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MANAGEMENT OF SOFT TISSUE INJURIES
Management of Soft Tissue Injuries
Soft tissue injuries can be divided into two rough categories, open and closed. This division is based on whether the skin is broken or not.
Both types of injury have the potential to be life-threatening, but open injuries require additional pre-hospital care to minimize potential morbidity and mortality. This section will examine open and closed injuries separately, along with treatment considerations for each.
Presentation of Closed Soft Tissue Injury
Closed soft tissue injuries are injuries to an area of the body where the skin is left intact. The 3 major types are contusions, hematomas, and crush injuries.
CONTUSIONS are bruises. They occur when the tissue of the skin or beneath the skin has taken blunt force, damaging the small blood vessels.
HEMATOMAS are large bruises with an underlying collection fo blood which forms a lump beneath the skin, tending to form when larger blood vessels are damaged.
CRUSH INJURIES result from the traumatic compression of tissue, usually against an underlying bone.
Closed soft tissue injuries present with pain, swelling, and discoloration of the overlying skin. They may be a sign of deeper internal injury, so you should have a high index of suspicion for underlying injury in patients with significant closed soft tissue injuries.
MANAGEMENT OF CLOSED SOFT TISSUE INJURY
When managing closed soft tissue injuries, rule out damage to underlying neurovascular structures by ensuring distal PMS in all affected limbs (pulse, motor function, and sensation.)
Management of these injuries is focused around R.I.C.E.S--an extension of the classic acronym RICE (rest, ice, compression, elevation). Injuries to the trunk, neck, and head should be managed similarly, with a focus on ice and direct pressure and regular reassessment of the ABC's to watch for internal injury.
- Ice - to constrict blood vessels, reducing swelling and numbing pain.
- Compression - reduces hematoma formation and can also assist with swelling.
- Elevation - again, reduces blood pooling and swelling.
- Splinting (the added item in the acronym) - can assist in providing compression to the injury and preventing further injury from movement.
ABCs: In closed tissue injury to the face, head, or neck, increased swelling may result in airway compromise. If the patient begins to become unstable, always shift your focus to maintaining an open and secure airway, adequate breathing, and adequate tissue perfusion.
Presentation of Open Soft Tissue Injury
Common open soft tissue injuries include abrasions, lacerations, puncture wounds, bites, avulsions, and amputations.
Each of these injuries come in a wide variety of severities, but regardless of the severity, there are two major concerns in all open soft tissue injuries, hemorrhage and infection.
HEMORRHAGE: loss of blood becomes a concern when enough is lost that shock develops and perfusion to tissues is lost.
- Penetrating trauma, deep lacerations, and amputations are especially likely to lead to hemorrhagic shock.
- Abrasions, avulsions, and minor lacerations can lead to shock if left unmanaged or in patients with conditions that predispose them to bleeding.
INFECTION: a risk with any injury that penetrates the skin, the main barrier which keeps bacteria and other potentially harmful microorganisms out of the body.
- Infection can lead to loss of life or limb late in the course of an injury.
- As with most medical conditions, prevention is the most effective treatment, and therefore this is the reason EMS professionals are often the first to sterilize and dress a wound.
MANAGEMENT OF OPEN SOFT TISSUE INJURY
Open injuries are similar to closed injuries in that damage to underlying structures is a constant concern. Even superficial injuries can overlie significant internal trauma, so evaluating the patient's ABC's and distal PMS in limbs is of significant importance.
Open injuries require management of bleeding and protection from infection, the steps of which are outlined below:
- Ensure BSI (body substance isolation).
- Ensure an open airway, adequate ventilation, and tissue perfusion (circulation).
- Apply an occlusive dressing to open chest injuries.
- Apply direct pressure over any open wound with a dry, sterile dressing.
- Apply pressure dressing or compressive splint
- If bleeding continues or recurs, apply a tourniquet to an extremity above the level of bleeding.
- Be alert for and treat for shock (hypoperfusion) by raising legs, fluid administration, maintaining body temperature, and administering high-concentration oxygen where appropriate.
- Whenever applying pressure dressings or splinting, always check to make sure distal pulses remain palpable.
- Never remove a flap of skin regardless of size as complete avulsions dramatically increase the risk of infection compared to those with a skin flap in place.
- Wash the wound with sterile saline, then return the skin to a normal anatomical position if possible. Then proceed to the steps outlined above for dressing the wound.
- Do not remove any impaled objects unless they are compromising the airway or impeeding compression.
NOTE: As with closed injury, If there is damage to the airway, face, or neck, increased bleeding into or around the airway will compromise the airway. If the patient begins to become unstable, always shift your focus to maintaining an open and secure airway, adequate breathing, and adequate tissue perfusion (ABC).