Soft-Tissue Trauma
Soft-tissue trauma is interconnected with multiple emergency medical topics, including the basics of emergency medical services, EMT well-being, and scene size-up, which are foundational for effective trauma care.
Management of soft-tissue trauma often overlaps with other emergencies, such as poisoning, overdose, bleeding, shock, chest and abdominal trauma, musculoskeletal injuries, and trauma to the head, neck, and spine.
Highway safety and vehicle extrication are important considerations in soft-tissue trauma cases, as these scenarios frequently involve complex injuries requiring coordinated emergency response.
Standard
Soft-tissue trauma involves injuries to the skin, muscles, and underlying tissues, which can range from minor abrasions to severe lacerations and avulsions.
Assessment of an acutely injured patient requires identifying the type and extent of soft-tissue injury, including checking for bleeding, signs of shock, and potential underlying damage.
Basic emergency care for soft-tissue trauma includes controlling bleeding, preventing infection, and protecting the wound, often through direct pressure, sterile dressings, and appropriate bandaging.
Rapid transportation may be necessary if the patient shows signs of severe injury or shock, emphasizing the importance of ongoing assessment and monitoring during care.
Core Concepts
Closed wounds are injuries where the skin is not broken, such as bruises or internal bleeding; emergency care includes applying cold packs, elevating the injured area, and monitoring for signs of shock.
Open wounds involve a break in the skin, such as cuts, abrasions, or punctures; emergency care focuses on controlling bleeding, cleaning the wound, and covering it with a sterile dressing to prevent infection.
Burns are classified by depth (first, second, or third degree); emergency care includes removing the source of the burn, cooling the area with water (not ice), covering with a clean cloth, and seeking medical attention for severe burns.
Electrical injuries can cause both external and internal damage; emergency care requires ensuring the scene is safe, turning off the power source, checking for responsiveness and breathing, and seeking immediate medical help due to the risk of hidden injuries.
Dressing and bandaging wounds involves cleaning the wound, applying a sterile dressing, and securing it with a bandage to protect the area and promote healing.
Learning Objectives
Soft-tissue injuries involve damage to the skin, muscles, fat, and connective tissues, with the skin serving as a protective barrier and playing a key role in physiology.
Complications from soft-tissue injuries depend on the mechanism of injury, such as blunt force (causing closed wounds like contusions) or penetrating trauma (causing open wounds like lacerations and punctures).
Closed wounds are characterized by damage beneath intact skin, while open wounds involve a break in the skin and exposure of underlying tissues; each type has distinct features and risks.
Soft-tissue injuries can indicate possible trauma to deeper structures, such as nerves, blood vessels, or organs, requiring careful assessment.
Management of soft-tissue injuries is guided by the mechanism of injury, with different approaches for closed (e.g., rest, ice, compression, elevation) and open wounds (e.g., control bleeding, prevent infection).
Penetrating trauma and impaled objects require special care, including stabilizing the object and preventing further injury during transport.
Partial and complete avulsions, as well as amputations, require specific management, such as preserving tissue and controlling bleeding.
Injuries to the genitalia need sensitive and appropriate care to prevent further damage and address patient comfort.
Burn injuries are classified by depth (superficial, partial-thickness, full-thickness) and severity, which varies by age and extent of body surface area affected.
Burns can result from various agents (thermal, chemical, electrical, radiation) and sources, each with unique treatment considerations.
Treatment priorities for burns include stopping the burning process, assessing airway and breathing, and preventing shock and infection.
Complications from burns may include infection, fluid loss, and shock, and the choice of dressing and bandaging depends on the type and severity of the burn.
Key Terms
Soft-tissue injuries include a wide range of conditions, from minor abrasions and contusions to severe lacerations, amputations, and avulsions.
Immediate care for soft-tissue injuries is crucial and can involve lifesaving interventions like bleeding control or providing emotional support for disfiguring wounds.
Types of injuries discussed include open wounds (such as lacerations, puncture wounds, and avulsions), closed wounds (like contusions and hematomas), burns (superficial, partial thickness, and full thickness), and crush injuries.
Treatment options vary and may involve the use of dressings (including pressure, occlusive, and universal dressings), bandages, and specific assessment tools like the rule of nines and rule of palm for burn evaluation.
Anatomical layers affected by these injuries include the epidermis, dermis, and subcutaneous layers, each with different implications for treatment and healing.
Soft Tissues
Soft tissues include skin, fatty tissues, muscles, blood vessels, connective tissues, membranes, glands, and nerves, while teeth, bones, and cartilage are classified as hard tissues.
The skin is the largest organ of the body, with a surface area over 20 square feet in adults, and serves several major functions:
Protection: Acts as a barrier against microorganisms, debris, and chemicals; supports beneficial bacteria that help defend against harmful organisms.
Water balance: Prevents water loss and blocks environmental water from entering, maintaining fluid and chemical balance.
