chapter 30 soft tissue injuries let's talk about what is soft tissue to start off with it is everything on the outside of the body um it is the skin the fatty tissues the muscles of blood vessels connective tissue all the membranes that hold everything together our glands our nerves pretty much everything but the bones and the liquid in the body so major function of the skin is it serves our protection keeps the bad stuff out it also helps regulate water balance by retaining fluids or releasing fluids through sweat it controls our temperature by releasing fluids and causing evaporation it controls how much fluid by excretion and then it is shock absorbing it keeps the injuries from how being even worse they could be because of the layers of the skin and the uh the fatty tissue underneath so we've got the layers major layers of the skin the epidermis it's the outside layer it's the mostly dyeing or dead skin cells that flake up flake off as we go the dermis is where all the action happens in the skin it's where our nerve endings are the hair follicles our blood vessels our capillaries it's our sweat glands everything kind of lives in the dermis in the subcutaneous that's where our veins and nerves are the arteries uh it's a fatty tissue that kind of goes around it so that's where or kind of help us understand how deep the wound is and what could be impacted by the soft tissue injury we use the basic classifications for wounds as open or closed open is there's a break in the skin closed as there's not so let's talk about the closed wounds there's no pathway to the outside so everything underneath it can be damaged but you don't have leakage of fluids or blood to the outside these could be minor from just a simple bruise all the way up to major life-threatening injuries of severe bleeding internally that cannot be stopped by anything we have in ems simple uh soft tissue injury that is closed is a bruise i'm sure everybody's had a bruise at one time hematoma is very similar to contusion but has more tissue damage and larger blood vessels it's where you actually get some swelling because you've got blood leaking in the interstitial tissue closed crush injury the force is transmitted to the internal organs so you have a impact to the outside it causes crushing or damage the inside that's where we went over the difference between solid and hollow organs in the abdominal cavity the solar organs will bleed and cause shock the hollow organs leak into the body cavities and cause sepsis which eventually causes shock this is kind of an overview of what they look like you get your contusion or a bra uh with the swelling got ruptured hollow organs leaking into the internal cavities where you've got a laceration of the blood vessels on a broken bone crush injuries causing more tissue damage or a solid organ that's damaged bleeding into the abdominal cavity when we see bruising on the exterior of a patient that means there is a higher potential for interior bleeding and bruising so we need to be very cautious with these patients consider the mechanisms of injury do they have enough force to cause injury to the interior sometimes our crush injuries are harder to work with because you can't see what happened inside if you get bleeding inside of the body you can put pressure on other body parts by filling up voids that do not have the capability to expand within the muscles there's different fascia that keeps the muscles keep the blood from escaping when it starts to swell and that causes more problems for us as with any bleeding or potential bleeding injury you need to have your standard precautions always do your abc's that's our high priority there get that taken care of be aware of potential for shock a fractured femur from the tissue damage inside can actually cause enough bleeding to put the patient into shock so one fractured femur complete up to a leader into the interior of the thigh so there's there's high potential for shock for internal bleeding if there's a break potential break or pain to an extremely splinted if it hurts when they move it tell them don't move it and put a splint on it pain is an excellent splinter but we can use uh any other devices and we'll get into that on musculoskeletal injuries but keep the divide keep the body part from moving which could cause more uh tissue damage look for vomiting because of the chain the possibility of bleeding into the digestive system or the activation of the fight or flight because of the injury and causing more uh nausea and vomiting always be aware of changes monitoring at least every five minutes sometimes an ice pack will help reduce the pain and swelling if you've ever had a twisted ankle or a bruise you put ice on it it feels better because reduce the pain the the nerve endings are numbed and you release reduce the swelling which is causing pain so let's talk about the open wounds things that get into the body and causes a breach in the skin so we have different types we have the abrasions lacerations penetrating trauma punctures avulsions and amputations other types of uh open wounds crush open crush injuries bite wounds from animals or people blast injuries or high pressure injection injuries a friend of mine was cleaning a paint gun with paint thinner and activated the trigger and actually ejected himself with paint thinner that was a pretty serious injury from uh some type of uh high pressure process always use your standard precautions make sure you have gloves maybe a gown protective