Chapter 27. Soft Tissue Injuries. Introduction. As an emergency medical technician, you'll be regularly called to care for victims with soft tissue injuries. These injuries can be as simple as a cut or scrape or as serious as a life-threatening internal injury. It is important to not allow yourself to become distracted by dramatic wounds and make the critical mistake of neglecting more life-threatening conditions such as airway obstructions.
It is your responsibility as an emergency medical technician to assess and treat each of these injuries within the current standard of care guidelines. The soft tissues of the body can be injured through a variety of mechanisms. A blunt injury occurs when the energy exchange between the patient and an object is more than the tissues can tolerate. This is discussed in greater detail in Chapter 25, Trauma Overview.
Whereas a blunt injury does not penetrate the skin, A penetrating injury occurs when an object, such as a bullet or knife, breaks through the skin, and enters the body. Barotrauma, commonly seen in blast injury victims, refers to injuries that result from sudden or extreme changes in air pressure. Burns may also result in soft tissue injuries.
Soft tissue trauma is a common form of injury. In fact, wound care is one of the most frequently performed procedures in emergency departments across the United States. Most of these injuries require basic interventions such as wound irrigation, dressing, bandaging, and limited suturing.
Death resulting from soft tissue injury is often related to hemorrhage or infection. Uncontrolled hemorrhage can quickly lead to shock and death. When the skin barrier is breached, invading pathogens, bacteria, fungi, and viruses can cause local or systemic infection.
Infection can be life- or limb-threatening. especially in children, older adults, and people with diabetes or other conditions that may compromise the immune system. Soft tissue injuries, and their associated complications can often be prevented by using simple protective actions.
For example, wearing gloves when working with abrasive materials helps prevent skin injuries. To reduce injuries in the workplace, Safety measures have been implemented that include the use of safety devices to prevent interaction between machine parts and body parts. Using plastic scissors, plastic knives, and plastic drinking cups at home will reduce the risk of cuts and other skin injuries among children.
Effective strategies that have reduced injury and death from burns include using smoke alarms, controlling the temperature of hot water heaters, and enforcing building codes that regulate electrical and construction practices. This chapter discusses the various types of soft tissue injuries, and the appropriate assessment and treatment of this classification of injuries. Anatomy and Physiology of the Skin The skin is our first line of defense against external forces and infection. It is also the largest organ in the body.
Although it is relatively tough, skin is still quite susceptible to injury. Injuries to Soft Tissue Injuries Soft tissues range from simple bruises and abrasions to serious lacerations and amputations. Soft tissue injury may result in exposure of deep structures such as blood vessels, nerves, and bones. In all instances, you must control bleeding, prevent further contamination to decrease the risk of infection, and protect the wound from further damage. Therefore, you must know how to apply dressings and bandages to various parts of the body.
varies in thickness. depending on the person's age and the area the skin covers. The skin of the very young and the very old is thinner than the skin of a young adult.
The skin covering the scalp, the back, and the soles of the feet is quite thick, whereas the skin of the eyelids, lips, and ears is very thin. Thin skin is more easily damaged than thick skin. Anatomy The skin has two principal layers, the epidermis and the dermis.
The epidermis is the tough. external layer that forms a watertight covering for the body. The epidermis contains several layers. The cells on the surface layer of the epidermis are constantly worn away.
They are replaced by cells that are pushed to the surface when new cells form in the germinal layer at the base of the epidermis. Deeper cells in the germinal layer contain pigment granules. Along with blood vessels in the dermis, these granules produce skin color. The dermis is the inner layer of the skin. It lies below the germinal cells of the epidermis.
The dermis contains the structures that give the skin its characteristic appearance, hair follicles, sweat glands, and sebaceous glands. The sweat glands' primary function is to cool the body. They discharge sweat onto the surface of the skin through small pores, or ducts, that pass through the epidermis. Sebaceous glands produce sebum, the oily material that waterproofs the skin, and keeps it supple. Sebum travels to the skin's surface along the shaft of adjacent hair follicles.
Hair follicles are small organs that produce hair. There is one follicle for each hair, each connected with a sebaceous gland, and a tiny muscle. This muscle pulls the hair erect whenever a person is cold or frightened. Blood vessels in the dermis provide the skin with nutrients and oxygen.
Small branches reach up to the germinal cells, but blood vessels do not penetrate farther into the epidermis. The dermis also contains specialized nerve endings. The skin covers all external surfaces of the body.
The various openings in the body, including the mouth, nose, anus, and vagina, are not covered by skin. Instead, these openings are lined with mucous membranes, similar to skin. These membranes provide a protective barrier against bacterial invasion, but mucus membranes differ from skin in that they secrete a watery substance that lubricates the openings. Therefore, mucus membranes are moist, whereas skin is generally dry. Physiology The skin serves many functions.
It protects the body by keeping pathogens out and fluids in, and it helps regulate body temperature. The nerves in the skin report to the brain on the environment. and on many sensations.
It is this nerve pathway connection that allows the body to adapt to environments through responses in the skin, and surrounding tissues. The skin is the body's major organ for regulating temperature. In a cold environment, the blood vessels in the skin constrict, diverting blood away from the skin, and decreasing the amount of heat that radiates from the body's surface.
In hot environments, the vessels in the skin dilate. The skin becomes flushed or red. and heat radiates from the body's surface. In addition, sweat glands secrete sweat to help cool the body.
As the sweat evaporates from the skin's surface, the body temperature drops, and the person begins to cool down. Any break in the skin allows bacteria to enter and increases the possibilities of infection, fluid loss, and loss of temperature control. Any one of these conditions can cause serious illness, and even death.
Soft tissues are often injured because they are exposed to the environment. There are three types of soft tissue injuries. Closed injuries, in which soft tissue damage occurs beneath the skin or mucous membrane but the surface of the skin or mucous membrane remains intact. Open injuries, in which there is a break in the surface of the skin or the mucous membrane, exposing deeper tissues to potential contamination.
Burns, in which the soft tissue damage occurs as a result of thermal heat. frictional heat, toxic chemicals, electricity, or nuclear radiation. Pathophysiology of closed and open injuries. Wounds heal in a natural process that involves several overlapping stages, all directed toward the larger goal of maintaining homeostasis or balance. Ultimately, the goal is for the body to return to a functional state, although the injured area may not always be restored to its pre-injury state.
Among the primary concerns in wound healing is the cessation of bleeding. Loss of blood, internal or external, hinders the provision of vital nutrients and oxygen to the affected area. It also impairs the tissue's ability to eliminate wastes.
The result is abnormal or absent function, which interferes with homeostasis. To stop the flow of blood, the vessels, platelets, and clotting cascade must work in unison. During inflammation, the next stage of wound healing. Additional cells move into the damaged area to begin repair. White blood cells migrate to the area to combat pathogens that have invaded exposed tissue.
Foreign products and bacteria are also removed from the body. Similarly, lymphocytes, a type of white blood cell, destroy bacteria and other pathogens. Mast cells release histamine as part of the body's response in the early stages of inflammation.
Histamine dilates blood vessels. increasing blood flow to the injured area, and resulting in a red and warm area immediately around the site. Histamine makes capillaries more permeable, and swelling may occur as fluid seeps out of these leaky capillaries. Inflammation ultimately leads to the removal of foreign material, damaged cellular parts, and invading microorganisms from the wound site. In the outer layer of skin, cells are stacked in layers, to replace the area damaged in a soft tissue injury.
A new layer of cells must be moved into this region. This is the next stage of wound healing. Cells quickly multiply and redevelop across the edges of the wound. except in cases of clean incisions the appearance of the restructured area seldom returns to the pre-injury state for example large wounds or injuries that result in significant disruption of the skin will often not complete this process people with lightly pigmented skin may see a pink line of scar tissue signaling the presence of collagen a structural protein that has reinforced the damaged tissue despite the changed appearance the function of the area may be restored to near normal. Tissue injuries may be difficult to detect in dark skin.
During the next stage of wound healing, new blood vessels form as the body attempts to bring oxygen and nutrients to the injured tissue. New capillaries bud from intact capillaries that lie adjacent to the damaged skin. These vessels provide a channel for oxygen and nutrients and serve as a pathway for waste removal.
Because they are new and delicate, bleeding might result from a very minor injury. It may take weeks to months for the new capillaries to be as stable as pre-existing vessels. Collagen is a tough, fibrous protein found in scar tissue, hair, bones, and other connective tissues. In the last stage of wound healing, collagen provides stability to the damaged tissue, and joins wound borders, thereby closing the open tissue. Unfortunately, collagen cannot restore damaged tissue to its original strength.
Closed Injuries Closed soft tissue injuries are characterized by a history of blunt trauma, pain at the site of injury, swelling beneath the skin, and discoloration. Such injuries can vary from mild to quite severe. A contusion, or bruise, is an injury that causes bleeding beneath the skin but does not break the skin.
Contusions result from blunt forces striking the body. The epidermis remains intact, but cells within the dermis are damaged. and small blood vessels are usually torn. The depth of the injury varies, depending on the amount of energy absorbed. As fluid and blood leak into the damaged area, the patient may have swelling and pain.
The buildup of blood produces a characteristic blue or black discoloration called ecchymosis. A hematoma is blood that has collected within damaged tissue or in a body cavity. A hematoma occurs whenever a blood vessel is damaged and bleeds into the surrounding tissues. It is often associated with extensive tissue damage. A hematoma can result from a soft tissue injury, a fracture, or any injury to a blood vessel.
In severe cases, the hematoma may contain more than one liter of blood. A crushing injury occurs when significant force is applied to the body. The extent of the damage depends on how much force is applied. and how long it is applied.
In addition to causing direct soft tissue damage, continued compression of the soft tissues cuts off circulation, producing further tissue destruction. For example, if a patient's legs are trapped under a collapsed pile of rocks, damage to the leg tissues will continue until the rocks are removed. When an area of the body is trapped for longer than four hours, and arterial blood flow is compromised, crush syndrome can develop. When a patient's tissues are crushed beyond repair, muscle cells die and release harmful substances into the surrounding tissues. The oppressing force prevents blood from returning to the injured body part, so these harmful substances are released into the body's circulation only after the limb is freed, and blood flow is returned.
