Chapter 31
Soft-Tissue Trauma
National EMS Education
Standard Competencies
Trauma
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression to implement a
comprehensive treatment/disposition plan for
an acutely injured patient.
National EMS Education
Standard Competencies
Soft-Tissue Trauma
Recognition and management of
− Wounds
− Burns
• Electrical
• Chemical
• Thermal
− Chemicals in the eye and on the skin
National EMS Education
Standard Competencies
Pathophysiology, assessment, and
management of
− Wounds
• Avulsions
• Bite wounds
• Lacerations
• Puncture wounds
• Incisions
National EMS Education
Standard Competencies
Pathophysiology, assessment, and
management of (cont’d)
− Burns
• Electrical
• Chemical
• Thermal
• Radiation
− High-pressure injection
− Crush syndrome
Introduction
• The skin is the largest organ of the body.
− Injuries are common.
− Wound: any injury to soft tissue
− Always search for other injuries or conditions
before treating soft-tissue trauma.
Incidence, Mortality, and
Morbidity
• Soft tissue can be injured by:
− Blunt injury
− Penetrating injury
− Burns
• Soft-tissue trauma is the leading form of
injury.
Incidence, Mortality, and
Morbidity
• Death from soft-tissue injury is rare.
− Uncontrolled bleeding
− Local or systemic infections
• Prevention involves simple actions.
Structure and Function of the
Skin
• Skin: complex organ with crucial role in
homeostasis
− Protects underlying tissue from injury
− Aids in temperature regulation
− Prevents excessive water loss
− Acts as sense organ
Structure and Function of the
Skin
• Significant damage may make the patient
vulnerable to:
− Bacterial invasion
− Temperature instability
− Fluid balance disturbances
Epidermis
• First line of defense
• Consists of five layers
− Stratum corneum (outermost layer)
− Four inner layers of living cells
Epidermis
Dermis
• Tough, highly elastic connective tissue
− Composed of:
• Collagen and elastic fibers
• Mucopolysaccharide gel
• Fibroblasts
− Subdivided into:
• Papillary dermis and reticular layer
Dermis
• Macrophages and lymphocytes
− Part of the inflammatory process
− Responsible for combating micro-organisms
• Results in increased blood flow, causing redness
and warmth
Dermis
• Specialized structures
− Nerve endings
− Blood vessels
− Sweat glands
− Hair follicles
− Sebaceous gland
Subcutaneous Tissues
• Layer beneath the dermis
• Mostly adipose tissue
− Insulates underlying tissues
− Provides a cushion for underlying structures
− Provides an energy reserve for the body
Deep Fascia
• Thick, dense layer of fibrous tissue below
subcutaneous tissue
− Composed of tough tissue bands
− Supports and protects underlying structures
Skin Tension Lines
• Static tension develops over areas with
limited movement.
− Lacerations parallel to lines may remain closed.
− Larger wounds may be pulled open.
− Smaller lacerations perpendicular to tension
lines will remain open.
Skin Tension Lines
• Dynamic tension found over muscle
− Open injuries interfere with healing:
• Disrupt clotting process
• Disrupt tissue repair cycle
• An abnormal scar may prompt scar revision
surgery.
Closed Wounds
• Soft tissue is
damaged but skin
is not broken
− Characteristic
closed wound is a
contusion.
Closed Wounds
• If small blood
vessels are
damaged,
ecchymosis will
cover the area.
• If large blood
vessels are torn, a
hematoma will
appear.
Courtesy of Rhonda Beck
Open Wounds
• Characterized by disruption in the skin
• Potentially more serious than closed
wounds
− Vulnerable to infection
− Greater potential for serious blood loss
Open Wounds
Crush Injuries
• An injury to the
underlying soft
tissues and bones
• Caused by a body
part being crushed
between two solid
objects
© Mark C. Ide
Crush Injuries
• May lead to compartment syndrome
• May lead to rupture of internal organs
• External appearance may not represent
level of internal damage.
− Grotesque injuries may not be primary problem.
Crush Injuries
• Body’s first responses to vessel injury is
localized vasoconstriction.
− If vessels are damaged, they may not be able to
constrict.
