Soft Tissue Trauma for Pre-Hospital Provider

Soft Tissue Trauma

1. Chapter 31
Soft-Tissue Trauma

2. National EMS Education
Standard Competencies
Trauma
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression to implement a
comprehensive treatment/disposition plan for
an acutely injured patient.

3. National EMS Education
Standard Competencies
Soft-Tissue Trauma
Recognition and management of
−Wounds
−Burns
•Electrical
•Chemical
•Thermal
−Chemicals in the eye and on the skin

4. National EMS Education
Standard Competencies
Pathophysiology, assessment, and
management of
−Wounds
•Avulsions
•Bite wounds
•Lacerations
•Puncture wounds
•Incisions

5. National EMS Education
Standard Competencies
Pathophysiology, assessment, and
management of (cont’d)
−Burns
•Electrical
•Chemical
•Thermal
•Radiation
−High-pressure injection
−Crush syndrome

6. Introduction
•The skin is the largest organ of the body.
−Injuries are common.
−Wound: any injury to soft tissue
−Always search for other injuries or conditions
before treating soft-tissue trauma.

7. Incidence, Mortality, and
Morbidity
•Soft tissue can be injured by:
−Blunt injury
−Penetrating injury
−Burns
•Soft-tissue trauma is the leading form of
injury.

8. Incidence, Mortality, and
Morbidity
•Death from soft-tissue injury is rare.
−Uncontrolled bleeding
−Local or systemic infections
•Prevention involves simple actions.

9. 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

10. Structure and Function of the
Skin
•Significant damage may make the patient
vulnerable to:
−Bacterial invasion
−Temperature instability
−Fluid balance disturbances

11. Epidermis
•First line of defense
•Consists of five layers
−Stratum corneum (outermost layer)
−Four inner layers of living cells

12. Epidermis

13. Dermis
•Tough, highly elastic connective tissue
−Composed of:
•Collagen and elastic fibers
•Mucopolysaccharide gel
•Fibroblasts
−Subdivided into:
•Papillary dermis and reticular layer

14. Dermis
•Macrophages and lymphocytes
−Part of the inflammatory process
−Responsible for combating micro-organisms
•Results in increased blood flow, causing redness
and warmth

15. Dermis
•Specialized structures
−Nerve endings
−Blood vessels
−Sweat glands
−Hair follicles
−Sebaceous gland

16. Subcutaneous Tissues
•Layer beneath the dermis
•Mostly adipose tissue
−Insulates underlying tissues
−Provides a cushion for underlying structures
−Provides an energy reserve for the body

17. Deep Fascia
•Thick, dense layer of fibrous tissue below
subcutaneous tissue
−Composed of tough tissue bands
−Supports and protects underlying structures

18. Skin Tension Lines
•Static tension develops over areas with
limited movement.
−Lacerations parallel to lines may remain closed.
−Larger wounds may be pulled open.
−Smaller lacerations perpendicular to tension
lines will remain open.

19. Skin Tension Lines
•Dynamic tension found over muscle
−Open injuries interfere with healing:
•Disrupt clotting process
•Disrupt tissue repair cycle
•An abnormal scar may prompt scar revision
surgery.

20. Closed Wounds
•Soft tissue is
damaged but skin
is not broken
−Characteristic
closed wound is a
contusion.

21. 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

22. Open Wounds
•Characterized by disruption in the skin
•Potentially more serious than closed
wounds
−Vulnerable to infection
−Greater potential for serious blood loss

23. Open Wounds

24. 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

25. Crush Injuries
•May lead to compartment syndrome
•May lead to rupture of internal organs
•External appearance may not represent
level of internal damage.
−Grotesque injuries may not be primary problem.

26. Crush Injuries
•Body’s 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-to-control
hemorrhage.

27. Blast Injury
•Explosions can result in:
−Soft-tissue trauma
−Abdominal trauma
−Skeletal trauma
−Blast lung
•Assess the scene for hazards.

