Soft Tissue Injuries

Soft tissue injuries: overview

  • Soft tissue injuries include anything affecting the skin, muscles, or internal organs beneath the skin. They range from minor to life-threatening.
  • Classification by mechanism and wound type:
    • Closed injuries: skin remains intact but underlying tissues are damaged (contusions, hematomas, crush injuries, compartment syndrome).
    • Open injuries: skin is penetrated (abrasions, lacerations, avulsions, penetrations).
    • Burns: thermal, chemical, electrical, or radiation-related injuries to skin and underlying tissues.
  • Infections in soft tissue can be life- or limb-threatening and can lead to sepsis or amputations if not treated properly.
  • Integumentary system (skin) basics:
    • Skin is the largest organ and a primary barrier against infection, a sensory organ, helps regulate temperature, and maintains fluid balance.
    • Skin layers: epidermis (outer, watertight barrier) and dermis (inner, contains hair follicles, sebaceous/sweat glands, blood vessels; site of nutrient and oxygen exchange).
    • Thicker vs thinner skin varies by location (hands/feet often thicker; scalp thinner; elderly and very young have thinner skin; calluses form with repetitive use).
  • Skin functions:
    • Barrier to infection
    • Sensory perception
    • Temperature regulation (sweating, vasodilation/constriction)
    • Fluid balance maintenance
  • Wound healing is a staged process: hemostasis, inflammation, proliferation, and remodeling with collagen.
    • 1) Hemostasis: platelets aggregate to form a clot and stop bleeding.
    • 2) Inflammation: white blood cells, lymphocytes, and mast cells migrate to the wound; swelling due to histamine release.
    • 3) Proliferation: new cells migrate and capillaries and tissue are rebuilt to restore blood supply and structure.
    • 4) Remodeling: collagen is laid down to stabilize and provide elasticity; scar tissue forms.
  • Important concepts:
    • Inflammation is part of healing, not always a sign of infection.
    • Healing can be slow, especially in immunocompromised patients (e.g., diabetics).
    • Open wounds increase infection risk; always consider systemic involvement and potential for sepsis.

Skin anatomy details

  • Epidermis: visible, outer layer; forms water-tight barrier.
  • Dermis: inner layer; contains hair follicles, sebaceous glands, sweat glands, and blood vessels (nutrient/oxygen exchange).
  • Integumentary system has four main functions: barrier, sensory, temperature regulation, fluid balance.

Wound types and pathophysiology (overview)

  • Wound healing sequence:
    • Hemostatic plug formation (platelets aggregate).
    • Inflammatory response (neutrophils, lymphocytes, mast cells; swelling from histamine).
    • Proliferation and tissue rebuilding (granulation, angiogenesis).
    • Remodeling with collagen for stability and elasticity.

Closed injuries

  • Contusions (blunt force): epidermis intact; possible dermal damage; blood vessel injury in dermis; ecchymosis (bruise) forming blue/black discoloration; word for bruise: ecchymosis (spelled ecchymosis).
  • Hematoma: collection of blood within damaged tissue or body cavity; can cause a raised lump; may indicate significant vascular injury.
  • Crush injuries:
    • Depend on force and duration.
    • Prolonged compression (>4 hours) can cause crush syndrome due to arterial flow interruption and toxin buildup.
    • Release of toxins and potassium/toxins into circulation can cause shock or cardiac events; ALS may be needed prior to freeing the patient; prepare for potential cardiac arrest on release.
  • Compartment syndrome: swelling within a tissue compartment increases pressure, impairs circulation, and disrupts metabolism; increases pain with movement; prolonged duration increases tissue death risk.
  • Reassessment of closed injuries: monitor skin color, temperature, and distal pulses; watch for signs of compromised perfusion.

Open injuries

  • Abrasions: superficial, epidermis may be scraped; minimal bleeding; may bruise at surface; not typically life-threatening but prone to infection.
  • Lacerations: jagged or smooth cuts through skin and subcutaneous tissue; can extend to muscle, nerves, vessels; depth/length varies.
  • Avulsions: tissue layers separated or detached; bleeding is common; if possible, replace and immobilize flap; never remove tissue that is still attached; keep detached parts with the patient for possible reattachment; if an avulsed part is removed, keep it clean, dry, and cool (ice packs) without submerging in water.
  • Penetrating wounds: caused by a piercing object; may damage structures deep inside; may carry foreign material that increases infection risk.
  • Gunshot/blast injuries: often multiple injuries; count entrance vs exit wounds when possible; determine the weapon type if possible but do not delay transport.
  • Blast injuries: primary (pressure wave/ barotrauma), secondary (shrapnel), tertiary (thrown/impact with objects), quaternary (chemical exposure and other results); can be a mix of blunt and penetrating injuries.