For this reason, when possible, if a patient has been trapped with the crushing object for a prolonged period of time, Advanced Life Support providers should administer intravenous fluid before the crushing object is lifted off the body, freeing the limb or other body part from entrapment results in the release of the byproduct of metabolism, and harmful product of tissue destruction, and as a result it can create the potential for cardiac arrest, and renal failure. Consider requesting advanced life support assistance for situations of prolonged entrapment prior to extrication. Compartment syndrome develops when edema and swelling result in increased pressure within a closed soft tissue compartment.
Because tissues are limited in the amount they can stretch or expand, pressure increases within the compartment, which interferes with circulation. Compartment syndrome commonly develops in the extremities, and may occur in conjunction with open or closed injuries or when swelling occurs under restrictive immobilization devices such as a cast. As pressure develops, Delivery of nutrients and oxygen is impaired and byproduct of normal metabolism accumulate.
This causes pain that worsens with passive movement of the tissues within the compartment. Signs of impaired circulation may also be present. The longer the situation persists, the greater the chance for tissue death. Continually reassess skin color, temperature, and pulses distal to the injury site during transport if compartment syndrome is suspected. Severe closed injuries can also damage internal organs.
The greater the amount of energy absorbed from the blend force, the greater the risk of injury to deeper structures. Therefore, you must assess all patients with closed injuries for more serious hidden injuries. Remain alert for signs of shock or internal bleeding.
and begin treatment of these conditions if necessary. Open injuries. Open injuries differ from closed injuries in that the protective layer of skin is damaged.
This can produce extensive bleeding. A break in the protective skin layer or mucous membrane also means that the wound is contaminated and may become infected. Contamination is the presence of infectious organisms, pathogens, or foreign bodies, such as dirt, gravel, or metal, in the wound.
You must address excessive bleeding and contamination in your treatment of open soft tissue wounds. There are four types of open soft tissue wounds that you must be prepared to manage. Abrasions, lacerations, ovulsions, penetrating wounds.
An abrasion is a wound of the superficial layer of the skin, caused by friction when a body part rubs or scrapes across a rough or hard surface. An abrasion usually does not penetrate completely through the dermis, but blood that may ooze from the injured capillaries in the dermis. Also known as road rash, road burn, strawberry, and rug burn, abrasions can be extremely painful because the nerve endings are located in this area. A laceration is a jagged cut in the skin caused by a sharp object or a blunt force that tears the tissue, whereas an incision is a sharp, smooth cut.
The depth of the injury can vary, extending through the skin and subcutaneous tissue. even into the underlying muscles and adjacent nerves and blood vessels. Lacerations and incisions may appear linear, regular, or stolid, irregular, and may occur along with other types of soft tissue injury.
Lacerations or incisions that involve arteries or large veins may result in severe bleeding. An avulsion is an injury that separates various layers of soft tissue, usually between the subcutaneous layer and fascia, so they become either completely detached or hang as a flap. Often there is significant bleeding. If the avulsed tissue is hanging from a small piece of skin, the circulation through the flap may be at risk. If you can, replace the flat avulsed flap in its original position as long as it is not visibly contaminated with dirt and or other foreign materials.
If an avulsion is complete, you should wrap the separated tissue in sterile gauze, and take it with you to the emergency department. This type of avulsion often has serious risk for infection. Never remove an avulsion skin flap, regardless of its size. An amputation is an injury in which part of the body is completely severed.
Chapter 32, Orthopedic Injuries, covers this topic in detail. We usually think of amputations as involving the upper and lower extremities. But other body parts, such as the scalp, ear, nose, penis, or lips, may also be totally avulsed or amputated. You can easily control the bleeding from some amputations, such as a finger, with direct pressure and pressure dressings.
If an amputation involves a large area of muscle mass, such as a thigh, there may be massive bleeding. In this situation, you should stop the bleeding, which often requires a tourniquet, and treat the patient for hypovolemic shock. For more information see Chapter 26, Bleeding.
A Penetrating Wound, or Puncture Wound is an injury resulting from a piercing object such as a knife, ice pick, splinter, or bullet. Such objects leave relatively small and trance wounds, so there may be little external bleeding. However, these objects can damage structures deep within the body and cause unseen bleeding.
If the wound is to the chest or abdomen, the injury can cause rapid, fatal bleeding. Assessing the amount of damage caused by a puncture wound is difficult and is reserved for the physician at the hospital. Objects that penetrate the skin but remain in place are referred to as impaled objects.
The concerns with this type of injury include the amount of damage to structures deep inside the body, and the presence of foreign materials deep inside the tissue. The damage to underlying structures is difficult to determine and manage. and the presence of foreign materials inside the tissue results in a significantly higher risk of infection. An impaled object also requires specific treatments and care.
Described later in this chapter, stabbings and shootings often result in multiple penetrating injuries. You must assess these patients carefully to identify all wounds. Because a penetrating object can pass completely through the body, always count the number of penetrating injuries, or holes, especially with gunshot wounds. Knowing the difference between entrance wounds and exit wounds may be difficult in a pre-hospital setting, especially when considering different types of ammunition.
Although entrance wounds are often smaller than exit wounds, it is better to simply count the number of penetrating injuries. and leave the distinction between entrance and exit to the physician who is working in a more controlled environment. Gunshot wounds have unique characteristics that require special care. The amount of energy transmitted by a gunshot injury is directly related to the speed of the bullet.
When possible, determine the type of gun used in the shooting, but do not let this delay patient transport. Sometimes, the patient or bystanders can tell you how many rounds were fired. but given the stress of the environment, their information may be unreliable. However, it may help hospital personnel to better care for the patient.
Shotgun wounds create multiple paths of missiles shot and create a larger surface area and volume of tissue damage. Many cases involving shootings go to court at some point, and you may be called to testify. Therefore, you must carefully document the circumstances surrounding any gunshot injury, the patient's condition, and the treatment you give. As with closed wounds caused by crushing forces, open crush wounds may involve damaged internal organs or broken bones, as well as extensive soft tissue damage. Whereas external bleeding may be minimal, internal bleeding may be severe, or even life-threatening.
The crushing force damages soft tissues as well as vessels and nerves. This frequently results in a painful, swollen, deformed area. Blast Injuries Discussed in Chapter 25, Trauma Overview, may also result in multiple penetrating injuries.
The mechanism of injury from a blast is generally caused by three factors. Primary blast injury. Injuries to the body caused by the blast wave itself. Damage to the body is caused by the sudden pressure changes generated by the explosion.
Secondary blast injury. Injuries caused to the body from being struck. by flying debris propelled by the force of the blast. These small objects may cause multiple penetrating wounds. Tertiary blast injury.
Injuries to the body from being thrown or hurled by the force of the explosion into an object or onto the ground. It is important to conduct a complete primary and secondary assessment to determine what types of injuries are sustained from a blast injury, and treat them appropriately. assessment of closed and open injuries.
Assessing closed injuries is often more difficult than assessing open injuries. Therefore, any time you observe bruising, swelling, or deformity, or the patient reports pain, the possibility of a closed injury should be considered. Assessing an open injury in some ways is easier than assessing a closed injury because you can see the injury. Open wounds are defined as injuries in which there is a break in the surface of the skin or the mucous membrane, exposing deeper tissues to potential contamination.
You must use caution to avoid letting a patient's non-life-threatening gruesome injury distract you from recognizing another injury that is more of a threat to his or her life. Scene size up. As you arrive on scene, observe the scene for hazards and threats to the safety of the crew, bystanders, and the patient.
Assess the effect of hazards on patient care and address the hazards. As always, ensure the scene is safe, and consider the need for additional resources. Ensure that you and your crew have taken the necessary standard precautions before you approach the scene. A minimum of gloves and eye protection. Eye exposures may occur from splashes and droplets at a busy scene.
Eye and mask protection are as required when managing open injuries to avoid potential splashing. Place several pairs of gloves in your pocket for easy access in case your gloves tear or there are multiple patients with bleeding. Open soft tissue injuries can be very messy but should not be. take priority over more serious life-threatening injuries.
Controlling bleeding and bloody contaminants can be difficult because of the nature of the wounds. Be careful where you put your hands or place your equipment, and how you package the patient for transport. Because of the color of blood, and how well it soaks through clothing, you can often identify patients with an open injury as you approach the scene. However, blood can be hidden under thick, dark clothing, such as denim and leather. or in the environment such as sand, grass, or carpeting.
Do not spend time trying to estimate blood loss. Focus on controlling the bleeding. As you observe the scene, look for indicators of the mechanism of injury.
This helps you develop an early index of suspicion for underlying injuries in a patient who has sustained a significant mechanism of injury. Remember, the mechanism of injury alone does not necessarily describe the true extent of injuries but it helps you understand the potential for injury. When you put together information from dispatch, and your observations of the scene, consider how the mechanism of injury produced the injuries expected. Remember, medical emergencies may result in trauma, so there may be conditions to consider beyond the traumatic injuries. Your interactions with the patient and your assessment will ultimately provide you with additional information about the extent of the actual injuries.
For example, in a vehicle crash, a patient who has sustained abrasions and lacerations to the face from an impact with the steering wheel or windshield may have experienced enough force to injure the cervical spine as well. In this case, Spinal motion restriction should be maintained throughout your care of the patient. The mechanism of injury may also provide information about potential safety threats. For example, gunshot wounds may indicate the presence of an angry and violent offender in the area or a dangerous scene.
Make sure you use all available information to evaluate scene safety and consider whether additional resources may be necessary. Primary Assessment The primary assessment of a patient with a A closed or open injury should focus on identifying and managing life-threatening concerns, and identifying transport priority. Your general impression will help you develop an index of suspicion for serious injuries, and determine how urgently your patient needs care. As you approach the patient, important indicators will alert you to the seriousness of the patient's condition, including the following. Is the patient awake and interacting with his or her surroundings, or lying still and not making sounds?