Temperature regulation: Blood vessels in the skin dilate to release heat and constrict to conserve heat; sweat glands produce perspiration for cooling; subcutaneous fat insulates the body.
Excretion: Removes salts and excess water.
Shock absorption: Fat layers cushion and protect underlying organs from minor impacts.
Sensory function: Nerve endings in the skin provide tactile sensations, temperature detection, and pain/pleasure responses, contributing to daily interactions and personal identity.
Skin structure consists of three main layers:
Epidermis: Outermost layer, made of dead cells on the surface and living, dividing cells deeper down; contains pigment granules; lacks blood vessels and nerves.
Dermis: Middle layer, rich in blood vessels, nerves, sweat and oil glands, and hair follicles; contains specialized nerve endings for touch, temperature, and pain; exposure increases risk of infection and bleeding.
Subcutaneous layer: Deepest layer, composed of fat and soft tissue; provides insulation and shock absorption; injury can lead to contamination, bleeding, and pain.
Soft-tissue injuries are classified as closed or open wounds and can result from mechanical, chemical, thermal, or electrical causes, with trauma being the most common mechanism.
Closed Wounds
A closed wound is an internal injury where the skin remains intact, with no external opening to the injury site.
Closed wounds are typically caused by blunt force impacts, leading to damage beneath the skin such as bruises, internal lacerations, or punctures.
Possible causes include fractured bones, crushing forces, or ruptured internal organs, which can result in significant tissue damage without visible external signs.
Internal bleeding from closed wounds can vary in severity, ranging from minor to potentially life-threatening situations.
Types of Closed Wounds
Contusions are the most common type of closed wound, where the epidermis remains intact but cells and blood vessels in the dermis are damaged, leading to internal bleeding, pain, swelling, and discoloration that may appear immediately or be delayed up to 48 hours.
Swelling in contusions is caused by both blood collection under the skin and inflammation, which helps cushion the area and dilute toxins but can also cause harmful tissue compression, especially in confined spaces like the skull.
Internal organs such as the brain, heart, lungs, and kidneys can also experience contusions, resulting in similar damage as seen in the skin.
Hematomas involve more severe tissue damage than contusions, with larger blood vessels affected and greater internal blood loss; up to a liter of blood may collect beneath the skin in a hematoma.
Closed crush injuries occur when external force damages internal structures without breaking the skin, potentially crushing or rupturing internal organs and causing significant internal bleeding.
Solid organs (like the liver and spleen) bleed heavily when crushed, leading to shock, while hollow organs can leak their contents, causing severe inflammation and tissue damage.
Emergency Care for Closed Wounds
Ensure your own safety first by confirming that the cause of the patient's injury cannot harm you before providing care.
Verify that the scene is secure prior to beginning any treatment for traumatic injuries, especially those resulting from violent trauma.
Use Standard Precautions at all times, even if the patient's skin is not visibly broken, to protect yourself from potential exposure to blood or bodily fluids.
Patient Assessment
Bruising, swelling, pain, or deformity after blunt trauma are key signs of possible internal injuries and internal bleeding.
The mechanism of injury (MOI) is crucial in assessing closed wounds, especially when crush injuries may not be visible.
Specific bruise locations can indicate underlying injuries:
Swelling or deformity at a bruise site suggests a possible fracture.
Bruises on the head or neck may indicate cervical spine or brain injury, or damage to major neck blood vessels; check for blood in the mouth, nose, and ears.
Bruises on the trunk or evidence of rib/sternum damage may signal chest injury; coughing up frothy red blood can indicate a punctured lung, and difficulty breathing or abnormal breath sounds should be assessed.
Bruises on the abdomen may point to injuries of internal organs like the spleen, liver, or kidneys.
Bleeding from the ears, nose, rectum, or vagina, or coughing up blood after trauma, are important signs of internal injury to the head, brain, respiratory, abdominal, or pelvic organs.
Patients with significant MOI should be treated as having internal injuries until these are ruled out by further medical evaluation.
Patient Care
Ensure airway, breathing, and circulation are managed first, and consider administering high-concentration oxygen with a nonrebreather mask if needed.
Treat the patient as if internal bleeding is present and provide care for shock if internal injuries are suspected.
Splint any painful, swollen, or deformed extremities to prevent further injury.
Monitor for vomiting and signs of shock, and be prepared to respond quickly.
Apply cold packs to isolated injuries to reduce pain and swelling, making sure not to place them directly on the skin.
Continue to monitor the patient’s condition and transport promptly for further medical care.
Open Wounds
An open wound occurs when the skin is broken, exposing underlying tissues.
The break in the skin can result from external forces, such as a laceration (cut), or from internal causes, like a fractured bone end piercing through the skin.
Types of Open Wounds
Open wounds are classified into several types: abrasions, lacerations, punctures, avulsions, amputations, crush injuries, blast injuries, and high-pressure-injection injuries, each with distinct characteristics and risks.
