Study Guide 9

Chapter 30 - Soft Tissue Trauma, Ch 31 - Chest and Abdominal Trauma, Ch 32 - Musculoskeletal Trauma, and Ch 33 - Trauma to the Head, Neck, and Spine

Soft tissues include:

• Skin

• Fatty tissues

• Muscles

• Blood vessels

• Connective tissues

• Membranes

• Glands

• Nerves

Major functions of the skin

• Protection

• Water balance

• Temperature regulation

• Excretion

• Shock (impact) absorption

Soft Tissues

• Skin layers

  • Epidermis

  • Dermis

  • Subcutaneous layers

• Wounds often classified as closed or open.

Closed Wounds

• Internal injuries with no pathway from the outside to the injured site

• Although skin unbroken, may be extensively crushed tissues beneath

• Range from minor to life-threatening

Closed wounds include:

• Contusions

  • Bruise

    

• Hematomas

  • Similar to contusion

  • More tissue damage

  • Involves larger blood vessels

    

• Closed crush injuries

  • Force transmitted from exterior to internal structures

  • Crush or rupture internal organs

    • Solid organs bleed severely and cause shock

    • Hollow organs leak into body cavities

Closed wounds are what?

• Contusions

• Rupture of a hollow organ

• Internal laceration and puncture

• Crush injury with no open wound

• Injury of a solid organ

Patient Assessment of Closed Wound

• Bruising may be indication of internal injury or internal bleeding.

• Consider mechanism of injury.

• Crush injuries are difficult to identify.

Patient Care of Closed Wound

• Take appropriate Standard Precautions

• Manage airway, breathing, and circulation

• Manage as if there were internal bleeding and shock if there is any possibility of internal injuries

• Splint extremities that are painful, swollen, or deformed

• Stay alert for vomiting

• ****Continuously monitor for changes and transport promptly

• Apply cold pack to isolated injuries to manage pain and swelling

Types of Open Wounds

• Abrasions

  

• Lacerations

  

• Penetrating trauma and punctures

• Avulsions

  

• Amputations

Degloving also consistent with Avulsion

Where a large piece of skin and underlying tissue is forcefully torn away.

Evisceration

Removal of internal organs or viscera from the body cavity

More Types of Open Wounds

• Open crush injuries

• Bite wounds

• Blast injuries

• High-pressure-injection injuries

Blast Injuries

• Can be injured multiple ways

  • Initial blast (High pressure wave)

  • Hit by debris

  • Thrown (landing Impact)

  • Closed or open injuries

  • Penetrating injury

  • Chemical burns

Blast injuries impacts 

• Primary

  • Pressure wave leading to injuries to organs like lungs, fluid filled organs like spleen etc.

• Secondary

  • Projectiles Shrapnel

  • Blast injury leading to open and penetrating wounds

• Tertiary

  • If patient is thrown, fractures, avulsions, amputations

• Quaternary - Exposure to chemicals

High Pressure injury

• Machinery operating at high pressures

  • Are used to project fluid or air into particular areas

• If this pressure goes into the body what occurs

  • Can travel long distances

  • Damage tissue, bone etc.

  • May present with intense pain or none at  all

  • Do not treat with ice. (Why)

Emergency Care for Open Wounds

• Strict attention to Standard Precautions

  • In addition to wearing gloves, a gown and protective eyewear may be required.

Patient Assessment for Open Wounds

• Primary assessment

–Airway           Breathing 

–Breathing      Airway 

–Circulation    Circulation (Severe Bleeding)

–Severe bleeding

Care for individual wounds

Patient Care for Open Wounds

• Expose wound.

• Clean wound surface.

• Control bleeding.

• For all serious wounds, provide care for shock, including administration of high-concentration oxygen.

• Prevent further contamination.

• Bandage dressings in place after bleeding is controlled.

• Keep patient lying still.

• Reassure patient.

Treating Abrasions and Lacerations

• Reduce wound contamination

• Hold direct pressure to control bleeding

• Always check pulse, motor, and sensory function distal to injury to assure function

Treating Penetrating Trauma

• Use caution because objects may be embedded deeper than they appear.

• Check for exit wounds.

  • May require immediate care

• Bullets can fracture bones as they enter.

• Stab wounds are considered serious, especially if in a vital area of body.

