Soft Tissue Flashcards
What % of body weight is skin
16%
Functions of the skin
- Keeps invading pathogens out
- keeps.fluid and substances in
- senses
- temperature control
Structural features of skin
Durable
Pliable
Accommodating tissue
Highly capable of self repair ( first tissue to experience affects of trauma )
What makes up integumentary system
Epidermis
Dermis
Subcutaneous layer
Trauma to integumentary system may present as (4)
- Open injury
- Closed injury
- Uncontrolled blood loss
- May seriously affect health
What are open injuries
Abraisions Lacerations Incisions Punctures Avulsions Amputations
What are closed injuries
Contusions hematoma and crush injuries
What is uncontrolled blood loss
Hypovolemia or shock
What is uncontrolled blood loss
Hypovolemia or shock
In what way can trauma of integumentary system affect health
Severe blood/fluid loss, infection and hypothermia
Who is more prone to soft tissue trauma
School aged children
Elderly
Alcohol or drug abuse
Certain occupations
What is appearance of arterial blood
Bright red
Spurting / pulsing
What is appearance of venous blood
Dark red
Flowing
What is appearance of capillary blood
Red oozing
What is hemorrhage
Blood loss
- can be minor to life threatening
- can be from artery, vein, capillary or any combo of those
Management of hemorrhage
- usually easy to control with diret pressure
- may need surgery or sutures
- important to determine amount of blood loss (to find tx plan)
- type of injury important (clean or jagged cut)
What would be the result of a clean cut laceration
Cause smooth muscle in vessel walls to constrict and decrease lumen size, assisting in blood loss and initiating clotting
What would jagged cut lacerations cause
Cause vessel expansion with every muscle contraction, increasing blood loss if not controlled by pressure
When does wound healing begin
Immediately following injury and may take months to fully repair
- important in management of homeostasis
What are the stages of healing
Hemostasis Inflammation Epithelialization Neovascularization Collagen synthesis (Some stages may overlap)
What is hemostasis
Bloods natural ability to stop bleeding, the ability to clot blood
When does hemostasis begin
Almost immediately following injury
How does hemostasis work
Muscular layers begin constricting, longitudinal muscles pull cut ends into contracted muscle to reduce loss.
- platelets begin clotting process, vessel walls and platelets themselves become sticky in turbulent blood flow
How is platelet plug formed
Platelets sticking to vessel and themselves causes an initial clot (platelet plug) that is unstable
What happens to capillaries when cut (re: hemostasis)
Nothing; they have no muscular layer so cannot constrict; they continue to bleed
What happens when tunica intima is disrupted
Collagen and other structural proteins are exposed to blood
- complex series of enzyme reactions change certain blood proteins to fibrin strands
- strands catch RBCs and make gelatinous mass that binds with platelets = coagulation
What is the last part of hemostasis wound healing
- over time, the clot shrinks and contracts, pulling wound edges closer
- when clot not needed anymore, body reabsorbs it and superficial scab falls away naturally
What is inflammation
Complex process of local cellular and biochemical changes as a consequence of injury or infection (an early stage of healing)
What is involved in inflammation
Involves WBCs, proteins that are involved in immunity, hormone like chemicals that signal cell to mobilize
What are chemotactic factors of inflamtion
Chemicals released by WBCs that attract more WBCs to area of inflammation
- bring phagocytes
What are 2 types of phagocytes
Granulocyte= WBCs with primary purpose of neutralizing foreign bacteria Macrophages = immune system cells that can recognize and ingest foreign pathogens
What is phagocytosis
Process where a cell surrounds and absorbs a bacterium or other particle
What do Lymphocytes and immunoglobulins do
Released to attackers invading pathogens directly
What starts the inflammatory process
Chemotactic factors
What is release by mast cells based on chemotactic factors responses
Histamine
What does histamine do
Dialates precapillary vessels
- increases cap permeability and blood flow (increased Oxygenation) to injured site
What produces swollen, red and warm appearance at site of injury
Histamine
What is the result of the inflammatory process
Clear away dead/ dying tissue, remove bacteria and prep damaged area for rebuilding
What is epithelialization
Early stage of wound healing where epithelial cells migrate over surface of the wound
How does epithelialization work
Stratum germinativum divide and regenerate rapidly to make a new layer of skin cells along healing site
