Chapter 27 - Soft Tissue Injuries Flashcards
A 21-year-old male was working in an auto repair shop and sustained radiator burns to the anterior aspect of both arms and to his anterior chest. According to the rule of nines, this patient has burns that cover _____ of his BSA.
Select one:
A. 45%
B. 27%
C. 18%
D. 36%
C. 18%
Explanation (scroll down and click on the picture for visual)
One side of Right Arm = 4.5%
One side of Left Arm = 4.5%
Upper Chest Area = 9%
Total = 18%
A 33-year-old male sustained an abdominal evisceration to the left lower quadrant of his abdomen after he was cut with a large knife. After appropriately managing his ABCs and assessing him for other life-threatening injuries, how you should care for his wound?
Select one:
A. Carefully replace the exposed bowel into the abdomen and transport.
B. Cover it with moist, sterile gauze and secure with an occlusive dressing.
C. Irrigate it with sterile water and cover it with a dry dressing.
D. Cover the exposed bowel and keep his legs in a straight position.
B. Cover it with moist, sterile gauze and secure with an occlusive dressing
Explanation
The wound is managed in the prehospital setting by covering the eviscerated contents with a moist, sterile gauze or trauma dressing to prevent further contamination and drying.
Abdominal eviscerations are a surgical emergency. The protruding organ requires careful cleaning and evaluation prior to reinsertion into the peritoneal cavity by definitive care.
No attempt should be made to replace eviscerated organs into the peritoneal cavity
A. Incorrect - Carefully replace the exposed bowel into the abdomen and transport.
This has a high potential cause harm to the bowels due to exerted force on the bowels by pushing or tugging on them; this is in addition to the high probability to transfer microorganisms to the exposed organs.
C. Incorrect - Irrigate it with sterile water and cover it with a dry dressing.
Only a surgical staff should clean the bowels. A dry dressing would adhere to the organs and cause further damage
D. Incorrect - Cover the exposed bowel and keep his legs in a straight position.
This does not specify the moist sterile gauze, not the need for an occlusive dressing to maintain the moisture.
A 39-year-old male was struck in the head by a baseball during a game. He is confused and has slurred speech. He has a large hematoma in the center of his forehead and cannot remember the events preceding the injury. After manually stabilizing his head and assessing his airway, you should:
Select one:
A. administer high-flow oxygen.
B. apply ice to the hematoma.
C. perform a neurologic exam.
D. palpate his radial pulses.
A. administer high-flow oxygen.
Explanation
The patient is exhibiting signs of a concussion (MOI, altered mental status, slurred speech, cannot remember the event) and needs to see a physician for possible traumatic brain injuries (TBI). Especially since hematomas are associates with severe tissue damage, and this example in the area of the brain, which is sensitive to pressure changes.
Our focus here is to slow down the damage of possible secondary brain injury. Airway compromise from TBI comes in many forms.
Irreversible brain damage can occur in TBI patients after only four minutes of anoxia, which can be caused by a compromised airway, altered respiratory patterns from the head injury, or lung injury in multi-system trauma. Use pulse-oximetry, skin color, and respiratory rate to assess adequate oxygenation. Administer oxygen via nasal cannula, non-rebreather mask, or bag valve to maintain a pulse-ox reading of at least 95%.
Following MARCH algorithm:
M - Massive Bleed Control - None Apparent - move to ABC’s
A - Airway Patent (AVPU, GCS, C-Spine Considerations) - Stabilized
R - Respiration - Administer High Flow Oxygen (Correct Answer)
C- Circulation - Pulse Rate, Blood Pressure
H - Head Injuries & Other Injuries
B. Incorrect - apply ice to the hematoma.
This is not part of the primary assessment. This may play a role once life-threats have been cared for first.
C. Incorrect - perform a neurologic exam.
This will come into play after the ABC’s have been managed.
D. Incorrect - palpate his radial pulses.
This is the C in both the ABC & MARCH algorithms, which follows breathing. High flow oxygen comes first.
A 56-year-old male has an incomplete avulsion to his right forearm. After controlling any bleeding from the wound, you should:
Select one:
A. carefully remove the avulsed flap and wrap it in a moist, sterile trauma dressing.
B. replace the avulsed flap to its original position and cover it with a sterile dressing.
C. thoroughly irrigate the wound with sterile water and cover it with a sterile dressing.
D. carefully probe the wound to determine if the bleeding is venous or arterial.
B. replace the avulsed flap to its original position and cover it with a sterile dressing.
Explanation (pg. 909)
“If the avulsion tissue is hanging from a small piece of skin, the circulation through the flap may be at risk. If you can, replace the flat ovals flap in its original position as long as it is not visibly contaminated with dirt and/or other floor materials.”