eyewear face shields a lot of your ems jackets that you get issued have a blood barrier in there so you can wear that as your protection but somehow keep the blood off of you and keep your skin in good condition if you've got cuts on your skin nicks any anything that could cause an opening you can get blood into there and cause you an exposure so anytime you try not to shave right before you come to class or come to go to work and then you don't get blood on the knicks that caused by shavings always do your primary assessment mental status airway breathing circulation and as part of circulation you're looking for severe bleeding if you find severe bleeding take care of it right away stop the bleed you want to expose the wound clean the wound get the dirt off of get the glass out of it whatever you need to do control the bleeding with one of a few steps we're going to talk about if you have serious bleeding give them treatment for shock blanket high flow oxygen and then try to keep everything clean so we don't recontaminate stuff band use the dressing in place after the bleeding's controlled or to try to even even try to control it there keep the patient calm and lean still make sure they know you're taking care of them and you're trying your best to take stop the bleeding and keep their pulse rate down if you can because the harder the heart beats the faster things bleed so let's talk about some specific types of open wounds abrasions and lacerations big thing here is a try to keep the wound clean and dry so we don't cause any more infections direct pressure just take your gloved hand a piece of gauze and put pressure right on it as you hold pressure check pulse motor function sensation distal document what you find if you have penetrating trauma try to find out what it was that caused the injury itself was it a a pocket knife or was it a a butcher knife was it an ice pick if it was something long enough to go through the body is there an exit wound if it was a projectile was is there an exit wound sometimes with projectiles that go through the body they hit bone they will break apart when they hit the bone and cause a cone shape injury after the impact it will also break the bone so it's a lot of a lot of guesswork a lot of using your knowledge and just kind of predicting what may be going on inside the patient reassure the patient you're going to take care of everything always look for more than one wound if something went in that's a chance it came out just because it doesn't come out that doesn't mean they're okay because now they've got more injuries as it bounced around through the body get your bls in place get into the hospital as quick as possible use your local protocols on spinal motion restriction here in el paso county if the patient has penetrating trauma and no neural deficit we do not do spinal motion restriction we do not we figure that if it had if they had damage to the spinal cord it would be evident if it's not then we just protect them as needed now if the injury is close to the spine you're going to use your little common sense and probably be of some protection against it but make some good decisions there based on your local protocols and then transport to the appropriate facility here's an illustration of what happens when you go in entrance room in the back it hits a rib once it goes inside bounces down and comes out the front through the liver so now you have multiple organs damaged through the process looks like you got a lung and a liver on this one so that's a that's the double whammy on this guy here's a gunshot wound to the the lower abdomen lower upper abdomen lower chest treating impaled objects something goes into the body but it stays there do not pull it out it is plugging a hole you want to leave it in so we don't cause more problems if it is too big to transport with the object still in your local firefighters will help you reduce the size of it really easily they have cutters they have torches they have all kinds of stuff expose the area around it control the bleeding with direct pressure do not push the object in but try to stabilize it from all the different sizes sides with bulky dressings keep it in one place so it doesn't move put dressings on all the way around if it's coming through the body completely stabilize both sides and try to transport the patient in a position that is safe for them secure everything treat for shock transport to the appropriate facility there are times that we have asked a surgeon to come to the scene to help remove the object or help stabilize the object that is something you'll have to work with your local protocols and see if that's an option for you there's a picture of his stabilizing the object gauze pads on both sides to keep it from moving around and bouncing we want it to stay in the body so we don't have a bigger hole coming out and then wrap it up so that everything stays in place if it's in the oral cavity and it's causing airway obstruction airway comes first so we're going to remove it if it is stuck where it's not coming out you leave it there you treat the bleeding as you can but we want to protect the airway so this is one of those judgment calls you're going to have to make examine the wound both in and out can you pull it out without causing more damage if not leave it in place it's plugging up a hole as long as it's not blocking the airway but if it's blocking the airway now you've got to make some decisions for your patient's life here's an