Soft Tissue Injury

Scenario
You are caring for a woman who
punched out a second-story window
and jumped into some bushes to
escape a fire. She has a laceration on
her hand, with fatty tissue exposed
that is bleeding briskly. Her face is
badly scraped and is oozing red fluid.
A branch punctured her leg and is
protruding through the other side.
She is developing a “goose-egg”
 Discussion
 Which skin layers have been injured?

 How will you control the bleeding?

 What risk factors for wound infection are

present?

 How will you manage her injuries?

 What type of dressing will you place on

each wound?
Incidence/Morbidity/Mort
ality
 40 million people
each year seek
medical care for
soft tissue trauma
 Causes:
 Falls
 Motor vehicle
accidents
 Blunt trauma
 Penetrating trauma
Incidence/Morbidity/Mort
ality
 Most soft tissue
trauma is not life-
threatening
 73,000 died in
2001
 Anatomy & Physiology of
the Skin
 Largest Organ – 16%
of body weight
 Layers:
 Epidermis, outer layer
 Waterproof
 Dermis, inner layer
Connective tissue
Elastic fibers
Blood vessels
Lymph Vessels
Motor & Sensory
fibers
Hair, nails, sebaceous
and sweat glands
 Anatomy & Physiology of
the Skin
 Role:
 Protection
 Temperature
maintenance
 Storage of nutrients
 Sensory reception
 Excretion &
secretion
Pathophysiology of Wound
Healing
 Homeostasis
 Vasoconstriction
 Formation of a clot
plug
 Coagulation
 Fibrous tissue
development
Pathophysiology of Wound
Healing

 Homeostasis  Formation of a
Vasoconstriction platelet plug
Slows blood flow 1. Platelets adhere
May last as long as 10 to collagen
minutes 2. Swell, become
sticky
3. Secrete
chemicals that
attract other
platelets
Pathophysiology of Wound
Healing
 Homeostasis
 Coagulation
 Occurs within
minutes
 After 30 minutes,
clot retracts and
vessel is sealed
 Cascade Event
 Prothrombin
activator
 Prothrombin →
Thrombin
 Fibrinogen → Fibrin
 Threads capture
platelets, blood
Pathophysiology of Wound
Healing
 Homeostasis
 Fibrous tissue
development
 As wound is
repaired, replaces
damaged tissue with
new connective
tissue
 Fibroblasts –
Collagen synthesis
 Scar tissue
formation
Pathophysiology of Wound
Healing
 Homeostasis
 Other points
 Disruption of clotting
 Genetic diseases
 Medications
 Generally protective
 Sometimes life-
threatening
 AMI
 Stroke
 Pathophysiology of Wound
Healing
 Inflammation –
Prepares wound for
healing and clears it of
foreign and dead
tissue
 Capillary dilation
 Heat/redness
 Capillary permeability
 Swelling/pain/tenderne
ss
 Accumulate for up to
72 hours
 Attraction of leukocytes
 Pus
 Systemic response (?)
Pathophysiology of Wound
Healing
 Epithelialization and
Neovascularization
 Neovascularization
 New vessel formation
 Epithelialization
 Re-establishes the skin layers
Pathophysiology of Wound
Healing
 Collagen synthesis
 Structural protein of
most body tissue
 Deposited at injury
site within 48 hours
after wound
 Alteration of Wound
Healing
 Interference of
healing or delays
 Medical conditions
 Advanced age,
alcoholism, uremia,
diabetes, hypoxia,
peripheral vascular
disease,
malnutrition,
advanced cancer,
hepatic failure, and
C.V. disease
 Medications
 Corticosteroids,
NSAIDS, PCN and
 Alteration of Wound
Healing
 High Risk Wounds
 Potential for
infection
 Location
 Wound cause or
force
 Immuno-
compromised
patients
 Lots of dead tissue
 Alteration of Wound
Healing
 Abnormal Scar Formation
 Keloid – Scar tissue outside the original
wound
 Hypertrophic – Excessive scar tissue
within the original wound
 Tension lines
 Amount of tension on the skin
 Vary from body part to body part
 Knee wound vs. forearm wound
 Alteration of Wound
Healing
 Keloid scar tissue
 Alteration of Wound
Healing
 Hypertrophic scar
tissue
 Types of Open Soft Tissue
Injuries
 Abrasions  Impaled objects
 Lacerations  Amputation
 Major arterial  Incisions
lacerations  Penetrations/punct
 Avulsions ures
 Types of Open Soft Tissue
Injuries
 Abrasions
 Partial thickness
skin injury
 Caused by scraping
or rubbing
 Painful
 High for infection
 Types of Open Soft Tissue
Injuries
 Laceration
 A tear, split, or
incision
 Can be caused by a
knife or other sharp
object
 Vary in depth
 Can have significant
blood loss
 Types of Open Soft Tissue
Injuries
 Major arterial lacerations
 Lacerations involving larger arteries
 Extensive bleeding possible