Is the patient appropriately or inappropriately responding to you? Is the patient's breathing pattern rapid or slow, deep or shallow? What is the color and condition of the patient's skin?
Although paleness, or a decrease in blood flow, can be difficult to detect in dark-skinned people, it may be observed by examining mucous membranes inside the inner lower eyelid, and capillary refill. On general observation, the patient may appear ashen or gray. Does the patient have any apparent life threats? The answers to these questions contribute to your general impression and help to determine your treatment priorities and the urgency of care needed. A good question to ask yourself is, how sick is my patient based on what I know right now?
Closed soft tissue injuries may appear to be minor. However, they may indicate serious internal injuries. For example, a patient with a hematoma on the head. and a decreased level of consciousness may have a serious brain injury.
Open injuries may be obvious and significant, likely indicating a serious condition. However, other injuries may not be as obvious but may still indicate a serious condition. Check for responsiveness. If the patient is alert, ask about the chief complaint to help direct you to any apparent life threats.
If the patient is not alert, Determine if he or she responds to verbal or painful stimuli or if he or she is unresponsive. An unresponsive patient may indicate a life-threatening condition. Administer high-flow oxygen via a non-rebreathing mass to patients whose level of consciousness is less than alert and oriented. Treat for potential shock, and provide immediate transport to the emergency department.
If significant trauma has likely affected multiple body systems, Start with a rapid exam of the patient to be sure you have found all of the problems and injuries. A rapid 60- to 90-second exam may identify factors that assist you in determining whether a patient requires rapid transport. Begin with the head and neck while manually holding the head in place.
When you are done, apply a cervical collar if it is indicated. When performing the rapid exam, look for life threats, and treat them as you find them. Significant bleeding is an immediate life threat and must be controlled quickly using appropriate methods. A patient with massive hemorrhage may require a tourniquet before the airway is opened.
If the patient has obvious life-threatening external bleeding, control the bleeding first, before airway and breathing, then assess and treat the ex-airway, breathing, and circulations, and treat for shock. Providing high-flow oxygen may help reduce the effects of shock. and assist in oxygenation of damaged tissues, particularly in crush injuries. If the patient has signs of hypoperfusion, treat him or her aggressively for shock, place the patient supine, prevent heat loss with a blanket, and provide rapid transport to the hospital. Request advanced life support as necessary to assist with more aggressive shock management.
Ensure the patient has a clear and patent airway. If the airway is not patent, take the necessary steps to make it clear and patent. Protect the patient from further spinal injury as you manage the airway by preventing the head and torso from moving. If the patient is unresponsive or has a significantly altered level of consciousness, Consider inserting an oropharyngeal airway or nasopharyngeal airway, and suction the airway as needed.
You must quickly assess the patient for adequate breathing. Inspect and palpate the chest wall for D-cap BTLS. If a soft tissue injury is discovered on the chest or abdomen, auscultate for clear and symmetric breath sounds, and look at the structure of the chest wall to ensure equal expansion and rise and fall of the chest.
Provide high flow oxygen. or provide assisted ventilations using a bag mask device as needed, depending on the level of consciousness, and if your patient is breathing inadequately. Open soft tissue injuries of the face and neck have the potential to interfere with the effectiveness of the airway and breathing.
Evaluate the patient's voice and ability to speak to identify throat injuries. If an open injury is found on the chest, evaluate for air movement through the wound in the form of bubbling or sucking sounds, which indicate a deep, Penetrating injury. Assess the patient's back for injuries that might need treatment.
Quickly place an occlusive dressing over the wound. Provide high-flow oxygen or assisted ventilations with a bag mask device as needed, depending on the patient's level of consciousness and on the adequacy of the patient's breathing. Monitor the patient for signs of increasing respiratory distress that may require you to relieve pressure built up under the dressing, caused by a pneumothorax. Quickly assess the patient's pulse rate, rhythm, and quality, determine the skin condition, color, and temperature, and check the capillary refill time.
These assessments will help you determine the presence of circulatory problems or shock. Closed soft tissue injuries may not always have visible signs of bleeding because most of the bleeding is occurring inside the body. Your assessment of the pulse and skin will indicate how aggressively you need to treat your patient for shock.
Determine whether your patient needs immediate transport or stabilization on scene. If the patient you are treating has an airway or breathing problem or signs and symptoms of shock or internal bleeding, you must consider rapid transport to the hospital for treatment or request advanced life support. Also, if you identify conditions that have the potential to become unstable, such as a distended abdomen or femur fractures, the patient requires rapid and immediate transport.
You should also consider whether transport to the closest hospital is appropriate or whether the patient would be better served by transport to a trauma center that might be farther away. In some situations it may be appropriate to request air medical transport to expedite transfer to a trauma or specialty center. Each consideration requires that you clearly and completely understand your local resources and protocols.
Most patients do not require immediate, rapid transportation. But there are certain conditions for which treatment is limited in the field, and, therefore, immediate transport is the better choice. The following list will help guide you in determining the types of patients that need immediate transportation. Poor initial general impression.
Altered level of consciousness. Dyspnea. Abnormal vital signs. Shock.
Severe pain. Do not delay transport of a seriously injured trauma patient to complete non-lifesaving treatments in the field, such as splinting extremity fractures or treating minor bleeding such as abrasions. Instead, complete these types of treatments en route to the hospital during the secondary assessment. Patients who have visible significant bleeding or signs of significant internal bleeding may quickly become unstable.
Stay alert for signs of hypoperfusion, tachycardia, tachypnea, weak pulse, cool, moist. scan, and reassess your priority, and transport decision if these signs develop. History taking.
After you manage life threats during the primary assessment, investigate the chief complaint or history of present illness. Obtain a medical history, and be alert for injury-specific signs and symptoms as well as any pertinent negatives such as no pain or loss of sensation. Make every attempt to obtain a signs and symptoms, allergies, medications, Pertinent past medical history, last oral intake, events leading up to the illness or injury history from your patient. Using onset provocation or palliation quality region or radiation severity timing may provide some background on isolated extremity injuries.
When you use signs and symptoms, allergies, medications, pertinent past medical history, last oral intake, events leading up to the illness or injury, onset provocation or palliation quality region or radiation severity timing, and DCAP BTLS together, your assessment will be well-rounded and provide significant insight into the patient's condition. You have the opportunity to interview the patient well before the emergency department physician's examination. Any information you receive will be valuable if the patient loses consciousness.
If the patient is not responsive, attempt to obtain the history from other sources, such as friends, family members, or even bystanders who might have witnessed the event. Medical identification jewelry and wallet cards may also provide information about the patient's medical history or alert you to the presence of implanted medical devices. Although these items may not seem significant. They can provide information about the patient's underlying medical conditions.
This information, in conjunction with the physical assessment, may help provide an overview of the patient's overall status. Typical signs of an open injury include bleeding, a break in the skin, shock, hemorrhage, and disfigurement or loss of a body part. Typically, symptoms include pain and or burning at the injury site. Chronic medical conditions such as anemia, low quantity of hemoglobin in the blood. hemophilia a disorder in which blood has a diminished ability to clot as well as a host of other medical conditions can complicate open soft tissue injuries medications such as aspirin or others that impair the blood's ability to clot and are frequently taken by older patients may make it more difficult to control bleeding secondary assessment after you evaluate the X airway breathing and circulations and identify and treat immediate life threats A more detailed assessment should follow.
The secondary assessment is a more systematic full body scan or focused examination of the patient that is used to reveal injuries or medical conditions that may have been missed during the primary assessment. In some instances, such as with a critically injured patient or a short transport time, you may not have time to conduct a full secondary assessment. Typically, the secondary assessment, which includes assessing interventions and repeating vital signs. occurs en route to the emergency department.
Listen to breath sounds with a stethoscope. Breath sounds should be clear and equal bilaterally, anteriorly, and posteriorly. Determine the patient's respiratory rate and note the pattern and quality of the respiratory effort. Assess for asymmetric chest wall movement.
Assess the neurologic system to gather baseline data on your patient. This examination should include the level of consciousness. pupil size and reactivity and motor and sensory response assess the musculoskeletal system by performing a detailed exam of the entire body look for dcap btls assess the chest abdomen and extremities for hidden bleeding and injuries log roll the patient and assess the posterior torso for injuries once the back has been assessed the patient can be log rolled back down onto a backboard followed by spinal motion restriction if indicated.
Log rolling and maintaining spinal motion restriction should take into consideration injuries found during the primary assessment as well as local protocols. Assess all anatomic regions, looking for the following signs or symptoms. Check the neck for jugular vein distension and tracheal deviation.
Be alert for patients with a stoma or tracheostomy. Check the pelvis for stability. Check the abdomen.
Feel all four quadrants for tenderness or rigidity, and inspect for bruising. If the abdomen is tender, expect internal bleeding. Check the extremities and record the pulse and motor, and sensory function. Patients who have hidden internal injuries under a closed soft tissue injury may have internal bleeding, and may rapidly become unstable. It is important to reassess the vital signs to identify how quickly the patient's condition is changing.
A single vital sign will not always provide the necessary information to evaluate the patient's condition. Make sure you obtain a series of vital signs to ensure subtle changes are evident as soon as possible. Signs such as tachycardia, tachypnea, low blood pressure, weak pulse, and cool, moist, and pale skin indicate hypoperfusion and imply the need for rapid transport and treatment at the hospital.
Remember that soft tissue injuries can cause shock. Even without a significant mechanism of injury, the reassessment of your patient's vital signs will give you a good understanding of how well or how poorly your patient is tolerating the injury, and whether your interventions have been effective. Reassessment.
Reassessment of a patient is just as important as your original assessment, and should be regularly conducted during transport to ensure your patient's condition is not declining. Repeat the primary assessment completely, but pay extra attention to areas of concern that you identified during your initial assessment, and assess the effectiveness of prior treatments. Reassess vital signs, and the chief complaint.