More Info on Treating Penetrating Trauma

• Reassure patient.

• Search for exit wound.

• Assess need for basic life support.

• Follow local protocols regarding spinal motion restriction.

• Transport patient.

Treatment: Penetrating Trauma

Bullets travel in an unpredictable path once they are inside the patient’s body, and can therefore cause damage to multiple organs and bones.

Treating Impaled Objects

• ****Do not remove object; may cause severe bleeding.

• Expose wound area.

• Control profuse bleeding by direct pressure.

• Get a description of the object.

• ****Apply several layers of bulky dressing so dressing surrounds the object on all sides.

More Info on Treating Impaled Objects

• Place bulky dressing on opposite sides of the object.

• Secure dressings in place.

• Care for shock.

• Keep patient at rest.

• Transport the patient carefully and as soon as possible.

• Reassure patient throughout all aspects of care.

Treatment: Impaled Objects

1. Stabilize an impaled object with bulky dressings.

   

2. Bandage the impaled object and surrounding dressings in place.

Object Impaled in the Cheek

• Object may enter oral cavity, causing airway obstruction.

• If cheek wall is perforated, profuse bleeding into mouth and throat can cause nausea and vomiting.

• External wound care will not stop the flow of blood into the mouth.

• Examine wound site, both inside and outside mouth

• ****If you find the perforation and can see both ends, remove object.

  • If this cannot be easily done, leave object in place.

Treatment: Impaled Object in Cheek

The process of removing an impaled object from the cheek.

More Info on Object Impaled in the Cheek

• Position patient to allow for drainage.

• Monitor patient’s airway.

• Dress outside of wound.

• Consider the need for oxygen and care for shock.

Puncture Wound or Object Impaled in the Eye

• ****Stabilize the object.

• Apply rigid protection.

• Have another rescuer stabilize dressings and cut while you secure them in place with self-adherent roller bandage or with wrapping of gauze.

Treatment: Puncture Wound or Object Impaled in Eye

1. Managing an object impaled in the eye.

   

2. Wrap both eyes. The object is contained and immobilized.

More Info on Puncture Wound or Object Impaled in the Eye

• ****Dress and bandage uninjured eye.

  • Eyes want to track together

• Consider need for oxygen and care for shock.

• Reassure patient and provide emotional support.

Treating Avulsions

• Clean wound surface.

• Fold skin back into normal position.

• Control bleeding and dress with bulky dressings.

• ****If avulsed parts are completely torn away, save in sterile dressing and keep moist with sterile saline.

Treating Amputations

• Take steps to control hemorrhage immediately.

• Apply direct pressure to control bleeding; use tourniquet only if all other methods fail.

1. Do not place directly on ice. Care for an amputated part. The amputated digit sits on sterile gauze, awaiting reimplantation at the trauma center.

More Info on Treating Amputations

• Wrap amputation site in sterile dressing, and secure dressing with self-adhesive gauze bandage.

• Then wrap or bag amputated part in plastic bag; keep it cool by cold pack. (Not in direct contact)

• ****Do not immerse amputated part directly in water or saline.

Treating Genital Injuries

• Control bleeding.

• Preserve avulsed parts.

• Consider whether injury suggests another, possibly more serious, injury.

• Display calm, professional manner.

• Dress and bandage wound.

• Consider possibility of sexual assault.

Burns

• May involve more than just skin-level structures.

• ****If respiratory structures are affected, swelling may occur, causing life-threatening obstruction. 

• Do not let burn distract from spinal damage or fractures.

Patient Assessment

• Classifying burns

  • Agent and source

    • (What caused the burn)

  • Depth

    • How Deep

  • Severity

    • Where located, percentage of body, agent, age, health.

Classifying Burns by Agent and Source

• Agent could be chemicals or electricity

• ****Report the agent and, when practical, the source of the agent.

  • Never assume the agent or source of the burn.

  • Always gather information from your observations of the scene, bystanders’ reports, and the patient interview.

