Soft Tissue Injuries
Temple College
EMS Professions
ECA
Skin Anatomy and Physiology
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Body’s largest organ
Layers
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Epidermis
Dermis
Subcutaneous tissue
Skin Anatomy and Physiology
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Functions
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Sensation
Control of water loss
Protection against microbes
Temperature control
Soft Tissue Injuries
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Closed
Open
Closed Injury
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Associated with blunt trauma
Skin remains intact
Damage occurs below surface
Types
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Contusions
Hematomas
Contusion
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Produced when blunt force
damages dermal structures
Blood, fluid leak into damage area
causing swelling, pain
Presence of blood causes skin
discoloration called ecchymosis
(bruise)
Hematoma
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“Blood lump”
Larger blood vessel damaged
Causes mass of blood to
collect in the injured area
Fist-sized hematoma = 10%
volume loss
Closed Tissue Injury Considerations
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How much blood is tied up in that injury rather than
circulating in the vessels?
What could the force the caused the soft tissue trauma have
done to underlying organs?
Closed Injury Management
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Rest
Ice
Compression
Elevate
Splint
When in doubt assume underlying
fractures are present
Open Injury
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Skin broken
Protective function lost
External bleeding, infection become problems
Open Injury Types
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Abrasions
Lacerations
Punctures
Avulsions
Amputations
Abrasion
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Loss of portions of epidermis,
upper dermis by rubbing or
scraping force.
Usually associated with
capillary oozing, leaking of
fluid
“Road rash”
Laceration
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Cut by sharp object or blunt
trauma
Typically longer than it is deep
May be associated with severe
blood loss, damage to underlying
tissues
Types
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Linear
Stellate
Punctures
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Result from stabbing force
Wound is deeper than it is long
Difficult to assess injury extent
Object producing puncture may
remain impaled in wound
Avulsions
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Piece of skin torn loose as a flap or completely torn from body
Result from accidents with machinery and motor vehicles
Replace flap into normal position before bandaging
Treat completely avulsed tissue like amputated part
Amputations
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Disruption of continuity of
extremity or other body part
Part should be wrapped in sterile
gauze, placed in plastic bag,
transported on top of cold pack
Do NOT pack part directly in ice
Do NOT let part freeze
Open Wound Management
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BSI
Manage ABCs first
Control bleeding
Prevent further contamination, but do not worry about trying
to clean wound
Immobilize injured part
Mange hypoperfusion if present
Dressing and Bandaging
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Function
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Stop bleeding.
Protect the wound from further damage.
Prevent further contamination and infection.
Dressings
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Universal dressing
4 X 4 inch gauze pads
Adhesive-type
Occlusive
Bandages
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Purpose - holds dressing in place
Types
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Self-adherent bandages
Gauze rolls
Triangular bandages
Adhesive tape
Air splint
Special Considerations
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Impaled objects
Eviscerations
Open chest wounds
Neck wounds
Gunshot wounds
Impaled Objects
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Do NOT remove
Stabilize in place
Impaled objects in the eye
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Cover both eyes
Exception
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Object in cheek
Remove, dress inside and outside
mouth
Eviscerations
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Internal organs exposed through
wound
Cover organs with large
moistened dressing, then with
aluminum foil or dry multitrauma dressing
Do NOT use individual 4 x 4’s
Do NOT attempt to replace
organs
Open Chest Wound
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May prevent adequate ventilation
Cover with 3 sided occlusive dressing
Monitor patient for signs of air becoming trapped under pressure in chest
(tension pneumothorax)
If tension pneumothorax develops lift dressing corner to relieve pressure
Neck Wounds
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Risk of severe bleeding from large vessels
Risk of air entering vein and moving through heart to lungs
Cover with occlusive dressing
Do NOT occlude airway or blood flow to brain
Suspect presence of spinal injury
Gunshot Wound
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Special type of puncture wound
Transmitted energy can cause injury remote from bullet track
Bullets change direction, tumble
Impossible to assess severity in field or ER
Patient must go to OR
Burns
Critical Factors
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Burn Depth
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Superficial (1st Degree)
Partial Thickness (2nd Degree)
Full Thickness (3rd Degree)
Extent
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% of body that is damaged
Burn Depth
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First Degree (Superficial)
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Involves only epidermis
Red
Painful
Tender
Blanches under pressure
Possible swelling, no blisters
Heal in ~7 days
Burn Depth
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Second Degree (Partial
Thickness)
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Extends through epidermis
into dermis
Salmon pink
Moist, shiny
Painful
Blisters may be present
Heal in ~7 to 21 days
Burn Depth
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Burns that blister are
second degree.