Open wound management principles

  • General: treat life threats first (airway, breathing, circulation).
  • Bleeding control: direct pressure with sterile dressings; after failure of direct pressure, escalate to pressure dressings and then tourniquets if indicated.
  • Occlusive dressings (one-way/venting options) for chest, neck, or abdominal wounds to prevent air or fluid entry.
  • Chest wounds: assume sucking chest wound until proven otherwise; cover with an occlusive dressing; may use chest seals with a one-way valve; apply manual occlusion if chest seal not available until seal is placed.
  • Abdominal wounds with evisceration: manage as follows:
    • Place sterile moist dressing over exposed organs if possible.
    • Apply an occlusive dressing to seal and protect.
    • Use three layers of trauma dressings to prevent heat loss.
    • Flex the knees to reduce abdominal tension.
    • Immediate transport to a level one trauma center.
  • Impaled objects: only remove if they interfere with CPR or airway; otherwise leave in place and stabilize; if needed, shorten the object only under professional guidance.
  • Impaled objects in the cheek/mouth: may require removal to secure airway; this should be performed by trained personnel.
  • Neck/airway injuries: cover neck wounds with an occlusive dressing; apply manual pressure but monitor for impaired cerebral/hemodynamic perfusion; immobilization of the neck may be necessary.
  • Small animal bites: assess for infection risk and vaccination status; debridement, antibiotics, tetanus prophylaxis; rabies risk; involve animal control.
  • Human bites: can introduce serious infection; manage with dry sterile dressings, immobilization, transport for surgical cleansing and antibiotics.
  • Burns are soft-tissue injuries that may involve underlying tissues; treat with temperature regulation, infection prevention, and pain control.

Burns: depth, severity, and management

  • Burn types by energy source:
    • Thermal burns: heat sources (scalds, open flames); exposure time increases damage (progressive injuries).
    • Chemical burns: acids/alkalis (strong bases/strong acids); severity depends on chemical type, concentration, duration of exposure; eyes are particularly vulnerable.
    • Electrical burns: current flow through tissue; entry/exit wounds; depth can be greater than what is seen on the surface; risk of cardiac/respiratory arrest; higher risk with high-voltage sources.
    • Radiation burns: from ionizing radiation (alpha, beta, gamma); gamma is most penetrating; assess exposure and hazmat needs.
  • Depth categories:
    • First-degree (superficial): epidermis only; red and painful, no blistering.
    • Second-degree (partial thickness): epidermis and part of the dermis; moist, blistering; very painful.
    • Third-degree (full thickness): through all skin layers into subcutaneous tissue; dry/leathery; white/brown/charred; nerves destroyed; least pain in the burned area itself.
  • Airway involvement in burns:
    • Signs of airway burns: singed nasal hairs, soot around mouth/nose, carbon in sputum, hoarseness, hypoxia.
    • Management: rapid transport; anticipate airway edema; consider definitive airway early; call ALS if signs of edema, stridor, or facial burns.
  • Burn depth and surface area assessment:
    • Rule of Palms: the palm of the clinician’s hand ≈ 1% of TBSA burned; use to approximate area.
    • Rule of Nines (adult): head 9%, each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18% (9% anterior + 9% posterior per leg).
    • Pediatric considerations differ; head is proportionally larger in children, so TBSA estimates differ from adult charts.
    • Documentation should include depth (superficial/partial/full), percentage TBSA, and involvement of critical areas (face, hands, feet, genitalia, airway).
    • First-degree burns are not counted toward TBSA in many calculations, but should still be documented.
  • Burn management (initial):
    • Stop the burn source (dry chemical: brush off; wet chemical: irrigate).
    • In Maryland, routine irrigation of burns done? The protocol notes Maryland is a "dry state" and irrigation is not routinely performed on all burns; cover with dry sterile dressings and maintain warmth.
    • Remove jewelry if possible to prevent constriction from swelling.
    • Cover burn with dry dressings to maintain body temperature and prevent contamination; use burn blankets to maintain warmth.
    • For inhalation injuries, humidified oxygen and potential airway management; consider ALS early.
    • For suspected cyanide or carbon monoxide exposure, decontaminate and call hazmat when needed; CO poisoning may show a falsely normal SpO2; treat with high-flow oxygen; monitor patient closely.
    • Chemical burns require decontamination specific to chemical type; dry chemicals brushed off; wet chemicals irrigated for 15–20 minutes (eye irrigation also 15–20 minutes).
    • Eye chemical burns: irrigate eyes for 15–20 minutes while keeping eyelids open; protect and control contamination.
  • Special burn scenarios:
    • Circumferential/full-thickness burns can compromise chest expansion or limb perfusion; may require ALS involvement and consideration of CPAP for chest wall mechanics.
    • Burns near joints or on hands/feet have higher risk for functional impairment due to scar formation and contractures; involve burn center and follow up.
    • Electrical burns: be prepared for delayed tissue damage; assess for arrhythmias; monitor airway as well as cardiac function; provide oxygen and consider defibrillation if indicated.
    • Radiation exposure: maintain distance, decontaminate, call hazmat; identify exposure type and duration; limit exposure time; shield clinician when possible.
  • Practical/clinical considerations:
    • Always consider scene safety and personal safety (BSI). Burns patients with inhalation risk need prompt airway management; prioritize life threats.
    • Document thoroughly: source of burn, mechanism, depth, TBSA, involved body regions, treatments provided, and any special considerations (e.g., preexisting conditions, age, pregnancy, comorbidities).
    • For burns, continuous reassessment is essential due to progression risk and potential airway edema.
    • Post-episode transport considerations: most burn patients with airway involvement, significant TBSA involvement, or involvement of critical areas should be transported to a burn center; for pediatrics and elderly, monitor more closely for shock and hypothermia.