Abrasions involve superficial damage to the outer skin layer, often from scraping against a rough surface. They may bleed minimally but are painful and have a high risk of infection due to embedded debris.
Lacerations are cuts with smooth or jagged edges, caused by sharp or blunt objects. The depth and extent of tissue damage are not always visible externally, and bleeding can be significant if major blood vessels are involved. Natural vessel constriction may help limit bleeding.
Puncture wounds result from objects like nails or bullets penetrating the skin. They often appear minor externally but can cause severe internal damage and bleeding. The risk of infection is high, and exit wounds (as in gunshots) may be more severe than entry wounds.
Avulsions occur when skin and tissue are torn away, either partially or completely. Examples include degloving injuries and avulsed ears or eyes. Avulsed tissue loses its blood supply and quickly becomes nonviable.
Amputations involve complete removal of a limb or extremity. Bleeding may be massive, but sometimes is limited by vessel collapse or constriction.
Open crush injuries happen when a body part is compressed between heavy objects, leading to damage of blood vessels, nerves, muscles, and bones, with both internal and external bleeding and possible bone protrusion.
Bite wounds are open injuries with a higher risk of infection, especially from human bites, and may indicate abuse or assault. They should always be evaluated by a physician.
Blast injuries can cause a combination of open and closed wounds. Primary injuries are from the pressure wave, secondary from shrapnel, tertiary from being thrown, and quaternary from burns, toxins, or structural collapse. Multiple injury types may occur simultaneously.
High-pressure-injection injuries are caused by substances injected under high pressure (e.g., grease, paint) into tissue, often appearing minor externally but causing extensive internal damage and tissue death. Immediate medical evaluation is critical, and cold should not be applied to the injury.
In all open wounds, infection risk is significant, and the extent of internal damage may not be apparent from external examination. Always consider underlying structures and the potential for life-threatening complications.
Emergency Care for Open Wounds
Open wounds necessitate adherence to Standard Precautions, which include wearing gloves and, when necessary, a gown and protective eyewear to prevent exposure to blood or bodily fluids.
Proper disposal of all soiled materials is essential to prevent contamination and the spread of infection.
Handwashing after each patient interaction is mandatory to maintain hygiene and reduce the risk of transmitting infectious agents.
Patient Assessment
Airway, breathing, circulation, and severe bleeding are prioritized and managed during the primary assessment.
After completing the primary assessment and physical examination, you should begin treating individual wounds.
Always consider whether an injury impacts airway, breathing, or circulation, as these are critical to patient survival.
Patient Care
Always use Standard Precautions to protect yourself when caring for patients with open wounds.
Expose the wound by carefully removing or cutting away clothing, avoiding further injury and preserving evidence in cases of penetrating trauma.
Clean only the wound surface by removing large debris with sterile dressing; do not pick out embedded particles or spend excessive time cleaning, as controlling bleeding is the priority.
Control bleeding using direct pressure and elevation; if these are not possible (such as in crush injuries or amputations), apply a tourniquet immediately.
Be aware of internal bleeding in cases of penetrating trauma or puncture wounds, as bleeding may not always be visible.
Provide care for shock in all serious wounds, including administering high-concentration oxygen when appropriate.
Prevent further contamination by covering the wound with a sterile dressing (or the cleanest available material) and securing it with a bandage after bleeding is controlled.
Check for distal pulse after bandaging an extremity to ensure circulation is not compromised, and periodically recheck to confirm bleeding has not restarted.
Keep the patient lying still to minimize movement, which can increase circulation and risk of renewed bleeding.
Reassure the patient to help reduce anxiety, lower pulse and blood pressure, and encourage cooperation with remaining still.
Treating Specific Types of Open Wounds
Reducing wound contamination is crucial when treating abrasions; use appropriate cleaning and dressing techniques.
For lacerations, control bleeding by applying direct pressure over a dressing rather than pulling apart wound edges.
Most lacerations can be managed by bandaging a dressing in place; for minor lacerations, wound-closure strips may be used to bring wound edges together before applying a gauze dressing and bandage.
Always assess pulse, motor, and sensory function distal to the injury to check for underlying damage.
Do not underestimate lacerations, as they may require further medical intervention such as stitches, plastic surgery, antibiotics, or a tetanus shot to prevent infection or scarring.
Never simply bandage and leave a patient with a laceration at the scene, as complications can arise.
Treating Penetrating Trauma
Puncture wounds can be deceptive in severity; an object may penetrate deeper than it appears, potentially reaching bone or causing significant internal injury and bleeding, even if pain is minimal.
Always search for exit wounds in addition to entry wounds, as a seemingly minor puncture may be accompanied by a severe exit wound requiring immediate care.
Gunshot wounds are particularly serious because bullets can fracture bones, damage multiple organs, and follow unpredictable paths inside the body, regardless of bullet caliber or entry/exit points. All gunshot wounds should be treated as potentially life-threatening.
Close-range gunshot wounds may show burns around the entry site, and any gunshot wound to the face can compromise the airway, even if it appears minor.