• Crush injuries often result in difficult-to-control
hemorrhage.
Blast Injury
• Explosions can result in:
− Soft-tissue trauma
− Abdominal trauma
− Skeletal trauma
− Blast lung
• Assess the scene for hazards.
The Process of Wound Healing
• Hemostasis
− Vessels, platelets, and clotting cascade must
work together to stop bleeding.
− The release of chemicals:
• Constricts the blood vessels
• Activates platelets
The Process of Wound Healing
• Inflammation
− Additional cells enter area for repair.
− White blood cells combat pathogens.
− Chemotactic factors are released.
− Lymphocytes destroy bacteria and pathogens.
− Mast cells release histamine.
The Process of Wound Healing
• Inflammation (cont’d)
− Leads to the removal of:
• Foreign material
• Damaged cellular parts
• Invading micro-organisms
The Process of Wound Healing
• Epithelialization
− New epithelial cells move to outer layer of skin
to replace those lost in injury.
• Area seldom regains previous look.
• Function of area may be restored.
The Process of Wound Healing
• Neovascularization
− New blood vessels form to bring oxygen and
nutrients to injured tissue.
• New capillaries form from intact capillaries.
The Process of Wound Healing
• Collagen synthesis
− Collagen: Tough, fibrous protein in scar tissue,
hair, bones, connective tissue
− Repair unit is synthesized by fibroblasts.
• Cannot restore damaged tissue to former strength
Alterations of Wound Healing
• Healing does not always follow pattern
because there may be:
− Infection or abnormal scarring
− Excessive bleeding
− Slow healing
Alterations of Wound Healing
• Anatomic factors
− Body areas with repeated motion
− Relationship of open wound to skin tension lines
− Medications
− Medical conditions
Alterations of Wound Healing
• High-risk wounds
− Human and animal bites
• High risk of infection
− Injuries from foreign bodies or organic matter
• Do not remove an impaled object in the field.
Alterations of Wound Healing
• Abnormal scar formation
− Excessive collagen formation can occur if
healing phases are not balanced, leading to:
• Hypertrophic scar
• Keloid scar
Alterations of Wound Healing
• Pressure injuries
− Occur from:
• Being bedridden
• Pressure applied for prolonged periods
− Involved tissues are deprived of oxygen.
Alterations of Wound Healing
• Wounds requiring closure
− Include:
• Open injuries affecting cosmetic areas
• Gaping wounds and wounds over tension lines
• Degloving injuries
• Ring injuries and skin tears
Alterations of Wound Healing
• Wounds requiring closure (cont’d)
− Open injuries should be closed within 24 hours.
− Three types of wound closure:
• Primary closure
• Secondary intention
• Delayed primary closure
Pathophysiology of Wound
Healing
• Infection
− Pathogens grow and multiply once they reach
body tissues.
− Clinical signs may not appear for days.
Pathophysiology of Wound
Healing
• Infection (cont’d)
− Visible signs
• Pus
• Warmth
• Edema
• Local discomfort
• Red streaks
Pathophysiology of Wound
Healing
• Infection (cont’d)
− Systemic signs
• Fever
• Shaking
• Chills
• Joint pain
• Hypotension
Pathophysiology of Wound
Healing
• Gangrene
− Caused by Clostridium perfringens
• Causes foul-smelling gas
− If untreated:
• Skin will become necrotic.
• Infection may lead to sepsis.
Pathophysiology of Wound
Healing
• Tetanus
− Caused by infection from Clostridium tetani
− Causes a potent toxin, resulting in:
• Painful muscle contractions
• Muscle stiffness
− Rare because of vaccine
Pathophysiology of Wound
Healing
• Necrotizing fasciitis
− Involves tissue death from bacterial infection
− Rare, but with high mortality
− Treatment includes:
• Antibiotic therapy
• Surgical debridement
Patient Assessment
• Skin trauma is rarely life-threatening.
− Stay focused on assessment process.
• Identify threats to EMS crew.
• Identify threats to patient.
Scene Size-Up
• Address safety first.
• Evaluate MOI.
− If significant, keep a high index of suspicion.
