Soft Tissue Trauma

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Information about Soft Tissue Trauma
Science-Technology

Published on October 18, 2008

Author: aSGuest1254

Source: authorstream.com

Soft Tissue Trauma : Soft Tissue Trauma EMS Professions Temple College Test Alert!!! : Test Alert!!! You have one week Topics for Discussion : Topics for Discussion BSI Review A&P Review Wound Healing High Risk Wounds Soft Tissue Injuries Review Crush Injury & Compartment Syndrome Soft Tissue Injury Hemorrhage Control Soft Tissue Injury Management BSI Review : BSI Review Risks from Exposure to Body Substances Bloodborne Pathogens Infectious Disease Body Substance Isolation vs Universal Precautions PPE Disposal of Sharps and Contaminated Materials Anatomy & Physiology Review : Anatomy & Physiology Review Layers of soft tissue Cutaneous layer Epidermis Dermis Subcutaneous layer Loose connective tissue Fat Deep Fascia Fibrous tissue Supportive & protective Anatomy & Physiology Review : Anatomy & Physiology Review Functions of Soft Tissue Protection from Trauma Thermoregulation Sensory functions Pain, Touch, Temperature Protection from infection Fluid maintenance Anatomy & Physiology Review : Anatomy & Physiology Review Skin Tension Lines Static Tension constant force due to taut skin scar formation Dynamic Tension underlying muscle contraction scar formation Anatomy & Physiology Review : Anatomy & Physiology Review Wound Healing - Hemostasis Change in skin anatomy Initial vasoconstriction for up to 10 minutes Clotting process Wound Healing - Inflammatory phase granulocytes and macrophages collect debris histamine release Wound Healing - Epithelialization phase Within 12 hours Healing by establishing new skin layers Anatomy & Physiology Review : Anatomy & Physiology Review Wound Healing - Neovascularization New vessel formation Begins ~ 3 days after injury Continues for ~ 21 days Wound Healing - Collagen Synthesis Fibroblasts synthesize collagen Collagen binds margins together Remodeling: collagen broken down and relaid Factors Affecting Wound Healing : Factors Affecting Wound Healing Anatomic Location of the injury Skin Tension areas Pigmented skin Oily skin Factors Affecting Wound Healing : Factors Affecting Wound Healing Drug Use Corticosteroids NSAIDs Penicillin Colchicine (used in gouty arthritis) Anticoagulants Antineoplastics Factors Affecting Wound Healing : Factors Affecting Wound Healing Medical Conditions & Diseases Advanced age Alcoholism Acute uremia Hepatic failure Diabetes mellitus Hypoxia Severe anemia Malnutrition CVD & PVD Advanced cancer High Risk Wounds : High Risk Wounds Bites human animal Foreign Bodies Contaminated with organic matter Injection wounds Significant devitalized tissue Crush injury Immunocompromised patients Poor peripheral circulation Factors Leading to Abnormal Scar Formation : Factors Leading to Abnormal Scar Formation Keloid Excessive accumulation o scar tissue beyond original wound borders common in darkly pigmented common areas ears extremities sternum Factors Leading to Abnormal Scar Formation : Factors Leading to Abnormal Scar Formation Hypertrophic scar Excessive accumulation of scar tissue within the original wound borders Common in areas of high stress flexion creases across joints Factors Leading to Abnormal Scar Formation : Factors Leading to Abnormal Scar Formation Wounds Requiring Closure Cosmetic areas face, lip, eyebrow, etc Gaping Wounds Wounds over tension areas Degloving injuries Ring injuries Skin tearing injuries Soft Tissue Injuries Review : Soft Tissue Injuries Review Contusion epidermis intact vessels in dermis are torn swelling & pain blood accumulation results in ecchymosis Hematoma collection of blood beneath skin larger amount of tissue damage larger vessels are damaged Soft Tissue Injuries Review : Soft Tissue Injuries Review Abrasion superficial injury outermost skin damaged by shearing forces painful in proportion to degree of injury no bleeding or minor bleeding contamination is primary concern Soft Tissue Injuries Review : Soft Tissue Injuries Review Laceration Skin disruption with greater depth than abrasion jagged wound ends bleed easily may involve other soft tissue injuries caused by forceful impact