Soft Tissue Trauma Flashcards

Question

what is a degloving injury?

Answer 1

DEGLOVING INJURY = avulsion in which the mechanism of injury tears the skin off the underlying muscle, tissue, blood vessels, and bone Seen most frequently in farming and industrial setting, and also with watches and rings Poor prognosis for use of digit or extremity unless vasculatures is not completely damaged Essentially, the object (like a ring or a watch) or the skin around the extremity gets caught and is pulled the opposite direction as the weight of the patient or machinery Literally the same mechanism as removing a glove or a sock where you take the wrist/ankle band and turn it inside-out as it is being removed

Answer 2

Severance, removal, or detachment, either partial or complete, of a body part Typically results in complete loss of limb or digit May have limited hemorrhage as the vessel ends spasm and contract back into surround muscle tissue Surgical repair may include reattaching the detached part – including surgical repair of blood vessels, or may involve using the skin from the detached part to graft the end of the remaining limb/digit If skin is too tight or unavailable, the surgeon may be required to further cut back the bone and muscle to allow extra skin to close over the damaged end Often times surgical reattachment is only possible with clean severing of the limb/digit May result in permanently shortened limb/digit, decreasing mobility and function

Answer 3

Most common complication of open wounds Statistically 1:15 wounds lead to some type of infection – can be isolated, involve surround tissue, or cause sepsis Present with pain, tenderness, erythema, and increased warmth to the area; may also present with pus (collection of WBCs, cellular debris, and dead bacteria) discharging from wound site Thick, pale yellow-green in colour, and has a foul smell

Answer 4

Staphylococcus and Streptococcus bacteria families are the most common cause of skin infections Gram positive, aerobic, and very common in the environment Staphylococcus colonizes on the surface of skin, so it is easily pushed into open wounds at time of injury ``` Psudomonas aeruginosa (diabetics and foot puncture wounds) and Pasteurella multocida (cat/dog bites) also cause infection ``` Less common; considered gram negative May also accompany a complaint of fever and generalized weakness, especially as sepsis sets in

Answer 5

Lymphangitis = inflammation of the lymph channels, usually as a result of a distal infection Visible red streaks extending from wound margins up the affected extremity

Answer 6

-PATIENTS HEALTH, MEDICATIONS, WOUND TYPE/LOCATION, DIRTY OBJECTS, BITES, TREATMENT PROVIDED (WOUND CLOSING, ANTIBIOTIC RESISTANCE, ETC) Related to the patient’s health, type/location of injury, associated contamination, and treatment provided Diabetics, hospitalized, elderly, and chronically ill patients heal more slowly and less effectively than healthier individuals Patients with cancer, anemia, hepatic failure, and cardiovascular disease to not initiate immune or tissue-repair response as efficiently Human immunodeficiency virus (HIV) causes acquired immune deficiency syndrome (AIDS) attacks immune system Smoking constricts blood vessels, which robs healing tissue of oxygen and nutrients Certain medications also inhibit the body’s ability to fight infection Corticosteroids (Prednisone and Cortisone), NSAIDS (Ibuprofen and Motrin) Colchicine (medication for gout) decreases inflammatory response Neoplastic agents (chemotherapy) – used to fight rapid reproduction of cancer cells – disrupt cell regeneration at wound Wound type/location Puncture traps contamination within tissue Avulsion tears away tissue and blood cells, decreasing available blood supply Crush injuries (and other large wounds) cause a large dead/devitalized area – larger environment for bacterial growth Areas of higher vascularity (scalp and face) ward off infection more efficiently; distal areas of poor circulation are higher risk Clean objects (clean knife or clean glass) do not expose the patient to as much contamination Dirty objects (rusted nails, old wood, or a dirty needle) introduce bacteria immediately Bites (human or animal) are laden with bacteria and cause some of the most serious infections Treatment provided plays a large role in infection control Clean gloves protects both paramedics and patients Sterile dressings and sterile water flushing of wounds sites ``` Closing wound (with sutures, for example) increases the infection risk by trapping bacteria, but are better for healing cleanly ``` Antibiotics and tetanus shots are best within an hour of injury (especially with puncture wounds to feet, gunshot wounds, stabbings, or wounds where a foreign part remains in the skin) Antibiotics after the fact may increase risk of infection if patient is resistant to the medication, or has resistant microorganisms