• Determine the number of patients involved.
• Protect yourself and patient from bodily
fluid.
Primary Assessment
• Form a general impression.
− Determine any life threats.
− Check patient and immediate surroundings.
− Check for potential injuries to neck and spine.
− Evaluate level of consciousness.
Primary Assessment
• Airway and breathing
− Assess immediately.
− Correct anything that interferes with airway.
− Assess the patient’s breathing.
− Take prompt action for compromised breathing.
Primary Assessment
• Circulation
− Assess circulation by:
• Palpating a pulse
• Palpating and inspecting the skin using CTC
− Control of severe hemorrhage with a tourniquet
takes precedence.
Primary Assessment
• Transport decision
− Transport patients with significant trauma.
− Patients with isolated injuries can often be
treated at the scene.
Primary Assessment
• Significant MOI
− Serious trauma indicated by:
• Altered level of consciousness
• Lack or airway protection or patency
• Inadequate breathing
• Uncontrolled bleeding
• Significant MOI
Primary Assessment
• Significant MOI (cont’d)
− If possibility of serious injury, perform a rapid
exam, assessing:
• Head and neck
• Chest
• Abdomen
• Pelvis
• Lower and upper extremities
• Posterior
Primary Assessment
• Significant MOI (cont’d)
− Identify need for attention using DCAP-BTLS:
• Deformities
• Contusions
• Abrasions
• Punctures or penetrations
• Burns
• Tenderness
• Lacerations
• Swelling
Primary Assessment
• Significant MOI (cont’d)
− Assess areas with:
• Alteration in sensation
• Uneven temperature
• Abnormal muscle tone
− Note blood from hidden injuries.
− Address any life threats.
Primary Assessment
• Significant MOI (cont’d)
− After assessment, apply a cervical collar.
− Decide whether to rapidly transport.
− Perform a complete set of vital signs and a
SAMPLE history.
Primary Assessment
• No significant MOI
− Isolated extremity trauma does not warrant a
fully body exam.
− If protocols allow, some patients can be
released after treatment on the scene.
History Taking
• Ask about events leading to injury.
• Ask about the last tetanus booster.
• Ask about over-the-counter medicines.
• Use the mnemonic SAMPLE.
Secondary Assessment
• Conduct a more thorough examination en
route if there is:
− A significant MOI
− Adequate time
− Patient in stable condition
Reassessment
• Do frequent reassessments en route.
− Stable patient—every 15 minutes
− Serious condition—every 5 minutes minimum
• Obtain and evaluate vital signs.
• Check interventions and monitor patient.
Reassessment
• Complete written documentation.
• Note specific injuries, describing wounds.
• Note assessment findings for:
− Distal neurovascular status
− Range of motion
− Presence or absence of infection
Reassessment
• Obtain patient demographic information.
• Record any interventions performed,
documenting:
− Patient’s response
− Patient’s understanding
− Which provider attended the patient
Emergency Medical Care
• Basic management principles:
− Attend to clinical issues and patient’s feelings.
− Control bleeding with direct pressure, elevation,
or a tourniquet if necessary.
− Document any care provided.
Treatment of Closed Wounds
• Minimize bleeding and swelling (ICES):
− Apply Ice or cold packs.
− Apply firm Compression.
− Elevate the injured part higher than the heart.
− Apply a Splint.
Treatment of Closed Wounds
• Edema is the body’s way of dealing with
injury to soft or connective tissues.
• Using ice as early as possible may speed
up healing time.
Treatment of Open Wounds:
General Principles
• General principles:
− Control bleeding by most effective method.
− Keep wound as clean as possible.
• Determine injury magnitude, and relay
information to the receiving facility.
Treatment of Open Wounds:
General Principles
• If wound is already in healing stage:
− Examine edges to see if the wound is closing
properly.
− Check for signs of infection.
Bandaging and Dressing
Wounds
• Used to:
− Cover wound
− Control bleeding
− Limit motion
• Variety of materials used
Complications of Improperly
Applied Dressings
• Always use as sterile technique as possible.
− Irrigate open wounds with normal saline.
− Apply antibiotic ointment to smaller wounds.
