24: Soft-Tissue Injuries
Cognitive Objectives
(1 of 6)
5-2.1 State the major functions of the skin.
5-2.2 List the layers of the skin.
5-2.3 Establish the relationship between body
substance isolation (BSI) and soft-tissue injuries.
5-2.4 List the types of closed soft-tissue injuries.
5-2.5 Describe the emergency medical care of the
patient with a closed soft-tissue injury.
5-2.6 State the types of open soft-tissue injuries.
Cognitive Objectives
(2 of 6)
5-2.7 Describe the emergency medical care of the
patient with an open soft-tissue injury.
5-2.8 Discuss the emergency medical care
considerations for a patient with a penetrating
chest injury.
5-2.9 State the emergency medical care
considerations for a patient with an open wound to
the abdomen.
5-2.10 Differentiate the care of an open wound to the
chest from an open wound to the abdomen.
Cognitive Objectives
(3 of 6)
5-2.11 List the classification of burns.
5-2.12 Define superficial burn.
5-2.13 List the characteristics of a superficial burn.
5-2.14 Define partial-thickness burn.
5-2.15 List the characteristics of a partial-thickness
burn.
5-2.16 Define full-thickness burn.
Cognitive Objectives
(4 of 6)
5-2.17 List the characteristics of a full-thickness burn.
5-2.18 Describe the emergency medical care of the
patient with a superficial burn.
5-2.19 Describe the emergency medical care of the
patient with a partial-thickness burn.
5-2.20 Describe the emergency medical care of the
patient with a full-thickness burn.
5-2.21 List the functions of dressing and bandaging.
5-2.22 Describe the purpose of a bandage.
Cognitive Objectives
(5 of 6)
5-2.23 Describe the steps in applying a pressure
bandage.
5-2.24 Establish the relationship between airway
management and the patient with chest injury,
burns, and blunt and penetrating injuries.
5-2.25 Describe the effects of improperly applied
dressings, splints, and tourniquets.
5-2.26 Describe the emergency medical care of a
patient with an impaled object.
Cognitive Objectives
(6 of 6)
5-2.27 Describe the emergency medical care of a
patient with an amputation.
5-2.28 Describe the emergency care for a chemical
burn.
5-2.29 Describe the emergency care for an electrical
burn.
• There are no affective objectives for this chapter.
Psychomotor Objectives (1 of 3)
5-2.29 Demonstrate the steps in the emergency
medical care of closed soft-tissue injuries.
5-2.30 Demonstrate the steps in the emergency
medical care of open soft-tissue injuries.
5-2.31 Demonstrate the steps in the emergency
medical care of a patient with an open chest
wound.
5-2.32 Demonstrate the steps in the emergency
medical care of a patient with open abdominal
wounds.
Psychomotor Objectives (2 of 3)
5-2.33 Demonstrate the steps in the emergency
medical care of a patient with an impaled object.
5-2.34 Demonstrate the steps in the emergency
medical care of a patient with an amputation.
5-2.35 Demonstrate the steps in the emergency
medical care of an amputated part.
5-2.36 Demonstrate the steps in the emergency
medical care of a patient with superficial burns.
5-2.37 Demonstrate the steps in the emergency
medical care of a patient with partial-thickness
burns.
Psychomotor Objectives (3 of 3)
5-2.38 Demonstrate the steps in the emergency
medical care of a patient with full-thickness burns.
5-2.39 Demonstrate the steps in the emergency
medical care of a patient with a chemical burn.
5-2.40 Demonstrate completing a prehospital care
report for patients with soft-tissue injuries.
Anatomy of the Skin
Function of the Skin
• Protection
• Sensation
• Temperature control
Soft-Tissue Injuries
• Closed injuries
– Soft-tissue damage beneath the skin
• Open injuries
– Break in the surface of the skin
• Burns
– Soft tissue receives more energy than it
can absorb
Contusion
• Results from blunt force striking the body
Hematoma
• Pool of blood
that has
collected in
the body
Crushing Injury
• Occurs when a
great amount of
force is applied to
the body
Scene Size-up
• Observe for hazards.
• Take BSI precautions.
• Place several pairs of
gloves in pocket.
• You may be able to
identify bleeding before
even reaching patient.
• Look for indicators of
MOI.
Initial Assessment (1 of 2)
•
•
•
•
•
•
•
Observe patient for seriousness of condition.
Does patient have any apparent life threats?
Look for hidden injuries.
Ensure patent airway.
Protect patient from further spinal injury.
Quickly assess breathing.
Palpate chest wall for DCAP-BTLS.
Initial Assessment (2 of 2)
• If soft-tissue injury is discovered on chest or
abdomen:
– Check for clear and symmetrical breath sounds.