How soon after wound is made does epithelialization begin
As early as 48hrs with very clean wound
What is result of epithelialization
- Thinner, different pigment and lacking hair follicle (compared to regular skin)
- usually functional and cosmetically similar but not exact
- larger wounds cause new layer to be incomplete so pink color/ scar of collagen to show through
What is neovascularization
New growth of capillaries in response to healing; come from surrounding, undamaged capillaries and spread into wound
How long does it take for new capillaries to be strong enough for wound to protect them
It takes months and they are more fragile and may bleed easily until strengthened enough
What is required for neovascularization to be initiated
Well-oxygenated, nutrient rich blood supply
What is collagen
Tough, strong protein that makes up most of body’s CT
- main structural protein
- also in hair and bones
What are fibroblasts
Specialized cells that form collagen when brought to the wound site
- they continue to work at strengthening scar and tissue even after scab falls off
How strong and elastic is repaired tissue vs undamaged tissue
- only 60% as strong even after scar development
- collagen causes wound to be bound together
How long does it usually take scar to fully develop
Usually 4 months after scarring occurs
- why scars can reopen if aggravated
What is Remodeling
Stage in wound healing where collagen is broken down and relaid in an orderly way
- may take 6 - 12 months to complete
What are contusions
Injuries that crush and damage small blood vessels
What causes erythema in contusion
•Blood drawn into Inflamed tissue
- general reddening of skin from dilation of superficial capillaries
What causes color of contusions
- blood leaks into interstitial spaces through damaged vessels
- hgb in free blood loses O2, becomes dark red then blue = ecchymosis
What is ecchymosis
Blue-black discoloration of the skin ; typical “bruising”
- may not develop fast enough to be seen during prehospital care
Where will ecchymosis be more pronounced
Where blunt force mechanism and skeletal structure trap skin
- ex: steering wheel and ribs/ sternum
What is a hematoma
Collection of blood beneath the skin or trapped within a body compartment
- blood can actually separate tissue and pool in a pocket
Where are hematomas very visible
In areas directly above a solid bone structure (like head injury)
Where are hematomas less pronounced
Areas of the body with large “free” space/ body cavities
What is a risk with severe hematomas
May contribute to hypovolemia
- ex: the thigh can contain more than 1 L of blood before swelling is noticeable
What is a crush injury
Nowhere tissue is compressed by high pressure forces
What is crush syndrome
Systemic disorder of severe metabolic disturbances, resulting from the crush of a limb or other body part
- concidered life threatening
What happens if crush injury has pressure remain in place for several hours
Destruction of skeletal muscle cells leads to accumulation of large quantities of myoglobin (cell protein) , potassium, lactic acid, uric acid and other toxins
What happens when pressure of crush injury released after several hours
Built up toxins enter blood stream and cause severe metabolic acidosis
- which is toxic to heart and kidneys
What is abraision
Scraping or abrading away of the superficial layers of the skin ( epidermis and upper layer of dermis)
Symptoms of abraisions
- bleeding usually limited (just superficial capillaries)
- if it involves larger area of epidermis can lead to serious infection
What are incisions
- Very smooth or surgical lacerations,
- usually knife, scalpel, razor blade, piece of glass
- bleeds freely but heals well with proper care
What are lacerations
- Open wound, normally a tear with jagged borders
- usually over small surface area but goes more deep into dermis layer
Risks associated with lacerations
- higher risk of infection than abrasion
- endangers:
Arteries, arterioles, veins, venules, nerves, muscles, tendons, ligaments, organs in that area
Affect of attention lines with lacerations
- Cut across tension line = wound pulls apart, spreads widely or gapes
- cut parallel to tension line = spreads very little (easily repaired)
What is static tension lines
Areas with limited movement of tissue and structures beneath (like skin over abdo)
What are dynamic tension lines
Areas subject to great movement (skin over joints)
What complicates skin repair
Increased motion
What are punctures
Deep, narrow wound to the skin and underlying organs
- increased danger of infection
- if deep enough, many structures may be involved
What is risk with puncture wounds
- infection from opening to environment and foreign object carrying bacteria into body.
