Soft-Tissue Wounds

The skin is the largest organ in the body and is the first line of defense against external forces and infection. Soft tissue injury may result in exposure of deep structures such as blood vessels, nerves, and bones. You will always have to control the bleeding, protect from contamination and decrease the risk of infection, and protect the wound from further damage. Must control bleeding and prevent further contamination to decrease risk of infection.

The skin has two principal lateral layers consisting of the epidermis and the dermis. The epidermis is the tough external layer that forms a watertight covering for the body. It consists of pores, and the skin is constantly worn away and replaced by cells that are pushed to the surface when new cells form in the germinal layer at the base of the epidermis. It contains pigment granules along with melanocytes in the dermis; these granules produce skin color.

The dermis is the inner layer of the skin and contains the structures that give skin its characteristic appearance. There are hair follicles in addition to sebaceous glands, which produce an oily substance called sebum, which discharges along the shafts of the hairs. This oily material also waterproofs the skin and keeps it supple. Hair and sebaceous glands are connected, and there is a muscle that pulls the hair erect whenever a person is cold or frightened. Sweat glands cool the body, while blood vessels in the dermis provide the skin with nutrients and oxygen. The dermis also contains specialized nerve endings.

Skin covers all external surfaces of the body. The various openings in the body, including the mouth, nose, anus, and vagina, which are not covered by skin, instead these openings are lined with mucous membranes and provide a protective barrier against bacterial invasion and secrete a watery substance that lubricates the openings.

There are a few major functions of the skin. It protects the body by keeping pathogens out and fluids in and helps regulate body temperature. In a cold environment, blood vessels in the skin constrict, diverting blood away from the skin and decreasing the amount of heat that radiates from the body surface. In warm environments, vessels in the skin dilate, the skin becomes red, and heat radiates from the body’s surface, and sweat glands secrete sweat to help cool the body. The nerves in the skin report to the brain on the environment and on many sensations. Any break in the skin allows bacteria to enter and increases the possibility of infection, fluid loss, and loss of temperature control.

There are three types of soft tissue injuries, the first being closed injuries, in which soft-tissue damage occurs beneath the skin or mucous membrane but the surface of the skin or mucous membrane remains intact. Open injuries, where there is a break in the surface of the skin or the mucous membrane, exposing deeper tissues to potential contamination. Burns, in which soft-tissue damage occurs as a result of thermal heat, frictional heat, toxic chemicals, electricity, or nuclear radiation.

Wounds heal in a natural process involving several overlapping stages. Among the primary concerns in wound healing is the cessation of bleeding. To stop the flow of blood, the vessels, platelets, and clotting cascade must work in unison. During inflammation, additional cells move into the damaged area to begin repair, and white blood cells also migrate to the area to combat pathogens that have invaded exposed tissue. Cells release histamine as the body’s response in the early stages of inflammation. Histamine dilates blood vessels, increasing blood flow to the injured area and results in redness and a warm area immediately around the site. Histamine makes capillaries more permeable, and swelling may occur as fluid seeps out of the “leaky” capillaries. Inflammation ultimately leads to the removal of foreign material, damaged cellular parts, and invading microorganisms from the wound site.

In the outer layer, skin cells are stacked in layers to replace the area damaged. Cells quickly multiply and redevelop across the edges of the wound. Except in clean incisions, appearance seldom returns. Scarring is a structural protein that has reinforced the damaged tissue. During the next stage of wound healing, new blood vessels form as the body attempts to bring oxygen and nutrients to the injured tissue. New capillaries bud from intact capillaries, provide a check for oxygen, and serve as a path for waste removal. Collagen is a tough fibrous protein that provides stability to the damaged tissue and joins wound borders.

Closed injuries are characterized by a history of blunt trauma, pain at the site of injury, swelling beneath the skin, and discoloration. A contusion, or bruise, ecchymosis is the buildup of blood, which produces a characteristic blue or black color. The epidermis remains intact, but there is swelling and pain in this area. A hematoma is blood that has collected within damaged tissue or in a body cavity whenever a blood vessel is damaged and bleeds into the surrounding area. It can result from a soft-tissue injury, or any injury to a blood vessel. Severe cases, the hematoma may contain more than 1 liter of blood.