Airway management and trauma assessment priorities

  • Primary assessment sequence (ABC): Airway, Breathing, Circulation; life threats must be addressed before continuing.
  • If life-threatening bleeding is observed, apply direct pressure and tourniquet as needed; do not delay transport to treat the wound beyond applying pressure.
  • If airway compromise suspected (e.g., sucking chest wound, open neck wound, airway burns), address immediately and escalate to ALS as warranted.
  • On-scene time and monitoring:
    • Critical patient reassessment interval: every 5 minutes.
    • Noncritical patient reassessment interval: every 15 minutes.
    • On-scene time goal: 10 minutes or less when possible.
  • Secondary assessment (en route): conduct SAMPLE history, OPQRST, and consider additional assessments such as DCA/ETLS once in transit.
  • Co-morbid conditions impacting trauma: diabetes (infection risk and slow healing), hemophilia (bleeding risk even from minor injuries), anemia, and other clotting disorders increase risk; reassess interventions and monitor vitals for trends.
  • neck and chest exam cues:
    • Neck: Tracheal deviation; GBD (as noted in transcript) to be interpreted with clinical context; ensure cervical spine precautions as indicated.
    • Chest: Look for signs of a sucking chest wound; assess for equal chest rise/fall; palpate for rib integrity; watch for paradoxical motion (flail chest).
    • Flail chest/segment: paradoxical movement indicates significant injury; current best practice is to avoid padding flail segments; ALS may perform CPAP in appropriate cases to stabilize the chest.
  • Abdominal exam cues:
    • Abdominal tenderness, rebound tenderness, rigidity; signs of internal bleeding or organ injury.
  • Extremities:
    • Record PMS/CMS vital signs (Pulse, Motor, Sensation; Circulation, Motion, Sensation) before/after splinting or dressing; ensure circulatory integrity and avoid over-tight bandaging.

Special treatment notes and scenarios

  • Complications and management reminders:
    • Crush syndrome: watch for toxin buildup and acidosis on removal; provide fluids and medications as needed; anticipate rapid deterioration when freeing crushed tissue.
    • Compartment syndrome: early signs include severe pain, swelling; treat with ALS and rapid transport; avoid delaying care to reassess repeatedly on scene.
    • Sucking chest wounds: cover with occlusive dressing; if air leaks, burp the dressing via chest seal’s one-way valve; use one-handed seal while partner applies chest seal.
    • Open abdominal wounds with evisceration: keep organs moist with sterile gauze and cover with occlusive dressing; add two or three layers of trauma dressings to reduce heat loss; position patient with knees bent to reduce abdominal tension; transport to trauma center.
    • Impaled objects: only remove if interfering with CPR or airway; otherwise stabilize and transport; if removal is necessary, do it under the guidance of physicians or surgeons.
    • Neck injuries: occlusive dressing to neck wounds to prevent air embolism; manual pressure and neck immobilization as needed; avoid compromising cerebral perfusion.
  • Infections and antibiotics in open wounds:
    • Open wounds are considered contaminated; IV antibiotics may be available via ALS; call for antibiotics when significant infection risk exists.
    • For all open wounds: sterile dressings and prompt transport for surgical debridement and cleansing as needed.
  • Wound care basics:
    • Bandages vs dressings: dressings cover wounds to stop bleeding and prevent contamination; bandages secure dressings in place and can include various materials (gauze, soft rollers, triangular bandages).
    • Do not use elastic bandages for sealing dressings on open wounds in field care.
    • Avoid unnecessary irrigation unless indicated; if irrigation is used, use sterile solutions and avoid contaminating the wound further.
    • For small wounds, sterile saline or sterile water irrigation may be used prior to dressing; large or complex wounds require higher-level care.
  • Eye and chemical exposure care:
    • Eye chemical exposure: irrigate 15–20 minutes; protect eye structures; ensure proper disposal of chemical residues.
    • Hazmat involvement is indicated for toxic exposures; decontaminate patients before transport when needed; identify chemical agents if possible, and request hazmat resources.
  • Radiation exposure management:
    • Identify exposure type (alpha, beta, gamma); gamma is the most penetrating and common in events.
    • Maintain safety distance and shield responders; decontaminate the patient; notify hospital and hazmat teams.
    • Limit exposure duration to reduce risk to responders; use shields between patient and provider when possible.

