Soft Tissue Trauma

1
Soft Tissue Trauma
Chapter 20
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The Skin

• Tough, supple membrane that covers the entire
  body
• Largest and most dynamic organ of body
• Epidermis
• Dermis
• Subcutaneous layer (superficial fascia)
• Deep fascia

3
Key Functions of the Skin

• Shielding underlying tissues from fluid loss
• Temperature control
• Production of vitamin D
• Protecting internal structures from mechanical
  injury
• Preventing the entrance of infectious organisms

4
Hemostasis of Wound Healing

• Hemostasis is the initial physiological response
  to wounding
• A vascular reaction that involves
• Vasoconstriction
• Formation of a platelet plug
• Coagulation
• Growth of fibrous tissue into the blood clot that
  permanently closes and seals the injured vessel

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Clotting Mechanism
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Inflammatory Response

• The release of chemicals from injured vessel and
  various blood components (platelets, white blood
  cells) cause
• Localized vasodilation of arterioles,
  precapillary sphincters, and venules
• Increasing permeability of affected capillaries
  and vessels
• Plasma, plasma proteins, electrolytes, and
  chemical substances from leaking venules
  accumulate in the extracellular space for
  approximately 72 hours after injury

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Collagen

• Principal structural protein of most body tissues
• Normal tissue repair depends on collagen
  synthesis and deposition
• In the healthy body, fibroblasts synthesize and
  deposit collagen within 48 hours after injury
• Collagen increases the tensile strength of the
  tissue
• Four months or more are required for most injured
  tissue to regain its full strength and function

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Alterations of Wound Healing

• Many factors can affect or alter wound healing
  including
• Anatomic factors
• Concurrent drug use
• Medical condition and disease
• High-risk wounds

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Abnormal Scar Formation

• May result in a keloid and hypertrophic scar
• Keloid
• Excessive accumulation of scar tissue that
  extends beyond the original wound borders
• More common in
• Darkly pigmented patients
• Those who have injuries to the ears, upper
  extremities, lower abdomen, or sternum

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Abnormal Scar Formation

• Hypertrophic scar
• Excess accumulation of scar tissue confined
  within the original wound borders
• More common in areas of high tissue stress, such
  as the flexion creases across joints

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Wounds Requiring Closure

• Expect the following types of wounds to require
  closure
• Wounds to cosmetic regions (face, lips, eyebrows,
  etc.)
• Gaping wounds
• Wounds over tension areas (e.g., joints)
• Degloving injuries
• Ring finger injuries
• Skin tearing

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Closed Wounds

• Usually associated with minimal blood loss
• Some may cause significant blood loss in
• Cavities of the thorax, abdomen, pelvis
• Soft tissues of the leg

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Contusions and Hematomas

• Contusion
• Characterized by blood vessel disruption beneath
  the epidermis
• Results in swelling, pain, ecchymosis that may
  occur 24 to 48 hours after the injury

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Contusions and Hematomas

• Hematoma
• Collection of blood beneath the skin
• May occur along with a contusion
• Represents a larger amount of tissue damage and
  disruption of larger vessels

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Crush Injury

• Can occur when a crushing force is applied to a
  body area
• Can be severe and may be associated with
• Internal organ rupture
• Major fractures
• Hemorrhagic shock

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Crush Injury
Womans leg after being run over by the wheel of
a milk van.
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Abrasion

• Partial-thickness injury
• Caused by the scraping or rubbing away of a layer
  or layers of skin

Deep abrasion caused by a fall from a bicycle.
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Laceration

• Results from a tear, a split, or an incision of
  the skin
• Sizes and depths of lacerations can vary greatly
  depending on the injury sites and wounding
  mechanism
• May be sources of significant bleeding

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Laceration
Large wound caused by a broken power saw.
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Puncture

• Commonly results from contact with a sharp,
  pointed object
• Entrance wound generally small

Puncture wounds caused by broken glass from
shattered windshield.
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Impaled Object
Wood impaled in right chest, piercing diaphragm
and lacerating spleen, stomach, and liver.
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Injection injury

• A type of puncture wound that may result from
  injection of a substance into the body under high
  pressure
• Often have life- or limb-threatening potential
• Usually associated with minimal bleeding
• May not appear serious

23
Injection Injury
Injection of paraffin into hand resulted in index
finger amputation.
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Avulsion

• A full-thickness skin loss in which the wound
  edges cannot be approximated
• Frequently involves the ear lobes, nose tip, and
  fingertips

Ring avulsion injury.
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Degloving Injury

• A type of avulsion in which shearing forces
  separate the skin from the underlying tissues
• Bleeding may be significant

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Amputation

• Involves a complete or partial loss of a limb
  secondary to mechanical force
• Bleeding is a potentially fatal complication

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Bites

• An animal or human bite is frequently a
  combination of puncture, laceration, avulsion,
  and crush injury

Human bite to the hand.
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Crush Injury

• May occur when tissue is exposed to sufficient
  force to interfere with normal structure and
  metabolic function of involved cells and tissues
• Degree of injury produced depends on
• Amount of pressure applied to body
• Amount of time pressure remains in contact with
  body
• Specific body region in which injury occurs

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Compartment Syndrome

• A continuation in the disease spectrum of crush
  injury
• Usually results from compressive forces or blunt
  trauma to muscle groups confined in tight fibrous
  sheaths with minimal ability to stretch (below
  the knee, above the elbow)

Prolonged crushing, as when an unconscious person
lies on a body part for several hours.
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Crush Syndrome