Air guns at close range can cause serious internal damage by injecting air into tissues.
Stab wounds to critical areas (head, neck, chest, abdomen, groin, or proximal to the knee or elbow) are always considered serious and require careful assessment.
Key steps in managing moderate or serious puncture wounds include: reassuring the patient, searching for additional wounds, controlling bleeding, treating both entry and exit wounds, assessing for basic life support needs, monitoring and managing shock (including high-concentration oxygen as needed), and following local protocols for spinal motion restriction (especially for head, neck, or torso injuries).
Spinal immobilization is generally not recommended for penetrating trauma to the torso unless there is a neurologic deficit, as it may impair breathing and offers little benefit in most cases.
Transport the patient promptly, and if possible (and not at a crime scene), bring the object that caused the wound to the emergency department for further evaluation.
Treating Impaled Objects
Do not remove an impaled object from a puncture wound, as it may be controlling bleeding from a major vessel or preventing further tissue damage; removal can cause severe bleeding and additional injury.
Stabilize the impaled object by exposing the wound (cutting away clothing without disturbing the object), controlling bleeding with direct pressure on either side of the object (never on the object itself), and using bulky dressings (pads, towels, blankets) placed around the object in perpendicular layers to immobilize it.
Secure dressings with wide cravats (at least 4 inches/10 cm wide) tied above and below the object; adhesive strips may not be reliable due to blood, sweat, or movement.
Minimize patient movement and stress, immobilize the affected area if possible, provide oxygen and shock care as needed, and transport the patient promptly while avoiding any jarring or loosening of the object.
If the object is too long for transport, contact Medical Direction for instructions; if shortening is necessary, stabilize the object and use a fine-toothed saw to cut it carefully.
If the object was removed before arrival, bring it to the hospital for examination.
For objects impaled in the cheek, inspect both inside and outside the mouth; if both ends are visible and the object is not embedded in deeper structures, remove it in the direction of entry. If not, stabilize and leave in place. Control bleeding with pressure dressings externally and, if the patient is alert, gauze internally, ensuring airway patency and readiness to suction.
Monitor for airway compromise due to blood, broken teeth, or dentures, especially if the patient is not alert.
For objects impaled in the eye, stabilize the object with rolls of 3-inch (7.5 cm) gauze or folded 4×4s placed vertically on either side, then cover with a rigid shield (like a paper cup, not Styrofoam) without touching the object. Secure with a roller bandage, but do not wrap over the cup.
Dress and bandage the uninjured eye to minimize movement of the injured eye, unless local protocols advise otherwise.
Alternative eye stabilization method: Cut a hole in a thick sterile dressing for the object, pass it over the object, and proceed as above, taking care not to touch the object.
Throughout care, provide emotional support and reassurance, as patients with impaled objects are often frightened.
Treating Avulsions
Apply large, bulky pressure dressings to control bleeding in avulsion injuries.
Preserve any avulsed parts by wrapping them in a sterile dressing moistened with sterile saline, labeling them with the patient’s information, and keeping them cool (but not frozen) on a cold pack or sealed bag of ice.
Do not use dry ice, and do not immerse the avulsed part in ice, water, or saline.
For skin flaps that are still attached, gently clean gross contaminants, fold the skin back to its normal position, and dress with bulky pressure dressings.
Label both the avulsed part and its container with the patient’s name, the part, and the date and time of preservation; document the approximate time of avulsion in your records.
Use only fresh, sterile saline to moisten dressings, and be cautious to avoid contaminating the avulsed part with microorganisms from your gloves or the environment.
Follow local protocols for avulsed tissue care, as they may vary based on hospital reimplantation procedures.
Provide reassurance to the patient, as avulsions can be visually distressing.
Treating Amputations
Immediate control of serious bleeding is critical; use direct pressure first, and if that fails or is not possible, apply a tourniquet.
A pressure dressing can help control bleeding at the amputation site.
Proper care of the amputated part includes: wrapping it in a sterile dressing, securing with self-adhesive gauze, placing it in a plastic bag, and keeping it cool with cold packs.
Do not immerse the amputated part directly in water or saline, and do not allow it to touch ice directly to prevent freezing.
Never attempt to complete an amputation if it is still partially attached.
Treating Genital Injuries
Genital injuries are uncommon but can cause heavy bleeding and significant anxiety due to the high vascularity of the area and its role in reproduction.
Males are more frequently affected because their genitalia are less protected, but anyone can sustain genital trauma.
Types of genital injuries include lacerations, contusions, abrasions (from blunt or penetrating trauma), avulsions (such as degloving injuries), blunt trauma (like straddle injuries), zipper injuries (especially in uncircumcised boys), foreign bodies or impaled objects, and blood at the meatus (which may indicate urethral or pelvic injury).
Blood at the meatus is a key sign of possible urethral disruption, often associated with significant pelvic trauma, especially after blunt force.