 If closed, may develop a hematoma

 Types of Open Soft Tissue
Injuries
 Avulsions
 Flap of skin is torn
or cut, not
completely loose
 Tissue may not be
viable
 Examples:
 Ear lobe, nose tip,
finger tips,
degloving, and scalp
wounds
 Seriousness
depends on:

 Types of Open Soft Tissue
Injuries
 Impaled object
 Instrument that
causes injury
remains imbedded
in wound
 Knives, tree
branches…
 Types of Open Soft Tissue
Injuries
 Amputation
 Complete or partial
loss of a limb by a
mechanical force
 Digits, lower leg,
hand, forearm, and
foot
 Fatal bleeding may
result
 Partial amputation
have more severe
bleeding than a
complete
amputation
 Types of Open Soft Tissue
Injuries
 Incisions
 Similar to a
laceration – wound
edges are smooth
and not jagged
 Caused by a knife,
razor, glass, or
sharp metal
 Heal better
 Bleed freely
 Types of Open Soft Tissue
Injuries
 Penetrations and
punctures
 Caused by a
pointed or sharp
object
 Can cause deep
damage to
underlying tissue
 Hard to assess in
the field
 Stab wound, GSW
 Blast Injuries
 Is caused by a
blast or explosion
 Injuries are due to
3 forces:
 Primary
 Secondary
 Tertiary
 Blast Injuries
 Assessment
 Scene Survey
 Initial Assessment
 Rapid Trauma
Assessment
 Detailed
Assessment
 On-Going
Assessment
 Blast Injuries
 Management
 Same principles
apply for trauma
management:
 ABCs
 Oxygenation and
ventilation
 Stabilize impaled
objects, PRN
 Rapid transport
 Fix life threats on-
scene
 Trauma center
routing
 Maintain adequate
 Crush Injuries
 Crush Injury
 Compartment
Syndrome
 Crush Syndrome
 Crush Injuries
 Crush Injury
 Occurs when tissue is exposed to a
compressive force
 Interferes with normal tissue structure
and metabolic function
 Massive crush injury to vital organs =
Immediate death
 Severity depends on:
 Amount of pressure applied
 Amount if time the pressure stays in place
 Body region affected
 Crush Injuries
 Crush Injury
 Usually involves
upper/lower
extremities, torso,
or pelvis
 Common situations:
 Structural collapse
 Earth collapse
 Motor vehicle
crashes
 Warfare
incidents/Terrorism
 Industrial accidents
 Crush Injuries
 Compartment
Syndrome
 A result of a crush
injury (compressive
forces)
 Muscle groups are
confined within
their tough fibrous
sheaths and not
allowed to stretch
 Usually below the knee or
above the elbow
 Tibial fracture common
 Associated hemorrhage and
edema increase the pressure
within the closed fascial
space
 Result in ischemia –
More swelling and more
 Crush Injuries
 Compartment
Syndrome
 S/S
 5 Ps – Pain, Paresis,
Parathesia, Pallor,
Pulselessness
 Pain is out of
proportion of the injury
and with passive
stretch
 Swelling
 Tenderness
 Weakness in affected
muscle groups
 Diagnosis – History, MOI
and Index of Suspicion
 Crush Injuries
 Crush Syndrome
 Life-threatening condition
 Caused by prolonged immobilization or
compression
 Destruction and necrosis of tissue

 Rare – Occur when extrication or rescue

is prolonged > 4-6 hours
 Crush Injuries
 Crush Syndrome
 Pathophysiology
 Vascular integrity disturbed
 Loss of cell structure and membrane
 Survival until compressive force is removed
 Harmful processes:
 Oxygen rich blood returns to damaged (ischemic)
tissue (Reperfusion)
 Results in pooling of blood and shock
 Toxic substances and waste picked up from damaged
site
 Returns to systemic circulation – Metabolic acidosis
and electrolyte imbalance
 Rhabdomyolysis – Myoglobin from damaged muscle
filtered by kidneys
 Renal failure
 Crush Injuries
 Crush Syndrome
Treatment
 Difficult to diagnose
and treat
 Variables
 Extent of tissue
damage
 Duration and force
of crush
 Patient’s general
health
 Other injures?
 Crush Injuries
 Crush Syndrome Treatment
 Oxygenation and Ventilation
 Maintain body temperature
 Aggressive hydration
 Sodium bicarbonate - Hyperkalemia and
acidosis
 Insulin and dextrose – Hyperkalemia
 Mannitol – Kidney hydration
 Arterial tourniquets (?) before releasing
compressive force
 Amputation (?)
 Consider hospitals with hyperbaric oxygenation
 Hemorrhage Control
Techniques
 Direct pressure  Pressure point
 Elevation  Tourniquet
 Pressure dressing application
 Splinting
 Hemorrhage Control
Techniques
 Arterial bleed – Bright red, spurting
 Venous bleed – Dark reddish-blue,
oozing
 Capillary bleed – Bright red, oozing

 Apply PPE and take BSI precautions

 Hemorrhage Control
Techniques
 Direct pressure
 Hemorrhage control by apply direct
pressure at the injury site
 Applied for 4-6 minutes
 Manual or via bandage
 Never remove pressure