- internal, deoxygenated area is warm and moist = colonization of bacteria
What are impailed objects
Not a wound themselves, but associated with lacerations and punctures
Critical considerations with impailed objects
- consider damage that may be caused if prematurely removed
- > may be corking great vessel hemorrhage
- > may be entangled in arteries, nerves, structures
What is avulsion
- forceful tearing away or separation of body tissue (may be partial or complete)
- often from blunt trauma to skull, animal bites, or machinery accidents
- severity depends on: area and surface area involved, compromise of circulation, and degree of contamination
What is a degloving injury
Avulsion in which MOI tears the skin off the underlying muscle tissue, blood vessels and bone
Where is degloving most often seen
Farming and industrial setting
- also watches and rings
Progrnosis of degloving injury
Poor for use of digit or extremity
- unless vasculature is not completely damaged
What is amputation
Severance, removal or detachment either partial or complete of a body part
- usually complete loss of limb or digit
Why might there be only limited hemorrhage in amputation
As vessel ends spasm and contract back into surrounding muscle tissue
What is surgical repair of amputated limb/digit
- may include reattaching the detached part (including surgical repair of blood vessels)
- may involve using skin from detached part to graft the end of remaining limb/digit
- if skin too tight or unavailable, may have to cut more bone and muscle to to have enough skin to close wound
- surgical reatachment usually only possible with clean severed limb/digit
Ratio of wounds that usually get infected
1:15
Most common complication of open wounds
- can be isolated, involve surrounding tissue or cause sepsis
What is most common cause of skin infections
Staphylococcus and streptococcus bacteria families
- gram positive, aerobic, and very common in the environment
- staphylococcus colonized on surface of skin (easily pushed into open would when injured)
What are pseudomonas aeruginosa
Infection in diabetics and foot puncture wounds
Gram negative and less common
What are pasturella multocida
Infection from cat or dog bite
Gram negative and less common
When do infections appear
At least 2 to 3 days after injury (bacteria must multiply in numbers)
Symptoms of infection
Present with pain, tenderness, erythema, increased warmth to the area,
- may have pus (collection of WBCs, cellular debris, and dead bacteria)
- > thick, pale yellow green in color and has foul smell
What is lymphangitis
Inflammation of lymph channels, usually from distal infection
-> visible red streaks extending from wound margins up the affected extremity
Other symptoms of infection as sepsis sets in
Fever and generalized weakness
General considerations that increase risk of infection
Pts health
type/ location of injury
Associated contamination
Treatment provided
What pts tend to heal more slowly or less effectively
Diabetics, elderly, hospitalized, chronically ill
What pts do not initiate immune or tissue repair response as efficiently
Pts with cancer, anemia, hepatic failure, cardiovascular disease
What health conditions attacks immune system
Human immunodeficiency virus (HIV)
which causes
Acquired immune deficiency syndrome (AIDS)
What is smoking’s affect on risk of infection
Smoking constricts blood vessels
- robs healing tissue of oxygen and nutrients
What meds inhibit body’s ability to fight infection
- Corticosteroids (prednisone & cortisone)
- NSAIDS (ibuprofen & motrin)
- Colchicine (med for gout) - decrease immunity response
- Neoplastic agents (chemotherapy) - disrupt cell regeneration at wound
Wound type / location effect on infection
- puncture traps contamination within tissue
- Avulsion tears away tissue and blood cells, decreasing available blood supply
- Crush injuries ( and other large wounds) cause large dead/ devitalized area - larger environment for bacterial growth
- Areas of higher vascularity (scalp & face) ward off infection more efficiently; distal areas of poor circulation are higher risk
What causes some of most serious infections
Human and animal bites
Paramedic role in preventing infection
- clean gloves (protect PCP and Pt)
- sterile dressings and water flushing wounds
- closing wound (ex: sutures) increase infection risk but better for healing cleanly
Treatment of infections
Antibiotics and tetanus shots are best within an hour of injury
- especially puncture wounds to feet, GSW, stabbings, or if foreign part remains in skin
