BASIC SOFT TISSUE TRAUMA
Topic: Soft Tissue Trauma
Next Unit: Burn Severity and Management
20 minute read
Superficial skin injuries are some of the most commonly encountered injuries. While rarely dangerous on their own, they are commonly present in patients with more severe underlying conditions. The ones to know are:
- punctures, and
ABRASIONS: superficial wounds where the outermost layer of skin is scraped or rubbed off.
- "Road Rash" from a fall is a common abrasion.
- These injuries can be extremely painful as they involve the layer of the skin that contains the nerves.
- These injuries rarely bleed excessively once they have been dressed or had pressure applied to them for a short time.
LACERATIONS: a cut in the skin caused by impact with a sharp object. (A micro-assessment of lacerations shows that all are, in fact, tears--when a pressure exerted against the skin creates a force beyond which the skin's normal elasticity can tolerate.)
- The edges are usually rough or jagged unless the object was extremely sharp.
- Depending on the severity of the laceration, bleeding may be minimal or severe depending on the depth of the cut and involvement of deeper and larger blood vessels.
PUNCTURES: different than lacerations because the force is directed towards the body, as opposed to across the body in a laceration. (Like lacerations, technically punctures are tears.)
- Puncture wounds leave a wound in the shape of the offending object.
- All punctures must be assessed for the presence of an exit wound which is created when the penetrating object traverses the body completely and leaves a second wound with a tract connecting them.
- Removing the clothing and assessing all skin surfaces is vital and a key step in assessing these patients.
- Impaled Objects: These are penetrating objects that are stuck through the skin. As per other chapters, penetrating objects should not be removed. Applying a bulky dressing and stabilizing the object for transport is key.
BITES: Bites from insects or animals are another type of open soft trauma injury.
- Human bites are considered an emergency as they can become seriously infected.
- Transport is appropriate for a serious human bite.
- Animal bites are of varying concern.
- Bites from insects and some reptiles can be poisonous.
- Bites from large animals can obviously be severely traumatic, and smaller mammals may be hosts for various diseases, such as rabies.
Eye injuries are a unique category of soft tissue injury. Even simple things such as grit, metal dust, or chemicals that are harmless to skin can cause severe injury to the eye.
- Redness, tears, pain, and blurring of vision are key signs of eye injuries.
Treatment of abrasions, lacerations, punctures, and bites is focused around the use of dressings--sterile pieces of cloth that absorb blood and help compress the wound and control bleeding. They come in many shapes and sizes. Bandages go over dressings and hold them in place.
For eye injuries, pre-hospital procedures for dealing with foreign bodies or abrasions to the eye are
- to lay the patient flat and tilt their head to the affected side, so that whatever is in it does not get into the unaffected eye.
- Hold the patient's eyelid open with one hand, using the orbital bones for gentle leverage. Never press onto the eye itself.
- Flush the affected eye for at least 15 minutes with water or normal saline.
(For alkali burns--more damaging to the eyes than acids--even more flushing is necessary.)
Soft Tissue Injuries
There are countless possible forms that soft tissue injuries can take. Regardless of the severity, these injuries are managed in the same way, with external compression and pressure.
Soft tissue injuries take many forms. Those that bleed externally are universally managed with compression and pressure dressings. All external dressings are a variation on this theme, the remainder of this section will discuss the differences between these modalities.
STERILE GAUZE: The simple placement of sterile gauze over a wound and applying pressure with a gloved hand is the go-to traumatic dressing for a wide variety of situations. Everything from scrapes to stab wounds can be served by this dressing. Never remove gauze that is soaked with blood, as this may disrupt a forming clot! More severe bleeding or patients that require the rescuer to use both hands for other interventions may require one of the more advanced interventions listed below.
SECURED GAUZE: This intervention replaces the source of compression, switching from the rescuer's hand to tape and a specialized pressure bandage. This can increase the pressure on the wound compared to a hand and allows the rescuer to attend to other injuries or interventions.
MECHANICAL SPLINTING: Certain wounds on extremities are amenable to the placement of rigid support over the gauze that is covering the wound. This offers support to any damaged bones, compression over a wide area, and can act as a partial tourniquet, further slowing the rate of bleeding.
PNEUMATIC TOURNIQUET: Often the simple inflation of a blood pressure cuff upstream of the injured blood vessels on a limb, the pneumatic tourniquet is a quickly adjustable method of cutting off the blood flow to an area. Often used for any form of arterial bleeding, tourniquets can reduce the internal bleeding that occurs with arterial injury to a limb. Whenever applying a tourniquet it is important to note the time of application, as this has implications for the patient's treatment later in the emergency room.
MECHANICAL TOURNIQUET: Using the same philosophy as a pneumatic tourniquet, the mechanical version is generally used for more severe bleeds. There are several types of mechanical devices and you should be familiar with the version that your jurisdiction requires you to carry. Mechanical tourniquets generally cause more trauma to tissue than pneumatic variants but are less prone to failure when used correctly.
COMPLICATIONS OF TOURNIQUETS: Placing a tourniquet (of any type) can result in temporary or permanent nerve damage in a matter of minutes, limiting their use to situations where direct compression has failed. Even if nerve damage is temporary, placement for over 2 hours often results in ischemic damage to the limb, with times over 6 hours generally requiring partial or complete amputation.
Management of Bleeding Patients
Keep bleeding patients calm, warm, and lying flat to prevent falls from sudden lightheadedness and further shock from hypothermia. Ensure that you complete the remainder of your assessment after you have stopped the bleeding, as secondary injuries may be present.
The prehospital management of bleeding at the EMR level revolves around holding pressure on the site to slow loss of blood and arranging rapid transport. At the EMT/Paramedic level administration of intravenous saline and/or blood, products are routinely warranted.
Note that there are different types of bleeding, capillary bleeding causes a slowly oozing wound, venous bleeding presents with dark flowing non-pulsatile bleeding, and arterial bleeding is bright red and is pulsatile, often spurting with severe injuries.
REASSESSMENT: Bleeding patients should be assessed for the development of blood loss symptoms often. Exactly how often depends on the severity of the bleeding. A patient with a minor capillary bleed will likely be fine all throughout transport. While a patient with a major arterial bleed may require interventions on a minute by minute basis to keep them alive.
Some of the symptoms that signify a transition from mild blood loss to clinically significant blood loss are: Weakening pulses in the extremities, fatigue, somnolence, pale/cold/clammy skin, increasing tachycardia, shortness of breath at rest, and changing mental status (confusion, aggression, inappropriate laughter).
These symptoms should be noted and recorded for a patient with known or suspected blood loss.
[This topic is reviewed further in "Body Response and General Assessment of Bleeding."]