− Do not use ointment on larger wounds.
Complications of Improperly
Applied Dressings
• Hemodynamic complications may include
continued bleeding.
− Apply additional dressings in conjunction with
other interventions.
− Perform frequent assessments.
Complications of Improperly
Applied Dressings
• Structural elements can be damaged if
dressings are too tight.
− Assess and readjust if necessary.
− When extremity dressings are in place, assess:
• Distal pulses
• Motor function
• Sensation
Control of External Bleeding
• Bleeding can be characterized by type of
blood vessel damaged.
− Capillary bleeding—slow flow, bright or dark red
− Venous bleeding—slow, steady, darker color
− Arterial bleeding—spurts, bright red color
Control of External Bleeding
• Direct pressure
− Allows platelets to form blood clots
− Steps for management:
• Follow standard precautions.
• Maintain airway.
• Apply direct pressure with a dry, sterile dressing.
• Apply a pressure dressing and gauze.
Control of External Bleeding
• Direct pressure (cont’d)
− If bleeding is not controlled, apply a tourniquet.
− Apply high-flow oxygen as necessary.
− Monitor serial vital signs, and watch for shock.
• If signs of shock arise, transport rapidly.
− Assess circulation before and after application.
Control of External Bleeding
• Elevation
− Can substantially slow venous bleeding
• Immobilization
− Motion disrupts clotting process.
− Limit injured extremity movement.
− If necessary, apply a splint.
Control of External Bleeding
• Tourniquet
− Especially useful if:
• Extremity injury
below the axilla or
groin is severely
bleeding.
• Other bleeding
control methods
are ineffective.
Courtesy of Steven Kasser
Control of External Bleeding
• Tourniquet (cont’d)
− Follow standard precautions.
− Hold direct pressure over bleeding site.
− Place tourniquet above the bleeding site.
− Click the buckle into place.
− Turn the tightening dial clockwise until pulses
are no longer palpable distal to the tourniquet.
Control of External Bleeding
• Tourniquet (cont’d)
− To release the tourniquet, push the release
button and pull the strap back.
− If a commercial tourniquet is not available, use
a triangular bandage and a stick or rod.
− A blood pressure cuff can also be used.
Control of External Bleeding
• Tourniquet (cont’d)
− Take the following precautions:
• Do not apply over a joint.
• Use the widest bandage possible.
• Never use material that could cut into the skin.
• If possible, use wide padding under the tourniquet.
Control of External Bleeding
• Tourniquet (cont’d)
− Take the following precautions (cont’d):
• Never cover with a bandage.
• Inform the hospital.
• Do not loosen after it is applied.
Pain Control
• May include:
− Cold compress
− Pressure dressing
− Morphine sulfate or other pain medication
Managing Wound Healing and
Infection
• Basic measures should be used in the
prehospital setting.
− Wounds that look infected or are not healing
properly should be dressed and bandaged.
− Pain control management may be indicated.
Dressing Specific Anatomic
Sites
• Scalp dressings
− Direct pressure is usually effective.
− Determine the extent of injury.
• Balance bleeding control needs against the
possibility of causing further damage.
• If skull has been damaged, apply pressure to areas
around the break.
Dressing Specific Anatomic
Sites
• Facial dressings
− Reassure patient.
− Direct pressure is effective to control bleeding.
− If avulsed tissue is present, attempt to place it
as close to its previous position as possible.
− Assess for airway compromise.
Dressing Specific Anatomic
Sites
• Ear or mastoid dressings
− Do not place a dressing in the ear canal.
− Use gauze sponges to aid in stopping blood
loss.
− Do not try to directly stop blood flow from the
ear canal.
• Place a bulky dressing over the external ear.
Dressing Specific Anatomic
Sites
• Neck dressings
− Minor injuries can
become major.
− Use occlusive
dressings.
− Make sure
dressings do not
interfere with blood
flow or movement
of air through the
trachea.
© E. M. Singletary, MD. Used with permission
Dressing Specific Anatomic
Sites
• Truncal dressings
− Cover open wounds with occlusive dressing,
taping only three sides.
− Assess breath sounds.