Initial care steps are to control bleeding, preserve avulsed tissue, and assess for more serious underlying injuries (such as pelvic fractures if blood is present at the meatus).
Maintain a calm, professional demeanor to protect patient dignity, and provide reassurance, especially for modest or vulnerable patients.
Always consider the possibility of sexual assault as a cause of genital injury and involve appropriate authorities or advocacy resources if indicated.
Dress and bandage wounds according to standard soft-tissue injury protocols, adapting care as needed for the sensitive nature of the injury.
Burns
Burns can affect more than just the skin—they may damage deeper structures such as muscles, bones, nerves, blood vessels, and even the eyes, sometimes causing irreversible injury.
Burns can compromise the respiratory system, leading to airway obstruction from tissue swelling, respiratory failure, or respiratory arrest.
Emotional and psychological effects are common in burn patients and can begin immediately, often persisting long-term.
Assessment of burn patients must consider underlying or associated medical emergencies; for example, a burn may result from a heart attack or may be accompanied by other injuries like spinal damage or fractures from attempts to escape a fire.
Comprehensive patient evaluation is essential—you need to look beyond the obvious burn injury to identify and manage other potential life-threatening conditions.
Patient Assessment
Burns are classified and evaluated in three main ways: by agent and source, by depth, and by severity.
Classification by agent and source identifies what caused the burn (such as heat, chemicals, or electricity) and the specific source involved.
Classification by depth determines how deeply the burn has penetrated the skin and underlying tissues.
Classification by severity assesses how serious the burn is, which influences the urgency and type of emergency care needed.
All three classification methods are essential for determining the appropriate emergency response for a burn patient.
Patient assessment should always be performed before starting immediate burn care to ensure proper treatment decisions.
Classifying Burns by Agent and Source
Burns are classified by the agent causing the injury, such as thermal, chemical, electrical, light, or radiological agents.
The source of the burn provides further specificity; for example, thermal burns can result from flame, steam, hot liquids, or hot objects, while chemical burns may be due to acids, bases, or caustics.
Electrical burns can be caused by alternating current, direct current, or lightning, and light burns (often affecting the eyes) can result from intense light sources or ultraviolet light.
Radiological burns are usually from nuclear sources, but ultraviolet light can also be considered a source of radiation burns.
Always report both the agent and, when possible, the specific source (e.g., "chemical burn from dry lime").
Do not make assumptions about the cause of a burn; similar appearances can have different origins (e.g., a burn that looks thermal may actually be from radiation).
Gather information from multiple sources—scene observations, bystanders, and patient interviews—to accurately identify the agent and source of the burn.
Classifying Burns by Depth
Burns are classified by depth as superficial (first-degree), partial thickness (second-degree), and full thickness (third-degree) burns.
Superficial (first-degree) burns affect only the epidermis (outer skin layer), cause reddening or darkening, swelling, and pain, and typically heal without scarring; sunburn is a common example.
Partial thickness (second-degree) burns damage both the epidermis and dermis, result in deep pain, noticeable reddening or darkening, blisters, and a mottled appearance; swelling and blistering can continue for 48 hours, and healing usually occurs with little or no scarring.
Full thickness (third-degree) burns destroy all skin layers and may extend into subcutaneous tissue, muscle, bone, or organs; these burns often show black or brown charring or dry white areas, may cause severe pain or numbness (if nerves are destroyed), require skin grafting, and heal with dense scarring.
Blisters are a key sign of partial thickness burns, but may collapse before assessment, making diagnosis and size estimation more difficult.
Pain perception varies with burn depth: superficial and partial thickness burns are usually painful, while full thickness burns may be painless in the center due to nerve damage, with pain at the edges where less severe burns are present.
Determining the Severity of Burns
Severity of a burn is determined by several key factors: the source of the burn, body regions affected, depth and extent of the burn, patient age, and presence of other illnesses or injuries.
Source of the burn matters: Electrical burns can cause severe internal injuries with minimal external damage, while chemical burns (especially alkaline) may continue to damage tissue for hours or days and can enter the bloodstream.
Body regions burned are critical: Burns to the face can threaten the airway or eyes; burns to hands and feet risk loss of movement due to scarring; burns to the groin, genitalia, buttocks, or medial thighs increase risk of serious bacterial infection. Circumferential burns (encircling a body part) can restrict circulation or breathing and complicate healing, especially around joints, chest, or abdomen.
Depth of burn impacts severity: Partial thickness and full thickness burns penetrate the outer skin layer, increasing risk of tissue contamination and invasion by harmful substances.
Extent of burn area is estimated using two main methods:
Rule of Nines: For adults, major body areas are assigned percentages (e.g., each arm 9%, each leg 18%, head and neck 9%, chest 9%, abdomen 9%, back 18%, genitalia 1%). Percentages are adjusted for children and infants due to proportionally larger heads and different body surface area distribution.
Rule of Palm: The patient’s palm and fingers represent about 1% of body surface area; this method is useful for estimating smaller or irregular burns.