with sharp object bleeding may be severe Soft Tissue Injuries Review : Soft Tissue Injuries Review Incisions Skin disruption with greater depth than abrasion similar to laceration except wound ends are smooth and even tend to heal better than lacerations caused by very sharp objects Soft Tissue Injuries Review : Soft Tissue Injuries Review Avulsion flap of skin or tissue torn loose or pulled completely off avulsed tissue may or may not be viable Amputation involves extremities or body parts jagged skin and/or bone edges at site three types complete, partial, degloving Crush Injury & Compartment Syndrome : Crush Injury & Compartment Syndrome Crush Injuries caused by a crushing (compressive) force may result in organ injury often associated with severe fractures overlying skin may be intact causes collapse of structure onto body area compressive trauma to body area prolonged compression in a chronic situation Crush Injury & Compartment Syndrome : Crush Injury & Compartment Syndrome Crush Injuries & Crush Syndrome Injury sustained from a compressive force sufficient to interfere with the normal metabolic function of the injured tissue may lead to: rhabdomyolysis electrolyte abnormalities acid-base abnormalities hypovolemia acute renal failure Crush Injury & Compartment Syndrome : Crush Injury & Compartment Syndrome Compartment Syndrome local evidence of muscle ischemia results from compressive forces in a closed space e.g. within fascia Crush Injury & Compartment Syndrome : Crush Injury & Compartment Syndrome Crush Syndrome may be painful, swollen, deformed little or no external bleeding internal bleeding may be severe reperfusion phenomenon systemic effects occur after the issue is reperfused oxygen free radicals result in muscle injury high intracellular calcium Crush Injury & Compartment Syndrome : Crush Injury & Compartment Syndrome Rhabdomyolysis - Pathophysiology muscle destroyed extracellular fluid moves into muscle cells increased H20, NaCl, Calcium Fluid from muscle move into extracellular fluid Lactic acid Myoglobin Potassium, Phosphate Thromboplastin, Creatine kinase & Creatinine Crush Injury & Compartment Syndrome : Crush Injury & Compartment Syndrome Rhabdomyolysis - Potential Complications Hypovolemia Hypocalcemia Hyperkalemia Metabolic acidosis Hyperuricemia Hyperphosphatemia Possible DIC  Cardiotoxicity Crush Injury & Compartment Syndrome : Crush Injury & Compartment Syndrome Compartment Syndrome Tissue pressure > capillary hydrostatic pressure Results in ischemia to muscle Muscle cell edema begins Prolonged ischemia (>6-8 hrs) leads to tissue hypoxia and cell death Direct soft tissue trauma also adds to edema and ischemia Crush Injury & Compartment Syndrome : Crush Injury & Compartment Syndrome Compartment Syndrome Renal failure hypovolemia renal tubules become obstructed nephrotoxic agents present Crush Injury & Compartment Syndrome : Crush Injury & Compartment Syndrome Compartment Syndrome Early signs of crush syndrome paralysis and sensory loss to injured area rigor of joint distal to the injured muscles pain, swelling, sensory changes, weakness may have pulses present and warm skin Later signs indicating compartment syndrome 5 Ps pain, paresthesia, pallor, pressure, pulselessness some include “polar” Soft Tissue Injury Hemorrhage Control : Soft Tissue Injury Hemorrhage Control Direct pressure use dressing gloved hand or patient’s hand quickest and most efficient method promotes localized clotting avoid removing initial dressing continue pressure by securing dressing and applying additional dressings Soft Tissue Injury Hemorrhage Control : Soft Tissue Injury Hemorrhage Control Elevation Useful in extremity Used WITH direct pressure Elevate above level of heart Gravity used to slow hemorrhage & promote clotting Not always useful with extremity fracture Soft Tissue Injury Hemorrhage Control : Soft Tissue Injury Hemorrhage Control Pressure Points Site where artery lies near surface Direct compression applied Most common are brachial artery femoral artery Used when direct pressure, elevation and continued pressure fail Soft Tissue Injury Hemorrhage Control : Soft Tissue Injury Hemorrhage Control Tourniquets Last resort method when all others fail Placed within 2 