example of the pencil in the cheek if you pull it out now you're going to have more bleeding how far up into the jaw or into the mouth is it we're going to have to pay attention and try to try to figure out what's going on here position the patient so you allow for drainage we don't want to block the airway so we're going to try to keep them stable monitor the airway dress the wound from the outside give them oxygen if you need to and get them to the appropriate care facility anything stable as impaled in the eye we want to stabilize it where it is a cup is a great device to put on there or make a little donut out of your gauze all kinds of options there but what you want to do is keep it from moving the other thing you need to pay attention to is but bandaging both eyes we are not lizards if you move one eye the other eye moves so we want to keep both eyes from moving so we're going to stabilize the object and cover both eyes so they're not looking around as we go here's a night picture of him stabilizing the object in the eye put a bandage over the second eye so now they keep everything straight we put the cup over make sure the object is not longer than the cup before you start pushing the cup on it or if you have to poke a hole in the end of the cup so that you can let the object hang out the end also do not use the object that's stuck in the eye to poke the hole that's bad form and these young and dry give locks lots of oxygen and transport and reassuring them that they're not going to be hopefully not blind avulsions are ripping of the skin away from the body uh it's it's scalping is an avulsion give you a good example the skin what we want to do is clean the wound fold the skin back into its place and control with bulky dressings if it's torn away or an amputation we keep it in sterile dressing and keep it moist if we are trying to keep an organ such as the skin salvageable we want to keep it moist if we're trying to stop bleeding we use dry dressing because we want to suck the plasma out and help the platelets clot so saving tissue is moist stopping bleeding is dry control the hemorrhage if you have to use a tourniquet make sure you're saving the patient over the the body part amputations we want to put that on ice but not directly on ice wrap it in a moist gauze and then stick it in a bag of ice so that it stays nice and cold they have a really good history of reattaching body parts uh there was a kid out of michigan that lost both arms in a farming accident several years ago that they reattached both arms so bring the the body parts to you to the hospital with you make sure you label them so we don't get them mixed up with the right the wrong patients put it in the sterile dressing put it in a uh a plastic bag keep it cold stop at a local 7-eleven get a bag of ice if you need to but we don't want to fry get a frost bit so keep a little gauze around it so it doesn't get too cold genital injuries we need to make sure we are controlling the bleeding no matter what preserve the evolved parts they can reattach anything that's been did this uh dismembered so bring uh everything to the hospital with you use professionalism uh be aware that it may be an assault this is not one of those that it happens randomly unless they're driving down the road and someone has a seizure but it could be more of a uh assault like a lorena bobbitt all right let's let's talk about burns burns involve more than just the skin so we could be surface of the skin which is sunburned down into the dermis subcutaneous and down into the muscle things that cause more damage for burns or if it involves a respiratory structure as the skin gets damaged it starts to swell the swelling causes difficulty breathing uh the other thing to be aware of on burns is they are nasty looking don't let them uh distract you from the other injuries the patient may have maybe they were in a car crash and got burned so look for all the other distract the other injuries that may be there on top of the burn we're trying to find out what burn is what we're looking at what caused it looking at the agent was it water was it steam was it electricity was it chemical how deep is it does it go through the surface of the skin does it go down into the epidermis or does it go all the way through the subcutaneous down in the muscle and then we're looking severity how much of the body is burned so agent we're talking about chemicals electricity hot water steam what is the source try to get as much information as you can about that bystanders patient information just what you observe on the scene and there's these guys that really like to define flames and fire on almost every scene you go to ask the firefighters what the source of the injury is they will usually know what kind of fire it was that caused the injury we have the superficial everybody's had a sunburn at one time that is a superficial injury that's just reddening of the skin when it starts to blister that's partial thickness that's when it's getting down into the dermis causing some fluids to leak into the tissues and then when we have full third thickness it goes through the dermis into the fatty muscle tissue below it's black and cherry like you've had it on it's it's it's well done it's it's not good for your patient the good thing for the patient is that the center area that has the full thickness it's probably burned through the nerve ending so it won't be painful the painful part will be all the second partial thickness wounds