Age significantly affects burn severity: Infants, young children, and adults over 55 are at higher risk of severe complications and death from burns due to differences in body surface area, fluid and heat loss, and reduced healing capacity.
Other illnesses and injuries increase risk: Preexisting conditions like respiratory disease, heart disease, or diabetes make burns more dangerous. Burns combined with other injuries can lead to shock or mask more critical trauma.
All burns are more serious if accompanied by other injuries or medical problems; always conduct a thorough assessment and be alert for signs of shock or decreased blood pressure, which may indicate additional serious injuries.
Think Like an EMT
Burns are classified by body surface area affected and degree (severity) of tissue damage. The extent of burns is estimated using body regions involved, which guides care and transport decisions.
First-degree burns present as bright red skin without blisters, indicating superficial damage (e.g., sunburn over the backs of both legs, back, and backs of both arms).
Second-degree burns are characterized by redness and blistering, signifying deeper tissue involvement (e.g., hot grease burn on the anterior left forearm and entire right hand).
Third-degree burns involve severe charring, peeling, and full-thickness tissue destruction (e.g., circumferential burns on both legs with blistering and a severely charred right arm).
Body surface area estimation uses anatomical regions: each leg (18%), each arm (9%), back (18%), and hand (1%). This helps approximate the percentage of total body surface area burned for each case.
Classifying Burns by Severity
Burn severity classification is essential for determining the type and urgency of care, transport priority, and hospital destination.
Specialized burn centers are recommended for certain burn conditions, and protocols guide whether patients should be transported directly to these facilities.
Local resources and protocols influence transport decisions, especially if a burn center is not nearby, ensuring patients receive the most appropriate care based on their needs and available facilities.
Box 30-1
Patients with second-degree (partial thickness) burns covering more than 10% of total body surface area should be treated at a burn center.
Burns involving critical areas such as the face, genitalia or perineum, hands, feet, or major joints require burn center care due to risks of airway compromise, infection, and functional importance.
Third-degree (full thickness) burns, electrical burns (including lightning injuries), and inhalation burns are indications for burn center treatment.
Patients with additional medical problems, trauma, or specialized needs (such as rehabilitation) that cannot be managed at a typical hospital should be transported to a burn center.
Children may require specialized equipment or personnel, so protocols may specify transport to hospitals equipped to handle pediatric burn cases.
Treating Specific Types of Burns
Ensure your own safety first by confirming the burning process has stopped and avoiding hazards such as fire, electricity, chemicals, or radiological threats before approaching a burn patient.
Use specialized resources like fire and HAZMAT teams if the scene remains dangerous or the burning process is ongoing.
Immediate care after scene safety is crucial for the burn patient's long-term outcome, with specific approaches required for thermal burns, general chemical burns, and chemical burns to the eyes.
Patient Care
Initial burn care involves stopping the burning process and cooling the area: For flames, wet down, smother, and remove affected clothing; for semi-solids like grease or tar, cool with water but do not remove the substance.
Airway management is critical: Assess for airway injury signs such as hoarse voice, stridor, soot deposits, burned nasal hair, or facial burns. Airway burns can cause swelling and obstruction, sometimes delayed, so rapid transport and advanced airway management may be necessary.
Burns are evaluated by depth:
Superficial burns affect only the outer skin, appear red, are painful, and do not blister.
Partial thickness burns involve both outer and second skin layers, are deep red, painful, and blister.
Full thickness burns extend through all skin layers, appear charred black or white, are not painful, and do not blister.
Assess burn extent and severity: Use the rule of nines or rule of palm to estimate body surface area affected.
Dressings and cooling: Most protocols recommend dry sterile dressings for severe burns and moist dressings only for small, partial thickness burns (<10% body surface area). Cooling large burns or those in patients with other medical issues can cause hypothermia.
Special care for burns to hands, feet, and eyes: Remove jewelry, separate digits with sterile gauze, and for eye burns, do not open eyelids; cover both eyes with sterile gauze unless local protocol states otherwise.
Do not apply ointments, sprays, butter, or ice to burns: These can trap heat, cause tissue damage, or complicate hospital care. Do not break blisters or clear debris.
Prevent infection and hypothermia: Keep the burn site clean and the patient warm, as burns compromise the skin’s temperature regulation.
Monitor for toxic inhalation: Patients exposed to smoke or combustion by-products may be at risk for carbon monoxide or cyanide poisoning; treat with high-concentration oxygen and move to fresh air.
Always follow local protocols and transport burn patients promptly: Some burns, especially in children, may indicate abuse and require a high index of suspicion.
Rescuer safety is paramount: Do not attempt rescue in hazardous environments without proper training and equipment, as fire conditions can change rapidly and become deadly.
Point of View: Patient
Adding too much wood to a fire can cause a sudden increase in airflow, which rapidly intensifies the flames.
Burns can occur quickly, even if your hand is only in the fire for a short time, and may not be immediately painful but can result in visible damage such as redness, blistering, and burned hair.