Assessment: Burns

• Superficial

  • Skin reddened

• Partial thickness

  • Blisters

• Full thickness

  • Charring

Superficial burn (1^st degree)

• Involves only epidermis

• Reddening with minor swelling

Partial thickness burn (2^nd degree)

• Epidermis burned through, dermis damaged

• Deep, intense pain (Why)

• Noticeable reddening

• Blisters and mottling

Full thickness burn (3^rd degree)

• All layers of skin burned

• Blackened areas or dry and white patches

  • May not have pain at all, or may only be at the periphery. (Why)

Determining the Severity of Burns

• Consider the following factors:

  • Agent or source of the burn

  • Body regions burned

  • Depth of the burn

  • Extent of the burn

  • Age of the patient

  • Other illnesses and injuries

Rule of Nines

• ****Helps estimate extent of burn area

• Adult body is divided into 11 main areas

• Each represents 9 percent of body surface

Rule of palm

• Helps estimate extent of burn area

• ****Palm and fingers equal about 1 percent of body surface area

• Easier to apply to smaller or localized burns

Classifying Burns by Severity

• Must be classified to determine:

  • Order and type of care

  • Priority for transport

  • Maximum information to provide to the emergency department.

Pediatric Note

• Infants and children have a much greater relationship of body surface area to total body size, resulting in greater fluid and heat loss from burned skin.

Treating Specific Types of Burns

• Patient care for thermal burns

  • ****Stop burning process and cool burned area.

  • Ensure open airway and assess breathing.

  • Look for signs of airway injury.

  • Complete primary assessment.

  • Treat for shock.

More Info on Treating Specific Types of Burns

• ****Evaluate burns by depth, extent, and severity.

  • Do not clear debris.

  • Remove clothing and jewelry.

  • ****Wrap with dry sterile dressing.

  • For burns to hand or feet, remove patient’s rings or jewelry and separate fingers or toes with sterile gauze pads.

What patients go to burn centers

• 2^nd degree burns (What percentage of body)

• Burns to certain body areas (Where)

• 3^rd Degree burns

• Certain agents (Which ones)

• Certain types of burns (Ie. Inhalation burns)

• Certain patients (Such as)

Patient care for chemical burns

• ****Wash away chemical with copious amounts of flowing water.

• ****If dry chemical, remove contaminated clothing, then flush with water.

• Apply sterile dressings. → Treat for shock. → Transport.

Radiation Burns

• Exposure to high levels of radiation can harm the human body both immediately and in a delayed fashion.

• Great number of sources of radiation

  • Difficult to detect without specific monitoring equipment

• Extremely harmful

  • Do not approach a radiological injury without protective equipment and specialized training.

  • See patient with a radiological burn only after they have been decontaminated.

• Most will present like thermal injuries.

Electrical Injuries

• ****Severe damage through body along path of electrical current

• ****Entry and exit burns are possible.

• Respiratory/cardiac arrest are possible.

• Bones may fracture from violent muscle contractions.

Patient Care for Electrical Injuries

• Provide airway and breathing care.

• Provide basic cardiac life support; be ready to defibrillate.

• Care for shock and administer high-concentration oxygen.

More Info on Patient Care on Electrical Injuries

• ****Care for spinal and head injuries as well as extremity fractures.

• Evaluate burn sites.

• Cool burning areas and smoldering clothing the same you would for a flame burn.

• Apply sterile dressings.

• Transport as soon as possible.

What does dressing do?

Dressings cover wounds.

Information on Dressing and Bandaging

• Universal dressing

  • Available for profuse bleeding, large wound

• Pressure dressing

  • Used to control bleeding

• Occlusive dressing

  • Used to form an airtight seal

  • Wounds to the abdomen, large neck veins, open wounds to chest

What does a bandage do?

Bandages hold dressings in place. 

Dressing Open Wounds

• Take Standard Precautions.

• Expose wound.

• Use sterile or very clean materials.

• Cover entire wound.

• Control bleeding by direct pressure and/or hemostatic agents or dressings to stop or slow bleeding.

• Do not remove dressings.

Bandaging Open Wounds

1. To apply a self-adhering roller bandage, secure it with several overlapping wraps.

2. To apply a self-adhering roller bandage, keep it snug.

Review of Soft-tissue Injuries

Soft-tissue injuries may be closed (internal, with no pathway to the outside) or open (an injury in which the skin is interrupted, exposing the tissues below).

Review of Closed Injuries

Closed injuries include contusions (bruises), hematomas, crush injuries, and blast injuries.

Review of Open Wounds

Open wounds include abrasions, lacerations, punctures, avulsions, amputations, crush injuries, and blast injuries.

