5-2 Soft Tissue Injuries

Signs and symptoms

• Closed injuries: skin intact.
  • Contusions: bruise.
  • Ecchymosis: black and blue discoloration.
  • Hematomas: similar to a contusion, but on a larger scale. The collected blood forms a lump with bluish discoloration.
  • Crush injuries: severe blunt trauma that may cause either closed or open injury.
• Open injuries: skin open.
  • Abrasions: scraping of the skin.
  • Lacerations: cuts.
  • Avulsions: loose flap of skin.
  • Amputations.
  • Penetrations / Punctures: sharp object driven into the body.
  • Crush injuries: severe blunt trauma.
• Burn injuries
  • First degree: superficial. Red skin, pain, tenderness.
  • Second degree: partial. Blisters, red or white skin that is moist and mottled. Intense pain.
  • Third degree: full thickness. Leathery appearance, charring, dark brown or white skin that is hard to the touch. No pain because nerves are destroyed. Intense pain at the periphery where second degree burn occurs.
  • Burns to the face, neck and inside the mouth can cause airway compromise.
    • Singed nasal hairs.
    • Soot in sputum.
    • Breath smells smoky.
    • Burns to the oral mucosa.
    • Respiratory distress.
    • Hypoxia signs.
  • Circumferential burns - those that completely encircle a part of the body. This can cut off circulation as it swells.

Treatment

• Closed wounds indicate internal bleeding, so monitor and treat patient for shock.
• Expose the wound completely by cutting away or taking off clothing.
• Control any bleeding (direct pressure, elevation, pressure point). Once bleeding stops bandage the wound.
• If blood soaks through bandage or dressing, remove them and apply direct, finger tip pressure.
• Never pick out any embedded material in the wound, however small.
• Brush away loose particles on the wound with sterile gauze.
• Dress and bandage wounds.
• Open chest injuries need to be dressed with an occlusive dressing and sealed on three sides.
• Open neck injuries need to be dressed with an occlusive dressing and sealed on all sides
• Eviscerations need to be covered with a moist, sterile dressing or gauze, and then cover that with an occlusive dressing sealed on all sides. Maintain temperature by insulating the wound with layers of thicker dressing. If there is no spinal injury, position the patient in a supine position with knees bent, which helps to relax abdominal muscles.
• For impaled objects, leave them in place and immobilize them. Do so by using a bulky dressing that pack around the object in a doughnut shape.
• Wrap amputated parts in dry (or moist, depending on medical direction), sterile gauze dressing. Put in a plastic bag. Keep the amputated part cool by placing over ice or in a cooler, but do not freeze it. Take the amputated part with the patient.
• Standard care for airway, breathing and circulation.
• Splint suspected fractures.
• Suspect internal bleeding for crush injuries with significant MOI.
• Treat for shock if patient exhibits hypoperfusion.
• Treating burns.
  • Remove the patient from heat source.
  • Stop the burning process by pouring water or saline solution on burn.
    • For chemical burns, brush away the chemical before pouring water. Use emergency showers and eye washes where appropriate.
    • Remove any clothes that do not adhere to the burn site.
    • Cover burn area with dry, sterile dressing or burn sheet.
  • Keep the patient warm to prevent hypothermia (their skin insulation is compromised).
  • Keep the burn area clean and intact. Never contaminate burn areas with materials that leave particles and never pop any blisters.
  • Remove any restrictive clothing or jewelry that can cut off circulation if burn site swells.
  • Place dry sterile gauze or dressing between the digits of burnt toes and fingers.

Trauma and mechanisms

• Skin
  • Epidermis: outermost, watertight barrier.
  • Dermis: next layer, contains small capillary beds and nerve endings.
  • Hypodermis: innermost layer, contains fatty connective tissue and larger blood vessels.
• First degree burn: burns the epidermis.
• Second degree burn: burns reach the dermis. Very painful because this is where the nerve endings are.
• Third degree burn: burns all layers to the hypodermis. No pain because all nerve endings in the dermis are destroyed.
• Critical burns
  • Those that compromise the airway.
  • Those that can cause a loss of function such as the hands, feet, genitalia and major joints.
  • 3rd degree that covers >10% of the body.
  • 2nd degree that covers >25% of the body (>20% in children and elderly).
  • Chemical or electrical burns.
  • Circumferential burns.
  • Burns coupled to deformity.
  • Burns in children and the elderly.
• Rule of nines: estimates body surface area.
  • 9% Head and neck, each arm.
  • 18% anterior trunk (chest), posterior trunk (back), each leg.
  • 1% Genitalia.
• Rule of nines for children: they have bigger heads.
  • 18% Head, anterior trunk, posterior trunk.
  • 9% each arm.
  • 14% each leg.

Terms

• Road rash: head-to-toe abrasions from patients sliding along the pavement during a car crash.
• Scald: burns caused by contact with hot liquid.
• Flash burn: a type of flame burn but results from exposure to rapid ignition of flammable gas or liquid.