28. The Process of Wound Healing
•Hemostasis
−Vessels, platelets, and clotting cascade must
work together to stop bleeding.
−The release of chemicals:
•Constricts the blood vessels
•Activates platelets

29. The Process of Wound Healing
•Inflammation
−Additional cells enter area for repair.
−White blood cells combat pathogens.
−Chemotactic factors are released.
−Lymphocytes destroy bacteria and pathogens.
−Mast cells release histamine.

30. The Process of Wound Healing
•Inflammation (cont’d)
−Leads to the removal of:
•Foreign material
•Damaged cellular parts
•Invading micro-organisms

31. The Process of Wound Healing
•Epithelialization
−New epithelial cells move to outer layer of skin
to replace those lost in injury.
•Area seldom regains previous look.
•Function of area may be restored.

32. The Process of Wound Healing
•Neovascularization
−New blood vessels form to bring oxygen and
nutrients to injured tissue.
•New capillaries form from intact capillaries.

33. The Process of Wound Healing
•Collagen synthesis
−Collagen: Tough, fibrous protein in scar tissue,
hair, bones, connective tissue
−Repair unit is synthesized by fibroblasts.
•Cannot restore damaged tissue to former strength

34. Alterations of Wound Healing
•Healing does not always follow pattern
because there may be:
−Infection or abnormal scarring
−Excessive bleeding
−Slow healing

35. Alterations of Wound Healing
•Anatomic factors
−Body areas with repeated motion
−Relationship of open wound to skin tension lines
−Medications
−Medical conditions

36. Alterations of Wound Healing
•High-risk wounds
−Human and animal bites
•High risk of infection
−Injuries from foreign bodies or organic matter
•Do not remove an impaled object in the field.

37. Alterations of Wound Healing
•Abnormal scar formation
−Excessive collagen formation can occur if
healing phases are not balanced, leading to:
•Hypertrophic scar
•Keloid scar

38. Alterations of Wound Healing
•Pressure injuries
−Occur from:
•Being bedridden
•Pressure applied for prolonged periods
−Involved tissues are deprived of oxygen.

39. Alterations of Wound Healing
•Wounds requiring closure
−Include:
•Open injuries affecting cosmetic areas
•Gaping wounds and wounds over tension lines
•Degloving injuries
•Ring injuries and skin tears

40. Alterations of Wound Healing
•Wounds requiring closure (cont’d)
−Open injuries should be closed within 24 hours.
−Three types of wound closure:
•Primary closure
•Secondary intention
•Delayed primary closure

41. Pathophysiology of Wound
Healing
•Infection
−Pathogens grow and multiply once they reach
body tissues.
−Clinical signs may not appear for days.

42. Pathophysiology of Wound
Healing
•Infection (cont’d)
−Visible signs
•Pus
•Warmth
•Edema
•Local discomfort
•Red streaks

43. Pathophysiology of Wound
Healing
•Infection (cont’d)
−Systemic signs
•Fever
•Shaking
•Chills
•Joint pain
•Hypotension

44. Pathophysiology of Wound
Healing
•Gangrene
−Caused by Clostridium perfringens
•Causes foul-smelling gas
−If untreated:
•Skin will become necrotic.
•Infection may lead to sepsis.

45. Pathophysiology of Wound
Healing
•Tetanus
−Caused by infection from Clostridium tetani
−Causes a potent toxin, resulting in:
•Painful muscle contractions
•Muscle stiffness
−Rare because of vaccine

46. Pathophysiology of Wound
Healing
•Necrotizing fasciitis
−Involves tissue death from bacterial infection
−Rare, but with high mortality
−Treatment includes:
•Antibiotic therapy
•Surgical debridement

47. Patient Assessment
•Skin trauma is rarely life-threatening.
−Stay focused on assessment process.
•Identify threats to EMS crew.
•Identify threats to patient.