on the sides of that full thickness that's where the nerve endings are still intact and they'll be feeling pain so superficial used to be called first degree it's only the dermis uh partial thickness is epidermis is burned through you've got dermal dermis damage very intense pain reddening blisters modeling looks pretty bad there's a superficial burn on the redneck here this is your partial thickness you notice the blistering around the belly there's another blistering type of wound on the shoulder full thickness goes through all the skin it's black charry looking black and white patches uh it's not it's it's tissue pretty much debris destroyed all the tissue over the muscle this is a full thickness burn you notice the black patches there the skins falling off in certain areas things you want to kind of consider is the source we talked about that the body region burned face very high priority patient hands and feet because of the nerve endings the dexterity needed to survive hands and feet are very very high value body regions and genitalia because of nerve endings so anything to those is the high priority depth of the burn was a partial thickness or full thickness extent of the burn how much of the body part the age of the patient under five and over 55 do not have the reaction of the normal reactions to burning in the healing process or maybe to have the comorbid injuries or illnesses the same thing we've been learning about covin if you've got diabetes copd these things that make coven worse they make injuries an illness is worse too so now if you get a burn and the patient's a diabetic they increase their risk factor of long-term complications to estimate the severity of the burn we're going to go with the rule of nines it's kind of helping us establish how much of the body is burned based on percentage of body surface area we divide the body into nine main areas each one is nine percent of the body so in your textbooks you will have pictures of this or you can google it there's all kinds of sources for the rule of nine but think of the head is nine percent the right arm is nine percent the left arm is nine percent the upper chest in the front anterior is nine percent the belly is nine percent in the back you've got the upper back is nine percent lower nine lower back is nine percent the front of each leg is nine percent the back of each leg is nine percent and then to make out the 100 percent we have one percent for genitalia so know the rule of nines that helps you identify what body parts are what so you see on the diagram here we've got the rule of nine on the adult but then when we get to the kids because the kiddos heads are twice as big percentage-wise we give them eighteen percent to make up for that we take the legs down to fourteen percent total or seven percent on each side so what you will have to do is say the patient is burned from the waist down so you would have 18 on each leg so that's 36 and then one for genitalia said be 37 percent of the body is burned if you have the front half of the left arm burned you'd have four and a half percent so practice with that think of the different scenarios and add up the numbers in your head we also have a way to get down a little bit smaller by using the palmer method the palm of the hand is about one percent of the body surface area so you take the patient's hand use that as a comparison and you can estimate down to those one percent uh body surface area once you determine the the priority of the patient you want to figure out where they need to go we need to get that information to our local emergency department there may be a chance that if you need to move them to a burn center they'll ask you to transport them directly to a burn center and bypass the trauma center so you're going to have to work with your local protocols to figure out your best options here kids they don't have the body surface or the muscle mass or the fluids to help maintain uh their response to large burn surface areas so they get treated a little bit higher category so what we consider a moderate burn on a child would be considered a serious burn specific types of burns for thermal burns stop the burning process cool the area water great resource there cool them off making sure the airways open as we do this and k maintaining that our way if they have any burns around the face or mouth they become a high priority and take them to the trauma center or the bird center as quick as possible complete your primary assessment maybe that's all you get on some of these and treat for shock you're going to cool them off but you still want to cool them off too much so you're going to have a balancing act here as you go trying to figure out the the depth extent and severity if they have things burned to their skin do not peel that off if you can get rid of clothing and jewelry but you don't need to peel that off if it's stuck wrap everything in a sterile dressing if they have burns on their hands or toes take some gauze and put between each digit so that you can kind of separate those and keep them keep them more secure for the transport to the hospital chemical burns copious amounts of flowing water if it's dry brush it off first with a gloved hand and then flush with copious amounts of water you'll probably be on scene more than 20 minutes on these burns because you need to flush them before you transport get rid of the contaminants before you put them in the ambulance once you've got them uh did uh deconned