Transcript Soft Tissue Injury

Soft Tissue Injury
April Morgenroth RN, MN
David Peck RN, ARNP
Soft Tissue
Defined
Soft tissues are structures of
the body that connect,
envelope, provide support, or
move the structures around
it.
Examples: skin, muscle, fat
The Integumentary System
Includes all external coverings of the body
Hair
Skin
Exocrine Glands
Function:
Protects body from infection
Thermoregulation
Helps to maintain fluid
balance
Helps to maintain electrolyte
balance
Skin
Skin is composed of three layers:
Hair
Epidermis: outermost layer of cells,
contains melanin, gives skin pigment
Dermis: bottom layer of skin,
contains blood vessels,
connective tissue, nerves
Subcutaneous layer: fatty tissue,
stores nutrients
www.cawc.net/images/skin-sm.jpg
Soft Tissue Trauma
Fat/Adipose Tissue
 The most vulnerable soft tissue to trauma and infection.
 Adipose soft tissue heals more slowly
 Poor vascularity
 Limited capacity to form collagen
and tensile bonds.
ages.com
Soft Tissue Trauma
Open vs. Closed
Open Soft Tissue Trauma: Outer most
layer of skin is open. Damage may be
only on the surface or it may be deep
past the skin and fatty tissues.
Closed Soft Tissue Trauma:
Inner layers of soft tissue are
damaged but the outer most layer
remains intact .
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Classification of Soft Tissue Injury
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Abrasion: epidermal and dermal layers
are affected.
The injury is caused by friction.
Avulsion: skin flap, the edges
cannot be approximated
Laceration: Tearing or splitting of the
skin, can involve the fatty tissues as
well
Degloving: large amounts of skin are
torn away from the vascular supply
http://www.primarysurgery.org/ps/vol2/html/i
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Classification of Soft Tissue Injury
Contusion: damage to small blood vessels causes
bleeding into the tissue, skin remains intact
http://sportsnmedicine.blogspot.com
/2007_08_01_archive.html
Puncture: an open wound that tears through
skin and damages underlying tissues. These
wounds can be shallow or deep and some may
even have an entry point and an exit point.
Soft Tissue Trauma
Gunshot Wound Vocabulary
Wounds by projectiles are determined by size of the
projectile, the force/velocity at entry, the density of the tissue
and shape and design of the missile
 Tumble & Yaw - how the bullet turns while inside tissue
 Cavitation - the internal size of the wound tract
 Speed - Lead bullet cores melt when propelled
above a velocity of 2000ft/sec. causing internal burns
as well as cavitation on entry
Cavitation tracts from
various projectiles
Soft Tissue Trauma
Gunshot Wound Vocabulary
 Entry & Exit wounds- Two holes may indicate two separate gunshot
wounds or the path that one bullet took through and out of tissue.
Observing and documenting these wounds is an important trauma
function.
 Gunshot crepitis- Gasses injected into the tissues on bullet impact may
become lodged there and cause a popping crepitis on palpation
 Gunpowder tattoos- Residual gunpowder may burn the tattoo the skin
surrounding the entry and exit wounds. Washing powder off during
wound care may lessen this deformity
Wound Healing
“Golden Window for wounds” - 12 hours
 Wounds closed/sutured open more than 12 hours following
trauma display profound increases in
 infection
 failed closure
 significant cosmetic deformity
•
nevamwiti.com
Stages of Wound Healing
Phase I
Inflammatory Response- Day 1-5
A.D.A.M.
1. Plasma protein, blood cells, fibrin & antibodies flow into the
wound.
2. Within 4 hours leukocytes causes localized edema, pain, &
erythema.
3. Leukocytes and macrophages ingest & remove debris.
4. Skin margin basal cells begin migration over incision to close
the wound.
5. Connective tissue fibroblasts begin reconstruction of nonepithelial tissue.
Stages of Wound Healing
Phase II
Migration/Proliferation- Day 5-14
1.