But all second degree
burns don’t blister.
Burn Depth
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Third Degree (Full Thickness)
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Through epidermis, dermis into
underlying structures
Thick, dry
Pearly gray or charred black
May bleed from vessel damage
Painless
Require grafting
Burn Depth
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Often cannot be accurately determined in
acute stage
Infection may convert to higher degree
When in doubt, over-estimate
Burn Extent
Rule of Nines
Adult Rule of Nines
Pediatric Rule of Nines
For each year over 1 year of age, subtract 1% from head,
add equally to legs.
Burn Extent
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Rule of Palm
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Patient’s palm
equals 1% of his
body surface area
Burn Severity
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Based on
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Depth
Extent
Location
Cause
Patient Age
Associated Factors
Critical Burns (Require Burn Center)
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3rd Degree >10% BSA
2nd Degree > 25% BSA (20% pediatric)
Face, Feet, Hands, Perineum, Joints
Airway/Respiratory Involvement
Associated Trauma
Associated Medical Disease
Electrical Burns
Deep Chemical Burns
Moderate Burns
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3rd Degree 2 to 10%
2nd Degree 15 to 25% (10 to 20% pediatric)
Minor Burns
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3rd Degree <2%
2nd Degree <15% (<10% pediatric)
Associated Factors
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Patient Age
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< 5 years old
> 55 years old
Burn Location
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Circumferential burns of chest or extremities
MANAGEMENT
Stop Burning Process
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Remove patient from source of injury
Remove clothing unless stuck to burn
Cut around clothing stuck to burn, leave in
place
Assess Airway/Breathing
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Start oxygen if:
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Moderate or critical burn
Decreased level of consciousness
Signs of respiratory involvement
Burn occurred in closed space
History of CO or smoke exposure
Assist ventilations as needed
Assess Circulation
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Check for shock signs /symptoms
Early shock seldom results from effects of
burn itself.
Early shock = Another injury until proven
otherwise
Obtain History
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How long ago?
What has been done?
What caused burn?
Burned in closed space?
Loss of consciousness?
Allergies/medications?
Past medical history?
Rapid Physical Exam
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Check for other injuries
Rapidly estimate burned, unburned areas
Remove constricting bands
Treat Burn Wound
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Cover with DRY, CLEAN SHEETS
Do NOT rupture blisters
Do NOT put oil based products on burn
Special Considerations
Pediatrics
Geriatrics
Pediatrics
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Thin skin, increased severity
Large surface to volume ratio
Poor immune response
Small airways, limited respiratory reserve
capacity
Consider possibility of abuse
Geriatrics
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Thin skin
Poor Circulation
Underlying disease processes
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Pulmonary
Peripheral vascular
Decreased cardiac reserve
Decreased immune response
Chemical Burns
Concerns
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Damage to skin
Absorption of
chemical; systemic
toxic effects
Avoiding EMS
personnel exposure
Management
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Remove chemical from
skin
Liquids
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Flush with water
Dry chemicals
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Brush away
Flush what remains with
water
Chemical in Eyes
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Flush with NS or Ringers
No other chemicals in eye
Flush out contacts
Electrical Burns
Electrical Burns
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Conductive injuries
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“Tip of Iceberg”
Entrance/exit wounds may be small
Massive tissue damage between entrance/exit
“Tip of the Iceberg”
Management
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Make sure current is off!
Check ABCs
Assess carefully for other injuries
Patient needs hospital evaluation, observation