washed off good get a nice sterile dressing treat for shock and transport radiation burns they get exposed to some type of radiation it could be x-ray machines there are some uh industrial machines their x-ray machines are even more prevalent outside of medical facilities now they use them in manufacturing processes so know where they are know your resources and treat the patient just like a regular burn but you want to make sure the hospital knows they were exposed to radiation on top of it if you don't have the training or equipment to respond to a radiological event do not go in uh they can continue to burn after they've been decontaminated uh see treat them just like any thermal injury all right electrical injuries biggest concern with electrical energy is the danger to yourself if the patient is still connected to the electrical source they will transfer that electricity to you as the electricity seeks a path to ground as the electricity travels through the body it damages the tissue that it comes in contact with it likes to find the path of least resistance which is your the fluid in your body and your nerves it will travel to ground so it'll come enter your body whatever contact of the electrical source and then go out whatever body parts touching the ground so likely your feet could be a hand or a knee it will exit the body so you have interest in exit wounds because your heart runs on electrical cond conductivity it can cause respiratory and cardiac arrest because it causes muscle contractions that are very extreme you could affect your bones so people who have electrical injuries can have a large potential of a wide variety of injuries and illnesses going on with patient care airway breathing circulation be ready to defibrillate treat shock and give lots of oxygen be aware of spinal injuries and head injuries because of the intense electrical contact going through look at the burn sites make sure that you're cooling off those burn sites to stop the any more any additional burns nice sterile dressing and transport to the appropriate facility all right bandaging and dressing when we come across these wounds we need to take care of a dressing is any material applied to a wound to control the bleeding and prevent contamination cause non-stick cause quick clot cause lots of options there for dressings a bandage is anything you put on top of it to hold it in place kerlex is what we knew use or conforming gauze coban which is the elastic tape we can use an ace bandage we could we have commercialized dressings and bandages mixed together the trauma dressings it's got lots of options for this no one is going to be there to judge the the how pretty your dressings look they're looking did it stop the bleeding can protect contamination so you put the dressing over the wound nice contact if it bleeds through put more over do not lift the object the dressing off the dressing is where the cloths are starting to form so we want to leave it in place the dryness of your dressing is what's sucking the plasma out and allowing the clotting to function normally so at universal dressings they're just big and bulky uh call them trauma dressings uh abd dressings for abdominal you have pressure dressings these are ones that apply extra pressure as you tighten them on the patient the the most popular one is called the israeli bandage it's got some extra little hooks on it so as you put it on you hook it and pull tight and it gives you a real good steady pressure on the wound we also have occlusive dressings it is typically a piece of gauze that's been soaked in vaseline you take it's in a nice foil pouch so it stays moist you open it up you throw the gauze away and take the foil pouch and use that for your occlusive dressing you put it over abdominal wounds to keep the heat in because the abom abdominal cavity gives off so much heat the organs will lose heat quick any large open neck vein you put the occlusive uh dressing over it so that you can keep the air from going in that vein as it sucks the blood back into the body and we have open chest wounds there if you have a chest an injury in the chest you're going to allow the air to come in through the chest cavity into the thorax versus through the normal airway process so we're going to want to put the open the occlusive dressing over the open wound here's the bandage holding it in place that's a god's bandage just wrap it you want to make sure you're checking the pms before and after or cms sensation circulation sensation motor function always use your precautions expose the wound that's what your scissors are for get down to where the wound is direct pressure or hemostatic agents dress to stop the bleeding do not remove the dressing once you put it on it stays in place don't get it too tight or too loose you want it to stop the bleeding but not cut off circulation do not cover the fingertips and toes so that you can check that for profusion and then tape down all the edges so no one trips on them that's not you don't want to trip over the edge of your bandage and hurt your patient more here's that self-adhering roller bandage going over multiple times get it until it's step uh snug you can see the the fingers are still pink so it's not too tight but we're trying to stop the bleeding and always if you have any questions write them down bring them to class ask the instructor have a discussion and hit the like and subscribe to here for more of these as we go through the class thanks and have a great night