2.
3.
Collagen, fibrin & fibronectin contract wound margins &
initiate scar formation.
Tensile strength of the affected tissue increases, sutures are
not needed for wound closure.
Lymphatics, blood vasculature and granulation tissues
regenerate.
www.birminghammail.net
Stages of Wound Healing
Phase III
Maturation/Remodeling Day 14- complete healing
1.
Tensile strength increases up to one year.

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2.
3.
Skin tissue regains 70-90% of it’s original strength
Intestinal tissue may regain 100% of original strength within one
week!
Fibrous connective tissue stratifies to increase pliability
Scar structure remodels and retracts.
A.D.A.M
Stages of Wound Healing
Delayed ClosureSome wounds are not able to be sutured closed because of extensive
trauma, infection, tissue loss, or imprecise initial closure of wound.
These wounds are kept open to allow for drainage &prevent closed
(anaerobic) pockets from forming, as in puncture wounds.
(note granulation of tissue margins)
Care of Open Soft Tissue Injury
Ensure a patient airway
Evaluate patients respiratory
status
Note respiratory rate
Note work of breathing
(labored, use of accessory
muscles)
Care of Open Soft Tissue Injuries
Evaluate for signs of circulation and
major bleeding
Control bleeding using appropriate
method, stabilize impaled objects
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Ensure fluid and electrolyte balance
Check hematocrit and
electrolytes in the presence
of any major injury
Open Wound Management
Wound Assessment
following stabilization of patient
 Observe for foreign objects in wound
 Note debris & cues to trauma source (glass
shards/dirt/bite marks)
 Assess for parasthesia/paralysis
 Monitor for pallor/pulselessness distal to
wound
 Observe deformity, contusion, other
ruptures of skin integrity, swelling
 Assess & manage pain (analgesics or local
block)
 Document wound depth, size, location &
appearance
Open Wound Management
The following categories can be used to describe & document
wound characteristics based on a clinical estimation of microbial contamination
& risk for subsequent infection.
Clean
Mechanism of injury relatively
clean- knife/glass/plastic/milled wood
Clean/Contaminated
Appears clean, but known contact
with soil, stagnant water, feces
Contaminated (“dirty”)
Visible debris in wound, possible
foreign body
Contaminated and Infected
Foul odor, signs of infection,
visible debris or foreign body
Wound Cleansing & Care
 Use normal saline if available, avoid tap water
 Antimicrobial surgical scrub- Betadine
 Scrub with soft brush or gauze,
from the center of the wound out
 Irrigate wound liberally and frequently
 Consider antibiotics
The Solution to Pollution is Dilution!
isips.org
Care of Open Soft Tissue Injuries
Evaluate the need for sutures
Wound is a deep and/or
gaping laceration, avulsion, or
incision where the edges can be
approximated
Skin grafts may be needed for
major degloving injuries or major
burns.
Tetanus (lockjaw)Non-immunized trauma victims with open wounds
face a significant risk for tetanus.
A spore forming anaerobic bacteria
Found in soil and the feces of domesticated animals
Endemic in developing areas
Cedarcrest.edu
(In Mexico, tetanus immunization is inconsistent. Rates of infections are unreported.
CDC, 2009).