• For open wounds, expose the wound, control bleeding, and prevent further contamination.

Open and Closed Injuries Review

For both open and closed injuries, take appropriate Standard Precautions; note the mechanism of injury; protect the patient’s airway and breathing; consider the need for oxygen by nonrebreather mask; treat for shock; and transport.

How is burn severity determined?

Burn severity is determined by considering the source of the burn, body regions burned, depth of the burn (superficial, partial thickness, or full thickness), extent of the burn (by rule of nines or rule of palm), age of the patient (children under 5 and adults over 55 react most severely), and other patient illnesses or injuries.

How do we properly care for burns?

Care for burns includes stopping the burning process (using water for a thermal burn, brushing away dry chemicals), covering a thermal burn with a dry sterile dressing, flushing a chemical burn with sterile water, protecting the airway, administering oxygen as appropriate, treating for shock, and transporting the patient to a medical facility.

How do we treat electrical injuries?

For treatment of electrical injuries, be sure that you and the patient are in a safe zone away from possible contact with electrical sources. Protect airway, breathing, and circulation. Be prepared to care for respiratory or cardiac arrest. Treat for shock, care for burns, and transport the patient.

We must remember that soft tissue is what?

The soft tissue of the body is made up of skin, fatty tissues, muscles, blood vessels, connective tissues, membranes, glands, and nerves.

Our skin does what?

The skin provides protection, water balance, temperature regulation, excretion, and shock absorption.

Open or closed is in reference to what?

Open or closed in reference to a soft-tissue injury is dictated by whether or not the skin is still intact.

Closed injuries must be what?

Closed injuries must be evaluated with consideration to underlying anatomy and mechanism of injury.

Remember that

• Open injuries typically are easier to visualize, but they often can mask underlying injuries.

• Burns involve immediate destruction of tissue but also can have a long-term effect, both physically and emotionally.

• Safety must be a key concern when treating a patient with a burn or an electrical injury.

• The goal of dressing and bandaging wounds is to control bleeding and to prevent infection.

Chest cavity

• Extends from collarbones to diaphragm

• Dynamic because it depends on respiratory cycle

• Packed with organs, major blood vessels, and lung tissue

Organs of the chest are well protected

• 12 sets of ribs

• Sternum

• Thoracic spine vertebrae

• Scapula

Physiologic functions of the chest

• Heart beats to provide blood flow

• Large blood vessels enter and exit the heart

• Respiratory function

The Mechanism of Breathing

• Chest wall, diaphragm, and lungs work together

  • Change pressure within the chest cavity

  • Cause air to be moved in and out

• Inhalation

  • Active process that uses negative pressure to draw air into the lungs

• Exhalation

  • Passive process that uses positive pressure to push air out of the lungs

Anatomy and Physiology of the Abdomen

• Superior border is diaphragm

• Abdominal organs extend to the lower regions of the pelvis

  • Described in context of location relative to four abdominal quadrants

Anatomy of the Abdomen

• Solid Organs

  • Spleen

  • Liver

  • Pancreas

  • Kidneys

• Hollow Organs

  • Stomach

  • Gallbladder

  • Duodenum

  • Large Intestine

  • Small Intestine

  • Bladder

Information on Anatomy and Physiology of the Abdomen

• Trauma assessment and care takes into consideration placement and function of abdominal organs.

• Differentiate between hollow and solid organs

  • Hollow organs tolerate trauma well.

    • Bladder, intestines, stomache

  • Solid organs do not tolerate trauma well.

    • Liver, Spleen, Kidney

More Information on Anatomy and Physiology of the Abdomen

• Physiology of abdominal organs is dependent on individual function.

• Abdominal cavity is dynamic depending on location of diaphragm.

  • Organs shift location dependent on breathing cycle

• There is always a large volume of blood in the abdomen.

Pathophysiology of the Chest and Abdomen

• Disruption of breathing

• Hemorrhage and shock

• Disruption of organ function

• Infection

Chest Injuries

• Blunt trauma

  • Can fracture ribs, sternum, and costal (rib) cartilages

• Penetrating trauma

  • Bullets, knives, pieces of metal or glass, steel rods, pipes, other objects

  • Can damage internal organs and impair respiration

Info on Chest Injuries

• Compression and shearing injuries

  • Occurs when severe blunt trauma causes the chest to rapidly compress

  • Shearing can damage the aorta and vena cava

• Chest injuries are classified as either closed or open.