− Use medical tape to secure dressing.
Dressing Specific Anatomic
Sites
• Groin and hip dressings
− Combined with direct pressure
− Genitalia injuries should be managed by
someone of the same gender.
− Remain professional, and protect the patient’s
privacy.
Dressing Specific Anatomic
Sites
• Hand, wrist, and
finger dressings
− Place the hand in a
position of function.
− The hand and wrist
can be splinted.
− Leave fingers
exposed.
Dressing Specific Anatomic
Sites
• Elbow and knee dressings
− Movement may cause dressings to shift.
• For larger wounds, immobilize joint.
− Assess distal neurovascular status.
Dressing Specific Anatomic
Sites
• Ankle and foot dressings
− Control bleeding with direct pressure.
• If bleeding is arterial and not controlled, consider a
tourniquet proximal to injury.
− Always assess distal neurovascular function
before and after caring for a wound.
Abrasions
• Superficial wound
− Occurs when part of epidermis is lost from
being rubbed or scraped over a rough surface
Abrasions
• Assessment and management
− Oozes small amounts of blood
− May be painful and prone to infection
− Do not clean in the field.
− Cover lightly with sterile dressing.
Lacerations
• Cut from a sharp instrument that produces a
clean or jagged incision
− Can injure structures beneath skin
Courtesy of Rhonda Beck
Lacerations
• Assessment and management
− Seriousness depends on:
• Depth
• Structures damaged
− First priority is to control bleeding.
Puncture Wounds
• Caused by a stab from a pointed object
− Can result in injury to underlying tissues and
organs
Puncture Wounds
• Assessment and management
− Consider potential depth of wound.
− Treatment is similar to other wounds:
• Look for entrance and exit wounds.
• Take steps to prevent infection.
Puncture Wounds
• Assessment and management (cont’d)
− Air may be injected under the skin with certain
puncture wounds.
• Monitor for edema.
• Treat swelling with ice.
Puncture Wounds
• Assessment and
management
(cont’d)
− If the object is still
embedded in the
wound:
• Immobilize the
object.
• Transport the
patient.
© Custom Medical Stock Photo
Puncture Wounds
• Assessment and management (cont’d)
− Basic management points for impaled objects:
• Do not try to remove an impaled object.
• Use direct compression, but not on the impaled
object or adjacent tissues.
• Do not try to shorten the object.
• Stabilize the object with bulky dressing, and
immobilize the extremity.
Puncture Wounds
• Assessment and management (cont’d)
− Prehospital care goal—limit movement as soon
as possible.
− Secure the object as best as possible.
• Provide reassurance.
• Constantly assess for risks to life.
Puncture Wounds
• Assessment and management (cont’d)
− Removal of impaled object may be necessary:
• If object directly interferes with airway control
• If object interferes with chest compression
• If patient is impaled on an immovable object
Avulsions
• Occurs when a flap of skin is partially or
completely torn loose
− Amount of bleeding is dependent on the depth
of injury.
Avulsions
• Assessment and management
− Principle danger is loss of blood supply to the
avulsed skin flap.
− If wound is contaminated, provide irrigation.
− Gently fold and align the skin flap back as close
to its normal position as possible.
• Cover it with a dry, sterile compression dressing.
Avulsions
• Assessment and management (cont’d)
− Ice packs on the surrounding area may:
• Decrease pain and swelling
• Increase the length of time the underlying tissue
remains viable
− If patient is unstable, do not delay transport.
Amputations
• An avulsion involving the complete loss of a
body part
© E. M. Singletary, MD. Used with permission.
Amputations
• Assessment and management
− Be aware of sharp bone protrusions.
− The body part may be completely detached or
soft tissues may remain attached.
− Degloving injury: unraveling of skin from the
hand
Amputations
• Assessment and management (cont’d)
− If a body part is completed amputated, try to
preserve it in optimal condition.
• Rinse off any debris.
• Wrap it loosely in saline-moistened sterile gauze.
• Seal it in a plastic bag; place it in a cool container.
• Never warm it or place it in water.
• Never place it directly on ice or use dry ice.
Amputations
• Assessment and management (cont’d)
− Transport as soon as possible.