Are the airway, breathing, and circulation still adequate. Recheck patient interventions. Are the treatments you provided for problems with the X-airway, breathing, and circulation still effective?
Reassessing a patient with an open soft tissue injury is extremely important, especially if you did not put the bandage on the patient's injury. Frequently, other emergency care personnel may have dressed and bandaged the wound before your arrival. You may need to place additional dressings over the original dressing or bandages.
If so, frequently reassess the effectiveness of the bandaging. If blood continues to soak through bandages, use additional methods to control bleeding as discussed later in the chapter. How is the patient's condition improving with the interventions?
Identify and treat changes in the patient's condition. Closed soft tissue injuries can be life-threatening if not appropriately treated. Assess and manage all threats to the patient's airway, breathing, and circulation. Supplemental oxygen via a non-rebreathing mask is commonly given to all patients with traumatic injuries affecting airway or ventilation or those with the potential for shock. Although most open soft tissue injuries are not serious, they tend to be graphic and can be distracting to the patient.
If not appropriately treated, they can lead to substantial blood loss, and even shock. By appropriately treating open soft tissue injuries, you can decrease the risk of common complications such as bleeding. shock, pain, and infection.
Expose all wounds, control bleeding, and be prepared to treat the patient for shock. Consider flushing small wound surfaces without significant bleeding with sterile saline prior to applying a dressing. If any material is stuck in the wound, do not remove it because this may worsen bleeding and shock.
Extremities that are painful, swollen, or deformed should be splinted. Take great care when splinting these types of injuries. If done correctly, splinting can assist with pain management and bleeding control.
If done poorly, it may cause greater harm. When splinting these types of injuries, remember to assess the patient's pulse and motor and sensory functions distal to the injury zone both before and after applying the splint. Your communication and documentation must include a description of the mechanism of injury and the position in which you found the patient when you arrived on scene.
This will provide key information to the hospital staff that may affect the patient care plan provided at the hospital. You should attempt to report blood loss using terms that you are comfortable with and that will be easily understood by other personnel. For example, you may say the bleeding soaked through the patient's jeans prior to our arrival, or the bleeding soaked through three trauma dressings during our time with the patient. Include the location and description of any soft tissue injuries or other wounds you have located and treated. Describe the size and depth of the injury.
Provide an accurate account of how you treated these injuries. Your ability to clearly and accurately communicate and document enables the physicians and nurses at the hospital to continue to deliver quality care. Emergency medical care for closed injuries.
Small contusions generally do not require special emergency medical care. but you should note their presence when trying to determine the true extent of the patient's injuries. More extensive closed injuries may involve significant swelling and bleeding beneath the skin, which could lead to hypovolemic shock. Depending on the time the injury occurred, and the response time, the injuries might not have had time to cause swelling or bruising. Closely watch any area of injury throughout the time you are caring for the patient, no matter how minor it may look on initial assessment.
Treat a closed soft. tissue injury by applying the mnemonic RICEs. Rest.
Keep the patient as quiet and comfortable as possible. Ice. Use ice or cold packs to slow bleeding by causing blood vessels to constrict and to reduce pain. Compression.
Apply pressure over the injury site to slow bleeding by compressing the blood vessels. Elevation. Raise the injured part just above the level of the patient's heart to decrease swelling, splinting.
Immobilize a soft tissue injury or an injured extremity to decrease bleeding and reduce pain. In addition to using these measures to control bleeding and swelling, you should be alert for signs of developing shock. Look for anxiety or agitation and changes in mental status, as these can be early signs of developing shock. An increased heart rate, increased respiratory rate, diaphoresis, cool or clammy skin, and eventual decreases in blood pressure may not develop until late in your care of the patient.
Any or all of these signs may indicate internal bleeding resulting from injuries to internal organs. If the patient exhibits signs and symptoms of shock, treat accordingly and aggressively. Emergency medical care for open injuries. Before you begin caring for a patient with an open wound, be sure to protect yourself by following standard precautions. If life-threatening bleeding is observed, assign a team member to apply direct pressure over the wound to control the bleeding, then assess the severity of the wound.
If the wound is in the chest, upper abdomen, or upper back, cover it with an occlusive dressing. Your treatment priorities are performing the primary assessment and beginning life-saving interventions. This includes controlling the bleeding, which can be extensive and severe.
Several methods are available to control open injuries or external bleeding. Start with the most commonly used. These include the following. Direct, even pressure and elevation.
Pressure dressings and or splints. Tourniquets. It will often be useful to combine these methods. Different types of tourniquets are shown in figure 27-11. All open wounds are assumed to be contaminated and present a risk of infection.
By applying a sterile dressing, you are reducing the risk of further contamination. This keeps foreign material, such as hair, clothing, and dirt, out of the wound, and decreases the risk of infection. In general, you should not remove material from an open wound, no matter how dirty the wound is. Rubbing Brushing or washing an open wound can cause additional bleeding, but small wound surfaces without significant bleeding can be flushed with sterile saline prior to applying a dressing. Chemical burns and contamination should be flushed to remove remaining chemicals.
In most circumstances, hospital personnel, rather than emergency medical technicians, will clean open wounds. To prevent a wound from drying, you may apply sterile dressings moistened with sterile saline solution. and then cover the moist dressing with the dry, sterile dressing.
In some cases, you can better control bleeding from open soft tissue wounds by splinting the extremity. Even if there is no fracture, splinting can help you keep the patient calm and quiet, as it typically reduces pain. Splinting also keeps sterile dressings in place, minimizes damage to an already injured extremity, and makes it easier to move the patient. Abdominal wounds.
An open wound in the abdominal cavity may expose internal organs. In some cases, the organs may even protrude through the wound, an injury called an evisceration. Do not touch or move the exposed organs. Instead, cover the wound with sterile gauze moistened with sterile saline solution, and secure it with an occlusive dressing. Because the open abdomen radiates body heat very effectively and quickly, and because exposed organs lose fluid rapidly.
You must keep the organs moist and warm. If you do not have gauze compresses, you may use moist sterile dressings, covered and secured in place with a bandage and tape. Do not use any material that is adherent or loses its substance when wet, such as toilet paper, facial tissue, paper towels, or absorbent cotton. If the patient's legs and knees are uninjured, flex them to relieve pressure on the abdomen.
Most patients with abdominal wounds require immediate transport to a trauma center, depending on the local protocol. Impaled Objects Occasionally, a patient will have an object, such as a knife, fishhook, wood splinter, or piece of glass, impaled in his or her body. To treat this, follow the steps in Skill Drill 27-1.
Stabilize the impaled body part. Step 1. 2. Remove any clothing covering the injury. Control bleeding with direct pressure.
and apply a bulky dressing to stabilize the object. If the object is in the chest, neck, or back, consider applying a base layer of occlusive dressing around the object to prevent air from entering the wound. Some combination of soft dressings, gauze, and tape may be effective, depending on the location and size of the object. To prevent further injury, manually secure the object by incorporating it into the dressing.
Step 2. 3. Protect the impaled object from being bumped or moved during transport by taping a rigid item such as a plastic cup, a section of a plastic water bottle, or a supply container over the stabilized object, and its bandaging. Step 3. Skill Drill 27-1 Stabilizing an Impaled Object Step 1. Do not attempt to move or remove the object. Stabilize the impaled body part.
Step 2. Control bleeding, and stabilize the object in place using soft dressings, gauze, and or tape. Step 3. Tape a rigid item over the stabilized object to prevent it from moving during transport. The only exceptions to the rule of not removing an impaled object are objects in the cheek or mouth that actively obstruct breathing and objects in the chest that directly interfere with performing cardiopulmonary resuscitation on a patient who is already in cardiac arrest.
If the object is very long, cut off, shorten, the exposed portion, first securing it to minimize motion and, thus, internal damage and pain. Once the object has been properly secured, and the bleeding is under control. Provide prompt transport. Neck injuries.
An open neck injury can be life-threatening. If the veins of the neck are open to the environment, they may suck in air. If enough air is sucked into a blood vessel, it can block the flow of blood into the lungs and cause cardiac arrest.
This condition is called air embolism. To control bleeding, and prevent the possibility of air embolism, cover the wound with an occlusive dressing. Apply manual pressure.
but do not compress both carotid vessels at the same time. If you do, this may impair circulation to the brain and cause a stroke. Secure pressure dressing over the wound by wrapping roller gauze loosely around the neck, and then firmly through the opposite axilla. Use caution with patients who have sustained a neck injury, depending on the mechanism of injury involved.
Immobilize the cervical spine if indicated, including placing a cervical collar. The cervical collar may assist with holding a dressing in place over neck wound. Bites, small animal bites and rabies.
At times you may be called to care for a person who has been bitten by a small animal such as a dog, cat, raccoon, squirrel, or other small non-livestock animal. Be sure to consider scene and crew safety prior to entering the environment. Most people who are bitten by small animals do not report the incident to a physician. Believing that these bites are not serious, however, they can be very serious.
A small animal's mouth is heavily contaminated with bacteria. You should consider all small animal bites as contaminated, and potentially infected wounds that may require debridement, the removal of damaged tissue, antibiotics, and tetanus prophylaxis. Occasionally, small animal bites result in mangled, complex wounds that require surgical repair.
For these reasons. All small animal bites should be evaluated by a physician. Place a dry, sterile dressing over the wound, and promptly transport the patient to the emergency department. If an arm or leg was injured, splint that extremity. Often, the patient will be extremely upset and frightened, a situation that calls for reassurance on your part.
A major concern with small animal bites is the spread of rabies, an acute. potentially fatal viral infection of the central nervous system that can affect all warm-blooded animals. Although rabies is currently extremely rare, particularly with widespread vaccination of pets, it still exists.