48. Scene Size-Up
•Address safety first.
•Evaluate MOI.
−If significant, keep a high index of suspicion.
•Determine the number of patients involved.
•Protect yourself and patient from bodily
fluid.

49. Primary Assessment
•Form a general impression.
−Determine any life threats.
−Check patient and immediate surroundings.
−Check for potential injuries to neck and spine.
−Evaluate level of consciousness.

50. Primary Assessment
•Airway and breathing
−Assess immediately.
−Correct anything that interferes with airway.
−Assess the patient’s breathing.
−Take prompt action for compromised breathing.

51. Primary Assessment
•Circulation
−Assess circulation by:
•Palpating a pulse
•Palpating and inspecting the skin using CTC
−Control of severe hemorrhage with a tourniquet
takes precedence.

52. Primary Assessment
•Transport decision
−Transport patients with significant trauma.
−Patients with isolated injuries can often be
treated at the scene.

53. Primary Assessment
•Significant MOI
−Serious trauma indicated by:
•Altered level of consciousness
•Lack or airway protection or patency
•Inadequate breathing
•Uncontrolled bleeding
•Significant MOI

54. Primary Assessment
•Significant MOI (cont’d)
−If possibility of serious injury, perform a rapid
exam, assessing:
•Head and neck
•Chest
•Abdomen
•Pelvis
•Lower and upper extremities
•Posterior

55. Primary Assessment
•Significant MOI (cont’d)
−Identify need for attention using DCAP-BTLS:
•Deformities
•Contusions
•Abrasions
•Punctures or penetrations
•Burns
•Tenderness
•Lacerations
•Swelling

56. Primary Assessment
•Significant MOI (cont’d)
−Assess areas with:
•Alteration in sensation
•Uneven temperature
•Abnormal muscle tone
−Note blood from hidden injuries.
−Address any life threats.

57. Primary Assessment
•Significant MOI (cont’d)
−After assessment, apply a cervical collar.
−Decide whether to rapidly transport.
−Perform a complete set of vital signs and a
SAMPLE history.

58. Primary Assessment
•No significant MOI
−Isolated extremity trauma does not warrant a
fully body exam.
−If protocols allow, some patients can be
released after treatment on the scene.

59. History Taking
•Ask about events leading to injury.
•Ask about the last tetanus booster.
•Ask about over-the-counter medicines.
•Use the mnemonic SAMPLE.

60. Secondary Assessment
•Conduct a more thorough examination en
route if there is:
−A significant MOI
−Adequate time
−Patient in stable condition

61. Reassessment
•Do frequent reassessments en route.
−Stable patient—every 15 minutes
−Serious condition—every 5 minutes minimum
•Obtain and evaluate vital signs.
•Check interventions and monitor patient.

62. Reassessment
•Complete written documentation.
•Note specific injuries, describing wounds.
•Note assessment findings for:
−Distal neurovascular status
−Range of motion
−Presence or absence of infection

63. Reassessment
•Obtain patient demographic information.
•Record any interventions performed,
documenting:
−Patient’s response
−Patient’s understanding
−Which provider attended the patient

64. Emergency Medical Care
•Basic management principles:
−Attend to clinical issues and patient’s feelings.
−Control bleeding with direct pressure, elevation,
or a tourniquet if necessary.
−Document any care provided.

65. Treatment of Closed Wounds
•Minimize bleeding and swelling (ICES):
−Apply Ice or cold packs.
−Apply firm Compression.
−Elevate the injured part higher than the heart.
−Apply a Splint.

66. Treatment of Closed Wounds
•Edema is the body’s way of dealing with
injury to soft or connective tissues.
•Using ice as early as possible may speed
up healing time.

67. Treatment of Open Wounds:
General Principles
•General principles:
−Control bleeding by most effective method.
−Keep wound as clean as possible.
•Determine injury magnitude, and relay
information to the receiving facility.