A crushing injury occurs when significant force is applied to the body; damage depends on force. Direct soft-tissue damage and continued compression cut off circulation, producing further tissue destruction. Damage will continue until the source of crush is removed. When the body is trapped for longer than 4 hours and arterial blood flow is compromised, crush syndrome can develop. Tissues are crushed beyond repair, muscle cells die and release harmful substances into the surrounding tissues. These substances are released only after the limb is freed and blood flow is returned. IV should be applied before the crushing object is lifted off the body. This release of the by-products of metabolism can create potential for cardiac arrest and renal failure. Call ALS for situations of prolonged entrapment prior to extrication.

Compartment syndrome develops when edema and swelling result in increased pressure to the compartment. Due to tissues being limited in the amount that they can expand, pressure increase interferes with circulation. As pressure develops, delivery of nutrients and oxygen is impaired and abnormal metabolism accumulation may be present. Compartment syndrome can result in tissue death.

Continuous reassess skin color, temperature, and pulses distal to the injury site during transport if compartment syndrome is detected. Contamination is the presence of infectious organisms (pathogens) or foreign bodies, such as gravel, etc. There are four types of open soft-tissue wounds that you must be prepared to manage: abrasions, lacerations, avulsions, penetrating wounds.

Abrasion is a wound of the superficial layer of the skin, caused by friction. Abrasions usually do not penetrate completely through the dermis, but blood may ooze from the injured capillaries in the dermis. Examples of this are road rash or rug burn and can be really painful because nerve endings are located in that area.

A laceration is a jagged cut in the skin caused by a sharp object or a blunt force that tears the tissue. An incision is a sharp, smooth cut. The depth of the injury can vary, extending through the skin and subcutaneous tissue, even into the underlying muscles.

An avulsion is an injury that separates the various layers of soft tissue so they become either completely detached or hang as a flap. Circulation through the flap may be at risk; if you can, replace the flap in its original position as long as it is not visibly contaminated with dirt and/or other foreign materials. If an avulsion is complete, you should wrap the separated tissue in sterile gauze and take it with you to the ED; this type has a serious risk for infection. Never remove an avulsion skin flap, regardless of size.

An amputation is an injury in which part of the body is completely severed. You can easily control the bleeding from some amputations, such as a finger, with direct pressure and pressure dressings. If it involves a large area of muscle mass, such as a thigh, massive bleeding may require a tourniquet and treatment for hypovolemic shock.

A penetrating wound is an injury resulting from a piercing object, such as a knife, ice pick, splinter, or bullet. There may be little external bleeding; however, it can damage structures deep within the body and cause unseen bleeding. Objects that penetrate and remain in place are referred to as impaled objects. There is a significantly higher risk of infection. With stabbings and shootings often involving multiple penetrating injuries, you must assess these patients and identify all wounds.

Blast injuries may also result in multiple penetrating injuries. Primary blast injury – blast wave. Secondary blast injury – struck by flying debris. Tertiary blast injury – injuries to the body from being thrown or hurled by the force of the explosion into an object or onto the ground.

Assess the musculoskeletal system – Look for DCAP-BTLS, assess chest, abdomen, and extremities for hidden bleeding and injuries. Log roll the patient and assess the posterior torso for injuries, afterwards roll onto a backboard, followed by spinal motion restriction if indicated. Assess the neurologic system, LOC, pupil size (miosis, mydriasis), motor and sensory response. Check the neck for jugular vein distention, pelvis for stability, abdomen, all four quadrants for tenderness or rigidity, and inspect for bruising. If the abdomen is tender, expect internal bleeding. Check the extremities and record the pulse and motor and sensory function. Open soft-tissue injuries of the face and neck have the potential to interfere with the effectiveness of the airway and breathing. Evaluate the patient’s voice. If an open injury is found on the chest, evaluate for air movement through the wound in the form of bubbling or sucking sounds. Quickly place an occlusive dressing over the wound. An airtight dressing that protects a wound from air and bacteria; a commercial vented version allows air to passively escape from the chest, while an unvented dressing may be made of petroleum jelly. Monitor the patient for signs of increasing respiratory distress that may require you to relieve pressure built up under the dressing caused by pneumothorax.