Stray dogs that have not been vaccinated can be carriers of the disease, as can squirrels, bats, foxes, skunks, and raccoons. The virus is in the saliva of a rabid, or infected, animal and is transmitted through biting or licking an open wound. Infection can be prevented in a person who has been bitten by such an animal only by a series of special vaccine injections, a painful procedure that must be started soon after the bite. Because animals that have rabies do not always demonstrate symptoms immediately, a person's only chance to avoid the vaccine is to find the animal, and turn it over to the health department for observation and or testing.
Refer to your local animal control procedures. Children, particularly young ones, may be seriously injured or even killed by dogs. These dogs are not always vicious or rabid. Sometimes a child unknowingly provokes the animal.
However, you must assume the animal may turn and attack you as well. Therefore, you generally should not enter the scene until the animal has been secured. Then you may carry out the necessary emergency care, and transport the child to the emergency department.
Human bites. The human mouth, more so than even the small animal's mouth, contains an exceptionally wide range of bacteria and viruses. For this reason, you should regard any human bite that has penetrated the skin as a serious injury.
Similarly, Any laceration caused by a human tooth can result in a serious, spreading infection. Remember this if you treat someone who has been punched in the mouth. The person who delivered the punch may also need treatment. The emergency treatment of bites consists of the following steps. 1. Apply a dry, sterile dressing.
Often, these calls involve pediatric patients. Burns are among the most serious and painful of all injuries. A severe burn injury presents several simultaneous life threats, including hypovolemic shock, sapsis, hypothermia. respiratory failure management of severe burn injuries has improved over the years including an emphasis on the psychological challenges that survivors face burn units typically employ social workers vocational counselors and psychologists as part of a multidisciplinary approach to patient care a burn occurs when the body or a body part receives more radiant energy than it can absorb resulting in an injury potential sources of this energy include heat toxic chemicals, and electricity.
The proper emergency care of a burn may increase a patient's chances of survival and decrease the risk or duration of a long-term disability. Although a burn may be the patient's most obvious injury, you should always perform a complete assessment to determine whether there are other serious injuries. Finally, keep in mind that children, older patients, and patients with chronic illnesses are more likely to experience shock from burn injuries. Be prepared to treat accordingly. Pathophysiology of burns.
Burns are soft tissue injuries spread out over a large area created by the transfer of radiation, thermal, or electrical energy. Thermal burns can occur when skin is exposed to temperatures higher than 111 degrees Fahrenheit, 44 degrees Celsius. In general, the severity of a thermal injury directly correlates with temperature, concentration.
or amount of heat energy possessed by the object or substance, and the duration of exposure. For example, solids generally have higher heat content than gases, so exposure to a hot solid, such as the rack inside an oven, typically causes a more significant burn than exposure to hot gases, such as those coming out of an oven. Burn injuries are progressive.
The greater the heat energy, the deeper the wound. Exposure time is another important factor. Thermal injury can occur to unresponsive or paralyzed patients from seemingly innocent heat sources such as heating pads or heat lamps if the patient is left unattended and exposed for long periods of time. It may be difficult to evaluate the amount of heat energy or the amount of exposure time in many cases. There can be a vast difference in the temperature of a fire from the floor to the ceiling, although most people naturally limit the amount of time they are exposed to such heat.
If clothing is on fire or the person is trapped or unconscious, exposure time can be extended. Complications of burns. Several complications can result from a burn injury, all of which can be life-threatening. The skin serves as a barrier between the environment and the body.
When a person is burned, this barrier is destroyed. The victim is now at a high risk for infection, hypothermia, hypovolemia, and shock. Burns to the airway are of great importance because the loose mucosa in the hypopharynx can swell and result in complete airway obstruction.
Circumferential burns of the chest can compromise breathing. Circumferential burns of an extremity can lead to compartment syndrome, resulting in neurovascular compromise, and irreversible damage if not appropriately treated. If you suspect any complications, call for advanced life support backup if available or provide rapid transport to the emergency department.
Burn Severity. The seriousness of a burn may influence the choice of a treatment facility. Five factors will help you to determine the severity of a burn.
After gauging these, ask yourself the following questions. 3. Are any critical areas, face, upper airway, hands, feet, genitalia, involved? Also included in critical areas are any circumferential burns, which are burns that go completely around a body part such as an arm, foot, or chest.
The American Burn Association and the American College of Surgeons recommend transfer to a designated burn center for any patient with an acute burn with any of the following. 1. Partial thickness burns of 20% TBSA or greater in patients 10 to 50 years of age. 2. Partial thickness burns of 10% TBSA or greater in children younger than 10 years or adults older than 50 years.
Full thickness burns of 5% TBSA or greater in patients of any age. 4. Partial or full thickness burns to the hands, face, feet, genitalia. or major joints. 5. High voltage electrical injuries.
Significant chemical burns. 7. Concomitant traumatic injury. Note, if the trauma causes a greater immediate risk than the burn injury, consider stabilizing the patient at a trauma center, and then transferring to a burn unit, per local protocol. 8. Inhalation injury. 9. significant ongoing medical problems.
Special social or emotional or long-term rehabilitative support, for example, victims of abuse or substance abuse. Remember, burns to the face are high risk due to the risk of airway involvement. Burns to the hands, feet, or genitalia, or over joints, are also serious due to potential loss of function from scarring. Depth.
Burns are first classified according to their depth. You must be able to identify the following three types of burns. Superficial, first degree, burns involve only the top layer of skin, the epidermis. The skin turns red but does not blister or burn through this top layer. The burn site is often painful.
Sunburn is a good example of a superficial burn. Partial thickness, second degree, burns involve the epidermis, and some portion of the dermis. These burns do not destroy the entire thickness of the skin, nor is the subcutaneous tissue injured.
Typically, the skin is moist, mottled, and white to red. Blisters are present. Partial thickness burns cause intense pain.
Full thickness, third degree, burns extend through all skin layers, and may involve subcutaneous layers, muscle, bone, or internal organs. The burned area is dry and leathery and may appear white, dark brown. or even charred.
Some full thickness burns feel hard to the touch. Clotted blood vessels or subcutaneous tissue may be visible under the burned skin. If the nerve endings have been destroyed, a severely burned area may not have feeling, and the surrounding less severely burned areas may be extremely painful. A pure full thickness burn is unusual. Severe burns are typically a combination of superficial, partial thickness, and full thickness burns.
Superficial burns heal well without scarring. Small partial thickness burns also heal without scarring. However, deep partial thickness burns and all full thickness burns are prone to scarring and may be best managed surgically.
Significant airway burns are also serious. They may be associated with singed hair within the nostrils, soot around the nose and mouth, hoarseness, and hypoxia. These patients should be rapidly transplanted.
ported to an emergency department or facility capable of advanced airway management. It becomes increasingly difficult to achieve airway control once swelling begins. It may be impossible to accurately estimate the depth of a burn shortly after injury.
Even experienced burn surgeons sometimes underestimate or overestimate the extent of a burn. Extent. One quick way to estimate the surface area that has been burned is to compare it to the size of the patient's palm.
including their fingers, which is roughly equal to 1% of the patient's TBSA. This technique is called the rule of palm. Another useful measurement system is the rule of nines, which divides the body into sections, each of which is approximately 9% of TBSA. Remember that the head of an infant or child is relatively larger than the head of an adult, and the legs are relatively smaller.
When you calculate the extent of burn injury, include only partial thickness, second degree, and full thickness, third degree, burns. Document superficial, first degree, burns, but but do not include them in the body surface area estimation of extent of burn injury. Patient Assessment of Burns When you assess a burn, it is important to classify the patient's burns.
Classifying burns involves determining the source of the burn, the depth of the burn, and its severity. Assessing a patient with a burn is essentially the same as assessing any other trauma patient. Again, be careful to focus not on the dramatic appearance of the injury. but rather on potential life threats that require treatment.
Scene size up. As you arrive on scene, observe the scene for hazards and threats to the safety of you and your crew, bystanders, and the patient. Ensure that the factors that led to the patient's burn injury do not pose a hazard to you and your crew.
Is the electricity turned off? Is the chemical leak secure? Has the fire been extinguished?
Is there any potential for violence? Has the patient been decontaminated, if needed? When possible, determine the type of burn that has been sustained and the mechanism of injury. What the patient reports will often provide some important information about the extent of the injury.
Patients with burn injuries can be a challenge to treat both physically and emotionally. It is easy to become overwhelmed by the sights, sounds, and smells of burn victims. Assess the scene for any environmental hazards.
If the patient is the victim of a lightning strike, is the weather still a threat to your safety? Wear gloves and eye protection when treating any patient with a burn, and gowns when serious injuries are expected. Determine the number of patients. The possibility for multiple patients grows if you are responding to a lightning strike or a vehicle crash.
At vehicle crashes, ensure the scene is safe from energized electrical lines or leaking fuel in the area where you'll be working. If you determine the power company, the fire department, or advanced life support units are needed. Call for additional resources early. Remember, the patient with the burn is a trauma patient. Consider the potential for spinal injuries, broken bones, inhalation injuries, and other injuries.
Primary assessment. The primary assessment includes a rapid exam of the patient to identify and manage life-threatening concerns, and to assist with transport decisions. The primary assessment begins when you approach the patient and form a general impression. As you approach the burn trauma patient, simple clues can help identify how serious the injuries are, and how quickly you need to assess and treat them. If your patient greets you with a hoarse voice or reports being in an enclosed space with a fire or intense heat source, these should be indications of a significant mechanism of injury.
The presence of stridor means your patient's airway is significantly swollen and can signal impending complete airway obstruction. Similarly, if the patient has singed facial hair, eyebrows, or nasal hair, your initial general impression might be the patient has a potential airway and or breathing problem. Child abuse and elder abuse are unpleasant situations to handle. Unfortunately, they are often situations that involve burns. As you enter a scene where burns are involved, Be suspicious of clues that may indicate abuse.
The burn patient you encounter may have graphic injuries. However, stay focused on the primary assessment. As you begin, always consider the need for manual spinal stabilization.