– Provide high-flow oxygen or assisted ventilations.
• Quickly assess pulse rate and quality.
• Closed soft-tissue injuries do not have visible signs
of bleeding.
• Pulse will indicate how aggressively you need to
treat for shock.
Transport Decision
• If patient has signs of
shock or airway or
breathing problem,
consider quickly
transporting or
requesting ALS.
• Do not delay transport
of closed-injury patient
who may have more
serious deeper injury.
Focused History and Physical Exam
• Patients with significant MOI may need a rapid
physical exam to identify injuries.
• Focused physical exam
– Focus assessment on the isolated closed injury,
complaint, and affected body region.
• Rapid physical exam
– Perform if significant trauma has likely affected
multiple systems.
– Make sure cervical collar is applied.
Baseline Vital Signs
• Closed-injury patients may rapidly become
unstable.
• Look for tachycardia; tachypnea; low blood
pressure; weak pulse; and cool, moist skin.
• Soft-tissue injuries, even without a significant MOI,
can cause shock.
SAMPLE History
• Obtain from responsive patient or
bystanders/family.
• Look for medical ID jewelry or cards.
Interventions
• Provide complete spinal immobilization early if
spinal injuries are suspected.
• Provide high-flow oxygen.
• Treat aggressively for shock.
• Request ALS if necessary.
• Do not delay transport.
Detailed Physical Exam
• Any time there is a significant MOI, perform
detailed physical exam if time permits.
Ongoing Assessment
• Repeat the initial assessment.
• Reassess vital signs frequently.
• Communication and documentation
– Provide accurate account of how you treated
injuries.
RICES
• Rest—keep patient quiet and
comfortable as possible.
• Ice slows bleeding.
• Compression over an injury slows
bleeding.
• Elevation above the level of the heart
reduces swelling.
• Splinting decreases bleeding and
reduces pain.
Abrasions
• Caused by friction
Laceration
• Jagged cut
Avulsion
• Separation of various layers of the skin
Penetrating Wound
• Results from
a sharp
pointed
object
Gunshot Wounds
• Gunshot wounds have unique characteristics
Crushing Open Wound
• May involve
damaged
internal organs
or broken bones
Scene Size-up
• Wear BSI.
• Do not touch equipment with bloody gloves; wear
several pairs.
• Beware of contaminating one patient with another
patient’s blood.
• Wear eye protection.
• Consider MOI.
Initial Assessment
•
•
•
•
•
•
•
•
There may be internal underlying injuries.
Injuries can affect airway and breathing.
Provide spinal immobilization.
If the patient has an open chest wound, evaluate
for bubbling or sucking sounds.
Quickly place an occlusive dressing over wound.
Provide high-flow oxygen.
Assess pulse and skin for shock.
Control significant bleeding.
Transport Decision
• Consider quick transport if patient has airway or
breathing problem or significant bleeding.
• Stay focused on problems at hand.
• Patients with significant bleeding or internal
bleeding may quickly become unstable.
• Watch for signs of shock.
Focused History and
Physical Exam
• Focused physical exam
– Perform in responsive patient with simple open
injury.
– Focus on isolated injury, complaint, and affected
body region.
• Rapid physical exam
– Perform if there is significant trauma likely
affecting multiple systems.
– Look for DCAP-BTLS.
– Do not delay transport.
– Be sure that spine is stabilized.
Baseline Vital Signs/SAMPLE
History
• Baseline vital signs
– Will help determine if patient is going into shock
• SAMPLE history
– Anemia and hemophilia
– Medications that thin the blood (aspirin,
prescribed blood thinners)
Interventions
• Control bleeding.
• If bleeding is not
significant, control later
in assessment.
• Stabilize spine and
assist breathing.
• Splint painful, swollen,
deformed extremities.
Detailed Physical
Exam
• Perform if patient is stable and time allows.
Ongoing Assessment
• Assess all bandaging frequently.
• Reassess ABCs often.
• Communication and documentation
– Include description of MOI and patient’s position.
– Estimate and report amount of blood loss.
– Describe location, size, depth of injury.
Emergency Medical Care (1 of 3)
• Use proper BSI precautions.
• Administer oxygen if needed.
• Treatment priority is ABCs—including
controlling bleeding.
Emergency Medical Care (2 of 3)
• Apply dry, sterile
dressing over entire
wound.
• Maintain pressure
and secure
dressing with a
roller bandage.
Emergency Medical Care (3 of 3)
• Leave original dressing
in place if bleeding
continues.
• Apply a second
dressing on top of first
and secure.
• Splint the extremity.
Abdominal Wounds
• Open wound in
abdomen may
expose organs.
• Organ protruding
through abdomen is
called an
evisceration.
Abdominal Wound Management
• Do not touch
exposed organs.