For an open wound, there are typically occlusive dressings, direct pressure, splints, and tourniquets. Never remove, rub, or wash, as this can cause additional bleeding, but small burns and contaminations should be flushed to remove remaining chemicals. In most circumstances, hospital personnel will clean open wounds. To prevent drying, moisten with sterile saline solution and cover the moist dressing with a dry, sterile dressing. Sometimes splinting will help. Open wounds in the abdominal cavity may expose internal organs. When they protrude, that is called an evisceration. Don’t touch or move the exposed organs; instead, cover the wound with sterile gauze moistened with sterile saline solution and secure it with an occlusive dressing. Do not use any material that is adherent or loses its substance when wet, such as toilet paper, facial tissue, paper towels, or absorbent cotton. Flex knees to relieve pressure on the abdomen. When there is an impaled object, do not remove it; stabilize the impaled body part, tape a rigid item over the stabilized object to prevent it from moving during transport. For neck injuries, they may suck in air, called an air embolism, which blocks flow of blood into the lungs and can cause cardiac arrest. Apply an occlusive dressing, apply manual pressure, but do not compress both carotid vessels at the same time, which would impair circulation to the brain and cause a stroke. If needing a cervical collar, it may assist with holding a dressing in place. Due to bacteria in an animal’s mouth, the person may require debridement, removal of damaged tissue, antibiotics, and tetanus prophylaxis. Spread of rabies is a major concern; any human bite that has penetrated the skin is a serious injury.

A severe burn injury presents several simultaneous life threats, including hypovolemic shock, sepsis, hypothermia, and respiratory failure. Thermal burns can occur when skin is exposed to temperatures higher than 111°F. In general, the severity of a thermal injury directly correlates with temperature, concentration, or amount of heat energy possessed by the object or substance and the duration of exposure. Solids generally have higher heat content than gases, so exposure to a hot solid typically causes a more significant burn than exposure to hot gases. The greater the heat, the deeper the wound; exposure time is another important factor. Thermal injury can occur to unresponsive or paralyzed patients from heating pads or heat lamps.

The skin is a barrier between the environment and the body; when that barrier is destroyed, the victim is now at a high risk for infection, hypothermia, hypovolemia, and shock. Burns to the airway are of great importance because the loose mucosa in the hypopharynx can swell, resulting in complete airway obstruction. Circumferential burns of the chest can compromise breathing. Circumferential burns of an extremity can lead to compartment syndrome, resulting in neurovascular compromise and irreversible damage if not appropriately treated. Burns can cause hypothermia and acidosis and can prevent the blood from clotting effectively. Keep the patient warm and provide supplemental oxygen. Isolated burn injury should not cause an altered level of consciousness in patients, so you should expect other potential complications such as hypoperfusion, hypoxia, hypoglycemia, or head injury. Burns of 20% total body surface area (TBSA) or more will likely require IV fluid resuscitation. 30% TBSA or more, and less than 15% in older adults, may be fatal without appropriate treatment. Inhalation injury can double the risk of death from a burn.

Severe burns are any critical areas (face, upper airways, hands, feet, genitalia) involved. Circumferential burns, which are burns that go completely around a body part such as an arm, foot, or chest. Does the patient have any preexisting medical condition, younger than 5 or older than 55. In the neck, check for burns, especially circumferential, which can impair circulation. In the chest, check for burns, especially circumferential, which can impair chest rise and fall. Full-thickness burns involving the hands, feet, face, genitalia, airway, or circumferential burns. Full-thickness burns covering more than 10% TBSA in any patient. Partial-thickness burns covering more than 25% TBSA (age 10 to 50) and 20% (younger than 10, older than 50). Burns with concomitant traumatic injuries, i.e., a broken femur. Burns to patients younger than 5 years or older than 50 that would otherwise be classified as moderate. Look for singed nasal or facial hair, burns or swelling of the face or ears or in the mouth; if electrical, check scalp for signs of entrance or exit wounds.

Moderate burns: full-thickness burns involving 2% to 10% TBSA (excluding hands, feet, face, genitalia, and upper airway). Partial-thickness burns covering 15% to 30% TBSA. Superficial burns covering more than 50% TBSA. Minor burns: full-thickness burns covering less than 2% TBSA. Partial-thickness burns covering less than 15% TBSA. Superficial burns covering less than 50% TBSA.