Check for responsiveness using the awake and alert verbal stimuli pain unresponsive scale. Assess a patient's mental status by asking the patient about his or her chief complaint. If the patient is alert, This should help direct you to any apparent life threats. If the patient is not alert, determine if he or she responds to verbal or painful stimuli or if he or she is unresponsive. An unresponsive patient may very well have a life-threatening condition.
In all patients whose level of consciousness is less than alert and oriented, you should administer high-flow oxygen via a non-rebreathing mask and provide immediate transport to the emergency department. Ensure the patient has a clear and patent airway. If the patient is unresponsive or has a significantly altered level of consciousness, consider inserting a properly sized oropharyngeal or nasopharyngeal airway. Be alert to signs that the patient has inhaled hot gases or vapors, such as singed facial hair or soot present in or around the airway. Heavy amounts of secretions and frequent coughing may also indicate a respiratory burn.
Quickly assess for adequate breathing. Inspect and palpate the chest wall for decap-B TLS. Check for clear and symmetric breath sounds, and provide high-flow oxygen or provide assisted ventilations using a bag-mask device as needed. depending on the level of consciousness and breathing rate or quality of your patient. Patients with burns are trauma patients.
Evaluate and treat them for spinal injuries and airway problems concurrently. How you open the airway depends on whether a neck injury is suspected. Could the patient have fallen? Do the circumstances surrounding the mechanism of injury suggest a possible spinal injury?
Quickly assess the pulse rate and quality and determine perfusion based on the patient's skin condition, color, temperature, and capillary refill time. If you see significant bleeding, take the necessary steps to control it. Significant bleeding is an immediate life threat.
If the patient has obvious life-threatening external hemorrhage, control the bleeding first, before airway and breathing, then treat the patient for shock as quickly as possible. Shock frequently develops in patients with burns. Treat the shock by preventing heat loss. This is important because the damaged skin has only a limited ability to regulate body temperature.
After the burning process has stopped, cover the patient with a blanket to prevent heat loss. If the patient you are treating has an airway or breathing problem, significant burn injuries, significant external bleeding, or signs and symptoms of internal bleeding. Consider rapid transport to the nearest hospital, trauma center, or burn center for treatment.
Consulting with advanced life support providers may be appropriate for patients with moderate or severe burns and burns of the airway or inhalation injury. Advanced life support providers can treat these patients with endotracheal intubation and intravenous fluids to support airway, breathing, and circulation, shock, difficulties. These can progress so rapidly that immediate advanced life support assistance can make the difference between life and death.
History Taking Investigate the chief complaint or history of present illness. Next, be alert for signs or symptoms of other injuries due to the mechanism of injury. If the patient was burned in a confined space, suspect an inhalation injury. When burns result from explosive forces, be alert for other internal injuries and fractures.
Obtain a medical history and be alert for injury-specific signs and symptoms as well as any pertinent negatives such as no pain, typical signs of a burn or pain, redness, swelling, blisters, or charring. Typically, symptoms include pain and or burning at the injury site. Regardless of the type of burn injury, it is important to stop the burning process, apply dressings to prevent contamination, and treat the patient for shock.
obtain a sample history from your patient. In addition, ask the following questions of a patient with a burn. Are you having any difficulty breathing?
Are you having any difficulty swallowing? Are you having any pain? When you assess a patient with a burn, check to see whether the patient has an emergency medical identification device, a wallet card, necklace, or bracelet, or ask the patient or a family member about pre-existing conditions.
which may increase the chances of a poor outcome. Remember that the environment, bystanders, and medical identification devices may provide important clues about your patient's condition. Secondary Assessment The secondary assessment is a more detailed, comprehensive, or focused examination of the patient that is conducted to reveal injuries that may have been missed during the primary assessment.
In some instances where the patient is critically injured or the transport time is short. you may not have time to conduct a secondary assessment. In other instances, the secondary assessment may occur en route to the emergency department. After you complete the primary assessment, perform an exam of the entire body. Quickly assess the patient from head to toe looking for D-cap BTLS to ensure you have found all of the problems and injuries.
Make a rough estimate, using the rule of nines, of the extent of the burned area to report to medical control. Determine what classification of burns the victim has sustained. The patient may report pain depending on the amount of nerve damage. Before you package your patient, determine the severity of the burns the victim has sustained.
Severity is calculated by considering what caused the burn, the body region that is burned, the depth and extent of the burn, the patient's age, and pre-existing illness or injuries. Follow your local protocols for criteria for transport to a burn center. Package the patient for transport based on your findings. Remember to immobilize your patient for spinal injuries as appropriate.
Assessing the respiratory system involves looking, listening, and feeling. A patient who is conscious, alert, and talking does not have immediate airway or breathing difficulties. When you assess the respiratory system of a patient with a burn, Look specifically for the following findings. 1. Soot around the mouth. 2. Soot around the nose.
Determine the patient's rate and quality of respiration. Finally, assess the chest for decap-BTLS and asymmetric chest wall movement. Patients with burns who present with any type of airway problem should be considered critical.
Quickly assess pulse rate and quality. Determine the skin condition, color, and temperature, and check the capillary refill time. If you see visible significant bleeding, you must begin the steps necessary to control bleeding.
Significant bleeding, internal or external, is an immediate life threat. If the patient has obvious life-threatening bleeding, quickly control it and treat for shock as quickly as possible. Non-life-threatening bleeding, such as in abrasions, can be bandaged later in your assessment as necessary.
Assess the patient's neurologic system to formulate baseline data for further decisions on patient management. This examination should include assessing for the following. Level of consciousness, use awake and alert verbal stimuli pain unresponsive, pupil size and reactivity, motor response, sensory response. Assess the musculoskeletal system by performing a detailed full body scan.
Assess all anatomic regions looking for D-cap BTLS. Specifically look for the following features. In the head, check for singed nasal or facial hair, burns or swelling of the face or ears, or burns or swelling in the mouth. If the patient sustained an electrical injury, examine the scalp for signs of an entrance or exit wounds.
In the neck, check for burns, especially if they encircle the entire neck, which can impair circulation. In the chest. Check for burns that encircle the entire chest, which can impair normal chest rise.
In the abdomen and pelvis, feel all four quadrants for tenderness or rigidity. If the abdomen is tender, expect internal bleeding. Look for burns of the genitalia, as burns to this area are considered high risk. Look for burns that encircle an extremity, as they can impair circulation. If the patient sustained an electrical injury, Assess the relief or entry or exit burn wounds.
This should include the axilla, and the area between digits. Record the pulse and motor and sensory function. Examine the posterior surface of the body, as large burns or electrical exit burns may be located in this body area. A systematic examination helps you understand what has happened to the outside of your patient. Vital signs are a good indication of how your patient is doing on the inside.
If you obtain an early set of vital signs, you'll know how your patient is tolerating his or her injuries while en route to the hospital. Because shock is often pronounced in a patient with a burn, blood pressure, pulse, and skin assessment for perfusion are important vital signs to obtain. In addition to hands-on assessment, use monitoring devices, including oxygen saturation monitors and carbon monoxide monitors, to quantify oxygenation and circulatory status. Reassessment.
Repeat the primary assessment and reassess the patient's vital signs. Reassess the patient's chief complaint. Re-evaluate interventions and treatment you have provided to the patient, particularly those used to treat shock. Identify and treat any changes in the patient's condition.
The goals in treating patients with burns are to stop the burning process, assess and treat breathing, support circulation, and provide rapid transport. Because patients with burns are also trauma patients, provide spinal motion restriction consistent with your local protocol if you suspect spinal injuries. Oxygen is mandatory for inhalation burns, and large body surface area burns.
If the patient has signs of hypoperfusion, treat aggressively for shock, and provide rapid transport to the appropriate hospital. Cover all burns according to your local protocols. The risk of infection is very high and can be reduced if you cover large burn areas with sterile burn sheets or clean linen.
Do not delay transport of a seriously injured patient to complete non-life-saving treatments in the field such as splinting extremity fractures. Instead, Complete these types of treatment en route to the hospital. Provide hospital personnel with a description of how the burn occurred. Often, the emergency department staff can determine the appropriate dilutant for chemical burns or calculate appropriate treatments for other types of burns with enough advanced notice.
Report and document the extent of the burns. This should include the amount of body surface area involved, the depth of the burn, and the location. For example, You may say 10% full thickness burns, 15% partial thickness burns, and 25% superficial burns to the chest, abdomen, and left lower extremity. If special areas are involved, genitalia, feet, hands, face, or circumferential, they should be specifically mentioned and documented.
Emergency medical care for burns. Your first responsibility in caring for a patient with a burn is to stop the burning process. and prevent additional injury.
When caring for a patient with a burn, follow the steps in skill drill 27-2. 1. Follow standard precautions. Because a burn destroys the patient's protective skin layer, always wear gloves and eye protection when treating a patient with a burn.
If the burning has stopped before you arrive, do not immerse the affected part at all. As an alternative to immersion, irrigate the burned area until the burning stops. Next apply a sterile dressing. Step 1. Cover large greater than 10% body surface area burns with a dry, sterile, non-adherent dressing. for example a sterile burn sheet other than for the purpose of stopping the burning process do not apply water or saline to large surface burn areas four provide high flow oxygen remember that more fire victims die of smoke inhalation than of skin burns a patient who has facial burns or has inhaled smoke or fumes may experience respiratory distress Therefore, provide high flow oxygen to the patient.
Keep in mind that a patient who appears to be breathing well at first may suddenly experience severe respiratory distress. Therefore, continually assess the airway for possible problems. Step 2. 5. Rapidly estimate the burn severity. Cover the burned area with a dry, sterile dressing to prevent further contamination.
Sterile gauze is best if the area is not too large. You may cover larger areas with a clean, white sheet. Do not put anything else on the burned area. Never use ointments, lotions, or antiseptics of any kind, and do not intentionally break any blisters. 6. Check for traumatic injuries or other medical conditions that may be immediately life-threatening.