68. Treatment of Open Wounds:
General Principles
•If wound is already in healing stage:
−Examine edges to see if the wound is closing
properly.
−Check for signs of infection.

69. Bandaging and Dressing
Wounds
•Used to:
−Cover wound
−Control bleeding
−Limit motion
•Variety of materials used

70. Complications of Improperly
Applied Dressings
•Always use as sterile technique as possible.
−Irrigate open wounds with normal saline.
−Apply antibiotic ointment to smaller wounds.
−Do not use ointment on larger wounds.

71. Complications of Improperly
Applied Dressings
•Hemodynamic complications may include
continued bleeding.
−Apply additional dressings in conjunction with
other interventions.
−Perform frequent assessments.

72. Complications of Improperly
Applied Dressings
•Structural elements can be damaged if
dressings are too tight.
−Assess and readjust if necessary.
−When extremity dressings are in place, assess:
•Distal pulses
•Motor function
•Sensation

73. Control of External Bleeding
•Bleeding can be characterized by type of
blood vessel damaged.
−Capillary bleeding—slow flow, bright or dark red
−Venous bleeding—slow, steady, darker color
−Arterial bleeding—spurts, bright red color

74. Control of External Bleeding
•Direct pressure
−Allows platelets to form blood clots
−Steps for management:
•Follow standard precautions.
•Maintain airway.
•Apply direct pressure with a dry, sterile dressing.
•Apply a pressure dressing and gauze.

75. Control of External Bleeding
•Direct pressure (cont’d)
−If bleeding is not controlled, apply a tourniquet.
−Apply high-flow oxygen as necessary.
−Monitor serial vital signs, and watch for shock.
•If signs of shock arise, transport rapidly.
−Assess circulation before and after application.

76. Control of External Bleeding
•Elevation
−Can substantially slow venous bleeding
•Immobilization
−Motion disrupts clotting process.
−Limit injured extremity movement.
−If necessary, apply a splint.

77. Control of External Bleeding
•Tourniquet
−Especially useful if:
•Extremity injury
below the axilla or
groin is severely
bleeding.
•Other bleeding
control methods
are ineffective.
Courtesy of Steven Kasser

78. Control of External Bleeding
•Tourniquet (cont’d)
−Follow standard precautions.
−Hold direct pressure over bleeding site.
−Place tourniquet above the bleeding site.
−Click the buckle into place.
−Turn the tightening dial clockwise until pulses
are no longer palpable distal to the tourniquet.

79. Control of External Bleeding
•Tourniquet (cont’d)
−To release the tourniquet, push the release
button and pull the strap back.
−If a commercial tourniquet is not available, use
a triangular bandage and a stick or rod.
−A blood pressure cuff can also be used.

80. Control of External Bleeding
•Tourniquet (cont’d)
−Take the following precautions:
•Do not apply over a joint.
•Use the widest bandage possible.
•Never use material that could cut into the skin.
•If possible, use wide padding under the tourniquet.

81. Control of External Bleeding
•Tourniquet (cont’d)
−Take the following precautions (cont’d):
•Never cover with a bandage.
•Inform the hospital.
•Do not loosen after it is applied.

82. Pain Control
•May include:
−Cold compress
−Pressure dressing
−Morphine sulfate or other pain medication

83. Managing Wound Healing and
Infection
•Basic measures should be used in the
prehospital setting.
−Wounds that look infected or are not healing
properly should be dressed and bandaged.
−Pain control management may be indicated.

84. Dressing Specific Anatomic
Sites
•Scalp dressings
−Direct pressure is usually effective.
−Determine the extent of injury.
•Balance bleeding control needs against the
possibility of causing further damage.
•If skull has been damaged, apply pressure to areas
around the break.

85. Dressing Specific Anatomic
Sites
•Facial dressings
−Reassure patient.
−Direct pressure is effective to control bleeding.
−If avulsed tissue is present, attempt to place it
as close to its previous position as possible.
−Assess for airway compromise.

