Chapter 34 Bleeding and Soft Tissue Trauma

Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

34-1

Objectives 34-2

Anatomy of the Skin

•

Body's first line of defense against

–

Bacteria and other organisms

–

Ultraviolet rays

–

Harmful chemicals

–

Cuts and tears

•

Helps regulate body temperature

•

Senses heat, cold, touch, pressure, and pain 34-3

Layers of the Skin 34-4

Bleeding

34-5

Wounds

•

Wound

–

Injury to the soft tissues

•

Closed wound

–

Soft tissues under the skin are damaged

–

Skin surface is not broken

–

Example: bruise 34-6

Wounds

•

Open wound

–

Skin surface is broken 34-7

Hemorrhage

• • •

Bleeding

–

Can occur from capillaries, veins, or arteries The larger the blood vessel, the greater the bleeding and blood loss Hemorrhage

–

Excessive loss of blood from a blood vessel

–

Also called major bleeding 34-8

Blood Clotting

•

If a blood vessel is cut or torn:

–

Immediate contraction of blood vessel wall

–

Platelets try to plug the torn vessel

–

Clot begins to form at site of torn vessel

–

Clotting usually complete within 6 to 10 min 34-9

Types of Bleeding Arterial

•

Arterial bleeding

–

Life-threatening

–

Bright red, oxygen-rich blood

–

Spurts from the wound 34-10

Types of Bleeding Venous

•

Venous bleeding

–

Flows as a steady stream

–

Dark red or maroon

•

Oxygen-poor blood

–

Usually easier to control than arterial bleeding 34-11

Types of Bleeding Capillary

•

Capillary bleeding

–

Oozes slowly from the wound

–

Dark red blood

–

Usually not serious

–

Often clots and stops by itself 34-12

Types of Bleeding C o l o r Blood Flow Bleeding Control Arterial Bright red

Spurts with each heart beat Difficult to control

Venous Dark red, maroon

Flows steadily

Capillary Dark red

Oozes slowly Usually easier to control than arterial bleeding Bleeding from deep veins may be hard to control Often clots and stops by itself

27-13

External Bleeding

•

External bleeding is bleeding that you can see

–

Blood flows through an open wound

•

Control bleeding manually until bleeding stops 34-14

Emergency Care of External Bleeding 34-15

Scene Size-Up

•

Make sure the scene is safe to enter

•

Evaluate mechanism of injury / nature of illness

•

Personal protective equipment (PPE) 34-16

Remember!

• • • • •

NEVER

touch blood or body fluids with your bare hands

ALWAYS

contact wear PPE during

every

patient Wash your hands Throw away contaminated PPE in an appropriate container Report the exposure immediately 34-17

Primary Survey

• •

Form a general impression Then, assess:

–

Airway

–

Breathing

–

Circulation

• •

Look for major (severe) bleeding Control bleeding if present 34-18

Adult Child Infant

Severity of Blood Loss

Normal Blood Volume 800 mL Severe Blood Loss 5000 to 6000 mL Loss of 1000 mL or more 2000 mL Loss of 500 mL or more Loss of 100 to 200 mL or more

34-19

•

Controlling External Bleeding Three methods: 1. Applying direct pressure to the wound 2. Applying a splint 3. Applying a tourniquet (if the bleeding is severe and cannot be controlled with direct pressure) 34-20

Direct Pressure 34-21

Pressure Bandage 34-22

Pressure (Air) Splint 34-23

Pneumatic Antishock Garment 34-24

Tourniquet

•

Tourniquet

–

A tight bandage that surrounds an arm or leg

–

Used to stop the flow of blood in the limb

–

May be considered when direct pressure has failed to control hemorrhage 34-25

Tourniquet 34-26

Tourniquet 34-27

Tourniquet 34-28

Tourniquet 34-29

Tourniquets Precautions

•

Always use a wide bandage

•

Do not use:

–

Wire

–

Rope

–

A belt

–

Any material that may cut into skin and underlying tissue 34-30

Tourniquets Precautions

•

Do not remove or loosen the tourniquet unless directed to do so by a physician 34-31

Tourniquets Precautions

•

Be sure the tourniquet is in open view

–

Do not cover it with a bandage, a sheet, or the patient’s clothing 34-32

Tourniquets Precautions

•

Never apply a tourniquet directly over a joint

•

Place it as close to the injury as possible 34-33

Internal Bleeding 34-34

Hollow Abdominal Organs

•

Hollow abdominal organs:

–

Stomach

–

Intestines

–

Gallbladder

–

Urinary bladder

•

Hollow organ rupture:

–

Contents empty into the abdominal cavity

–

Causes irritation and pain 34-35

Solid Abdominal Organs

•

Solid abdominal organs:

–

Protected by bony structures

–

Bleed when injured

–

Can result in a large amount of blood loss

•

Examples:

–

Liver

–

Spleen

–

Kidneys 34-36

Internal Bleeding

•

Bleeding that occurs inside body tissues and cavities

•

Example: bruise

–

Capillary bleeding

–

Blood collects under the skin 34-37

Internal Bleeding

•

Most common causes of internal bleeding:

–

Injured or damaged internal organs

–

Fractures

• •

Femur Pelvis 34-38

Internal Bleeding

•

Sites where major bleeding is most likely to occur:

–

Abdominal cavity

–

Chest cavity

–

Digestive tract

–

Tissues surrounding broken bones 34-39

Internal Bleeding 34-40

Signs and Symptoms

• • • • • • • •

Pain, tenderness, swelling, or bruising in the injured area Weak, rapid pulse Pale, cool, moist skin Broken ribs or bruising on the chest Vomiting or coughing up bright red blood or dark, “coffee-ground” blood Tender, rigid, and/or swollen abdomen Bleeding from mouth, rectum, vagina, or other body opening Black (tarry) stools or stools with bright red blood 34-41

Emergency Care

• • • • • • •

Scene size-up, put on appropriate PPE Primary survey Vital signs, medical history Manage the ABCs, give oxygen if indicated, keep the patient warm Recovery position if no trauma Rapid transport to closest appropriate hospital Reassess at least every 5 minutes 34-42

Soft-Tissue Injuries 34-43

Soft-Tissue Injuries

• • • •

Injuries that damage the layers of the skin and the fat and muscle beneath them Open injury

–

Skin surface broken Closed injury

–

Skin surface intact Always wear PPE when dealing with soft tissue injuries 34-44

Closed Soft-Tissue Injury

• • •

Body is struck by a blunt object No break in the skin Tissues and vessels beneath skin surface are crushed or ruptured

•

Types

–

Contusion

–

Hematoma

–

Crush injury without a break in the skin 34-45

Contusion (Bruise)

• • • • • •

Most common type of closed wound Outer skin layer (epidermis) intact Small blood vessels in dermis are torn Bleeding occurs in the area that was struck Swelling, pain, and skin discoloration occur Most heal and disappear within 2 to 3 weeks 34-46

Hematoma

• • • •

Localized collection of blood beneath skin Larger blood vessels torn Often occur with trauma of enough force to break bones Larger amount of tissue damage than contusion 34-47

Crush Injury

• • •

May be open or closed Crushing force applied to body from blunt trauma Swelling and bruising often present

•

Severe crush injury

–

Extent of injury may be hidden

–

May see only minimal bruising, but force of injury may cause internal organ rupture

– –

Internal bleeding may be severe Can lead to shock 34-48

Closed Soft-Tissue Injuries 34-49

Compartment Syndrome 34-50

• • • • •

Compartment Syndrome Possible Causes Compression injury Strenuous exercise Circumferential burns Frostbite Constrictive bandages, splints

• • • • •

Animal / insect bites Bleeding disorders Arterial bleeding Soft-tissue injury Fracture 34-51

Compartment Syndrome 34-52

“ 5 P’s ” of Compartment Syndrome

•

P ain on passive stretching of the muscle

•

P aralysis (or weakness)

•

P aresthesias

•

Increased p ressure

•

Diminished peripheral p ulses 34-53

Crush Syndrome

•

Mine cave-ins

•

Trench collapse

•

Motor vehicle crash (MVC)

•

Landslide, avalanche, rockslide

•

Rubble from war, earthquake

•

Pinning under heavy objects

•

Severe beatings 34-54

Crush Syndrome

•

Consider when three criteria exist: 1. Involvement of a large amount of muscle 2. Compression of the muscle mass for a long period (usually 4 –6 hours, although it may be as little as 1 hour); and 3. Compromised local blood flow 34-55

Crush Syndrome

•

Blood flow compromised

•

Movement and sensation compromised

•

Damaged cells leak toxic substances into the bloodstream

•

Hypovolemic shock develops

•

Compartment syndrome develops

•

Reperfusion injury 34-56

• • • • •

Closed Wounds Management Scene size-up

–

Assess mechanism of injury

–

Put on appropriate PPE Primary survey

–

Stabilize cervical spine if needed

–

Treat for shock if signs of shock present or internal bleeding suspected Physical exam, vital signs, medical history Splint bone or joint injuries Extremity injury – rest, ice, elevate 34-57

Closed Wounds Management

•

If signs of compartment syndrome are present:

