Wounds Flashcards
what is a wound?
An injury to living tissue, breaking its continuity
Blood Loss - arteries
Arteries have a higher pressure of blood to get it to where it needs to go.
If an artery is damaged it will spurt in time with the beat of the heart.
Will also be bright red as it is oxygenated blood.
Blood Loss - Veins
Veins have less pressure and less muscle so if a vein is cut there will be a steady flow of blood.
not as much oxygen as it carries blood to the heart so will be dark red in colour.
Blood Loss - Capillaries
Slow, even flow of blood
oozes to the wound surface
What factors affect blood loss?
- Depth, type and size of wound
- size of the blood vessel
- duration
- position of wound - which blood vessel (scalp wounds bleed a lot as there is not much muscle in the head to do anything about it - muscle normally contracts down to slow bleeding)
- age and size
What are the priorites in wound care?
E.g dog bite or needle stick. you need to encourage wound to bleed as you dont want whatever was in it going into blood stream.
also cooling an injury e.g. burn
What are the 5 cardinal signs of inflammation?
- pain
- heat
- swelling
- redness
5, loss of function
Where are some pressure points?
- radial (wrist)
- brachial (above inside of elbow)
- carotid (kneck)
- femeral artery (groin)
What is shock?
Shock is a clinical state in which the delivery of oxygenated blood (and other nutrients) is not adequate to meet metabolic demand.
What are the signs of hypovolaemic shock? (loss of blood)
paleness nausea fast breathing (tachypnoea) to compensate for the lack of blood circulating cool peripheries agitated behaviour tachycardia (fast HR)
When may signs of shock become apparent?
May not become apparent until 1 to 1.5 litres of blood has been lost.
these signs may be even later in pregnant women and fit individuals.
Circulating blood volumes: (ml/kg)
Neonates 85 -90
Infants 75 – 80
Children70 – 75
Adults 65 – 70
Childrens circulating blood volume…
Children have a smaller absolute circulating blood volume and a smaller cardiac output. As a result,even small amounts of blood loss can compromise systemic
perfusion.
What is the average Adult circulating blood volume (litres)?
5-6 litres
What factors affect blood volume?
Age
Weight
Height
Pregnancy (as have more plasma)
How do you manage external haemorrhage?
SCENE/SMART approach control any catastrophic haemorrhage give patient as much 02 as can give think about their position (can we lie them down, raise legs?) elevate injured area apply pressure (direct or indirect) clean and dress wound immobilise the injured area treat for any shock paramedic backup reassess consider trauma alert
How do we manage foreign objects in management of external haemorrhage?
PEEP
Position
Expose
Elevate
Pressure
What is direct pressure?
• Pressure applied directly to the wound. • By application of a dressing. • By hand. • NOT to be used in the case of a fracture. • NOT to be used in the case of a foreign body.
What is indirect pressure?
Pressure applied proximal to the wound. • Can use pressure points. • Can use built up dressings. • To be used in the case of a fracture. • To be used in the case of a foreign body.
What is haemostasis?
The stopping of the flow of blood
Haemostasis escalator:
- Direct pressure and elevation of limb
- wound packing and/or haemostatic agent
- limb positioning, traction and splint
- pressure points
- tourniquet
What are the considerations in wound care?
- infection - inflammation, wound healing will not occur until the infection has gone
- dog bites or needle stick - bleed the wound
- wound cleaning - irrigation/ debridement (not us) antibiotics (not us)
- infection tracking - sepsis
What is a catastrophic haemorrhage?
an exsanguinating bleed that is immediately life threatening.
managing this takes priority over all other considerations.
What is the management for an internal haemorrhage?
- SCENE/SMART
- 02 as per guidelines
- assess pulse sites
- position patient lying
- incline the patient to the injured side - blood wont pool over
- if bleeding from an orifice, allow for drainage
- treat for shock
- elevate the legs
- reassess
- paramedic backup
trauma alert
What are the advantages of major trauma centres?
specialist surgeons
specialist scanning facilities
specialist support facilities e.g. Intensive care
general and emergency medicine
What is a burn?
Caused by dry heat sources
What is a scald?
