue to contamination 4 Types: -Abrasions -Lacerations -Avulsions -Punctures/ Penetrations
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Abrasions
Wound of the superficial layer of the skin caused by friction across a hard surface blood and plasma may ooze from surface capillaries Ex: Road rash, rug burn

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Lacerations
Smooth or jagged cut caused by a sharp object or a blunt force that tears the tissue Depth can vary, may sever arteries or veins

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Bleeding of Soft-Tissue Injury


Hemorrhage
Arterial Venous Capillary

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Avulsions
An injury that separates layers of soft tissue so that they are either completely unattached or hanging by a flap

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Punctures and Penetrations


Injury resulting from a sharp pointed object Can leave relatively small entrance wounds but can damage structures deep in the body Ex: Stabbings, shootings, ice pick accidents
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Amputations
An avulsion involving the complete loss of a body part

E. M. Singletary, MD. Used with permission.

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Amputations
Assessment and management
Be aware of sharp bone protrusions. The body part may be completely detached or soft tissues may remain attached. Degloving injury: unraveling of skin from the hand

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Amputations
Assessment and management (contd)
If a body part is completed amputated, try to preserve it in optimal condition.
Rinse off any debris. Wrap it loosely in saline-moistened sterile gauze. Seal it in a plastic bag; place it in a cool container. Never warm it or place it in water. Never place it directly on ice or use dry ice.

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Amputations
Assessment and management (contd)
Transport as soon as possible. If the amputated part is a limb or part of one, notify ED staff of:
Type of amputation Estimated arrival time

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Bite Wounds
Animals bites can be serious.
Cat and dog mouths are contaminated with virulent bacteria.
Courtesy of Moose Jaw Police Service Chuck Stewart, MD

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Bite Wounds
Assessment and management
Place a sterile dressing and transport promptly. Splint an arm or leg if it is injured. Determine and document:
When the bite occurred Type of animal What led to the biting incident

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Bite Wounds
Assessment and management (contd)
Rabies is a major concern with dog bites.
Once signs appear, it is almost always fatal. Spread by bites or licking an open wound Can be prevented by a series of vaccine injections

Do not enter until the scene is secured.

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Bite Wounds
Human bites usually occur on the hand.
Human mouths contain a wide variety of virulent pathogens.

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Bite Wounds
Assessment and management (contd)
Emergency treatment for human bites includes:
Control all bleeding and apply a sterile dressing. Immobilize the area with splint or bandage. Provide transport.
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Severe 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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Crush Injuries
An injury to the underlying soft tissues and bones Caused by a body part being crushed between two solid objects

Mark C. Ide

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Crush Injuries
May lead to compartment syndrome May lead to rupture of internal organs External appearance may not represent level of internal damage.

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Crush Injuries
Bodys first responses to vessel injury is localized vasoconstriction.
If vessels are damaged, they may not be able to constrict.
Crush injuries often result in difficult-tocontrol hemorrhage.

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Crush Injury
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 Free Powerpoint Templates Page 41

Blast Injury
Explosions can result in:
Soft-tissue trauma Abdominal trauma Skeletal trauma Blast lung

Assess the scene for hazards.

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Other option Soft-Tissue Injury


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

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High-Pressure Injection Injuries


Occurs when a foreign material is forcefully injected into soft tissue, causing:
Acute and chronic inflammation Damage from:
Direct insult Chemical inflammation Ischemia from compressed blood vessels Secondary infection
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Compartment Syndrome
Develops when edema and swelling cause increased pressure within a closed soft-tissue compartment
Leads to compromised circulation Commonly develops in extremities Can cause tissue necrosis

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Compartment Syndrome
Assessment and management
Presents with six Ps:
Pain Paresthesia Paresis Pressure Passive stretch pain Pulselessness

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Compartment Syndrome
Assessment and management (contd)
Many signs may be delayed or nonspecific. Can cause death of local tissues Risk of sepsis In-hospital intervention includes fasciotomy.
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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 Free Powerpoint Templates Page 48

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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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 Bleeding


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 Free Powerpoint Templates Page 52 Monitor distal pulse, motor, and

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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Sprain / Strain

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SPRAIN
stretch and/or tear of a ligament caused by a sudden pull one or more ligaments can be injured at the same time severity of injury extent of injury and number of ligaments involved

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STRAIN
injury to either a muscle or a tendon as a result of suddenlly pulling them too far simple overstretch of muscle or tendon, or result of a partial or complete tear

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What Causes a Sprain?


fall sudden twist blow to the body that forces a joint out of its normal position and stretches or tears the ligament supporting that joint

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Where Do Sprains Usually Occur?


most common site: the ankle

frequently occur at the wrist sprain to the thumb common in skiing and other sports
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What Are the Signs and Symptoms of a Sprain?


pain swelling bruising instability loss of functional ability sometimes a pop or tear when the injury happens
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What Causes a Strain?


twisting or pulling a muscle or tendon acute or chronic recent trauma or result of overuse

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Where Do Strains Usually Occur?


two common sites: the back and the hamstring muscle hand and forearm, elbow

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What Are the Signs and Symptoms of a Strain?


typicalpain, limited motion, muscle spasms, possibly muscle weakness localized swelling, cramping, or inflammation and, with a minor or moderate strain, usually some loss of muscle function

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How Are Sprains and Strains Treated? RICE Therapy

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Rest Ice

Compression Elevation

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Can Sprains and Strains Be Prevented?


Avoid exercising or playing sports when tired or in pain. Maintain a healthy, well-balanced diet to keep muscles strong. Maintain a healthy weight. Practice safety measures to help prevent falls. Wear shoes that fit properly. Replace athletic shoes as soon as the tread wears out or the heel wears down on one side.
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Do stretching exercises daily. Be in proper physical condition to play a sport. Warm up and stretch before participating in any sports or exercise. Wear protective equipment when playing. Run on even surfaces.
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Bone and Joint Injuries


Dislocation
Occurs when the end of a bone is displaced from a joint or moves out of its normal position within a joint Frequently accompanied by a tearing or stretching of ligaments, muscles or other soft tissue

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Bone and Joint Injuries Dislocation


Signs and symptoms
Deformity of joint or limb Limited or abnormal movement Swelling and discoloration Pain and tenderness Shortening or lengthening of affected limb

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Bone and Joint Injuries Dislocation


First aid care
Basically the same as first aid for fractures Make no attempt to reduce the dislocation or replace the bone in the joint Immobilize the affected part in the position in which it is found by using splints and/or slings Avoid any movement of part because movement can lead to additional injury to nerves, blood vessels and other tissues in the area Obtain medical help immediately
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Splints
Splints Devices that can be used to immobilize injured parts when fractures, dislocations and other similar injuries are present or suspected Many commercial splints are available
Inflatable or air splints Padded boards Traction splints (used for fractured femur)
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