–

Do not apply ice or elevate the extremity

–

Splint the affected extremity for comfort and protection only when necessary 34-58

Closed Wounds Management

•

If the patient is trapped, try to find out how long the patient has been trapped

•

Contact medical direction for instructions 34-59

Open Wounds

•

Break occurs in the skin

•

Open wound at risk of:

–

External bleeding

–

Infection

•

Dressing the wound:

–

Helps protect against infection

–

Helps control bleeding 34-60

Open Soft-Tissue Injuries Types

•

Abrasions

•

Lacerations

•

Punctures

•

Avulsions

•

Amputations

•

Open crush injury 34-61

Abrasion

•

Outermost skin layer damaged by rubbing or scraping

•

Little or no bleeding

•

Infection primary concern 34-62

Laceration

•

Cut or tear

–

May occur by itself or with other soft-tissue injuries

•

Types

–

Linear (regular)

–

Stellate (irregular) 34-63

Laceration 34-64

Puncture Wound

•

Skin pierced with a sharp, pointed object

•

Increased risk of infection

•

May have little or no external bleeding

•

Internal bleeding may be severe 34-65

Puncture Wound

•

Severity depends on:

–

Location of injury

–

Depth of wound

–

Size of penetrating object

–

Forces involved in creating the injury 34-66

Impaled Object 34-67

Entrance / Exit Wounds

•

Gunshot and stab wounds are types of puncture wounds that can go completely through the body or body part

–

Creates an entrance and exit wound

•

Bullet entrance wound usually looks like a puncture wound

•

Exit wound is typically larger and more irregular

•

Carefully assess to find all wounds 34-68

Avulsion

• •

Piece of skin or tissue is torn loose or pulled completely off Bleeding varies with extent and depth of injury 34-69

Amputation

•

Separation of a body part from the rest of the body

34-year-old with a traumatic amputation caused by a gear

34-70

Open Crush Injury

• •

Broken bone ends may stick out through the skin Internal bleeding may be present

–

Can be severe enough to cause shock 34-71

•

Scene size-up Open Injuries Management

•

Primary survey

– – –

Stabilize cervical spine if needed Control bleeding, apply dressing Treat for shock if signs of shock present

•

Physical exam, vital signs, medical history

•

Splint bone or joint injuries 34-72

Special Considerations 34-73

Special Considerations Soft-tissue injuries that require special consideration:

–

Penetrating chest injuries

– – –

Eviscerations Impaled objects Amputations

– – – – –

Neck injuries Eye injuries Mouth injuries Ear injuries Nosebleeds 34-74

Penetrating (Open) Chest Injuries

•

A break in the skin over the chest wall

•

Severity depends on wound size

•

Sucking chest wound

–

Life-threatening injury

–

Can cause lung on injured side to collapse 34-75

Penetrating (Open) Chest Injuries

The front of this patient's chest showed visible bleeding but no obvious injury. When the patient’s back was assessed, multiple wounds were found.

Remember, the back is part of the chest. Never ever forget to check the back.

34-76

Penetrating (Open) Chest Injuries 34-77

Evisceration

• • • • • • •

Organ sticks out through an open wound Do not touch or try to replace exposed organ Remove clothing from around wound Lightly cover exposed organs / wound with a thick, moist dressing Secure dressing in place Position of comfort if no spinal injury Keep patient warm 34-78

Evisceration 34-79

Impaled Object

• • • • • •

Object remains embedded in an open wound Do not remove an impaled object

–

Exceptions:

• •

Interferes with CPR Object in cheek interferes with patient’s airway Secure object to prevent movement

–

Shorten only if necessary Control bleeding Stabilize object in place with bulky dressings Treat for shock if present 34-80

Amputation

• • • •

Control bleeding with direct pressure Put amputated part in a dry plastic bag or waterproof container

–

Seal bag or container

–

Place bag/container in water that has a few ice cubes Immobilize injured area Treat patient for shock 34-81

Amputation

•

DO NOT:

–

Use dry ice to keep an amputated part cool

–

Allow the amputated part to freeze

–

Place an amputated part directly on ice or in water 34-82

Open Neck Injury

•

The neck contains important blood vessels and airway structures

– – –

Swelling can cause an airway obstruction Penetrating injury can result in severe bleeding Risk of air being sucked into a torn blood vessel

• •

Air embolism Air can travel to heart, lungs, brain, or other organs

•

Air displaces blood and prevents tissue perfusion 34-83

Open Neck Injury

•

Possible causes of a neck injury include:

–

Hanging

–

Steering wheel impact

–

“Clothesline” injuries in which a person runs into a stretched wire or cord that strikes his throat

–

Knife or gunshot wounds 34-84

This patient is a 33-year-old man involved in a motor vehicle crash. He wore no seat belt and hit the windshield of the car he was driving. Despite the appearance of the injury, there were no injuries to the major blood vessels, trachea, or esophagus. The patient underwent surgery and was sent home 72 hours later.