Caused by wet heat sources
What are the different types of burn?
flame radiation electricity friction corrosive chemicals
Radiation burn…
most commonly UV radiation from sunburn In the event of suspected radioactive material request specialist help, do not approach. • Await Fire Service and / or HART
Electrical burn…
isolate electricity before touching
visible burn may not reflect extent of damage internally to deeper tissue
Cardiac arrhytmias – always take monitor
• Consider ‘C’ spine injury
Friction Burn
• Causes may include sliding or machinery.
• If machinery consider own safety.
• Mechanism may cause
other flesh wounds /injuries.
Chemical Burns
Consider own safety • What type of chemical is it? • Is a neutralising agent available? • May be corrosive and destroy tissue • May be hot / produce heat • May contaminate clothing • May solidify on / in tissues • May be toxic • Alkali burns require prolonged irrigation
What are the types of scald sources?
water
steam
fat
hot liquid chemicals
What are some additional hazards about scalds?
Boiling water, steam or fat take a long time to cool and continue to cause damage after initial
contact.
If safe remove contaminated / hot clothing that is not adhering to skin.
What is the composition of skin/ 3 main layers?
epidermis
dermis
subcutaneous layer
The epidermis itself is made up of how many layers?
5
what is a Superficial Burn
1st degree burn
reddening of skin
damage to epidermis
What is a partial thickness burn?
2nd degree burn blisters damage to epidermis and dermis still have sensation longer to recover
What is a full thickness burn?
severe blistering
may be charred
damage to all 3 layers of skin and underlying tissue
no pain
How to assess the Severity of a burn…
area not depth of burn is assessed.
calculate TBSA affected
use all of burn area but not areas of erythema (area of reddening)
Children may develop shock more easily as the plasma part of blood gets pulled out so as a result of less circulating fluid.
Infants and the elderly are at risk of
death from burns as little as 10% of
TBSA.
Time critical burns %
10% in children TBSA
15% adults TBSA
what is wallace rules of nines -
methods of calculating % body surface area affected adults: arms and head 9% each
legs and torso and back 18% each
pelvic - 1%
children: head, torso and back - 18% each arms - 9% legs 14% pelvic 1%
what are the complications of thermal burns?
shock
infection
hypothermia (from cooling the burn)
respiratory tract injury from inhalation or ingestion.
how do patients with burns get hypothermia?
Patients with burns lose heat from none epithelialised areas of skin due to evaporation. With the thermoregulatory function of the skin disrupted, patients are at risk of hypothermia even on a warm day
What are the causes of shock in burns?
• Local and systemic response to thermal trauma.
• Build up of oedema and vascular fluid in the area of injury.
• Initial decrease in blood flow to damaged area followed by a considerable increase in arteriolar
vasodilation.
• Concurrent release of vasoactive substances from burned tissue causes increased capillary permeability and leads to intravascular fluid loss and wound oedema
(burnt skin releases a chemical, this chemical thats now next to the capillaries says they can become permeable. so fluid starts to leak out the capillaries. the chemicals pull the fluid out to the surface (blisters form)
what are the effects of shock in burns?
- Compromised cardiac output • Increased systemic vascular resistance • Reduced peripheral blood flow. • Hypovolaemia (loss of fluid) • Loss of electrolytes • Bursting of red blood cells in severe burns (heamolyse) • Renal failure • Further tissue damage from impaired peripheral blood flow and can result in metabolic acidosis. • Greater the burn – greater the fluid loss
What are the signs/increased risk of airway burns?
Facial or neck burns Soot in nasal or oral cavities Coughing up blackened sputum Cough and hoarseness Difficulty in breathing and swallowing Blistering around mouth and tongue Scorched hair, eyebrows Wheezing or stridor on auscultation Loss of consciousness Fires / blasts in enclosed space
What are the steps for managing/treating burns?