- antibiotics after the fact may increase infection if pt is resistant to the meds or has resistant microorganisms
What is gangrene
Deep space infection usually caused by the anaerobic bacterium Clostridium perfringens
Symptoms of gangrene
- Produce gas deep in wound causing subcutaneous emphysema and foul smell with gas escape
- can spread quick once developed
- can = sepsis and death if not treated rapidly and aggressively (sometimes with hyperbaric oxygenation)
- if antibiotics dont work may need to amputate
What is tetanus
Aka Lockjaw
Caused by anaerobic bacterium Clostridium tetani which produces potent toxin that spreads systemically
Treatment of tetanus
Tx is slow and prolonged as antidote only neutralizes circulating toxins
- immunizing 3 x as child then every 10 years has drastically reduced cases
Symptoms of tetanus
Less local involvement (wound site) and more widespread pain and muscle contraction
Best current form of tx of infection
Antibiotics
Aka chemical bactericidals
How to treat Gram- positive infections
Antistaphylococcal penicillin, cephalosporin, erythromycin (for pts allergic to PNC)
How to treat Gram- Negative infections
Psudomonas require 2 meds together
Pasturella is treated with penicillin
How to treat abscess (accumulation of pus)
Lancing to allow drainage may be required
When might you need to surgically remove bateria-infested tissue
If antibiotics are too slow or ineffective
What is impaired hemostasis and its affect on wound repair
- anticoagulation therapy prolongs clotting time and efficiency by anti-platelet aggregation or break down of clot protein fibres ( ASA, heparin, coumadin)
- penicillin may also increase clotting time and blood cell production
- abnormalities in proteins involved in fibrin formation (hemophiliacs) delay clotting
What is rebleeding and effect on wound repair
- movement of underlying structures or dressing may disrupt clotting
- more absorbent dressing may hide active bleed ( monitor all dressings that blood loss is not accumulating)
- reopening of partially healed wound
What pts suffer from delayed healing and extra care needed
Chronically ill, diabetic, elderly, malnourished pts, pts with very large wounds, chronically infected wounds, wounds in area with less circulation
- may have incomplete or halted healing
- serous fluid (cellular component of blood like plasma) may drain from partially healed wounds
- home care for dressing changes and antibiotics
What is keloid scar formation
Formation resulting from overproduction of scar tissue; scar extending past injury borders
- common in dark pigmented skin; on sternum, abdo, upper extremities and ears
What is hypertrophic scar formation
Excessive scar tissue within injury borders
- common at dynamic tension points like joints
What is compartment syndrome
Muscle ischemia that is caused by rising pressures within anatomical fascial space
- usually in closed wounds
- usually extremity injury causing swelling /edema in deep tissues due to limited room for expansion
What happens in compartment syndrome if pressure rises above 45-60 mmHg
- blood flow compromised to muscle/ tissue (ischemia)
- muscle mass may die interfering with limb function
- resulting scar tissue shortens length of muscle strand and produces Volkmann’s contracture (interfering with.limb usefulness)
What is area at greatest risk of compartment syndrome
Calf because of its bulk and fascial anatomy
What are pressure injuries
Caused by prolonged compression of skin and tissue beneath
Who might get pressure injuries
Chronically ill pts (bed-ridden), pt who falls and remains in one position (especially if unconcious) for multiple hours
- alcohol intoxication, stroke, drug OD, elderly who cant get up alone
- pt immobile on spinal board or splint too long
- weight of pt against ground compresses tissue and induces hypoxic injury
What is difference of pressure injury and crush injuries
Similar but pressure injury is more passive (more likely to go unoticed)
What is minor crush injury and massive crush injury
Crush injury = tissue subjected to severe compressive forces
Minor = maybe just a finger
Massive = much or all of the body
MOI are varied
What is disrupted in crush injury
Muscles Blood vessels Bone Occasionally internal organs Skin may remain intact or be open Structure may be normal or deformed
Why would hemorrhage be difficult to control in crush injury
- source of bleeding may be hard to find
- large vessels can be damaged
- structural damage may prevent direct pressure
What does palpation of tissue hypoxia and acidosis feel like
They cause muscle rigor so muscle may be very hard