Answer 7

Deep space infection usually caused by the anaerobic bacterium Clostridium perfringens Characteristically produce a gas deep within a wound, causing subcutaneous emphysema and foul smell with gas escape Can spread rapidly once developed, potentially infecting an entire extremity Can lead to sepsis and death if not treated rapidly and aggressively (occasionally using hyperbaric oxygenation) If antibiotics to not work, amputation may be the only treatment to prevent further spread (less common now)

Answer 8

Also known as lockjaw Caused by the anaerobic bacterium Clostridium tetani – produce a potent toxin that spreads systemically Less local (wound site) involvement, and more widespread pain and muscle contraction Treatment is slow and prolonged – since antidote only neutralizes circulating toxins Modern routine immunization has drastically reduced cases of tetanus (series of 3 in childhood, and 1 shot every 10yrs)

Answer 9

Despite potential risk, antibiotics are the best current form of treatment Also referred to as chemical bactericidals Gram-positive infections Antistaphylococcal penicillin, cephalosporin, and erythromycin (for patients allergic to PNC) Gram-negative infections Psudomonas require two medications together, whereas Pasteurella is treated with penicillin If an abscess occurs (accumulation of pus), lancing to allow drainage may be required Surgical removal of bacteria-infested tissue may also be required if antibiotics are too slow or ineffective

Answer 10

Anticoagulation therapy – whether routine like ASA, or more aggressive like Coumadin or Heparin – prolong clotting time and efficiency by anti-platelet aggregation or break down of clot protein fibres Penicillin may also increase clotting time and blood cell production Abnormalities in proteins involved in fibrin formation (hemophiliacs) delay clotting

Answer 11

Movement of underlying structures (bone or muscle), or removal/movement of a dressing may disrupt clotting More absorbent dressings may hide bleeding that appears otherwise controlled until it bleeds through Monitor all dressings to ensure blood loss is not accumulating (ring of blood is not growing/leaking through) Partially healed wounds, such as surgical sites, may re-open more easily and cause significant hemorrhage

Answer 12

Chronically ill, diabetic, elderly, and malnourished patients, in particular, may have incomplete or halted healing Also resulting from of large wounds, chronically infected wounds, or wounds in locations with decreased circulation (distal extremities) Serous fluid = cellular component of blood, similar to plasma May drain from partially healed wounds Home-care may be set up for patients with these types of wounds for frequent dressing changes and antibiotics

Answer 13

Keloid = formation resulting from overproduction of scar tissue; scar extending past injury borders Common in darkly pigmented skin; on sternum, abdomen, upper extremities, and ears Hypertrophic scar formation = excessive scar tissue within injury borders Common at dynamic tension points, like joints

Answer 14

Muscle ischemia that is caused by rising pressures within an anatomical fascial space Typically in closed wounds Typically an extremity injury causing edema/swelling in deep tissues; due to the limited room for expansion If pressure rises above 45-60mmHg, blow flow becomes compromised to muscle/tissue of that area = ischemia Muscle mass may die – interfering with limb function Resulting scar tissue shortens the length of the muscle strand and produces Volkmann’s contracture, further interfering limb usefulness All extremities could be at risk, but calf is at greatest risk because of its bulk and fascial anatomy

Answer 15

Caused by prolonged compression of skin and tissues beneath May occur in chronically ill patients (bed-ridden), a patient who falls and remains in one position (especially if unconscious) for multiple hours Alcohol intoxication, stroke, drug overdose, or elderly who are unable to get off floor themselves Weight of patient against ground compresses tissue and induces hypoxic injury Similar to crush injuries, but is more passive – more likely to go unnoticed Also occurs if a patient remains immobilized to a spinal board or splint for an extended period of time