86. Dressing Specific Anatomic
Sites
•Ear or mastoid dressings
−Do not place a dressing in the ear canal.
−Use gauze sponges to aid in stopping blood
loss.
−Do not try to directly stop blood flow from the
ear canal.
•Place a bulky dressing over the external ear.

87. Dressing Specific Anatomic
Sites
•Neck dressings
−Minor injuries can
become major.
−Use occlusive
dressings.
−Make sure
dressings do not
interfere with blood
flow or movement
of air through the
trachea.
© E. M. Singletary, MD. Used with permission

88. Dressing Specific Anatomic
Sites
•Truncal dressings
−Cover open wounds with occlusive dressing,
taping only three sides.
−Assess breath sounds.
−Use medical tape to secure dressing.

89. Dressing Specific Anatomic
Sites
•Groin and hip dressings
−Combined with direct pressure
−Genitalia injuries should be managed by
someone of the same gender.
−Remain professional, and protect the patient’s
privacy.

90. Dressing Specific Anatomic
Sites
•Hand, wrist, and
finger dressings
−Place the hand in a
position of function.
−The hand and wrist
can be splinted.
−Leave fingers
exposed.

91. Dressing Specific Anatomic
Sites
•Elbow and knee dressings
−Movement may cause dressings to shift.
•For larger wounds, immobilize joint.
−Assess distal neurovascular status.

92. Dressing Specific Anatomic
Sites
•Ankle and foot dressings
−Control bleeding with direct pressure.
•If bleeding is arterial and not controlled, consider a
tourniquet proximal to injury.
−Always assess distal neurovascular function
before and after caring for a wound.

93. Abrasions
•Superficial wound
−Occurs when part of epidermis is lost from
being rubbed or scraped over a rough surface

94. Abrasions
•Assessment and management
−Oozes small amounts of blood
−May be painful and prone to infection
−Do not clean in the field.
−Cover lightly with sterile dressing.

95. Lacerations
•Cut from a sharp instrument that produces a
clean or jagged incision
−Can injure structures beneath skin
Courtesy of Rhonda Beck

96. Lacerations
•Assessment and management
−Seriousness depends on:
•Depth
•Structures damaged
−First priority is to control bleeding.

97. Puncture Wounds
•Caused by a stab from a pointed object
−Can result in injury to underlying tissues and
organs

98. Puncture Wounds
•Assessment and management
−Consider potential depth of wound.
−Treatment is similar to other wounds:
•Look for entrance and exit wounds.
•Take steps to prevent infection.

99. Puncture Wounds
•Assessment and management (cont’d)
−Air may be injected under the skin with certain
puncture wounds.
•Monitor for edema.
•Treat swelling with ice.

100. Puncture Wounds
•Assessment and
management
(cont’d)
−If the object is still
embedded in the
wound:
•Immobilize the
object.
•Transport the
patient.
© Custom Medical Stock Photo

101. Puncture Wounds
•Assessment and management (cont’d)
−Basic management points for impaled objects:
•Do not try to remove an impaled object.
•Use direct compression, but not on the impaled
object or adjacent tissues.
•Do not try to shorten the object.
•Stabilize the object with bulky dressing, and
immobilize the extremity.

102. Puncture Wounds
•Assessment and management (cont’d)
−Prehospital care goal—limit movement as soon
as possible.
−Secure the object as best as possible.
•Provide reassurance.
•Constantly assess for risks to life.

103. Puncture Wounds
•Assessment and management (cont’d)
−Removal of impaled object may be necessary:
•If object directly interferes with airway control
•If object interferes with chest compression
•If patient is impaled on an immovable object

104. Avulsions
•Occurs when a flap of skin is partially or
completely torn loose
−Amount of bleeding is dependent on the depth
of injury.