Most patients who have been burned have normal vital signs, and can communicate at first, which will make your assessment easier. Step 3. 7. Treat the patient for shock. 8. An extensive burn can produce hypothermia, loss of body heat.
Prevent further heat loss by covering the patient with warm blankets. 9. Provide prompt transport by local protocol. Do not delay transport to perform a prolonged assessment or to apply coverings to burns in a critical patient. Step 4. Skill Drill 27-2 Caring for Burns. Step 1. Follow standard precautions to help prevent infection.
If safe to do so, remove the patient from the burning area, extinguish or remove hot clothing and jewelry as necessary. If the wound is still burning or hot, immerse the hot area in cool, sterile water, or cover with the wet. Cool dressing. Step 2. Provide high flow oxygen and continue to assess the airway. Step 3. Estimate the severity of the burn and then cover the area with a dry, sterile dressing or clean sheet.
Assess and treat the patient for any other injuries. Step 4. Prepare for transport. Treat for shock. Cover the patient with blankets to prevent loss of body heat. Transport promptly.
Management of specific burns. Thermal burns. A thermal burn is caused by heat, as opposed to electricity, chemicals, or radiation. Many different situations can cause thermal burns, and all pose a safety hazard to responding emergency care providers. Most commonly, thermal burns are caused by scalds or an open flame.
A flame burn is very often a deep burn, especially if a person's clothing catches fire. Hot liquids produce scald injuries. A scald burn is most commonly seen in children and handicapped adults but can happen to anyone, particularly while cooking.
Scald burns often cover large surface areas of the body because liquids can spread quickly. Coming in contact with hot objects produces a contact burn. Ordinarily, reflexes protect a person from prolonged exposure to a very hot object.
so contact burns are rarely deep unless the patient was prevented from drawing away from the hot object, for example, unconscious, intoxicated, restrained, or impaired. A steam burn can produce a topical burn. Minor steam burns are common when uncovering the plastic wrap from microwaved food.
When the plastic is peeled away, hot steam escapes directly onto the person's hand . may also cause airway burns. Another important source of thermal burns is the flash burn produced by an explosion, which may briefly expose a person to very intense heat.
Lightning strikes can also cause a flash burn. These injuries are usually minor compared with the potential for trauma from whatever caused the flash. Manage thermal burns mostly the same as you would manage any other burn.
Stop the burning source, cool the burned area if appropriate, and remove all jewelry. Maintain a high index of suspicion for inhalation injuries. Increased exposure time will increase damage to the patient. The larger the burn, the more likely the patient will be susceptible to hypothermia and or hypovolemia. All patients with large surface burns should have a dry sterile dressing applied to help maintain body temperature, prevent infection, and provide comfort.
Inhalation Burns Inhalation injuries can occur when burning takes place in enclosed spaces without ventilation. When the upper airway is exposed to excessive heat, the patient can experience rapid and serious airway compromise. The heat can be an irritant to the lungs and the airway, causing coughing, wheezing, and rapid swelling or edema of the mucosa of the upper airway tissues, often evidenced by stridor.
Upper airway damage is often associated with the inhalation of superheated gases. Lower airway damage is more often associated with the inhalation of chemicals, for example, acids, aldehydes, and particulate matter. When treating a patient for inhalation injuries, you may encounter severe upper airway swelling that requires immediate intervention. Sometimes airway swelling and compromise will develop more slowly and not manifest until transport.
You should consider requesting advanced life support backup if the patient has signs or symptoms of edema. such as stridor, a hoarse voice, singed nasal hairs, singed facial hairs, burns of the face, or carbon particles in the sputum. Alternatively, expediting transport to the nearest emergency department capable of advanced airway management should be considered if faster than waiting for advanced life support arrival at the scene. Remember that these patients can deteriorate quickly. Apply cool mist, aerosol therapy, or humidified oxygen to help reduce a minor edema.
inhalation of toxic gases. The combustion process produces a variety of toxic gases. The less efficient the combustion process, the more toxic the gases, such as carbon monoxide and carbon dioxide, that may be created. When furnaces, kerosene heaters, and other heating devices are in poor repair, they may emit unsafe levels of these toxic gases. Internal combustion engines may emit many of the same gases and, consequently, should always have their exhaust vented to the outdoors.
A common cause of carbon monoxide exposure is running a small engine in an enclosed space such as a garage or basement. For this reason, many ambulance services and fire departments have added carbon monoxide detectors to their garages or ambulance bays. Firefighters who are performing an overhaul after a fire may be exposed to high levels of carbon monoxide, as may people who are exposed to large amounts of car exhaust, such as toll takers and auto mechanics. Carbon monoxide intoxication should be considered whenever a group of people in the same place all report a headache or nausea.
A malfunctioning furnace or car exhaust being sucked into the air handling system can cause carbon monoxide intoxication in groups of people. Similarly, you should be suspicious when people complain of feeling sick at home but not when they go to work or school. Carbon monoxide can displace oxygen from the alveolar air and from its attachment sites on hemoglobin molecules contained in circulating red blood cells.
Because carbon monoxide binds to receptors, sites on hemoglobin at least 250 times more easily than oxygen does the patient's hemoglobin may become saturated with the wrong chemical being exposed to relatively small concentrations of carbon monoxide such as in cigarette smoke will result in progressively higher blood levels of carbon monoxide most people have approximately 2% carbon monoxide attached to their hemoglobin but these levels may be as high as 4% to 8% in heavy smokers. Levels of 50% or higher may be fatal. Patients with severe carbon monoxide intoxication usually have an oxygen saturation level that is normal.
For this reason, patients who have potentially inhaled toxic gases should receive a high concentration of supplemental oxygen regardless of pulse oximetry readings. New devices that can measure a patient's carbon monoxide level are becoming more widespread in emergency medical service systems. allowing providers to recognize and treat low-level carbon monoxide intoxication rapidly.
The gaseous form of cyanide is hydrogen cyanide. It is generated by the combustion of commonly encountered substances such as paper, cotton, and wool. Hydrogen cyanide is colorless and has the smell of bitter almonds. However, it can be difficult to detect at the scene of a fire. Pre-hospital diagnosis of hydrogen cyanide poisoning is difficult because laboratory studies are necessary.
Signs and symptoms involve the central nervous, respiratory, and cardiovascular systems of the body, and include faintness, anxiety, abnormal vital signs, headache, seizures, paralysis, and coma. In situations in which you have patients who have sustained inhalation injuries, you must first ensure your own safety, and the safety of your co-workers. Once you have taken precautions, Pre-hospital treatment of a patient with suspected hydrogen cyanide poisoning may include decontamination and supportive care according to signs and symptoms displayed by the patient until an antidote can be administered by advanced life support providers. Exposure to other toxic gases can also cause damage to organs and systems and may cause death.
Care for any toxic gas exposure includes recognition, identification, and supportive treatment as necessary according to the patient's signs and symptoms. Chemical burns. A chemical burn can occur whenever a toxic substance contacts the body.
Most chemical burns are caused by strong acids or strong alkalis. The eyes are particularly vulnerable to chemical burns. Sometimes the fumes alone from strong chemicals can cause burns, especially to the respiratory tract.
The severity of the burn is directly related to the type of chemical, the concentration of the chemical, and the duration of the exposure. In cases of severe chemical burns or exposure, consider mobilizing a hazardous materials, hazmat, team, if appropriate. To prevent exposure to hazardous materials, determine if you can safely approach the patient. In some cases, you'll need to wait to provide care until hazardous materials technicians have decontaminated the patient.
You must wear the appropriate chemical-resistant gloves and eye protection whenever you are caring for a patient with a chemical burn. Be particularly careful not to get any chemical, dry or liquid, on yourself or on your uniform. Consider wearing a protective gown when this is a possibility.
Remember that exposure risk is also present when you are cleaning up after a call. Treatment of chemical burns can be specific to the chemical agent. If available, read all of the labels of the chemical agent. Do not risk exposure while attempting to gather information on the chemical. If the exposure occurs at an industrial site, such as a chemical manufacturing plant, an expert should be on site, and should be able to provide you with valuable information on the chemical.
The emergency care of a chemical burn is basically the same as that for a thermal burn, discussed earlier in the chapter. The severity of the burn will depend on the type of chemical, its strength, the duration of exposure, and the area of the body exposed. To stop the burning process, remove any chemical from the patient. A dry chemical that is activated by contact with water may damage the skin more when it is wet than when it is dry.
Therefore, always Please brush off dry chemicals from the skin and clothing before flushing the patient with water. Remove the patient's clothing, including shoes, stockings, gloves, and any jewelry or eyeglasses, because there may be small amounts of chemicals in the creases. Take great care to ensure you do not come in contact with the chemical. The patient should be properly decontaminated by properly trained personnel.
liquid chemicals immediately flush the burned area with large amounts of water Take care not to contaminate uninjured areas or make the patient hypothermic. Never direct a forceful stream of water from a hose at the patient. The extreme water pressure may mechanically injure the burned skin.
Continue flooding the area with gallons of water for 15 to 20 minutes after the patient says the burning pain has stopped. If the patient's eye has been burned, hold the eyelid open, without applying pressure over the globe of the eye, while flooding the eye with a gentle stream of water. Flush the eyes from the inside corners to the outside to prevent cross-contamination.
If only one eye has been affected, turn the patient's head to that side, and flush. If both eyes are affected, consider hooking up a nasal cannula to a bag of saline to flush both eyes simultaneously. The prongs can be placed on the bridge of the nose to flush from the inside corners of the eyes to the outside corners. Be careful not to touch the prongs to the eye or surrounding tissue. Continue flushing the contaminated area and route to the hospital.
As with any substance, once the fluid has been contaminated with the chemical, collect it and properly dispose of it. Conduct a property contamination prior to loading any patient into the ambulance, and again prior to entering a hospital. Electrical burns.