Burns to the hand are particularly serious and require specialized medical attention, as indicated by emergency responders choosing a hospital with burn treatment expertise.
The experience highlights the importance of fire safety and the potential for long-lasting pain and injury from burns.
Patient Care
Immediate care for chemical burns is crucial; washing away the chemical with copious, gentle flowing water is the primary procedure. Remove contaminated clothing and avoid contaminating unaffected skin. Continue irrigation for at least 20 minutes and en route to the hospital.
Protect yourself from chemical exposure. Use specialized response teams if the scene is unsafe, and handle contaminated clothing and patients with caution.
For dry chemicals, carefully remove contaminated clothing and brush off the chemical before irrigating. Avoid raising a cloud of the chemical agent.
Apply sterile dressings, treat for shock, and transport the patient. Remain alert for delayed reactions, renewed pain, or breathing difficulties.
Identify the chemical involved when possible, using safety data sheets (SDS) at industrial sites for specific emergency information.
Acid burns cause protein coagulation, limiting further damage, except for hydrofluoric acid, which penetrates deeply and causes significant internal tissue damage. Hydrofluoric acid requires prolonged irrigation and urgent transport, as damage may not be immediately visible and can be fatal at high doses.
Alkali burns liquefy tissue through saponification, allowing deeper penetration and more severe injury. Prolonged irrigation is essential to dilute and remove alkali agents.
Special chemical burns require specific procedures:
For mixed or strong acids, or unknown substances, continue washing even after pain subsides.
For dry lime, brush off before irrigating; water creates a corrosive liquid if applied directly.
For carbolic acid (phenol), use alcohol for initial wash on unbroken skin, then water.
For sulfuric acid, wash despite heat production when water is added.
For hydrofluoric acid, flood with water and do not delay care for neutralizing agents.
If chemical vapors are inhaled, provide high-concentration oxygen (humidified if available) and transport promptly, especially for acids that vaporize at room temperature (e.g., hydrochloric and sulfuric acid).
Always assess scene safety; do not attempt rescue in hazardous conditions without proper training and equipment.
Patient Care
Chemical burns to the eye require immediate action because corrosive substances can damage the eye rapidly, even if the eyelid is closed.
Personal protection is essential; always wear gloves and eye protection to prevent exposure during the washing process.
Begin care by immediately flooding the affected eye(s) and surrounding facial area with water, ensuring chemicals are not washed into the unaffected eye.
Use a continuous flow of water from the medial (nasal) corner to the lateral corner of the eye, using any available source such as a faucet, hose, cup, or IV setup.
Hold the eyelids open if the patient tries to keep them shut, as this is a natural reaction to pain.
Do not use neutralizing agents like vinegar or baking soda in the eye.
If advanced life support (ALS) is available, paramedics may administer anesthetic drops to facilitate irrigation.
Continue irrigating the eye for at least 20 minutes or until arrival at a medical facility, and maintain irrigation during transport.
After irrigation, cover both eyes with moistened pads. If burning or irritation returns, wash the eyes for an additional 5 minutes.
Radiation Burns
Radiation is energy transmitted as electromagnetic waves, which can travel through space and matter, including the human body.
Exposure to radiation occurs daily, such as from sunlight, which can cause mild burns like sunburn, but other forms can be much more dangerous.
Radioactive materials and processes like nuclear fission emit radiation in the form of waves and particles, which can cause immediate burns and delayed effects such as radiation sickness with various harmful side effects.
Sources of radiation include medical and industrial uses, electricity production, nuclear weapons, and dirty bombs, with the latter posing significant risks even with low technology.
Radiation is difficult to detect without specialized equipment, and identification of radiation injuries often requires knowledge of the source or input from specialized teams.
Contact with radiation sources or contaminated patients is hazardous; proper protective equipment and training are essential before approaching radiological injuries.
After decontamination, radiological injuries typically resemble thermal burns, requiring similar care such as covering the burns and transporting the patient to a suitable facility.
Radiation can cause additional harmful effects, so patients with radiological injuries should be closely monitored for airway and breathing complications.
Electrical Injuries
Electric current can cause severe bodily harm, including burns at entry and exit points, tissue damage from heat, and forceful muscle contractions along the current's path.
Electrical injuries disrupt body processes by causing significant chemical changes in nerves, heart, and muscles, potentially leading to shutdown of vital functions.
Scenes involving electrical injuries are highly dangerous; always assume the electrical source is still active unless confirmed otherwise by a qualified person, and do not attempt rescue without proper training and equipment.
Patient Assessment
Electrical injuries can cause both external and internal damage, including burns at the points where electricity enters and exits the body.
Disrupted nerve pathways may result in paralysis, muscle tenderness, and involuntary muscle twitching.
Respiratory complications are common, ranging from difficulty breathing to complete respiratory arrest.
Cardiac effects include irregular heartbeat and possible cardiac arrest, as well as changes in blood pressure (either elevated or low, sometimes accompanied by shock).