105. Avulsions
•Assessment and management
−Principle danger is loss of blood supply to the
avulsed skin flap.
−If wound is contaminated, provide irrigation.
−Gently fold and align the skin flap back as close
to its normal position as possible.
•Cover it with a dry, sterile compression dressing.

106. Avulsions
•Assessment and management (cont’d)
−Ice packs on the surrounding area may:
•Decrease pain and swelling
•Increase the length of time the underlying tissue
remains viable
−If patient is unstable, do not delay transport.

107. Amputations
•An avulsion involving the complete loss of a
body part
© E. M. Singletary, MD. Used with permission.

108. 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

109. Amputations
•Assessment and management (cont’d)
−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.

110. Amputations
•Assessment and management (cont’d)
−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

111. Bite Wounds
•Animals bites can
be serious.
−Cat and dog
mouths are
contaminated with
virulent bacteria.
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112. Bite Wounds
•Human bites usually occur on the hand.
−Human mouths contain a wide variety of virulent
pathogens.

113. 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

114. Bite Wounds
•Assessment and management (cont’d)
−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.

115. Bite Wounds
•Assessment and management (cont’d)
−Emergency treatment for human bites includes:
•Control all bleeding and apply a sterile dressing.
•Immobilize the area with splint or bandage.
•Provide transport.

116. Crush Syndrome
•Can develop if a body area is trapped for
longer than 4 hours and arterial blood flow
is compromised
−If muscles are crushed beyond repair, tissue
necrosis leads to rhabdomyolysis.

117. Crush Syndrome
•Freeing the body part from entrapment may
result in release of harmful products.
−“Smiling death” may occur.
−Other significant complications include:
•Renal failure
•Life-threatening dysrhythmias

118. Crush Syndrome
•Assessment and management
−Scene safety is the first consideration.
−Complete primary assessment as possible.
−Obtain IV access before removing the object.
−Infuse normal saline.
−Add sodium bicarbonate as part of the IV fluid.

119. Crush Syndrome
•Assessment and management (cont’d)
−If pretreatment not possible, apply a tourniquet.
•Will reduce some of the reperfusion damage
−Treat severe hyperkalemia with 25 mL of D
50W,
followed by 10 units of regular IV insulin.
−Rapidly transport once the patient is freed.

120. Crush Syndrome
•Assessment and management (cont’d)
−Manage other injuries once en route.
•Handle open injuries with dressing and bandages.
•Splint fractures.
•Prepare to administer fluids as needed.
•Take vital signs every 5 minutes at minimum.
•Get an ECG reading to detect dysrhythmias.

121. Crush Syndrome
•Assessment and management (cont’d)
−When transporting, consult with medical control
about using a hyperbaric chamber.

122. 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

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

124. Compartment Syndrome
•Assessment and management (cont’d)
−Many signs may be delayed or nonspecific.
−Can cause death of local tissues
−Risk of sepsis
−In-hospital intervention includes fasciotomy.

125. 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

126. High-Pressure Injection
Injuries
•Assessment and management
−Question patient about nature of injury.
−Inspect injury for extent of visibly damaged
tissue.
−Palpate affected area for signs of edema.
−Check for crepitus at injury site.

127. High-Pressure Injection
Injuries
•Assessment and management (cont’d)
−Gently irrigate open wounds with normal saline.
−Dress and bandage open injuries.
−Manage pain if necessary.
−Injury may require emergent surgery.

128. Facial and Neck Injuries
•May involve airway or large blood vessels
−Airway compromise may arise.
•Suctioning and positioning may be necessary.
−Open injuries to the jugular or carotid vessels
can result in exsanguinations.

129. Facial and Neck Injuries
•Assessment and management
−Assess airway patency, protection, and oxygen.
−May require more invasive management:
•Endotracheal tube
•A Combitube
•Laryngeal mask airway

130. Facial and Neck Injuries
•Assessment and management (cont’d)
−Bleeding control can be started while airway
control is underway.
•If only one EMS provider is available, address
bleeding after airway is secured.