Tetanus Immunization
 Tetanus can be prevented in trauma patients
through prophylactic treatment
 Trauma victims with high-risk wounds may be given tetanus
immune globulin (TIG) in addition to tetanus toxoid if their
immunization status is unknown or not current

 Tetanus toxoid ‘booster’ at least every 10 years,
every 5 years in cases of tetanus-prone exposures
 Assessment and documentation of immunization status and
tetanus-prone wounds is a vital component of trauma care
Tetanus Prone Wounds
Clinical Features
Non-Tetanus Prone
Wounds
Tetanus-Prone Wounds
Age of Wound
≤ 6 hours
> 6 hours
Configuration
Linear, abrasions
Stellate wound,
avulsions
Depth
≤ 1 cm
> 1cm
Mechanism of injury
Sharp surface (knife,
glass)
Missile, crush, burn,
frostbite
Sign of infection
Absent
Present
Contaminants
(dirt/feces/soil/saliva)
Absent
Present
Denervated/ischemic
tissue
Absent
Present
Soft Tissue Trauma- Respiratory
Types of PneumothoraxSimple pneumothorax- a portion of the
inflated lung pulls away from the pleural wall
causing a partial collapse
Treatment- Chest tube (small
pneumothorax may be allowed to
reinflate spontaneously)
Hemothorax- blood fills a portion of space
between lung tissue & the pleural wall. Blood
loss into the pleural cavity can be up to 1/3
total blood volume
Treatment- Chest tube
If large volume of blood is retrieved, auto
transfusion is performed to return the patient
blood volume. Surgical thoracotomy may be
required to stop hemorrhage resolve
accompanying tamponade
Tension Pneumothorax
A Medical Emergency
 Air is forced through a “one way
valve” through the lung tissue
into the pleural space
 Lung collapse
 Mediastinal shift
 Limited cardiac circulation
 Applies pressure on the
remaining lung with risk of
complete respiratory collapse
Treatment is Needle Decompression: large bore needle is
inserted into the second intercostal space at the
midclavicular line- converting the defect to a simple
pneumothorax. Then a chest tube is inserted.
Tamponade
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 Chest trauma can sometimes result in
blood or other fluids collecting in the
pericardium
 Pressure builds up and restricts
movement of the heart
 Signs and symptoms: anxiety, chest pain,
shortness of breath, narrowing pulse
pressure, signs of poor perfusion, death
 This an emergency, call the physician
immediately
 Monitor closely, obtain IV access, give
supplemental oxygen
The physician will need to
perform a pericardiocentesis.
Sucking Chest Wound
A puncture to the thoracic wall that communicates
with the pleural space may cause a sucking chest
wound
When the patient inhales,
intrathoracic pressure drops
below atmospheric pressure
creating a vacuum which sucks
air into the pleural space. (Air will
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also escape the pleural space to some
degree following pressures)
Pressure in the pleural space builds and the lung begins
to collapse. The patient now has a pneumothorax.
Sucking Chest Wound Evaluation and
Treatment
 Make a three way occlusive
dressing
 This makes a one way valve
 They will need a chest tube
 Use the sterile side of plastic
packaging that contained
something sterile
 Plastic bag….
 Tape down three sides
Soft Tissue Trauma- Respriatory
Tension Pneumothorax & Cardiac Tamponade are:
Two very different medical emergencies
that present with very similar symptoms-
The diagnosis of each is determined by clinical evaluation
you could make in a trauma care setting!
Cardiac Tamponade
Tension
Pneumothorax
Breath
sounds
Equal on both
sides
Decreased or
absent on
affected side
Trachea
Midline
Percussion Normal
resonance
Deviated away
from affected
side
Tympanic
(Hyperresonant)
Pulse
Normal
Affected by
breathing
Abdominal Trauma
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Evaluate for internal bleeding
Note any external bleeding
Treat for shock
If the wound is open and
intestines are exposed
(eviscerated organs) use sterile
saline on sterile gauze, then
cover with plastic
 This will be an occlusive
dressing
Impaled Objects
Do not attempt to remove the object
UNLESS: it is in the cheek and is
obstrubstructing the airway
If an object in the cheek needs to be
removed, gently pull it the rest of the
way through
Control bleeding using appropriate
methods
Minimize damage to internal organs
by stabilizing the object to minimize
movement and vibration
Treat patient for shock
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Prepare for emergent
surgical intervention
Burns
 Three Mechanisms
 Thermal: caused by heat
 Chemical: caused by
caustic chemicals
 Electrical: caused by
electicity (ex. Electical
shock)
Burn Classification
 First Degree/Shallow Thickness: involves just
the outer layer of skin, the skin is reddened,
hot, painful but overall the skin is intact
 Sunburn, minor scald burns
Images from A.D.A.M.