A. Incorrect - carefully remove the avulsed flap and wrap it in a moist, sterile trauma dressing.
Removing that flap of skin may prolong the healing process; if it is still vascularized, removing it will cause more damage.
C. Incorrect - thoroughly irrigate the wound with sterile water and cover it with a sterile dressing.
Irrigating is a good step to remove debris. This is missing the replacement of the flap (i.e. incomplete avulsion). Only after replacing the flap would you cover an incomplete avulsion with a sterile dressing.
Rinse the wound with water or saline solution, the cleaner the better. Sterile irrigation is the best. This will restart the bleeding in many cases. That’s OK. It’s good to clean the wound as well as stop the bleeding.
If the bleeding was difficult to stop and you are concerned that it will be out of control if you rinse the wound, then don’t worry about it. Get the patient to an emergency department immediately.
D. Incorrect - carefully probe the wound to determine if the bleeding is venous or arterial.
Probing the wound will cause more damage. Knowing whether it’s capillary, arterial, or venous is not necessary. It’s better to gauge the amount of bleeding and aid in sterilizing & clotting.
A burn that is characterized by redness and pain is classified as a:
Select one:
A. partial-thickness burn.
B. second-degree burn.
C. full-thickness burn.
D. superficial burn.
D. superficial burn.
Explanation (pg. 925)
“Superficial burns involve only the top layer of skin, the epidermis. The skin turns red but does not blister or burn through this top player. The burn site is often painful. Sunburn is a good example of a superficial burn.”
Only redness and pain = superficial burn
A. Incorrect - partial-thickness burn.
A partial-thickness burn involves the epidermis and some portion. of the dermis. These burns. do not destroy the entire thickness of the skin nor as a subcutaneous tissue destroyed. Typically, the skin is moist, mottled, and white to red. Blisters are present. Partial-thickness burns cause intense pain.
B. Incorrect - second-degree burn.
This is an outdated term for Partial-Thickness Burn
C. Incorrect - full-thickness burn.
“Full-thickness burns extend through all layers of skin 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 chard.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 closed soft-tissue injury characterized by swelling and ecchymosis is called a(n):
Select one:
A. crush injury.
B. contusion.
C. hematoma.
D. abrasion.
B. contusion.
Explanation (pg. 907)
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 changed, and small blood vessels are usually torn. The depth of the injury varies, depending on the amount of energy absorbed. As fluid and blood to leak into the damaged area, the patient may have swelling and pain. The buildup of blood produces a characteristic black and blue discoloration called ecchymosis.
A. Incorrect - crush injury.
A crushing injury occurs when significant forces 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 soft tissue damage, continued compression of the soft tissue cuts off circulation, producing further. tissue destruction. (pg. 908)
C. Incorrect - hematoma.
A hematoma is blood that has collected within the damaged tissue or in a body cavity. The hematoma occurs whenever a large blood vessel is damaged and bleeds rapidly. It is usually associated with extensive tissue damage. A hematoma can result from soft tissue injury, fracture, or any injury to a large blood vessel. In severe cases, the hematoma may contain more than a liter of blood. (pg. 908)
D. Incorrect - abrasion.
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 may ooze from the injured capillaries in the dermis. (pg. 909)
An 8-year-old male was bitten by a stray dog. He has a large laceration to the back of his left hand, which your partner covered with a sterile dressing and bandage. In addition to transporting the child to the hospital, you should:
Select one:
A. advise the child that he will need rabies shots.
B. ask the child’s father to try to locate the dog.
C. report the incident to the appropriate authorities.
D. administer oxygen via a nonrebreathing mask.
C. report the incident to the appropriate authorities.
Explanation (pg. 923)
“In many locations, reporting animal bites to public health officials is mandatory. Based on your protocols you may need to have law enforcement respond to the scene or to the hospital.”
A. Incorrect - advise the child that he will need rabies shots.
The child is not the legal decision-maker and it will only serve to upset them.
B. ask the child’s father to try to locate the dog.
You must assume that the animal may turn and attack. The animal needs to be secured by law enforcement or animal control. (pg. 923)
D. administer oxygen via a nonrebreathing mask.
As the bite was to the left hand, an acute infection that can only be treated by a series of vaccinations is indicated. No difficulty breathing has been indicated. (pg. 922-923)
As you approach a young male who was involved in an industrial accident, you note that his eyes are closed and that he is not moving. You can see several large contusions to his arms, a laceration to his forehead with minimal bleeding, and a closed deformity to his right leg. You should:
Select one:
A. open his airway and assess his breathing status.
B. perform an immediate head-to-toe assessment.
C. assess his pulse for rate, regularity, and quality.
D. apply high-flow oxygen and assess his injuries.
A. open his airway and assess his breathing status.
Explanation (pg. 923)
Following MARCH algorithm:
M - Massive Bleed Control - large contusions on the arm and minimal bleeding of the forehead does not immediately indicate massive bleeding - move to ABC’s
A - Airway Patent (AVPU, GCS, C-Spine Considerations) - Open His Airway (Correct Answer)
R - Respiration - Assess his breathing status (Correct Answer)
C- Circulation - Pulse Rate, Blood Pressure
H - Head Injuries & Other Injuries
B. Incorrect - perform an immediate head-to-toe assessment.
This is not a part of the primary assessment. This may be necessary after the primary assessment and all life-threatening conditions have been managed.