Answer 16

When body tissue is subjected to severe compressive forces Minor (involving only a finger) or massive (affects much or all of the body) Mechanisms are varied Disrupts body tissues – muscles, blood vessels, bone, and occasionally internal organs Skin may remain intact or be open; structure may be normal or deformed Hemorrhage may be difficult to control Source of bleeding may be difficult to identify Large vessels may be damaged Structural damage may prevent direct pressure Tissue hypoxia and acidosis cause muscle rigor – muscle may be very hard on palpation Additional injuries, hypothermia, or dehydration may result depending on mechanism of crush injury

Answer 17

Results when a bursting high-pressure line (like a hydraulic line) injects fluid through a patient’s skin and into subcutaneous tissue With strong pressure, fluid may push between tissue layers and travel along limb Chemicals of fluid damage surrounding tissues Body is unable to remove fluid Limb may be compromised due to: Direct physical damage Chemical damage from injected material From infection that follows injury

Answer 18

1st degree – superficial 2nd degree – partial thickness; blistering 3rd degree – full thickness; partially or fully charred 4th degree – complete thickness; likely into muscle and bone Major concerns: Infection Hypovolemia Hypothermia Pain

Answer 19

DRESSING – material placed directly over a wound to control bleeding Sterile/Non-sterile Occlusive/nonocclusive Adherent/nonadherent Absorbent/non-absorbent Wet/dry