 Treatment: may use aloe on the skin to restore
skin moisture and sooth the burn
 Prevention is key: protect from intense sun
Burn Classification
Continued
 Second Degree/Partial Thickness: The damage is
deeper and involves more layers. The area may
be blistered, red, and painful
 Example: hand on a hot stove
Images from A.D.A.M.
 Stop the burning!
Do Not: Put ointments on it (this keeps the heat in)
Lance the blisters
Burn Classification
Continued
 Third Degree/Full Thickness
 The burn is full thickness, open, weepy, there
may be nerve damage
 Keep it clean
 Dress with dry gauze
 Protect patient from hypothermia
 If the burn involves fingers or toes, they will
need to be separated when bandaging
Burn Classification
Estimation of the
percentage of body area
affected by the burns is
important as it helps us to
make clinical decisions.
Estimate the extent of a
burn by using the rule of
nines
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Soft Tissue Burns
Thermal injuries/Smoke inhalation
Clinical indications of inhalation injury
 Face/neck burns
allergyconsumerreview.com
 “ Sooty” sputum
 Carbon deposits and inflammation of oropharynx
 Singeing of eyebrows and nasal passage
 Hoarseness
 Impaired mentation after confinement in burning
environment
 Explosion with burns to head and torso
The presence of any of these findings suggests acute inhalation injury
Burns and Breathing
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 Sometimes burns can affect breathing
and the airway (smoke inhalation,
swelling)
 Inhalation of chemicals and smoke can
cause burns and/or damage to the
airway and lungs
 Protect the airway through:
positioning, placement of an artificial
airway if needed
 Provide supplemental oxygen
Soft Tissue Burns
Thermal injuries/Smoke inhalation
Assessment History of burn injury is vital to management
 Obtain information from witnesses & victim
 Inhalation injury may not appear for 24 hours
 Length of exposure to fumes/thermal assault affects severity of
injury
 Consider internal and orthopedic injuries from explosions, falling
debris
Soft Tissue Burns
Carbon Monoxide (CO) -
 Always assume CO exposure for patients burned in enclosed
areas
CO levels-
< 20% rarely result in symptoms
> 20% headache & nausea
> 30% confusion
> 40% coma
> 60% death
 Patients with CO exposure need 100% O2 because of CO’s
ability to bind oxyhemoglobin and cause decreased O2
absorption in the blood
Soft Tissue Burns
Escharotomy –
 Incisions through the skin layers in circumferential burns to
avoid compartment syndrome
 A surgical procedure used to maintain circulation & relieve
pressure from massive edema and rigid/non-elastic burned
skin (eschar)
 Not usually needed within the first 6 hours
following burn trauma
Soft Tissue Burns
Fasciotomy A rare surgical ‘limb saving’ procedure where fascia is
removed to relieve pressure and prevent compartment
syndrome
In addition to use in deep burns,
fasciotomy is also used in the following conditions
Skeletal trauma
Crush injuries
High voltage electrical injury
Fluid Resuscitation for Burns
In the case of severe burns the
body looses fluids due to the
impaired skin integrity and fluid
shifts that naturally occur during
inflammation.
The blood may become “sludgy” as
fluids are lost but cells are retained,
this is sometimes called burn shock
Fluid Resuscitation for Burns
Time for fluid resuscitation begins at the time of
the injury.
Use this formula for all patients with airway
trauma and patients who have 20% body surface
area burned.
Patients weight
X
% body burned
X
4 ml lactated ringers
=
Volume needed
Give 50% total amount over
the first 8 hours.
Give 25% total amount during
hours 8 to 16.
Give the remaining 25% of
total volume during hours 16-24