− If the amputated part is a limb or part of one,
notify ED staff of:
• Type of amputation
• Estimated arrival time
Bite Wounds
© Chuck Stewart, MD
− Cat and dog
mouths are
contaminated with
virulent bacteria.
Courtesy of Moose Jaw Police Service
• Animals bites can
be serious.
Bite Wounds
• Human bites usually occur on the hand.
− Human mouths contain a wide variety of virulent
pathogens.
Bite Wounds
• Assessment and management
− Place a sterile dressing and transport promptly.
− Splint an arm or leg if it is injured.
− Determine and document:
• When the bite occurred
• Type of animal
• What led to the biting incident
Bite Wounds
• Assessment and management (cont’d)
− Rabies is a major concern with dog bites.
• Once signs appear, it is almost always fatal.
• Spread by bites or licking an open wound
• Can be prevented by a series of vaccine injections
− Do not enter until the scene is secured.
Bite Wounds
• Assessment and management (cont’d)
− Emergency treatment for human bites includes:
• Control all bleeding and apply a sterile dressing.
• Immobilize the area with splint or bandage.
• Provide transport.
Crush Syndrome
• Can develop if a body area is trapped for
longer than 4 hours and arterial blood flow
is compromised
− If muscles are crushed beyond repair, tissue
necrosis leads to rhabdomyolysis.
Crush Syndrome
• Freeing the body part from entrapment may
result in release of harmful products.
− “Smiling death” may occur.
− Other significant complications include:
• Renal failure
• Life-threatening dysrhythmias
Crush Syndrome
• Assessment and management
− Scene safety is the first consideration.
− Complete primary assessment as possible.
− Obtain IV access before removing the object.
− Infuse normal saline.
− Add sodium bicarbonate as part of the IV fluid.
Crush Syndrome
• Assessment and management (cont’d)
− If pretreatment not possible, apply a tourniquet.
• Will reduce some of the reperfusion damage
− Treat severe hyperkalemia with 25 mL of D50W,
followed by 10 units of regular IV insulin.
− Rapidly transport once the patient is freed.
Crush Syndrome
• Assessment and management (cont’d)
− Manage other injuries once en route.
• Handle open injuries with dressing and bandages.
• Splint fractures.
• Prepare to administer fluids as needed.
• Take vital signs every 5 minutes at minimum.
• Get an ECG reading to detect dysrhythmias.
Crush Syndrome
• Assessment and management (cont’d)
− When transporting, consult with medical control
about using a hyperbaric chamber.
Compartment Syndrome
• Develops when edema and swelling cause
increased pressure within a closed softtissue compartment
− Leads to compromised circulation
− Commonly develops in extremities
− Can cause tissue necrosis
Compartment Syndrome
• Assessment and management
− Presents with six Ps:
• Pain
• Paresthesia
• Paresis
• Pressure
• Passive stretch pain
• Pulselessness
Compartment Syndrome
• Assessment and management (cont’d)
− Many signs may be delayed or nonspecific.
− Can cause death of local tissues
− Risk of sepsis
− In-hospital intervention includes fasciotomy.
High-Pressure Injection
Injuries
• Occurs when a foreign material is forcefully
injected into soft tissue, causing:
− Acute and chronic inflammation
− Damage from:
• Direct insult
• Chemical inflammation
• Ischemia from compressed blood vessels
• Secondary infection
High-Pressure Injection
Injuries
• Assessment and management
− Question patient about nature of injury.
− Inspect injury for extent of visibly damaged
tissue.
− Palpate affected area for signs of edema.
− Check for crepitus at injury site.
High-Pressure Injection
Injuries
• Assessment and management (cont’d)
− Gently irrigate open wounds with normal saline.
− Dress and bandage open injuries.
− Manage pain if necessary.
− Injury may require emergent surgery.
Facial and Neck Injuries
• May involve airway or large blood vessels
− Airway compromise may arise.
• Suctioning and positioning may be necessary.
− Open injuries to the jugular or carotid vessels
can result in exsanguinations.
Facial and Neck Injuries
• Assessment and management
− Assess airway patency, protection, and oxygen.
