Soft Tissue Injuries

Soft Tissue InjuriesMcHenry Western Lake County EMSRef: MWLCEMS Protocol

Objectives• During this session we will discuss:• Skin anatomy and functions• Open and closed wounds to include:• Abrasions, lacerations, punctures, avulsions• Amputations• Crush injuries• Impaled objects

Skin Anatomy• The skin is made up of three layers• The Epidermis: is the outermost layer• The Dermis: is the layer beneath theepidermis and has all of the nerve andvascular layers• Subcutaneous: fat layer of the skin belowthe dermis

Function of the Skin• Largest organ of the body• Protects against infection• Temperature and moisture control• Durable, flexable and able to repair itself

Closed Wounds• Contusions: Damage to the tissueimmediately beneath the skin• Hematomas: Collection of blood beneaththe skin

Closed InjuryContusionHematoma

Closed Wounds• Care and treatment:• Be aware of underlying damage• Ice• IV- pain meds as needed• Oxygen• Monitor

Open Wounds• Abrasions• Lacerations• Punctures• Avulsions• Amputations

Abrasions• A superficial wound• Caused by a rubbing or scraping• Partial loss of the skin surface

Lacerations• Cut• Clean or jagged• Skin surface and underlying structureshave been involved• May be a source of significant bleeding• Watch for arterial bleeding or spurting

Lacerations

Puncture Wounds• Wound created by piercing the skin• Not always caused by sharp, pointedobjects• Could hit underlying organs or structures

Avulsions• The tearing loose of a flap of skin• May be just hanging by another flap ofskin• Could tear all the way off if not taken careof appropriately

Avulsions

Treatment of Open Wounds• Keep it clean• Direct pressure• Elevation• Pressure Points to stop bleeding• Tourniquets are last resort• Never remove impaled object unlessobstructing the airway

Treatment of Open Wounds• Pay attention to blood loss• Be aware of signs of shock• IV, 02, Monitor• Pain meds as needed

Amputations• Partial or complete severance of digits orlimbs• Could be jagged, clean or crushed• Hemorrhaging depends on the area of theamputation

Treatment of Amputation• Life-saving procedures always take priority overmanagement of severed part.• Transport amputations above the wrist or ankleto a replantation center if ground transport timesare less than 25 minutes.• Amputation incomplete: Hemorrhage controland stabilize with bulky dressings and splints.• Uncontrolled bleeding: Apply tourniquet (BPcuff) just proximal to the injury.• Note time applied. DO NOT release tourniquetonce it has been applied.

Treatment of Amputation• Care of amputated parts:• Attempt to locate all severed parts.• Gently remove gross debris but do not removeany tissue; do not irrigate.• Wrap in saline-moistened gauze, towel, or sheet.Do NOT immerse directly in water or saline.• Place in water-proof container and seal.• Surround container with cold packs or place insecond container filled with ice or cold water.• Avoid overcooling or freezing the tissue.

Treatment for Pain• Assess pain (0-10), paralysis, paresthesias, pulse,pressure & pallor before and after splinting• Analgesia: VS stable, isolated MS trauma, nocontraindications (drug allergy, AMS):• NITROUS OXIDE if available. Contraindicated forpregnant females• FENTANYL 0.5 mcg/kg. May repeat 0.5 mcg/kg in 5min (max 100 mcg) IVP/IN/IM/IO. Additional dosesrequire OLMC. May repeat 0.5 mcg/kg q 5 min up to atotal of 2 mcg/kg (max 200 mcg).Long bone fx w/ severe pain and muscle spasm:Analgesia as above and:• VERSED (midazolam) in 2 mg increments every 30-60sec IVP (0.2 mg/kg IN) up to 10 mg.• May repeat to a total of 20 mg.

• Crush injury: MOI inwhich the tissue islocally compressedby high pressureCrush Injury

• X-Ray of hand fromprevious pictureCrush Injury

Treatment of Crush Injury• Start IV NS TKO prior to compression release.• Run wide open upon release. Use 200 mL fluidchallenges in elderly – monitor for fluid overload.• Add 1 amp SODIUM BICARBONATE to the2nd 1000 mL IV NS; run at 500 ml/hr.• Obtain baseline ECG before release if possible.• Do not apply PASG.

Treatment of Crush Injury• If P > 100, restless, ↑RR, wide QRS, long PRinterval, or peaked T waves after above:• IV NS up to total of 3 L over 1st 90 minutesfollowing release of compression unlesscontraindicated.• (Ensure clear lung sounds, no shortness ofbreath)• Assess for compartment syndrome: If presentdo not elevate or cool limb.

Impaled Objects

Treatment of Impaled Objects• Never remove an impaled object unless it isthrough the cheek and poses an airwayimpairment, and/or it would interfere with rescuebreathing, chest compressions, or transport.• Stabilize object with bulky dressings; insertgauze rolls into the mouth to absorb excessblood.• Elevate extremity with impaled object if possible.

Case Study• You are treating a 32 y/o female and sheis a victim in a MVC. She has an obviousfracture to her L Femur. You haveremoved her from the vehicle and haveapplied a Hare Traction Splint. She hasrated her pain at a 10 out of 10. Whatmedication and dose would you give her?

Answer• Fentanyl 1mcg/kg (max 100 mcg)IVP/IN/IM/IO. May repeat 0.5 mcg/kg (max50 mcg) in 5 min.• Additional doses require OLMC: May give0.5 mcg/kg q 5 min up to a total of 300mcg if available.

Case Study• You have given her all 300 mcg ofFentanyl and she is still having spasmsand rates her pain at 8/10. You would nowgive her what medication and dose?

Answer• Versed in 2mg increments every 30-60seconds IVP/IO (0.2mg/kg IN) up to 10mg.May repeat to a total of 20 mg if SBP >90.

Special ThanksTo the Spring Grove FireProtection District for the use oftheir materials in this presentation