Neurological symptoms may include restlessness, irritability, loss of consciousness, visual disturbances, and seizures in severe cases.
Physical trauma such as fractured bones and dislocations can occur, either from severe muscle contractions or from falls associated with the electrical injury.
Other complications include airway obstruction from a swollen tongue and possible convulsions.
Patient Care
Electrical injuries often cause severe internal damage that may not be visible externally; always assess for hidden injuries beyond small external wounds.
Airway and breathing care is critical, as electrical shock can lead to airway swelling and respiratory failure; be ready to provide positive pressure ventilations.
Cardiac rhythm disturbances are common after electrical shock; be prepared to perform basic cardiac life support and defibrillation if needed.
Administer high-concentration oxygen and treat for shock as required.
Spinal injuries are a risk due to severe muscular contractions or being thrown by high-voltage currents; always evaluate and stabilize the spine.
Look for at least two burn sites: one at the point of contact with the energy source and one at the ground contact; cool burns and smoldering clothing, then apply dry sterile dressings.
Transport the patient promptly, as complications such as heart problems may develop slowly and are often more serious than the burns themselves.
Respiratory and cardiac arrest are major risks; always be prepared to provide life-support measures, including automated defibrillation.
Dressing and Bandaging
A dressing is a sterile material applied directly to a wound to control bleeding and prevent further contamination.
A bandage is used to hold a dressing in place and does not need to be sterile.
Dressings and bandages serve different purposes: dressings protect and cover the wound, while bandages secure the dressing.
SCAN 30-1
Dressings used for wounds must be both sterile (free from microorganisms and spores) and aseptic (free from dirt and debris). In emergencies, clean cloth or similar materials can substitute if commercial dressings are unavailable.
Hemostatic dressings are specialized for stopping bleeding and are commonly included in emergency kits.
Sterile gauze pads are the most popular dressings, available in various sizes such as , , , and inches. Large, bulky dressings are used for extensive wounds or to stabilize impaled objects.
Pressure dressings control bleeding by layering gauze pads and bulky dressings, then securing with a self-adherent roller bandage. It's essential to check and recheck the distal pulse to ensure circulation is not compromised.
Occlusive dressings create an airtight seal and are used for open abdominal, chest, or neck wounds. These can be commercially prepared (plastic wrap or petroleum gel–impregnated gauze) or improvised from plastic bags or medical wrappers in emergencies.
Sterile burn sheets and sterilized bedsheets can be used for large wounds or burns, and to cover exposed abdominal organs.
Self-adhering, form-fitting roller bandages are preferred for securing dressings because they are easy to apply and do not require specialized techniques. They should be applied with overlapping wraps, kept snug, and secured by cutting and taping or tying.
Dressings can also be secured with triangular bandages, adhesive tape, air splints, or improvised materials like strips of cloth or handkerchiefs if standard supplies are unavailable.
Elastic bandages can hold dressings in place but must not be too tight, as swelling can cause them to become constricting and impair circulation. Always monitor distal pulses and circulation after bandaging.
Infection control is critical: always wear gloves and barrier devices to avoid contact with blood and body fluids.
Patient Care
Stopping bleeding and preventing infection are the main priorities when caring for open wounds.
Always take standard precautions and fully expose the wound by cutting away clothing as needed.
Use sterile or very clean materials for dressings, and avoid touching the part of the dressing that will contact the wound.
Cover the entire wound and surrounding area with the dressing to protect it.
Control bleeding by applying direct pressure and/or using hemostatic agents or dressings; do not bandage a dressing in place unless bleeding is controlled.
If bleeding continues, keep applying pressure and add new dressings over blood-soaked ones—do not remove the original dressing, as this can restart bleeding and damage tissues.
The only exception to not removing dressings is if a bulky dressing is soaked with blood and needs to be replaced to reestablish direct pressure or create a new pressure dressing; in this case, place gauze pads over the wound before the bulky dressing to allow removal without disturbing the wound.
Keep the patient at rest and treat for shock if necessary.
Patient Care
Bandages should be snug but not too tight or too loose—they must hold the dressing in place without restricting blood flow or allowing the dressing to slip.
Avoid leaving loose ends of gauze, tape, or cloth, as these can catch on objects during patient movement.
Leave fingers and toes exposed when bandaging extremities (unless they are burned) to monitor circulation and neurological status; signs of a too-tight bandage include pain, pale or blue skin, coldness, numbness, and tingling.
Cover all edges of the dressing to minimize contamination, except in specific cases like a flutter-valve dressing for open chest wounds.
Apply bandages from distal to proximal (from the smaller to the larger part of the limb) to ensure even pressure and proper contact.
Wrap a large area rather than a small one to avoid point pressure and ensure uniform support.
When bandaging across joints, do not bend the limb afterward to prevent circulation problems or loosening of the bandage; immobilization devices like splints or slings may be needed to keep the joint stable.