Additional injuries from crush injury
Hypothermia, dehydration, depending on MOI
What is injection injury
Results when a bursting high- pressure line (like hydraulic line) injects fluid through pts skin and into subcutaneous tissue
- with strong pressure, fluid may push btw tissue layers and travel along limb
- fluid damages surrounding tissues
- body cant remove fluid
How can injection injury compromise limb
- direct physical damage
- chemical damage from injection material
- from infection that follows injury
What level is affected in 1st degree burn
Superficial
What layer is 2nd degree burn
Partial thickness, blistering
What layer is 3rd degree burn
Full thickness, partially or fully charred
What layer is 4th degree burn
Complete thickness, likely into muscle and bone
Major concerns with burns
Infection
Hypovolemia
Hypothermia
Pain
What is dressing and 5 kinds
Material placed directly over a wound to control bleeding
- steril/ non sterile
- occlusive/ nonocclusive
- adherent / nonadherent
- absorbent / non-absorbent
- wet/ dry
What is bandage and 5 kinds
Material used to hold a dressing In place and apply direct pressure to co trolls hemorrhage
- roller/ king
- gauze
- adhesive
- elastic
- triangular
Sterile dressing
Cotton or other fiber pad
Free of microorganisms
Packed individually and remain sterile till open
Direct contact with wound
Non sterile dressing
Clean but not free of microscopic contamination
Not meant to go directly on wound
Place over sterile dressing
Adds bulk and absorption
Occlusive dressing
Prevent fluid movement and air aspiration into chest wounds ( sucking chest wound) or open neck wound (air emboli into jugular vein)
- sterilized plastic and petroleum gauze
Nonocclusive dressing
Most dressing material are nonocclusive category
- breathable and not resistant to fluid movement
Adherent dressing
Cotton or fiber pads that stick to drying blood and fluid
- promote blood clot formation (reduce hemorrhage)
- removal likely to break clot and cause rebleeding
Nonadherent dressing
Specifically treated with chemicals like polymers
- stoos fluids and clotting materials from sticking to dressing
- proffered for uncomplicated wounds
Absorbant dressing
Readily soak up blood and other fluid
- similar to a sponge
- helpful in heavy bleeding situations
- most dressings are absorbant
Nonabsorbant dressing
Absorb little to no fluid and used when a barrier to leaking is needed
- typically used over IV sites
Wet dressing
Applied to specific types of wounds (burns)
- help with healing post OP wounds
- sterile non- saline is used to wet dressing
- provide medium for movement of infectious material into wound
- used prehospitally for eviscerations or other injuries where tissue is exposed
Dry dressing
- most often employed in pre- hospital setting
- any dressing not dampened by saline = dry dressing
What is self-adherent roller bandage (kling)
- most common and convenient pre hospital bandage material
- resists unraveling as it rolls over itself
- confirms easily with body contours ( useful circumferentially)
- usually 4” and 6” in ambulance
What is gauze
- convenient for securing dressing
- do not stretch (dont contour linked kling)
- can increase pressure associated with tissue swelling at injury site
What are adhesive bandages
Strong plastic, paper or fabric material with adhesive applied to one side
- effectively secure small dressing where circumferential wrapping is impractical
(If wrapped circumferentially would prevent room for swelling and causes pressure to accumulate)
What are elastic bandages
- stretch and conform to body contours
- very easy to apply to much pressure ( may need to loosen bandage while swelling increases)
What are triangle bandages
- usually used to make slings/ swathe since they are not elastic
- do not provide direct pressure, but may be used to affix a splint
When doing scene assessment on arrival to musculoskeletal injury make sure to:
- make sure what caused trauma to pt is not risk to you paramedic
- consider additional PPE ( eye protection, gown, face shield based on extent of hemorrhage)
- for severe bleeding, consider applying 2 pairs of gloves( can easily slip off top pair if become too bloody)
Primary survey pt with soft tissue trauma
- always, ABCs and any life threatening gross hemorrhage come first
- consider rapid transport for pt with sign of shock, uncontrolled bleeding, or estimated large blood loss. Significant MOI also
Add to you assessment of soft tissue trauma
- inspect wounds for debris and ID what caused trauma to anticipate level of contamination