C. Incorrect - assess his pulse for rate, regularity, and quality.
This comes after open the airway and assessing breathing in the protocol. Even if you are checking the pulse while watching for bilateral chest rise and fall, opening the airway must come first, and this answer lacked that.
D. Incorrect - apply high-flow oxygen and assess his injuries.
Applying oxygen comes after assessing the airway. Assessing the injuries come after massive bleeding (external), airway, breathing, and circulation have been accounted for first.
Burns to pediatric patients are generally considered more serious than burns to adults because:
Select one:
A. most burns in children are the result of child abuse.
B. pediatric patients have a proportionately larger volume of blood.
C. pediatric patients are more prone to hyperthermia.
D. pediatric patients have more surface area relative to total body mass.
D. pediatric patients have more surface area relative to total body mass.
Explanation (pg. 927)
“Burns to children are generally considered more serious than burns to adults. The reason is infants and children have more surface area relative to body mass, which means greater fluid and heat loss. In addition, children do not tolerate burns as well as adults do. Children are also more likely to go into shock, have hypothermia develop, and experience airway difficulties because of the unique differences associated with their ages and anatomy.
Many burns in infants and children result from child abuse. The classic burn resulting from deliberate immersion involves the hands and wrists, as well as the feet, lower legs, and buttocks. Similarly burns around the genitals and multiple cigarette burns should be viewed as possible abuse. Report all suspected cases of abuse to the proper authorities, especially those where significant delaying evaluation and treatment is evident.
A. Incorrect - most burns in children are the result of child abuse.
This is a serious concern, that needs to be taken into account. Priority goes to the life-threatening conditions first.
- B. Incorrect - pediatric patients have a proportionately larger volume of blood.*
1. Despite a smaller stature, burned children have a greater body surface area per mass than adults.
2. Cardiac function, mean blood volume, and normal hemoglobin levels are age-dependent in children; hence, children have a higher blood transfusion/unit volume ratio. - C. Incorrect - pediatric patients are more prone to hyperthermia.*
This is secondary to the burn area.
During your assessment of a patient who was shot in the abdomen, you notice a large entrance wound with multiple small puncture wounds surrounding it. This wound pattern is MOST consistent with a:
Select one:
A. handgun.
B. .22-caliber pistol.
C. .357 magnum.
D. shotgun.
D. shotgun.
Explanation
Shotgun ammunition scatters multiple fragments as part of its exit from the gun barrel, while the other options do not fragment as they leave the barrel. The other options would have a single entry without fragmented punctures around it.
In addition to severe bleeding, the MOST life-threatening complication associated with an open neck injury is:
Select one:
A. a spinal fracture.
B. an ischemic stroke.
C. nerve fiber damage.
D. an air embolism.
D. an air embolism.
Explanation:
For air to enter a closed system (i.e. vascular system), a connection must occur between the gas, the vessel, and a pressure gradient, that enables the flow of air into the vessel. An open neck injury presents this opportunity.
Venous gas embolism can go to the lungs and block pulmonary blood flow. This can create pulmonary hypertension & right-heart failure quickly.
A gas embolism that enters the heart can cause an “air lock” in the right side of the heart: the heart valves do not work properly, and the heart cannot eject the gas. Cardiac out then falls rapidly. This is fatal.
A gas embolism that enters the arterial system or reaches the left side of the heart can be pumped into the arterial circulation, and then cause an infarction (i.e. blood flow blockage, lack of oxygen delivery, tissue death) in the vital organs, including the heart and brain.
A. Incorrect - a spinal fracture.
Spinal fracture with a neck injury is a consideration, but severe bleeding and an open neck injury indicate a gas embolism is likely.
B. Incorrect - an ischemic stroke.
Ischemic strokes occur in arteries where blood only. A gas embolism can enter either the venous or arterial system. Uniquely saying it can cause an ischemic stroke leaves a venous blockage out and thus is less complete of an answer as “air embolism.”
C. Incorrect - nerve fiber damage.
Nerve fiber damage with a neck injury is a consideration, but severe bleeding and an open neck injury indicate a gas embolism is likely.
In which of the following patients should you remove an impaled object?