SCENE/SMART and IPC measures ABC observe mouth and nose for any soot/swelling 02 high conc mask beware of carboxyhaemoglobin on sp02 monitoring. nebuilser if required. remove clothing if safe and not stuck to burns irrigate with copious amounts of running water or saline if water not avail for 15 mins if chemical burns and 20 mins for all other. do not use ice or ice water cling film (do not wrap) analgesia ECG in electrical injury chemical - note type consider other injuries/illness warm child and cool burn children with burns >10% require IV consider NAI (non accidental injury)
What should be conveyed to the hospital when bringing in burn patient?
any full thickness burns all chemical and electrical burns any suspicion of NAI burns associated with sepsis burns with significant other injuries
What are the time critical features when dealing with burns?
Major ABCD problems Airway burns (soot or oedema around mouth / nose) History of hot air or gas inhalation Respiratory distress Circumferential burns Significant facial burns Burns > 15% TBSA in adults and > 10% in children Presence of other major injuries
Things to consider when dealing with burns are…
airway status can deteriorate rapidly
stopping the burning process is essential
record time from burning
are there any pre-existing conditions that may be exacerbated? e.g. asthma
What does sp02 stand for and what is it?
SpO2 stands for peripheral capillary oxygen saturation, an estimate of the amount of oxygen in the blood. Specifically, it is the percentage of oxygenated haemoglobin (haemoglobin containing oxygen) compared to the total amount of haemoglobin in the blood (oxygenated and non-oxygenated haemoglobin). Normal SpO2 levels in a person without certain lung diseases are 94% to 98%.
What is a wound and what are the 7 types?
A wound is injury to living tissue breaking its continuity.
The are: contusion, abrasion, laceration, incision, puncture, gunshot and avulsion
What is the composition of blood?
Plasma - 55% of total blood
Buffy coat - leukocytes and platelets - <1% of total blood
Erythrocytes 45% total blood
What is a contusion?
(Bruise)
Damage to the capillaries or vessels under the skin leak into the area around them
Bright red blood bleeds in a tight space, RBC then lack 02 and die. Blood goes black/purple that then turns yellow. Yellow is the colour of broken down blood vessels that need clearing out by WBC
Treatment: rest, pain relief, consider any damage underneath
What is an abrasion?
(Graze)
Surface of the skin has been taken off. Caused by friction shearing the skin away
Can be superficial, painful (as top layer contains nerve endings) and contaminated. Infection risk.
Treatment: get debris out, use saline to clean, if dressing do not use fluffy dressing e.g gauze and compression if bleeding
What is a laceration?
Tearing or splitting of skin due to blunt trauma. Skin/tissue/muscle is torn open. Often a ragged wound which extends to underlying structures.
Treatment: apply pressure if bleeding or pack, debris surrounding is removed and dress, immobilse limb and raise
What is an incision?
A break in the continuity of the skin cause by a sharp implement e.g glass
Cans be a clean wound with neat edges
Treatment: may need to pack the wound, dressing and pressure
What is a puncture wound?
A penetrating wound, typically small externally but may be deep, causing serious internal damage to blood vessels /structures.
Think about is it straight, is it bleeding, where on the body is it, important to know size of weapon
Treatment is clean, pressure, dressing
What is a gunshot wound?
Complicated wound cause by a projectile moving at speed.
Not always an entry and exit wound
Cavitation occurs internally with varying degrees of damage
The projectile crushes structures along its track. This cavitation causes shearing and compression tearing structures or stretching in elastic tissue. Soft tissue collapses inwards
Make sure scene is safe
What is an avulsion wound?
E.g skin tears and devolving
This describes the forced detachment of body structures, most commonly skin and other soft tissue exposing underlying structures
What are the complications associated with wounds?
Bleeding Pain Infection Damage to underlying structures Location Age
Internal blood loss…
Can be concealed within the body
Mechanism of injury and presence of shock can help with diagnosis
May have reduced pulse, check cap bed refill, swelling and or contusion.
On the floor plus 4
External blood loss…
Bleeding is visible and should be detected during primary/secondary survey
Can usually be controlled
Think about what’s on the floor that could have been absorbed
Blood loss and haemorrage…
Haemorrhage refers to blood loss.
The amount and flow associated with blood loss will vary according to the vessels from which the haemorrhage arises.
We can often asses the type of damage from the presentation of the haemorrhage.
In many cases, more than one type of vessel is involved.