• Cover organs with a
moist sterile
dressing.
• Transport
immediately.
Impaled Objects (1 of 2)
• Do not attempt to move or remove object.
Impaled Objects (2 of 2)
• Control bleeding and
stabilize object.
• Tape a rigid item over
object to prevent
movement.
• Transport to hospital
carefully.
Amputations
• Immobilize partial amputation
with bulky dressings and
splint.
• Wrap complete amputation in
dry sterile dressing and place
in plastic bag.
• Put bag in cool container
filled with ice. Do not let
object freeze!
• Transport severed part with
patient.
Neck Injuries (1 of 2)
• An open neck injury can be life threatening.
• Air can get into the veins and cause an air
embolism.
Neck Injuries (2 of 2)
• Cover the wound with an occlusive dressing.
• Apply manual pressure.
• Secure a pressure dressing loosely over the neck
and firmly through the opposite axilla.
Burns
• Burns account for over 10,000
deaths/year.
• Burns are the most serious and
painful injuries.
• Remember to perform a complete
assessment on burn patients for
other injuries.
Determining Burn Severity
• What is the depth of the burn?
• What is the extent of the burn?
• Are any critical areas involved?
• Are there any preexisting medical
conditions or other injuries?
• Is the patient younger than 5 years or
older than 55 years of age?
Depth of Burns (1 of 3)
• Superficial (firstdegree) burns
• Involve only top
skin layer
Depth of Burns (2 of 3)
• Partial-thickness
(second-degree)
burns
• Involve epidermis
and some portion
of dermis
Depth of Burns (3 of 3)
• Full-thickness (thirddegree) burns
• Extend through all
layers of skin
Extent of Burns
Critical Burns (1 of 2)
• Full-thickness burns involving hands, feet, face,
upper airway, genitalia, or circumferential burns of
other areas
• Full-thickness burns covering more than 10% of
total body surface area
• Partial-thickness burns covering more than 30% of
total body surface area
• Burns associated with respiratory injury
Critical Burns (2 of 2)
• Burns complicated by fractures
• Burns on patients younger than 5 years old or older
than 55 years old that would be classified as
moderate on young adults
Moderate Burns
• Full-thickness burns involving 2% to 10% of total
body surface area excluding hands, feet, face,
upper airway, or genitalia
• Partial-thickness burns covering 15% to 30% of
total body surface area
• Superficial burns covering more than 50% of total
body surface area
Minor Burns
• Full-thickness burns involving less than 2% of the
total body surface area
• Partial-thickness burns covering less than 15% of
the total body surface area
• Superficial burns covering less than 50% of the
total body surface area
Pediatric Needs
• Burns to children are considered more serious than
burns to adults.
• Children have more surface area relative to body
mass than adults.
• Many burns result from abuse.
• Report all suspect cases of abuse to the
authorities.
Critical Burns in Infants
and Children
• Full-thickness burns covering more than 20% of
total body surface area
• Burns involving hands, feet, face, upper airway,
genitalia
Moderate Burns in Infants
and Children
• Partial-thickness burns covering 10% to 20% of
total body surface area
Minor Burns in Infants and Children
• Partial-thickness burns covering less than 10% of
total body surface area
• You arrive to an auto repair station for a 27-yearold man with burns from an accident. The
dispatcher indicated possible entrapment.
• The man is supine on the floor in a pool of
antifreeze.
• He is complaining of pain to his right thigh and
ankle.
You are the provider
• Owner says he heard a crashing noise followed by
screams.
• He found employee with ankle pinned under tire,
while other side of car was still on the jack.
• He used the jack to lift the car off the employee,
then pulled patient clear of car.
• Hot antifreeze drained over patient’s thigh.
• Patient denies loss of consciousness.
You are the provider
continued
Scene Size-up
• In addition to BSI, what are some considerations at
the scene?
• Are there any other hazards?
• What is the MOI?
• His respiratory effort is rapid and lips are pursed.
• Inspection and palpation of the chest is
unremarkable.
• A quick check of radial pulse indicates that it is
rapid.
• There is no obvious external bleeding.
You are the provider
continued (1 of 3)
• You and your partner opt to perform a rapid
physical exam.
• Partner maintains c-spine precautions.
• You determine no life-threatening injuries.
• You expose his burns.
• One thigh is completely reddened with a fist-sized
blister.
• Patient denies taking medications.
• States he is allergic to penicillin and has no past
medical history
You are the provider continued (2 of
3)
• At what point would you take vital signs?
• When should you start oxygen?
• How much would you administer? What type of
device would you use?
• What degree of burn does the patient have?
• Given the location and area, is this burn life
threatening?
• How do you treat this burn?
You are the provider continued (3
of 3)