inches of wound Useful only on extremities Never apply directly over a joint Once in place, avoid loosening risk of emboli or continued hemorrhage Use wide material Soft Tissue Injury Management : Soft Tissue Injury Management General Principles Control Bleeding Apply Dressing Method dependent on location of injury Immobilization Bandaging Antibacterial ointment Consider need for further Evaluation Soft Tissue Injury Management : Soft Tissue Injury Management Need for Further Evaluation Treat and Release Treat and Refer Treat and Transport Soft Tissue Injury Management : Soft Tissue Injury Management Wounds Requiring Transport for Evaluation Neural compromise Vascular compromise Muscular compromise Tendon/Ligament compromise Heavy contamination or High Risk Wounds Cosmetic complications Foreign body complications Soft Tissue Injury Management : Soft Tissue Injury Management Other Considerations Tetanus vaccine Caused by Clostridium tetani anaerobic bacteria Initial vaccine Booster q 10 years q 5 years for high risk persons Potential for allergic reaction Soft Tissue Injury Management : Soft Tissue Injury Management Other Considerations Potential Risk of Infection Common complication Risk factors Microflora common on skin surface Source on wound mechanism Patient immunocompromised Infection Minimization minimize contamination clean wound soon after injury protect Soft Tissue Injury Management : Soft Tissue Injury Management Management of Specific Injuries Avulsion ABCs Control bleeding Dress and Bandage Package avulsed tissue for transport Wrap in sterile gauze Place in plastic bag Place plastic bag in bag of ice Transport to appropriate facility Consider surgery & plastic surgery capabilities Soft Tissue Injury Management : Soft Tissue Injury Management Management of Specific Injuries Amputation ABCs Control bleeding Do not complete partial amputations Dress and Bandage Package amputated part for transport Transport to appropriate facility Consider surgery & plastic surgery capabilities Soft Tissue Injury Management : Soft Tissue Injury Management Management of Specific Injuries Crush Injuries Goals Prevent sudden death Prevent renal failure Salvage limb Treat early -- Before arrival at ED Fluid for hypovolemia Consider bolus of 1 - 1.5 liters in 250 ml increments No IV sites distal to crush injury!! Soft Tissue Injury Management : Soft Tissue Injury Management Management of Specific Injuries Crush Injuries Alkalinize urine Consider NaHCO3: Add 50 mEq to 1 liter bag of fluid Goal: Urine pH > 6.5 Controls hyperkalemia and acidosis to prevent acute myoglobinuria renal failure by changing structure of myoglobin so it passes thru renal tubules Soft Tissue Injury Management : Soft Tissue Injury Management Management of Specific Injuries Crush Injuries Maintain urine output Diuresis of at least 300 cc/hr Consider Mannitol Avoid loop diuretics (may acidify urine) Ideal fluid is D5 1/2 normal saline with 50 mEq NaHCO3 and Mannitol Treat hypovolemia Correct acidosis Soft Tissue Injury Management : Soft Tissue Injury Management Management of Specific Injuries Crush Injuries Other possible therapies Consider insulin/glucose for severe hyperkalemia (12.5 g D50 followed by 10 units regular insulin IV) Amiloride potassium sparing diuretic Hemodialysis (if needed) Soft Tissue Injury Management : Soft Tissue Injury Management Management of Specific Injuries Compartment Syndrome Clinical signs and symptoms may indicate need for emergency fasciotomy Early fasciotomy can preserve limb, avoid Volkmann’s contracture and preserve sensation Seldom but occasionally performed in out of hospital setting Soft Tissue Injury Management : Soft Tissue Injury Management Management of Specific Injuries Hyperbaric Oxygen Treatment Shown to decrease tissue necrosis Inhibits formation of oxygen free radicals Decreases muscle edema Most useful if performed early Soft Tissue Injury Management : Soft Tissue Injury Management Assessment & Documentation Effectively assess and document Size, location, depth and associated risks/complications of wound Neurovascular status of extremities (multiple assessments required) Joint involvement Increased risks of infection

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