Depth is another important factor. Superficial is redness (sunburn), involves only the epidermis; skin turns red but does not blister. Partial thickness (second degree), blistering, involves some of the dermis and does not destroy the entire thickness of the skin. Skin is mottled, white to red, and is often blistered. Full thickness (third degree) is blackening of all layers of the skin and may involve the subcutaneous tissue and muscle. The skin is dry, leathery, and often either white or charred. If the nerve endings have been destroyed, there may not be feeling, and the surrounding less severely burned areas may be extremely painful. Significant airway burns are also serious, associated with singed hair within the nostrils and soot around the nose and mouth, hoarseness, and hypoxia.

There are a few ways to measure the extent of the burn. The first is to estimate the surface area that has been burned by comparing it to the size of the patient’s palm, including their fingers, which is roughly equal to 1% of the patient’s TBSA. This technique is called the rule of palm. The rule of nines divides the body into sections, each of which is approximately 9%. Infant, child, and adult have different proportions. Infant – Head 18%, arms 9% each, chest 18%, genitals 1%, legs 13.5% each. Child – Head 12%, arms 9% each, chest 18%, genitals 1%, legs 16.5% each. Adult – Head 9%, arms 9% each, back 18%, chest 18%, genitals 1%, legs 18% each.

The emergency medical care for burn injuries is listed below. Stop the burning if the wound is still burning or hot, immerse the hot area in cool, sterile water, or cover with a wet, cool dressing. Provide high-flow oxygen. Cover with a dry, sterile dressing or clean sheet. Assess and treat the patient for any other injuries. Treat for shock, cover with blankets to prevent loss of heat. Transport promptly. Never use ointments, lotions, or antiseptics of any kind and do not intentionally break any blisters.

Thermal burns are caused by heat. Flame burns are very deep, especially if a person’s clothing catches fire. There are scald burns – hot liquids, contact burns – hot objects, reflexes typically protect, steam burns – topical scald burns, flash burns – explosions. Dry sterile dressing is applied to help maintain body temperature and prevent infection. Inhalation burns are caused when superheated gases damage the upper airway or when lower airway damage is caused by inhalation of chemicals. There are typical stridor sounds, a hoarse voice, and singed nasal hairs or carbon particles in the sputum. Inhalation of toxic gases can be considered a sister to inhalation burns. Carbon monoxide can displace oxygen from the alveolar air and from its attachment sites on hemoglobin molecules contained in circulating red blood cells. Cyanide is generated by the combustion of paper, cotton, and wool. Smell of bitter almonds. Includes abnormal vital signs, headache, seizures, paralysis, and coma. Must first consider your own safety.

Chemical burns are caused by strong acids or strong alkalis; fumes alone can cause burns. Consider hazmat, must wear appropriate PPE. Exposure risk is also a potential; do not risk exposure to the chemical. Emergency care is the same as that for thermal burns. When removing chemicals from a person, always brush off first before washing because some chemicals become more reactive when they are exposed to water, then flush with water. Remove patients’ clothing, including jewelry or eyeglasses, because they may contain small amounts of chemicals. For liquid chemicals, immediately flush the burned area with large amounts of water. Take care not to contaminate uninjured areas or make the patient hypothermic. Never direct a forceful stream of water from a hose at the patient; the extreme water pressure may mechanically injure the burned skin. Continue flooding the area with gallons of water for 15 to 20 minutes after the patient says the burning pain has stopped. If the patient’s eyes were hurt, flush the eyes from the inside corners to the outside to prevent cross contamination. Consider hooking up a nasal cannula to a bag of saline to flush both eyes simultaneously. Continue flushing en route to the hospital. Conduct proper decontamination prior to loading any patient into the ambulance and again prior to entering a hospital.

Electrical burns can cause severe burns and cardiac dysrhythmia. You can be fatally injured by touching a person who is still in contact with the voltage. Always look for entrance and exit wounds. The patient may go into cardiac arrest. Taser injuries can cause excited delirium and have led to dysrhythmias and sudden cardiac arrest. Radiation burns: alpha is stopped by skin. Beta can be blocked by simple protective clothing. Gamma radiation passes through the body and solid materials. Radiation is measured in units of radiation absorbed dose (rad) or (rem). 100 rad = gray (Gy). Average human exposure from background radiation is 0.31 rad. Mild radiation sickness can be expected with exposure of 1 to 2 Gy (100 to 200 rad), moderate sickness at 2 to 5 Gy, and severe sickness at 4 to 6 Gy. Exposure to more than 10 Gy may result in death within 2 to 4 weeks.