Select one:
A. A pulseless and apneic patient with a knife impaled in the back
B. A semiconscious patient with an ice pick impaled in the chest
C. An apneic patient with a shard of glass impaled in the abdomen
D. A conscious and alert patient with a fishhook impaled in the eye
A. A pulseless and apneic patient with a knife impaled in the back
Explanation
“The only exceptions to the rule of not removing an impaled object are the objects in the cheek or mouth that obstruct breathing and objects in the chest that directly interfere with performing CPR on a patient who is already in cardiac arrest.” (pg 920)
Being pulseless and apneic, the patient is already in cardiac arrest and the position of the knife would make it impossible to perform CPR.
B. Incorrect - A semiconscious patient with an ice pick impaled in the chest
This patient is not in cardiac arrest as they are semiconscious. Also, depending on the location of the ice pick, it may or may not interfere with CPR. With the provided information, removal is not indicated.
C. Incorrect - An apneic patient with a shard of glass impaled in the abdomen
This patient has a shard of glass in their abdomen and will not compromise CPR. Also, this patient is apneic, and it is possible to be apneic with cardiac activity, albeit not for long, thus it is not indicated that they are in cardiac arrest.
D. Incorrect - A conscious and alert patient with a fishhook impaled in the eye
The fishhook does not impair CPR, and there is a high probability that definitive care is required to remove the hook to salvaged function in the eye.
The sebaceous glands produce sebum, a material that:
Select one:
A. waterproofs the skin and keeps it supple.
B. facilitates shedding of the epidermis.
C. discharges sweat onto the skin’s surface.
D. pulls the hair erect when you are cold.
A. waterproofs the skin and keeps it supple.
Explanation:
“The sebaceous glands lie next to the hair follicles and secrete sebum along the hair follicle to the skin surface. In addition to providing waterproofing for the skin, sebum keeps the skin soft so it does not crack.” (pg. 212)
B. facilitates shedding of the epidermis.
The stratum corneum consists of a series of layers of specialized skin cells that are continuously shedding as new cells move superficially to replace older cells. (pg 212; 906)
C. Incorrect - discharges sweat onto the skin’s surface.
Sweat’s main purpose is to cool the body to aid in thermoregulation (pg 212; 906)
Apocrine sweat glands are believed to be adrenergic (part of the sympathetic nervous system), while eccrine sweat glands Eccrine glands are innervated by the sympathetic nervous system, primarily by cholinergic fibers whose discharge is altered primarily by changes in deep body temperature (core temperature), but by adrenergic fibers as well.
D. Incorrect - pulls the hair erect when you are cold.
The Erector Pillae muscle is what pulls a hair follicle erect. (pg 213; 906)
When caring for a patient whose arm is covered with a dry chemical, you should:
Select one:
A. brush away the chemical before flushing with water.
B. quickly irrigate the arm with large amounts of water.
C. use forceful streams of water to remove the chemical.
D. deactivate the chemical with a 5% vinegar solution.
A. brush away the chemical before flushing with water.
Explanation
To stop the burning process, remove any chemical from the patient. A dry chemical that is activated with water may damage the skin more when it is wet than when it is dry. Therefore, always brush off dry chemicals from the skin and clothing before flushing the patient with water. (pg 934)
For liquid chemicals, immediately flush the area with large amounts of water.
B. Incorrect - quickly irrigate the arm with large amounts of water.
From the above statement, water may activate the chemical causing more damage.
C. use forceful streams of water to remove the chemical.
From the above statement, water may activate the chemical causing more damage. Also, forceful streams of water can contaminate uninjured areas and may mechanically injure the burned skin.
D. deactivate the chemical with a 5% vinegar solution.
Treatment of chemical burns can be specific to the chemical agent. (pg 934) Vinegar is a weak aid but may increase the damage of the chemical agent. The emergency care for chemical burns is basically the same as a thermal burn.
Which of the following areas of the body has the thinnest skin?
Select one:
A. Soles of the feet
B. Back
C. Scalp
D. Ears
D. Ears
Explanation
“Skin varies in thickness, depending on a person’s age and the area the skin covers. The skin of the very young or 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, while the skin of the eyelids, lips, and ears is very thin. Thin skin is more easily damaged.” (pg. 906)
A. Incorrect - Soles of the feet
“The skin covering the scalp, the back, and the soles of the feet is quite thick, while the skin of the eyelids, lips, and ears is very thin.” (pg. 906)
B. Incorrect - Back
“The skin covering the scalp, the back, and the soles of the feet is quite thick, while the skin of the eyelids, lips, and ears is very thin.” (pg. 906)
C. Incorrect - Scalp
“The skin covering the scalp, the back, and the soles of the feet is quite thick, while the skin of the eyelids, lips, and ears is very thin.” (pg. 906)