Blunt Chest Injuries - Rib Fractures

• Painful but usually not life-threatening

• Can make breathing difficult

• Can lacerate blood vessels or lung tissue

Blunt Chest Injuries - Flail Chest

• ****Fracture of two or more consecutive ribs in two or more places

• Leaves a portion of the chest wall unstable

• Leads to inadequate breathing and hypoventilation

1. Best way to deal with a flail chest is with O2 or ventilate.

• Flail chest occurs when blunt trauma creates a fracture of two or more ribs in two or more places.

Blunt Chest Injuries - Paradoxical Motion

• Movement of flail segment is opposite to movement of the remainder of the chest cavities.

Patient Assessment of a Rib Fracture

• Consider mechanism of injury

• Pain at the site of injury that increases with breathing

• Tenderness

• Redness, swelling, or bruising of skin

• Respiratory distress, hypoxia, or respiratory failure

• Self-splinting

Patient Assessment of Flail Chest

• Mechanism of injury capable of causing injury

• Difficulty breathing

• Pain at injury site

• Likely signs of shock and hypoxia

• Chest wall muscle contraction

Patient Care of a Rib Fracture

• Consider need for A L S

• Allow patient to remain in position of comfort

  • Unless spinal precautions are needed

• Treat hypoxia

• Allow patient to hold pillow or cushion against chest (Not really done in the field anymore)

Patient Care of Flail Chest

• Primary assessment for life threats

• Administer oxygen.

• If patient is breathing inadequately, assist ventilation.

• Follow local protocols regarding using noninvasive positive pressure ventilations.

Info on Patient Care of Flail Chest

• Request ALS for pain management.

• Monitor patient carefully.

• Watch respiratory rate and depth.

• Do not restrict chest wall movement.

Penetrating Chest Injuries

• Difficult to tell what is injured from entrance wound

• Assume all wounds are life-threatening.

• Open wounds allow air into chest.

  • Sets imbalance in pressure

  • Causes lung to collapse

Patient Assessment for Penetrating Chest Injuries

• Determine description of object that penetrated

• If one penetrating wound is found, look for others.

• Visualize entire chest during assessment

• Listen to lung sounds

  • Identify pneumothorax or hemothorax

Info on Patient Assessment for Penetrating Chest Injuries

• Lung damage signs and symptoms

  • Difficulty breathing

  • Absent or unequal lung sounds

  • Hemoptysis

    • Coughing up blood

  • Hypoxia

More Info on Patient Assessment for Penetrating Chest Injuries

• Other signs and symptoms

  • Shock

  • Tachycardia

  • Tachypnea

  • Pale skin

  • Low blood pressure

“Sucking Chest Wound”

• Air drawn in through hole

• Wound to the chest

• Sucking sound

• Small air bubbles within wound

• Patient may gasp for air

Patient Care for “Sucking Chest Wound”

• Allow law enforcement to render scene safe.

• Consider A L S.

• Maintain open airway.

• ****Seal wound.

• ****Apply occlusive dressing.

Info on Patient Care for “Sucking Chest Wound”

• Allow patient to remain in position of comfort if possible.

• Administer high-concentration oxygen.

• Treat for shock.

• Immediate transport.

Occlusive and Flutter-Valve Dressings

• Occlusive dressing seals wound to stop movement of air.

• Flutter valve dressings involve taping dressing in place and leaving a side or corner of dressing unsealed

  • As patient inhales, dressing will seal wound.

  • As patient exhales, free corner or edge acts as flutter valve to release air trapped in chest cavity.

1. Creating a flutter valve to allow air to escape from the chest cavity.

2. Creating a flutter valve to allow air to escape from the chest cavity.

Injuries Within the Chest Cavity

• Pneumothorax and tension pneumothorax

  • JVD hyper resonant tympanic sound on percussion

• Hemothorax and hemopneumothorax

  • Hypo resonant, dull sound no jvd

• Traumatic asphyxia

  • Pressure pushes blood into the jugular veins

• Cardiac tamponade (JVD, Narrowed pulse pressure)

• Aortic injury