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IDENTIFICATION AND MANAGEMENT OF WOUNDS
While there are many types of soft tissue wounds, the management of most is focused around Hemostasis, RICE, and watching for local complications.
Two types of wounds, avulsions, and bites require a further understanding at the paramedic level.
Avulsions occur as a result of strong "shearing" forces that literally tear tissue from the body, leaving a chunk of missing soft tissue or a chunk of tissue hanging from the body like a flap.
The three categories that make this wound unique are the pathophysiology of healing, assessment findings, and management considerations.
PATHOPHYSIOLOGY: Avulsions have a particular risk of causing severe bleeding, depending upon their depth. Large areas of potentially de-vascularized tissue also put the wound at significant risk for infection. The healing process can be as expected if vascularity is retained; alternately, it may be slow and complicated by tissue death and chronic injury. This is all dependent upon the location/severity of the wound and patient factors.
"Degloving" is a term meant for a stripping away of the entire circumferential covering of an appendage, such as when a ring, bracelet, or other jewelry gets caught in machinery.
ASSESSMENT: These wounds are identified by a displaced area of soft tissue. At times a flap may be connecting this displaced tissue to the body. The cleanliness of the wound is of vital importance: avulsions are prone to retaining material from the environment, so inspection should occur concurrently with irrigation.
Old wounds may have copious straw-colored or red-tinged drainage, similar to surgical wounds. This is known as "serosanguinous" drainage and is a sign of healthy wound healing.
NOTE: This type of serosanguinous drainage is not to be confused with that coming from the abdomen in postoperative patients; that type indicates an imminent dehiscence of the wound.
MANAGEMENT: Managing these wounds comes with two major considerations:
- irrigating the wound and
- replacing the displaced tissue.
- Wound irrigation with sterile saline should be done with moderate pressure jets of fluid from a sterile syringe.
- Large embedded objects should not be removed.
- Significant hemorrhage may be present, and hemostasis begins with replacement of the tissue flap to the previous anatomical position and direct pressure. If this fails do not hesitate to consider a tourniquet, quik-clot, or other methods appropriate to your jurisdiction.
- RICE applies to these wounds, as does the risk of infection, hematoma formation, and healing complications that are present in other soft tissue wounds.
Bite injuries are a combination of crushing and penetrating trauma with additional concerns for infection. Animal, human, and insect bites each have unique pathophysiology, assessment findings, and management.
ANIMAL BITES: Commonly the result of domesticated dogs, cats, or other pets, but can rarely be due to wild animals. These bites have a significant risk.
PATHOPHYSIOLOGY: Infection is one of the major risks associated with animal bites. The elderly and young are most susceptible to infection, as are injuries to areas with lower blood-flow. Cat bites are some of the most infectious of common bites, with a special concern for the organism Pasteurella multocida.
ASSESSMENT: Aside from the obvious location and severity of the bite, knowing what animal inflicted the bite and its health history is vital. Though rare, there is a concern for rabies, especially in undomesticated animals or domesticated animals with recent injuries from other animals.
MANAGEMENT: Aside from basic wound irrigation and hemostasis, it is important to ensure your safety when evaluating patients with animal bites: DON'T BECOME A SECOND VICTIM. Ensure you know the animal which inflicted the injury and its medical history.
RABIES is an uncommon viral illness that is most often seen in bats (endemic in 10%). Any exposure to wild bats in which contact cannot be ruled out (sleep, drunk, a child, etc.) should prompt rabies prophylaxis. "Any contact" is the qualification here, because bites can be very small or unnoticed when they occur.
Rabies is a virus that travels up the nerves to the brain and is uniformly fatal. This means that the farther from the brain occurred, the larger allowable treatment window during which rabies prophylaxis can be given. (Bites on the hand allow more time for treatment than bites on the face.)
HUMAN BITES: These wounds are very similar to animal bites but with an even greater concern for infection. The potential for abuse/violence must also be considered.
PATHOPHYSIOLOGY: These wounds are often seen on the hand and are commonly a result of fights between adults or play between children. The "clenched fist" injury is one in which the skin is taut over the underlying connective tissue, bones, and joints, creating proximity of microorganisms delivered by the bite to promote infections farther into the hand. Also, the many tissue planes of sheaths, etc., allow for an easy vertical extension of infection up the arm toward the heart, via veins and lymphatics.
Delays in treatment dramatically increase the risk of infection; unfortunately, these delays are common and patients tend to present only after redness, pain, and swelling develop days later and when the infections are polymicrobial.
ASSESSMENT: Human bites often take a characteristic oval appearance with defined areas of bruising and puncture. Signs of infections should be carefully assessed, as should the cause of injury. Additional steps may be needed for bites on children due to the concern for abuse.
MANAGEMENT: Acutely, these bites often require irrigation and prophylactic oral antibiotics. If an infection is present when the patient is being treated, IV antibiotics are often required. As above, mandatory reporting of potentially abusive and violent situations may be required based on your jurisdiction.
INSECT BITES: Far more complicated than the above two etiologies, insect bites are an extremely broad category that encompasses everything from fleas to deadly spiders. If ever unsure about the nature of a bite/sting from an insect, revert to maintaining the ABC's and ensuring the patient is stable for transport.
ETIOLOGY: Random biting insects are the most common, such as simple ants, beetles, and other insects, but rarely causing little more than local irritation and mild pain.
Bees/wasps are the first potentially dangerous insect, as they can trigger anaphylaxis.
Fire ants, common scorpions, and common spiders are next, causing significant local pain but rarely becoming life-threatening.
Finally, special spiders (black widows, brown recluses), ticks, and exotic scorpions/insects. This last category of insects/arachnids can cause significant morbidity and mortality.
PATHOPHYSIOLOGY: Anaphylaxis is an extreme allergy that is mediated by the body's own immune system. Dramatic release of histamine leads to
- diffuse edema,
- bronchospasm, and
This can result in even minor stings becoming life-threatening.
- Toxins of the black widow target the neuromuscular junction and result in diffuse pains.
- Toxins of the brown recluse destroy cell membranes at the site of the bite and lead to local, necrotic ulceration.
- Ticks can harbor a variety of parasites, bacteria, and toxins which lead to rashes, ascending temporary paralysis ("Tick Paralysis"), or febrile illness.
- ABCs are at the forefront in anaphylactic patients.
- Regularly re-assessing the airway is of primary importance as edema can compromise the airway quickly!
- The activity preceding the bite is important: black widow bites generally occur out in nature, brown recluse bites within the home, and tick implantation in wooded areas.
- Rarely are there significant findings present on the skin other than erythema in the acute setting.
- Widow bites may acutely present with muscle pain or severe abdominal pain.
- Acute tick-borne illnesses can present with a rapidly ascending paralysis or a febrile illness.
- If the patient presents late, looking for necrotic tissue, implanted ticks, new rashes (bullseye for Lyme disease, petechiae for rocky mountain spotted fever) are important.
- Acute management of anaphylaxis requires administration of epinephrine, generally in the form of intramuscular injection. Following this IV access and oxygen should be supplied, and if the patient progresses to respiratory distress or has a history of refractory anaphylaxis, prompt intubation is indicated.
- Acute treatment of spider and scorpion bites is supportive; ice and compression of the bite will help with pain.
- Removing any other insects on the skin and watching for new developing symptoms during transport is essential.
- Removal of ticks is done by gripping the implanted head as close to the skin as possible with an instrument and pulling straight back.
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