- any pt with altered LOC or distracting injury make sure you do hands on secondary assessment on way to hospital
- inspect wound well, need to dress it and describe it to the ER
Objectives of soft tissue management (4)
- Control hemorrhage
- Keep wound clean
- Immobilize wound site to prevent clot disruption
- Prevent further injury/ pain
How to manage and control hemorrhage
~RED~
Rest
Elevate
Direct Pressure
Consider cold pack above wound site to assist in hemorrhage control and swelling
When can you consider additional care like tourniquets
If hemorrhage does not stop
- but always attempt direct pressure first
What to always check with circumferential bandaging and splinting
Monitor distal circulation
Treatment of sort tissue injury includes 2
- choose appropriate dressing for wound
- flush wound with sterile water if debris is present
What is presentation of scalp injuries
They are very vascular so often cause injury to look worse
Why do you need to make sure you asses underlying bone structure of scalp injury before applying pressure
If skull fx = gentle digital pressure around would d
No fx= direct pressure
Does scalp injury usually account for shock/ hypovolemia
Rarely
What to assess on pt with scalp injury
Signs of
Head injury
Concussion
Ocular disturbances
What to do if brain or CSF matter is evident when dressing wound
Brain matter = cover with moist, sterile dressing and consider plastic/foil to retain heat
CSF = apply loose dressing over any wound that appears to have CSF draining
Anatomical considerations for face injury
- often significant bleeding
- avoid or relieve airway obstruction, may need to suction
- may need gauze and tape to dress face wounds
What do you do if tooth is displaced
Attempt to put it back and have pt bite on gauze
Or bring it to hospital
Prepare for what if pt swallows blood
Blood is gastric irritant
- be prepared for nausea and or vomiting
How to dress a ear wound
Apply directly to ear and then wrap with kling wrap for external hemorrhage/ trauma
What to do if pt bleeding from ear canal
- check for CSF and then cover loosely with gauze
- if you prevent flow of CSF it may cause increased intracranial pressure
What kind of dressing do you use on neck
- never apply circumferential pressure dressing around the neck
- be aware of airway complications from tight bandages
If you need to apply continuous direct pressure to neck wound what should you be careful to avoid
Putting pressure on both carotids at the same time
How can you put pressure on wound with c- collar
Put bulky dressings under it to apply pressure
When to consider occlusive dressing to neck
If there is any risk of air entering the vasculature of the neck
What to watch for with soft tissue injury in abdomen
Watch for developing signs of contusions
- potential for organ damage
What to keep in mind with thorax injuries
External wound may be only a small part of the picture- internal damage may be significant
- watch for signs of pneumo/ hemothorax
How to dress sucking wounds on thorax
Occlusive 3 sided dressing
How to dress minimal thorax wound
Consider dressing with tape
What is may be a good way to manage significant hemorrhage of thorax
Wrapping around chest
How to manage an amputation wound
- gently rinse with saline if contaminated
- wrap exposed end part with moist, sterile gauze and plastic/ foil
- apply ice or submerge in cold water
- bring amputated part to hospital in a bag that is dry and sealed and placed in cold water on ice
How to manage impaled object wound
- stabilize in place with gauze or triangle “donut” to prevent movement
- prevent excessive limb movement
- remove object only.if interferes with CPR or airway
- secure dressing in place to increase direct pressure on external hemorrhage
How to manage crush/ compartment syndrome
- care for underlying injury/ hemorrhage
- splint and immobilize where required
- apply cold packs to any developing contusions
- provide fluid resuscitation
- prepare for risk of rapid decompensation if pt had been trapped for an extended period of time
(Constantly monitor vitals as can crash quickly)
What is max time of cooling a burn to avoid hypothermia
Less than 30 mins
How to manage 1st degree burns
Moist, sterile dressing and the cover with a dry dressing
How to manage 2nd degree burn
Less than 15% of body
Moist sterile dressing and then cover with dry dressing
More than 15% of body
Dry sterile dressing and keep them.warm
How to manage 3rd degree burn
Dry sterile dressing
How to bandage burns to fingers and toes
By wrapping a dressing in between each digit before wrapping whole hand /foot
