1	Chapter 22 Soft Tissue Trauma
2	Objectives Describe normal structure and function of skin Describe pathophysiological responses to soft tissue injury Discuss mechanism of injury, signs and symptoms of soft tissue injuries Outline prehospital care of soft tissue injuries
3	Objectives Describe hemorrhage control techniques Identify characteristics of dressings and bandages Describe management of soft tissue injuries not requiring closure Discuss factors that increase infection risk Describe care of soft tissue injuries
4	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” bruise on her forehead.
5	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?
6	The Skin Membrane that covers entire body Largest, most dynamic organ Epidermis Dermis Subcutaneous layer (superficial fascia) Deep fascia
7	Key Functions of the Skin Shield tissues from fluid loss Temperature control Produce vitamin D Protect internal structures from mechanical injury Prevent entrance of infectious organisms
8	Hemostasis of Wound Healing Initial response to wounding Vascular reaction that involves Vasoconstriction Formation of platelet plug Coagulation Growth of fibrous tissue into blood clot closes and seals injured vessel
9	Clotting Mechanism
10	Inflammatory Response Chemical release from injured vessel and blood (platelets, white blood cells) causes: Local vasodilation of arterioles, precapillary sphincters, and venules Increased permeability of affected capillaries and vessels Collection of plasma, plasma proteins, electrolytes, and chemical substances in extracellular space
11	Collagen Structural protein in body tissues Essential for tissue repair Fibroblasts deposit collagen within 48 hours Increases tissue strength 4 months to regain full strength and function
12	Factors Affecting Wound Healing Wound healing is affected by: Anatomic factors Concurrent drug use Medical condition and disease High-risk wounds
13	Abnormal Scar Formation May cause keloid and hypertrophic scars Keloid Scar tissue that extends beyond original wound borders More common in: Darkly pigmented patients Injuries to ears, upper extremities, lower abdomen, or sternum
14	Abnormal Scar Formation Hypertrophic scar Excess accumulation of scar tissue in original wound borders More common in areas of high tissue stress, such as the flexion creases across joints
15	Wounds Requiring Closure Wounds to cosmetic regions Examples Face Lips Eyebrows Gaping wounds Wounds over tension areas (e.g., joints) Degloving injuries Ring finger injuries Skin tearing
16	Closed Wounds Usually minimal blood loss May cause significant blood loss in: Cavities of thorax, abdomen, pelvis Soft tissues of leg
17	Contusions and Hematomas Contusion Blood vessel disruption beneath epidermis Swelling, pain, ecchymosis May occur 24 to 48 hours after injury
18	Contusions and Hematomas Hematoma Collection of blood beneath skin May occur with contusion Larger amount of tissue damage and disruption of larger vessels
19	Crush Injury Crushing force to body area Can be severe and may accompany: Internal organ rupture Major fractures Hemorrhagic shock
20	Crush Injury Woman’s leg after being run over by the wheel of a milk van
21	Abrasion Partial-thickness injury Scraping or rubbing away of layers of skin
22	Laceration Tear, split, or incision of skin Size and depth vary depending on injury sites and wounding mechanism May be significant bleeding
23	Laceration
24	Puncture Contact with sharp, pointed object Small entrance wound
25	Penetrating Injuries Potential major underlying damage to internal organs Chest injury Pneumothorax, hemothorax Pericardial tamponade Penetrating heart wound Abdominal injury Peritonitis Evisceration
26	Impaled Object
27	Injection injury Puncture wound from injection of substance into body under high pressure May have life- or limb-threatening potential Usually minimal bleeding May not appear serious
28	Injection Injury
29	Avulsion Full-thickness skin loss in which wound edges cannot be approximated Frequently involves ear lobes, nose tip, and fingertips
30	Degloving Injury Avulsion in which shearing forces separate skin from underlying tissues Bleeding may be significant
31	Amputation Complete or partial loss of limb due to mechanical force Bleeding is a potentially fatal complication
32	Bites Animal or human bite is often a combination of puncture, laceration, avulsion, and crush injuries
33	Crush Injury Tissue exposed to sufficient force to interfere with normal structure and metabolic function of involved cells and tissues Degree of injury depends on: Amount of pressure applied Amount of time pressure is in contact with body Specific body region in which injury occurs
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35	Compartment Syndrome Can occur with crush injury Compressive forces to muscle groups confined in tight fibrous sheaths with minimal ability to stretch
36	Crush Syndrome Life threatening and sometimes preventable complication of prolonged immobilization or compression Causes destruction or alteration of muscle tissue Relatively rare
37	Blast Injuries Primary blast injuries Secondary blast injuries Tertiary blast injuries Miscellaneous blast injuries
38	Blast Injury Blast injury to face Eardrums were normal Risk of swelling to his face and airway with potential airway obstruction
39	Management Principles Scene survey Treatment priorities Life-threatening injuries should be treated before isolated soft tissue trauma Airway Breathing Circulation Wound history Physical examination
40	Methods of Hemorrhage Control Direct pressure Elevation Pressure point Immobilization by splinting Pneumatic pressure devices Use of tourniquets (rare)
41	Pressure Point Artery must Be proximal to injury site Overlie a bony structure against which it can be compressed
42	Dressing Materials General categories Sterile Nonsterile Occlusive Nonocclusive Adherent Nonadherent Bandages Complications when improperly applied
43	Management of Specific Injuries Open wounds requiring physician evaluation include: Neural, muscular, or vascular compromise Tendon or ligament compromise Heavy contamination Cosmetic complications Foreign bodies Tetanus vaccine Patient instructions
44	Wound Infection Common complication of soft tissue injury Results from: Break in continuity of skin Exposure to nonsterile environment Goals of wound care Prevent infection
45	Causal Factors of Wound Infection Time Mechanism Location Severity Contamination Preparation Cleansing Technique of repair General patient condition
46	Assessment of Wound Healing Examine dressings for excess drainage Examine wounds for early signs of infection or delayed healing Signs of wound infection
47	Special Considerations Assess life-threatening injuries and resuscitate before caring for soft tissue injuries After control of airway, breathing, circulatory status (with spinal precautions if indicated) and body temperature, wound care can proceed
48	Penetrating Chest or Abdominal Injury Cover open wounds of chest or upper abdomen with a sterile occlusive dressing
49	Impaled Object—Management Do not remove impaled object Do not manipulate object unless it must be shortened for extrication or patient transport Control bleeding with direct pressure around impaled object Stabilize object with bulky dressings Immobilize patient to prevent movement
50	Avulsion—Management If tissue is attached to body: Clean wound surface of gross contaminants with sterile saline Gently fold skin back to normal position Control bleeding Dress wound with pressure dressings Maintain direct pressure
51	Avulsion—Management If tissue is completely separated: Control bleeding with direct pressure Retrieve avulsed tissue if possible Wrap tissue in gauze Dry or moistened with lactated Ringer’s or saline solution (per protocol) Seal tissue in plastic bag Place sealed bag on crushed ice
52	Amputations—Management Attempt hemorrhage control with direct pressure and elevation Avoid tourniquet if possible Retrieve amputated limb Manage in same manner as avulsed tissue
53	Crush Syndrome—Management Difficult to diagnose and treat Management controversial Airway and ventilatory support, with high-concentration oxygen administration Maintain body temperature Aggressively hydrate patient Alkalinize urine with sodium bicarbonate Arterial tourniquets may be beneficial before release of a crushed limb
54	Conclusion The paramedic must thoroughly understand soft tissue trauma to quickly assess life threatening injury and to intervene to promote normal healing and function.