Electrical burns may be the result of contact with high or low voltage electricity. High voltage burns may occur when utility workers make direct contact with power lines. Ordinary household current is still powerful enough to cause severe burns as well as cardiac dysrhythmias. There must be a complete circuit between the electrical source and the ground for electricity to flow.
Any substance that prevents this circuit from being completed, such as rubber, is called an insulator. Any substance that allows a current to flow through it is called a conductor. The human body, which is primarily water, is a good conductor.
Thus, electrical burns occur when the body, or a part of it, completes a circuit connecting a power source to the ground. The type of electric current, magnitude of current, amperage, and voltage have effects on the seriousness of burns. When an electric current enters the body, the skin is burned at the entrance wound as well as everywhere along the path until the current grounds and exits the body. In addition to tissues damaged by the heat, significant chemical changes take place in the nervous, cardiovascular, and muscular systems of the body, causing disruption of the body's normal functions and or even system failure.
Your safety is particularly important when you are called to the scene of an emergency involving electricity. Obviously, you can be fatally injured by coming into contact with power lines. But you can also be fatally injured by touching a patient who is still in contact with a live power line or any other electrical source.
For this reason, never attempt to remove someone from an electrical source unless you are specially trained to do so. Likewise, never move a downed power line unless you have the special training and equipment necessary for the job. Before even approaching someone who may still be in contact with a power line or an electrical appliance, make certain the power is turned off.
Always assume that any downed power line is live. A burn injury appears where the electricity enters, an entrance wound, and exits, an exit wound, the body. The entrance wound may be quite small, but the exit wound can be extensive and deep. Always look for both entrance and exit wounds. There are two dangers specifically associated with electrical burns.
First, there may be a large amount of deep tissue injury. Electrical burns are often more severe than the external signs indicate. The patient may have only a small burn to the skin but may have massive damage to the deeper tissues, organs, and the nervous system. The force of the electrical energy can also cause fractures or joint dislocations.
Second, the patient may go into cardiac or respiratory arrest from the electric shock. Electrical current can cross the chest and cause cardiac arrest or dysrhythmias. Cardiac arrest can also occur after a lightning strike, which is a form of an electrical burn. If indicated, begin cardiopulmonary resuscitation on the patient, and apply the automated external defibrillators Although cardiopulmonary resuscitation may need to be quite prolonged in patients with electrical burns, it has a high success rate if started promptly.
Be prepared to defibrillate if necessary. If neither cardiopulmonary resuscitation nor defibrillation is indicated, give supplemental oxygen, and monitor the patient closely for respiratory and cardiac arrest. Treat the soft tissue injuries by placing dry, sterile dressings on all burn wounds, and splinting suspected fractures.
Provide prompt transport. All electrical burns are potentially severe injuries that require further treatment in the hospital. Taser injuries.
In recent years, law enforcement has increased its use of tasers. These weapons fire two small darts, electrodes, that puncture the patient's skin. Taser injuries are generally treated as impaled objects, and the electrodes are removed by a physician.
However, in some jurisdictions, Emergency medical technicians are permitted to remove these barbs from patients, depending on local protocol. The barbs are approximately 0.5 inch, 13 millimeters, in length, and although they produce wounds, they are small and easily managed unless they penetrate the eye. When a taser has been used, the patient can experience potential complications, particularly when he or she is already experiencing certain underlying disorders. Considerable attention has focused on a condition known as excited delirium, which is often characterized by extreme agitation, reduced pain sensitivity, hallucinations, persistent struggling, and elevated temperature. This condition is commonly associated with illegal drug ingestion.
Excited delirium is a true emergency and warrants assisted advanced life support response. Previously Using a taser in patients with true excited delirium has been associated with dysrhythmias and sudden cardiac arrest. Other studies have found that the risk of sudden death is related to the excited delirium condition, rather than being associated with taser use. Regardless, be aware of this possibility, and be certain you have access to an automated external defibrillators when you respond to calls for patients who have been exposed to taser shots.
Radiation Burns Acute radiation exposure has become more than a theoretical issue because the use of radioactive materials has increased in industry and medicine. Therefore, you must understand it to effectively manage patients exposed to radiation. Potential threats include incidents related to the use and transportation of radioactive isotopes, and intentionally released radioactivity in terrorist attacks. To be effective, first determine if there has been a radiation exposure. and then determine whether ongoing exposure continues to exist.
Increasingly, special response units are equipped with pager-size radiation detectors, or such detection devices may be provided by other public safety services. There are three types of ionizing radiation, alpha, beta, and gamma. Alpha particles have little penetrating energy, and are easily stopped by the skin. Beta particles have greater penetrating power, and can travel much faster.
farther in air than alpha particles. They can penetrate the skin but can be blocked by simple protective clothing designed for this purpose. The threat from gamma radiation is directly proportional to its wavelength. This type of radiation is very penetrating, and easily passes through the body, and solid materials. Radiation is measured in units of radiation-absorbed dose, rad, or radiation equivalent in man, ram.
100 rad equals 1 gray. Small amounts of everyday background radiation are measured in rad, the amount of radiation released in a major incident may be measured in gray. The average human exposure from background radiation is 0.31 rem per year.
Mild radiation sickness can be expected with exposures of 1 to 2 gray, 100 to 200 rad, moderate sickness at 2 to 5 gray, and severe sickness at 4 to 6 gray. Exposure to more than 10 gray may result in death within 2 to 4 weeks. Most ionizing radiation accidents involve gamma radiation, or X-rays. People who have sustained irradiation exposure generally do not pose a risk to the people around them. However, in some types of incidents, particularly those involving explosions, patients may be contaminated with radioactive particulate matter.
It is speculated that after nuclear explosion, most patients will have sustained some type of trauma in addition to the radiation exposure. Being exposed to a radiation source does not make a patient contaminated or radioactive. However, when patients have a radioactive source on their body, such as debris from a bomb that dispersed radioactive material, they are contaminated and must be initially cared for by a hazmat responder.
Maintain a safe distance. and wait for the hazmat team to decontaminate the patient before initiating care. Once decontaminated by the hazmat team, care is often transferred to the emergency medical technician.
Most contaminants can be removed by simply removing the patient's clothes. Call for additional resources to manage this situation. Once the patient is decontaminated and there is no threat to you, begin treating the X-airway, breathing, and circulations and treat the patient for any burns or trauma. irrigate open wounds washing should be gentle to avoid further damage to the skin which could result in additional internal radiation absorption irrigate the head and scalp the same way the emergency department should be notified as soon as practical if you are transporting a potentially contaminated patient in contrast with other types of contamination radioactive particulate matter probably poses a relatively small risk to the provider Consider providing basic care to the patient before decontamination if you are wearing protective clothing.
Increasing your and the patient's distance from the source by even a few feet may dramatically decrease your exposure. Therefore, it is important to identify the radioactive source, and the length of the patient's exposure to it, if this information is available without putting you or your patient at risk for exposure. If not readily available, rely on the HAZMAT team to obtain this information. Limit your duration of exposure, increase your distance from the source, and attempt to place shielding between yourself and sources of gamma radiation.
With contact radiation burns, decontaminate the wound as if it were a chemical burn to remove any radioactive particulate matter, then treat it as a burn. Many radioactive isotopes are used in medicine and industry, some of which can be absorbed or have their toxic effects blunted by another substance, like their radioactive effects. The toxic effects of these isotopes vary. Antidotes may help bind an isotope, enhance its elimination from the body, or reduce the toxic effects on other organs.
Such antidotal therapy should be considered only under the guidance of a knowledgeable physician or public health agency. Dressing and bandaging. All wounds require bandaging.
In most instances, splints help to control bleeding, and provide firm support for the dressing. There are many different types of dressings and bandages. You should be familiar with the function and proper application of each. In general, dressings and bandages have three primary functions. To control bleeding.
To protect the wound from further damage. To prevent further contamination and infection. Sterile dressings. Universal dressings.
Conventional 4x4 inch, 10x10 centimeters, and 4x8 inch. 10 by 20 centimeters gauze pads and assorted small adhesive type dressings and soft self-adherent roller dressings will cover most wounds the universal dressing measures 9 by 36 inches 23 by 91 centimeters is made of thick absorbent material and is ideal for covering large open wounds it also makes an efficient pad for rigid splints these dressings are available in compact commercially sterilized packages gauze pads are appropriate for smaller wounds and adhesive type dressings are useful for minor wounds an occlusive dressing made of petroleum jelly based Vaseline gauze aluminum foil or plastic prevents air and liquids from entering or exiting the wound these dressings are used to cover sucking chest wounds abdominal eviscerations penetrating back wounds and neck injuries bandages To keep dressings in place during transport, you can use soft roller bandages, rolls of gauze, triangular bandages, or adhesive tape. The self-adherent, soft roller bandages are probably easiest to use.
They are slightly elastic, which makes them easy to apply, and you can tuck the end of the roll into a deeper layer to secure it in place. The layers adhere somewhat but should not be applied too tightly to one another. Adhesive tape holds small dressings in place and helps secure larger dressings. Some people, however, are allergic to adhesive tape. If you know your patient is allergic, use paper or plastic tape instead.
Do not use elastic bandages to secure dressings. If the injury swells, the bandage may become a tourniquet and cause further damage. Any improperly applied bandage that impairs circulation can result in additional tissue damage or even the loss of a limb.
Always check a limb distal to a bandage for signs of impaired circulation and loss of sensation. Air splints and vacuum splints are useful in stabilizing broken extremities, and they can be used with dressings to help control bleeding from soft tissue injuries. If a wound continues to bleed despite the use of direct pressure, quickly use a tourniquet.
This is discussed further in Chapter 26, Bleeding. Research from the Iraq War has taught us that use of a tourniquet is rarely harmful. If you cannot control bleeding from a major vessel in an extremity, a properly applied tourniquet may save a patient's life, specifically. The tourniquet is useful if a patient is bleeding severely from any limb injury.
Furthermore, the tourniquet is most effective as a life-saving measure if applied prior to the onset of shock from blood loss.