131. Thoracic Injuries
•May appear minor but produce deadly
internal damage
•Determine MOI during primary assessment
to detect life threats.

132. Thoracic Injuries
•Assessment and management
−Four steps to assessment:
•Inspection
•Palpation
•Auscultation
•Percussion

133. Abdominal Injuries
•Range from minor abrasions to evisceration
•Inspect abdomen and palpate area.
•During inspiration, the size of thoracic and
abdominal cavities change.
−Increases risk of drawing air into pleural space

134. Abdominal Injuries
•Assessment and management
−Focus on injury to underlying organs and blood
vessels.
•Could quickly lead to serious complications

135. Summary
•The skin fulfills crucial roles, including
maintaining homeostasis, protecting tissue,
and regulating temperature.
•The skin’s main layers are the epidermis
and dermis.
•The layer beneath the dermis is the
subcutaneous layer. Below that is the deep
fascia.

136. Summary
•Tension lines are patterns of tautness in the
skin. If a wound is parallel to skin tension, it
may remain closed, while a wound that runs
perpendicular may remain open.
•Soft-tissue injuries are seldom the most
serious injuries, although they may look
dramatic.
•In a closed wound, soft tissues beneath the
skin are damaged but the skin is not
broken.

137. Summary
•In an open wound, the skin is broken, and
the wound can become infected and result
in serious blood loss.
•In a crush injury, a body part is crushed
between two solid objects, causing damage
to soft tissues and bone.
•Cessation of bleeding is the first stage of
wound healing.
•Inflammation is the second stage of healing.

138. Summary
•Factors that affect wound healing include
the amount of movement the part is
subjected to, medications, and medical
conditions.
•Infection signs include redness, pus,
warmth, edema, and local discomfort.
•Observe scene safety first. Then assess the
ABCs.

139. Summary
•During the history intake, ask about the
event causing the injury. Ask about the
patient’s last tetanus booster, and if they
are taking mediations that may affect
hemostasis.
•Complete the physical exam either en route
or at the scene, depending on mechanism
of injury.
•Document scene findings.

140. Summary
•Be empathetic.
•Controlling bleeding is a part of soft-tissue
injury management. Follow the ICES
mnemonic for closed injuries.
•When managing open wounds, control
bleeding and keep wound clean by irrigating
and sterile dressings.
•Dressings and bandages cover wounds,
control bleeding, and limit motion.

141. Summary
•Medical tape may secure a bandage in
place. Dressings should not be applied too
tightly.
•Bleeding control methods include direct
pressure, elevation, immobilization, and
tourniquets.
•Dressing and bandaging techniques vary
for different areas of the body.

142. Summary
•Avulsion management includes irrigation;
gently folding the flap back onto the wound;
and applying a dry, sterile compression
dressing.
•Do not remove impaled objects.
•Animal and human bites can cause serious
infection. Dogs and cats can carry rabies.
•Crush syndrome may develop after a body
part has been trapped more than 4 hours.

143. Summary
•Patients trapped for prolonged periods of
time must be managed before being freed
to improve survival chances.
•Compartment syndrome results from
pressure increase in a closed soft-tissue
compartment. Presentation includes some
or all of the six Ps.
•Blasts can result in soft-tissue injuries. Use
the DCAP-BTLS guideline for assessment.

144. Summary
•High-pressure injection injuries involve
foreign material injection into soft tissue.
•Special attention should be paid to soft-
tissue injuries of the face, neck, thorax, and
abdomen because they contain vital
structures.

145. Credits
•Chapter opener: © Mark C. Ide
•Backgrounds: Orange—© Keith Brofsky/Photodisc/
Getty Images; Blue—Jones & Bartlett Learning.
Courtesy of MIEMSS; Purple—Jones & Bartlett
Learning. Courtesy of MIEMSS; Green—Courtesy of
Rhonda Beck.
•Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have been
provided by the American Academy of Orthopaedic
Surgeons.