 Continued bleeding?
 Second pressure dressing on top of first
 Hemorrhage Control
Techniques
 Elevation
 Elevate injury site above the heart, as
possible
 A supplement to direct pressure
 Hemorrhage Control
Techniques
 Pressure Point
 Used when direct
pressure and
elevation does not
get the job done
 Compression of an
artery (over a bone)
proximal to the
injury site
 Pressure should be
maintained for
about 10 minutes
 Hemorrhage Control
Techniques
 Tourniquet
application
 Has little or no
indication in the
emergency
management of
hemorrhage
 Associated with
nerve, vessel, and
eventual limb loss
 Last resort only
 Hemorrhage Control
Techniques
 Tourniquet application
 Guidelines:
 Select site – Need a 2 inch wide site
 Place tourniquet over artery to be
compressed, use wide material (BP cuff?)
 Place pad over artery to be compressed
 If using a bandage, encircle extremity twice
(pad), tie knot over pad
 Tie a windlass with a square knot
 Tighten windlass until bleeding stops.
Secure it
 Document tourniquet – Mark forehead –
Never loosen
 Hemorrhage Control
Techniques
 Splinting/Pneumatic Pressure Devices
 Uniform direct pressure
 Over a dressed would only after
bleeding is controlled
 Types of Bandages and
Dressings
 Bandage – Any material used to
secure a dressing
 Dressing – A sterile or non-sterile
cover that aids in hemorrhage
control and prevents further damage
or contamination.
 Types of Bandages and
Dressings
 Sterile
 Non-sterile
 Occlusive
 Non-occlusive
 Adherent Non-
adherent
 Complications of
Improperly Applied
Dressings and Bandages
 Discomfort
 Too loose - Do not control bleeding
 Too tight – Can cause ischemia,
structural damage to vessels, nerves,
tendons, muscles, and skin
 Unclean - Infection
 Wound Infection
 Common complication of soft tissue injury
 Can cause systemic infection sepsis
 Causes:
 Time (Should be cleaned and repaired within 8-
12 hours)
 Mechanism (GSW, knife, crush injury)
 Location (foot, hand, perineum)
 Severity (More tissue damage = more
infection)
 Contamination (Soil, saliva, and/or feces)
 Preparation (Cleanliness)
 Cleansing (Normal saline and high-pressure
syringe)
 Technique of repair (Some need to be left
open, other closed)
 Wound Infection
 S/S of infection
 Pain, swelling, and
redness at the site
 Purulent discharge
(yellow or green)
 Foul odor
 Red streaks from
wound – directed
towards the heart
 Fever, chills, sweats
 Related Protocols

Amputation

Pain management
PAIN MANAGEMENT
PROTOCOL
 PAIN MANAGEMENT
PROTOCOL
Pain Management
Inclusion Criteria: This
guideline applies to
patients suffering from
severe pain or discomfort,
including isolated
extremity injuries,
musculoskeletal or soft
tissue injuries, flank pain
due to suspected kidney
stone, sickle cell crisis,
labor, and other causes.
 
Basic Level
Assess and support ABCs. Offer
comfort and reassurance.
Patient positioning:
Initiate patient positioning and spinal
movement restrictions, as needed.
If no spinal injury suspected, place
the patient in a position of comfort.
If evidence of shock, place the patient
supine with the feet elevated and
monitor airway closely. Treat shock
according to the Shock Guidelines.
Guidelines.
Administer oxygen, as needed to
maintain an SpO2 of at least 96%.
Splint injured extremities and apply
cold packs.
Once advanced level care arrives on
scene, give report and transfer
care.
Advanced Level
6. If the patient can cooperate, have
the patient self-administer
nitrous oxide.
PAIN MANAGEMENT
PROTOCOL
 Amputation
Inclusion Criteria:
Patients with isolated amputation of any
extremity. EMS personnel may also need
to refer
to Shock Guidelines.
Basic Level
Assess and support ABCs. If the initial
assessment is abnormal, minimize
scene time. Continue treatment
guidelines enroute.
Initiate spinal movement restrictions,
as needed. If no spinal injury is
suspected, place the patient in a
position of comfort. If evidence of
shock, place the patient supine
with the feet elevated and
monitor airway closely. Treat
shock according to the
Shock Treatment Guidelines.
Administer oxygen as needed to
maintain an SpO2 of at least 96%.

Control any obvious external
bleeding with any
combination of direct
pressure, pressure points or
elevation. EMS personnel may
apply a tourniquet only as a
last resort.
Care of the amputated part:
Remove gross contaminants
by rinsing with saline.
Wrap in moistened saline
gauze and place in plastic
bag or container (sterile, if
available).
Seal the container tightly
and place in solution of
ice water, if available.
All parts should be brought
to the hospital, regardless
of the condition of the
part.
If the part cannot be
located immediately,
transport the patient
and instruct other field
 Amputation

Begin transport as soon

as possible.
Advanced Level
Consider establishing IV
access at a TKO rate
or use a saline lock.
Consider ECG and
ETCO2 monitor.
Follow
Pain Management Guidelines
.