• A life-threatening and sometimes preventable
  complication of prolonged immobilization or
  compression
• A pathological process that causes destruction or
  alteration of muscle tissue
• Relatively rare

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Blast Injuries

• Primary blast injuries
• Secondary blast injuries
• Tertiary blast injuries
• Miscellaneous blast injuries

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Blast Injury
Blast injury to the face. His eardrums were
normal. He was admitted because of the risk of
swelling to his face and and airway with
potential airway obstruction.
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Management Principles

• Scene Survey
• Treatment Priorities
• Treatment of life-threatening injuries should
  occur before isolated soft tissue trauma
• Life-threatening airway deficit
• Life-threatening breathing deficit
• Life-threatening circulatory deficit
• Wound history
• Physical examination

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Types of Bleeding

• Arterial bleeding
• Venous bleeding
• Capillary bleeding

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Methods of Hemorrhage Control

• Direct pressure
• Elevation
• Pressure point
• Immobilization by splinting
• Pneumatic pressure devices
• Use of tourniquets (rare)

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Direct Pressure

• External hemorrhage is best controlled by
  applying direct pressure over the injury site
• Can usually control most types of hemorrhage
  within four to six minutes

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Elevation

• Venous bleeding that occurs in an extremity may
  be controlled or reduced by elevating the
  extremity above the level of the heart
• Should be considered a supplement to direct
  pressure

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Pressure Point

• Should be attempted in cases where direct
  pressure and elevation have not controlled
  hemorrhage
• The chosen artery must
• Be proximal to injury site
• Overlie a bony structure against which it can be
  compressed

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Immobilization by Splinting

• Extremity injuries may be immobilized by
  appropriate splinting devices
• Or the patient may be fully immobilized on a long
  spine board

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Pneumatic Pressure Devices

• May help provide uniform direct pressure to an
  injury site as well as immobilization
• Should be applied over a dressed wound and only
  after the bleeding has been controlled by other
  methods

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Tourniquet

• There is little or no indication for tourniquet
  use in the emergency management of hemorrhage
• Should only be considered as a last resort when
  all other methods have failed and when its use is
  essential to save the patient's life

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Dressing Materials

• General categories of dressings
• Sterile dressings
• Non-sterile dressings
• Occlusive dressings
• Non-occlusive dressings
• Adherent dressings
• Non-adherent dressings
• Bandages
• Complications of improperly applied dressings and
  bandages

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Management of Specific Injuries

• Open wounds that always require physician
  evaluation include those with
• Neural, muscular, or vascular compromise
• Tendon or ligament compromise
• Heavy contamination
• Cosmetic complications
• Foreign bodies
• Tetanus vaccine
• Patient instructions

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Shoulder Dressing
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Ankle Dressing
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Torso Dressing
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Thigh Dressing
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Finger Dressing
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Elbow Dressing
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Forehead Dressing
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Scalp Dressing
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Ear/Mastoid Dressing
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Neck Dressing
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Wound Infection

• Infection is a common complication of soft tissue
  injury
• Results from
• A break in the continuity of the skin
• Subsequent exposure to the non-sterile external
  environment
• Goals of wound care
• Prevent infection
• Protect from infection

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Causal Factors of Wound Infection

• Time
• Mechanism
• Location
• Severity
• Contamination
• Preparation
• Cleansing
• Technique of repair
• General patient condition

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Assessment of Wound Healing

• Examine dressings for excess drainage
• Examine wounds for early signs of infection or
  delayed healing
• Signs of wound infection

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Special Considerations

• Assessment of life-threatening injuries and
  resuscitation precede evaluation of and
  intervention for nonlife-threatening soft tissue
  injuries
• After ensuring adequate airway, breathing,
  circulatory status (with spinal precautions if
  indicated), controlling severe hemorrhage, and
  maintaining normal body temperature, wound care
  can proceed

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Penetrating Chest or Abdominal Injury

• An open wound to the chest or abdomen must be
  appropriately covered with a sterile occlusive
  dressing

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Impaled Object - Management

• Do not remove the impaled object
• Do not manipulate the impaled object unless
  shortening the object for extrication is
  necessary or for patient transport
• Control bleeding with direct pressure applied
  around the impaled object
• Stabilize the object in place with bulky
  dressings and immobilize the patient to prevent
  movement

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Avulsion - Management

• If the tissue is still attached to the body
• Clean the wound surface of gross contaminants
  with sterile saline
• Gently fold the skin back to its normal position
• Control bleeding and dress the wound with bulky
  pressure dressings
• Maintain direct pressure

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Avulsion - Management

• If the tissue is completely separated from the
  body
• Control the bleeding with application of direct
  pressure
• Retrieve the avulsed tissue if possible
• Wrap the tissue in gauze, either dry or moistened
  with lactated Ringers or saline solution (per
  protocol)
• Seal the tissue in a plastic bag
• Place the sealed bag on crushed ice

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Amputations - Management

• Initial attempts at hemorrhage control for
  amputation should begin with direct pressure and
  elevation
• Although a tourniquet may be required, it should
  be avoided if possible
• The amputated limb should be retrieved and
  managed in the same manner as avulsed tissue

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Crush Syndrome - Management

• Difficult to diagnose and treat
• Management of crush syndrome is controversial
• Provide airway and ventilatory support, including
  high-concentration oxygen administration
• Maintain body temperature
• Aggressively hydrate patient
• Alkalinize urine with sodium bicarbonate
• Use of arterial tourniquets may be beneficial
  before the release of a crushed limb