Answer 20

``` STERILE Cotton or other fibre pads Free of microorganisms Packaged individually and remain sterile until opened Direct contact with wound ``` NONSTERILE Clean, but not free of microscopic contamination Not intended to be applied directly to wound Placed over sterile dressings Adds bulk and absorption

Answer 21

OCCLUSIVE 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 Most dressing material fall into nonocclusive category Breathable and not resistant to fluid movement

Answer 22

ADHERENT -Cotton or fibre pads that will stick to drying blood and fluid -Promote blood clot formation – reduce hemorrhage -Removal is likely to break clot and cause re-bleeding NONADHERENT -Specifically treated with chemicals – such as polymers -Prevent fluids and clotting materials from adhering to the dressing -Preferred for uncomplicated wounds

Answer 23

ABSORBANT - Readily soak up blood and other fluids - Similar to a sponge - Helpful in heavy bleeding situations - Most dressings are absorbant NONABSORBENT - Absorb little to no fluid and used when a barrier to leaking is needed - Typically used over IV sites

Answer 24

WET -Applied to specific types of wounds – as in burns -Used to help in healing post-op wounds -Sterile non-saline is used to wet dressings -Provide medium for movement of infectious material into wounds -Used prehospitally for eviscerations or other injuries where internal tissue is exposed DRY -Most often employed in pre-hospital setting -Any dressing not dampened by saline may be considered a dry dressing

Answer 25

BANDAGE – material used to hold a dressing in place and apply direct pressure to control hemorrhage Roller/Kling Gauze Adhesive Elastic triangular

Answer 26

Most common and convenient pre-hospital bandage material Resists unravelling as it rolls over itself Conforms easily with body contours – most useful when needed circumferentially Typical 4” and 6” in ambulance

Answer 27

Convenient for securing dressings Do not stretch – do not contour as well as Kling May increase the pressure associated with tissue swelling at injury site

Answer 28

Strong plastic, paper, or fabric material with adhesive applied to one side Effectively secure a small dressing where circumferential wrapping is impractical If wrapped circumferentially, would prevent room for swelling and causes pressure to accumulate

Answer 29

Stretch and conform to body contours Very easy to apply too much pressure – while swelling increases, the bandage may need to be loosened

Answer 30

Commonly used to make slings/swathe since they are not elastic Do not provide direct pressure, but may be used to affix a splint

Answer 31

Scene assessment -Ensure whatever caused trauma to the patient is not also a risk to you as the Paramedic -Consider additional PPE – eye protection, gown, or face shield depending on the extent of hemorrhage -For severe bleeding, consider applying x2 pairs of gloves before contact with the patient – if the top pair becomes covered in blood, a second pair is easily accessible by removing the first pair Primary survey -As usual, ABCs and any life-threatening gross hemorrhage should be addressed first -Consider rapid transport for any patient presenting with signs of shock, uncontrolled bleeding, or estimated large blood loss -Take into consideration the mechanism of injury – if significant, consider rapid transport as precaution for possible internal injuries -Inspect the wounds for debris, and identify what caused the trauma to anticipate the level of contamination -For any patient with altered LOC or distracting injury, be sure to complete a hands on secondary assessment on the way to the hospital -Ensure you have inspected the wound well – you will be dressing it, and you’ll need to describe it to ER staff

Answer 32

Objectives of soft-tissue management: Control hemorrhage Keep wound clean Immobilize wound site to prevent clot disruption Prevent further injury/pain For hemorrhage control = REST. ELEVATE. DIRECT PRESSURE (RED) Consider application of cold pack above wound site to assist in hemorrhage control and swelling Always attempt direct pressure first – if hemorrhage does not stop, then consider additional care, like tourniqets Choose the appropriate dressing for the wound Flush the wound with sterile water if debris is present For any circumferential bandaging, monitor distal circulation the same as with splinting/fractures

Answer 33

Very vascular – often causes the injury to look more severe than it is Rarely accounts of shock/hypovolemia Can be difficult to control Be sure to assess the underlying bone structure before applying significant pressure to a scalp injury If skull fracture = gentle digital pressure around wound Without skull fracture = direct pressure Be sure to assess for any signs of head injury/concussion/ocular disturbances Consider elevating the patient’s head, even if immobilized, with padding under long board/scoop If brain matter is evident, cover with moist, sterile dressing and consider plastic/foil to retain heat Apply a loose dressing over any wound that appears to have CSF draining

Answer 34

Often has significant bleeding Be cautious to avoid or relieve airway obstruction – may require suctioning If a tooth is displaced, attempt to put the tooth back in its socket and have the patient bite on gauze, otherwise bring with you to hospital If the patient has swallowed blood, be prepared for nausea and/or vomiting Blood is a gastric irritant May require gauze and tape to achieve dressing/bandaging of face wounds due to contouring of bone structures

Answer 35

Apply dressing directly to ear and then wrap with kling wrap for external hemorrhage/trauma If bleeding is from canal, check for CSF, and then loosely cover with gauze only Preventing flow of CSF may cause increased intercranial pressure

Answer 36

Be aware of airway complications caused by tight bandaging Never apply a circumferential pressure dressing around the neck Severe wounds may require you to continue with manual direct pressure until arriving at hospital Remember to avoid putting pressure on both carotids (both sides of neck) at the same time Consider whether C-collar is required C-collar can also be applied with a bulky dressing under it to apply pressure to a wound on the neck Consider occlusive dressing if there is any risk of air entering the vasculature of the neck

Answer 37

Potential for organ damage Watch for developing signs of contusion

Answer 38

Consider that external wound may be only a small part of the picture – internal damage could be significant Watch for developing signs of pneumo/hemothorax, Occlusive 3-sided dressing for sucking wounds Consider a dressing with tape if the wound is minimal For significant hemorrhage, the bleeding may be best managed by wrapping around the chest

Answer 39

Gently rinse with saline if contaminated Wrap exposed end part with moist, sterile gauze and plastic/foil Apply ice or submerge in cold water – avoid direct limb/water contact Bring amputated part to hospital in a bag that is dry and sealed and placed in cold water/on ice

Answer 40

Stabilize in place with gauze or triangular “donut” to prevent movement Prevent excessive limb movement Remove only if it interferes with CPR or Airway Secure dressings in place to increase direct pressure on external hemorrhaging

Answer 41

Care for underlying injury/hemorrhage Splint and immobilize where required Apply cold packs to any developing contusions Provide fluid resuscitation Prepare for the risk of rapid decompensation if the patient had been trapped for an extended period of time

Answer 42

Limit cooling to <30 minutes to avoid hypothermia 1st degree burns – moist, sterile dressing and then cover with a dry dressing 2nd degree burns <15% - moist, sterile dressing and then cover with a dry dressing 2nd degree burns >15% - dry, sterile dressing 3rd degree burns – dry, sterile dressing Bandage fingers/toes by wrapping a dressing in between each digit before wrapping the entire hand/foot