− May require more invasive management:
• Endotracheal tube
• A Combitube
• Laryngeal mask airway
Facial and Neck Injuries
• Assessment and management (cont’d)
− Bleeding control can be started while airway
control is underway.
• If only one EMS provider is available, address
bleeding after airway is secured.
Thoracic Injuries
• May appear minor but produce deadly
internal damage
• Determine MOI during primary assessment
to detect life threats.
Thoracic Injuries
• Assessment and management
− Four steps to assessment:
• Inspection
• Palpation
• Auscultation
• Percussion
Abdominal Injuries
• Range from minor abrasions to evisceration
• Inspect abdomen and palpate area.
• During inspiration, the size of thoracic and
abdominal cavities change.
− Increases risk of drawing air into pleural space
Abdominal Injuries
• Assessment and management
− Focus on injury to underlying organs and blood
vessels.
• Could quickly lead to serious complications
Summary
• The skin fulfills crucial roles, including
maintaining homeostasis, protecting tissue,
and regulating temperature.
• The skin’s main layers are the epidermis
and dermis.
• The layer beneath the dermis is the
subcutaneous layer. Below that is the deep
fascia.
Summary
• Tension lines are patterns of tautness in the
skin. If a wound is parallel to skin tension, it
may remain closed, while a wound that runs
perpendicular may remain open.
• Soft-tissue injuries are seldom the most
serious injuries, although they may look
dramatic.
• In a closed wound, soft tissues beneath the
skin are damaged but the skin is not
broken.
Summary
• In an open wound, the skin is broken, and
the wound can become infected and result
in serious blood loss.
• In a crush injury, a body part is crushed
between two solid objects, causing damage
to soft tissues and bone.
• Cessation of bleeding is the first stage of
wound healing.
• Inflammation is the second stage of healing.
Summary
• Factors that affect wound healing include
the amount of movement the part is
subjected to, medications, and medical
conditions.
• Infection signs include redness, pus,
warmth, edema, and local discomfort.
• Observe scene safety first. Then assess the
ABCs.
Summary
• During the history intake, ask about the
event causing the injury. Ask about the
patient’s last tetanus booster, and if they
are taking mediations that may affect
hemostasis.
• Complete the physical exam either en route
or at the scene, depending on mechanism
of injury.
• Document scene findings.
Summary
• Be empathetic.
• Controlling bleeding is a part of soft-tissue
injury management. Follow the ICES
mnemonic for closed injuries.
• When managing open wounds, control
bleeding and keep wound clean by irrigating
and sterile dressings.
• Dressings and bandages cover wounds,
control bleeding, and limit motion.
Summary
• Medical tape may secure a bandage in
place. Dressings should not be applied too
tightly.
• Bleeding control methods include direct
pressure, elevation, immobilization, and
tourniquets.
• Dressing and bandaging techniques vary
for different areas of the body.
Summary
• Avulsion management includes irrigation;
gently folding the flap back onto the wound;
and applying a dry, sterile compression
dressing.
• Do not remove impaled objects.
• Animal and human bites can cause serious
infection. Dogs and cats can carry rabies.
• Crush syndrome may develop after a body
part has been trapped more than 4 hours.
Summary
• Patients trapped for prolonged periods of
time must be managed before being freed
to improve survival chances.
• Compartment syndrome results from
pressure increase in a closed soft-tissue
compartment. Presentation includes some
or all of the six Ps.
• Blasts can result in soft-tissue injuries. Use
the DCAP-BTLS guideline for assessment.
Summary
• High-pressure injection injuries involve
foreign material injection into soft tissue.
• Special attention should be paid to softtissue injuries of the face, neck, thorax, and
abdomen because they contain vital
structures.
Credits
• Chapter opener: © Mark C. Ide
• Backgrounds: Orange—© Keith Brofsky/Photodisc/
Getty Images; Blue—Jones & Bartlett Learning.
Courtesy of MIEMSS; Purple—Jones & Bartlett
Learning. Courtesy of MIEMSS; Green—Courtesy of
Rhonda Beck.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have been
provided by the American Academy of Orthopaedic
Surgeons.