Summary of key measurements and concepts (LaTeX-ready)

  • Palm method for TBSA: extPalm≈1ext%of TBSAext{Palm} \approx 1 ext\% \text{of TBSA}
  • Rule of Nines (adult):
    • Head: 9%9\%
    • Each arm: 9%9\%
    • Anterior trunk: 18%18\%
    • Posterior trunk: 18%18\%
    • Each leg: 18\% \text{(9% anterior + 9% posterior)}
  • Burn severity thresholds:
    • Full-thickness burns on hands, feet, face, airway, or genitalia; or full-thickness burns involving ≥10%\ge 10\% TBSA are considered severe.
    • Partial-thickness burns involving ≥30%\ge 30\% TBSA are considered severe.
  • Wound healing stages: (hemostasis) → (inflammation) → (proliferation) → (remodeling, collagen synthesis).
  • Signs of shock include tachycardia, tachypnea, hypotension, cool/clammy skin; manage with high-flow oxygen and rapid transport; early ALS involvement.
  • Airway burn signs: extsingednasalhairs, extsoot, extcarboninsputum, exthoarseness, exthypoxia.ext{singed nasal hairs},\ ext{soot},\ ext{carbon in sputum},\ ext{hoarseness},\ ext{hypoxia}.
  • Key phrases:
    • ABCs: Airway, Breathing, Circulation.
    • CMS: Circulation, Motor, Sensation.
    • PMS: Pulse, Motor, Sensation.

Quick reference checklist (on-scene priorities)

  • Ensure scene safety and BSI; wear PPE; assess for hazards.
  • Perform primary survey (ABC), control life-threatening bleeding with direct pressure; apply tourniquet if needed.
  • If chest wounds suspected, cover with an occlusive dressing; use a chest seal when available; maintain one-way venting.
  • For open abdominal wounds with evisceration, cover with moist sterile dressing then occlusive; three-layer dressing to prevent heat loss; keep knees flexed; rapid transport.
  • For impaled objects, leave in place unless interfering with CPR or airway; stabilize and transport.
  • For burns, stop the burn source; moisture for eyes/chemical exposure; cover with dry dressings; maintain warmth; call ALS for inhalation, circumferential burn, or airway concerns.
  • For bites, assess infection risk; debridement and antibiotics as needed; tetanus and rabies considerations.
  • Document thoroughly: size, location, depth, blood loss, mechanism, treatment provided; photos if appropriate to aid hospital care.
  • Reassess vitals and patient status frequently; watch for trends indicating deterioration.
  • Coordinate with other responders and prepare for transport to appropriate facilities (trauma center, burn center, burn unit, etc.).

Example Q&A prompts (from training scenarios)

  • Contusion vs compartment syndrome: contusion is a bruise; compartment syndrome is a compression injury with reduced blood flow.
  • Sucking chest wound management: place a gloved hand as a temporary chest seal, then apply an occlusive dressing with a chest seal as soon as available.
  • Evisceration management: moistened sterile gauze over exposed organs, then occlusive dressing; three-layer wrap; position with knees bent; rapid transport.
  • Chemical burn handling: brush off dry chemicals first; irrigate for wet chemicals; eyes require 15–20 minutes of irrigation; hazmat involvement as needed.
  • Radiation exposure: maintain distance; decontaminate; call hazmat; use shielding; monitor for delayed effects.

(Note: All LaTeX-style expressions are provided for clarity and can be copied into exams or study sheets as …….)