Chap 36 Bleeding and Soft-Tissue Trauma

External Hemorrhage

Results from soft-tissue injury

• Often accompanied by mild hemorrhage 

• Often does not pose a threat to life

Seriousness of injury depends on: 

• Anatomic source of hemorrhage (arterial, venous, capillary)

• Degree of vascular disruption

• Amount of blood loss that patient can tolerate

Internal Hemorrhage

Can result from:

• Blunt or penetrating trauma

• Acute or chronic illnesses

May lead to an insufficient amount of circulating blood in body cavities:

• Chest

• Abdomen

• Pelvis/retroperitoneum

• Thigh

Signs and symptoms of Internal Hemorrhage

• Bright red blood from mouth, rectum, or other orifice

• Coffee-ground appearance of vomitus

• Melena (black, tarry stools)

• Hematochezia (passage of red blood through the rectum)

• Dizziness or syncope on sitting or standing

• Orthostatic hypotension

Epidermis

Thin, nonvascular epithelial tissue nourished by capillaries of dermis

Five layers

• Stratum basale, innermost layer

• Stratum spinosum

• Stratum granulosum

• Stratum lucidum

• Stratum corneum, most superficial layer

Stratum corneum has about 20 layers of dead skin cells filled with waterproofing protein keratin

Dermis 

Lies beneath epidermis

Contains:

• Connective tissue

• Elastic fibers

• Blood vessels

• Lymph vessels

• Motor and sensory fibers

Also houses structures of integumentary system (hair, nails, and sebaceous and sweat glands).

Has reservoir of defensive and regenerative elements, which collectively combat infection and repair deep wounds

Deep fascia

Dense layer of fibrous tissue beneath dermis 

Provides:

• Insulation

• Cushioning

• Caloric reserve

• Body substance and shape

Hemostasis

initial physiologic response to wounding

• Vasoconstriction

• Formation of a platelet plug

• Coagulation

• Growth of fibrous tissue into blood clot that permanently closes and seals injured vessel

Blood coagulation occurs as

a result of a chemical process.

• Within 3 to 6 minutes after vessel rupture, entire end of vessel is filled with a clot.

• Within 30 minutes, the clot retracts and the vessel is sealed further.

The clotting cascade includes the following three mechanisms:

Prothrombin activator is formed in response to rupture or damage of blood vessel.

Prothrombin activator stimulates conversion of prothrombin to thrombin.

Thrombin converts fibrinogen into fibrin threads, which entrap platelets, blood cells, and plasma to form the clot.

Inflammatory Response

Release of chemicals from injured vessel and various blood components causes localized vasodilation of:

• Arterioles

• Precapillary sphincters

• Venules

Increases permeability of affected capillaries and vessels

Existing medical conditions that can delay wound healing:

• Advanced age

• Alcoholism and tobacco use

• Acute uremia

• Diabetes

• Immunosuppression

• Hypoxia

• Obesity

• Malnutrition

• Stress

High-risk wounds

Those with increased potential for infection because of location or nature of wounding force.

• Examples: wounds located on or near hands, feet, and perineal areas

Keloid

excessive accumulation of scar tissue beyond original wound borders

Hypertrophic scar

excess accumulation of scar tissue within original wound borders

Wounds requiring closure

• Wounds to cosmetic regions (eg, face, lips, eyebrows)

• Gaping wounds

• Wounds over tension areas (eg, joints)

• Degloving injuries 

• Ring finger injuries

• Skin tearing

Contusion

characterized by blood vessel disruption beneath epidermis

• Swelling

• Pain

• Ecchymosis (bruising)

Hematoma

collection of blood beneath skin

Abrasion

Partial-thickness skin injury caused by scraping or rubbing away of layer of skin

Usually results from friction with hard object or surface

Laceration

Tear, split, or incision of skin

Often caused by knife or other sharp object, resulting in linear wound or incision

Puncture

Caused by contact with sharp, pointed object 

Entrance wound generally small

• Possible deep penetration and injury to underlying tissues

Chest or abdominal puncture injuries may result in severe damage, such as:

• Pneumothorax or hemothorax

• Pericardial tamponade

• Penetrating heart wound

• Hollow and solid organ damage

• Peritonitis

• Evisceration

High-pressure injection injuries

Injection of fluids under high pressure can cause a puncture wound.

Often have life- or limb-threatening potential

May require rapid surgical decompression and debridement.

Avulsion

Full-thickness skin loss

Wound edges cannot be approximated

Degloving injury—shearing forces separate skin from underlying tissues

Amputation

Complete or partial loss of limb by a mechanical force

Most commonly amputated body parts are digits, lower leg, hand and forearm, and distal portion of foot.

Bites

Frequently is combination of puncture, laceration, avulsion, and crush injuries

Can involve deep structures (tendons, muscles, and bones).

All patients who have been bitten should seek physician evaluation.

Compartment syndrome

Caused by increased external or internal pressure; usually result of crush injury

Typically results from compression forces or blunt trauma to muscle groups confined in tight fibrous sheaths with minimal ability to stretch (below knee, above elbow).

Less common causes

• Electrical injury

• Hemorrhage into compartment 

• Circumferential deep burns and electrical burns

• Vascular occlusion

• High-pressure injection injuries

• Immobility with development of pressure necrosis 

• Dextrose 50% extravasation

Sterile dressings

—use when infection of wound is a concern

Nonadherent dressings

—use after wound closure

Adherent dressings

—use for acute bleeding

Nonocclusive dressings

—use for most soft-tissue injuries

Occlusive dressings

—use in treating wounds of thorax and major vessels where pneumothorax or air embolism can result

Nonsterile dressings

—use when infection is not prime concern

Tranexamic Acid

Antifibrinolytic medication used to reduce or prevent bleeding

Inhibits activation of plasminogen to plasmin, thereby preventing breakdown of clots

TXA protocol must be developed and implemented collaboratively with local trauma system personnel.