34-85

Open Neck Injury 34-86

Eye Injuries

• •

Common injury Result of blunt and penetrating trauma

•

Signs of eye injury:

–

Swelling

–

Bleeding

–

Presence of a foreign object in the eye

–

Pain 34-87

Foreign Body in the Eye 34-88

Foreign Body in the Eye 34-89

Impaled Object in the Eye 34-90

Eye Chemical Burn

•

Most urgent eye injury

•

Damage depends on:

–

Type and concentration of the chemical

–

Length of exposure

–

Elapsed time until treatment 34-91

Early Signs of a Chemical Burn

•

Pain

•

Redness

•

Irritation

•

Tearing

•

Inability to keep eye open

•

A sensation of “something in my eye”

•

Swelling of the eyelids

•

Blurred vision 34-92

Chemical Burn to the Eye

•

Emergency care

–

Ask patient to remove contact lenses, if present

–

Immediately flush the eye with water or normal saline

–

Continue flushing for at least 20 minutes

–

Flush away from the unaffected eye 34-93

Mouth Injuries

•

Can result in airway obstruction

•

Signs and symptoms:

–

Tenderness

–

Bruising

–

Swelling 34-94

Jaw Fracture 34-95

•

Mouth Injuries Jaw Fracture Look in mouth for potential obstructions

–

Teeth, blood, vomitus

•

Suction as necessary

•

Look for broken or missing teeth

–

Preserve a knocked-out tooth

•

Control bleeding

•

Treat for shock if indicated 34-96

Ear Injuries

• •

Care for ear laceration as any other soft tissue injury Care for avulsed ear as for amputated part 34-97

Burns 34-98

Burn Types

•

Thermal (exposure to heat)

–

Examples: flame, scald, flash

•

Chemical

–

Examples: acids, alkalis

•

Electrical (including lightning)

•

Radiation 34-99

Burn Severity

• • • • • •

Depth Extent Location Patient age Conditions present before the burn Associated factors 34-100

Burn Depth

•

Superficial (first-degree) burn

•

Partial-thickness (second-degree) burn

•

Full-thickness (third degree) burn 34-101

Superficial (First-Degree) Burn

•

Involves only epidermis

•

Minor tissue damage

•

Skin red, tender, very painful

–

No blistering

•

Does not usually require medical care

•

Heals in ~2 to 5 days 34-102

Superficial (First-Degree) Burn 34-103

Partial-Thickness (Second-Degree) Burn

•

Extends through epidermis into dermis

•

Intense pain

•

Some swelling

•

Blistering may be present

•

Skin pink, red, or mottled

•

Heal in ~5 to 35 days 34-104

Partial-Thickness (Second-Degree) Burn 34-105

Full-Thickness (Third-Degree) Burn

•

Destroys epidermis, dermis

•

Skin color varies

•

Looks dry, waxy, or leathery

•

Numb – nerve endings destroyed

•

Rapid fluid loss 34-106

Full-Thickness (Third-Degree) Burn 34-107

•

Extent of Burn Key Points Only partial-thickness and full-thickness burns are included when calculating extent of a burn

•

Extent of the burned area is important to determine

–

The depth of the burn must also be considered, although superficial burns are not included in the calculation of the extent of a burn 34-108

•

Extent of Burn Rule of Nines “Rule of Nines”

–

Guide used to estimate body surface area burned

–

Divides adult body into 9%, or multiples of 9%, sections

–

Modified for children and infants 34-109

Extent of Burn Rule of Nines

Body Area Head and neck Front of trunk Back of trunk Each arm (shoulder to fingertips) Each leg (groin to toe) Genitals Adult 9% 18% 18% 9% Child 18% 18% 18% 9% Infant 18% 18% 18% 9% 18% 1% 13.5% 13.5% 1% 1%

34-110

Extent of Burn Rule of Nines 34-111

•

Extent of Burn Rule of Palms “Rule of Palms” can be used for:

–

Small or irregularly shaped burns

–

Burns scattered over the body

•

Palm of

patient’s

hand equals 1% of patient’s body surface area 34-112

Burns Best Treated in a Burn Center

• • • • • • • • •

Second-degree burns involving over 10% total body surface area (TBSA) in adults or 5% TBSA in children Chemical burns All burns involving hands, face, eyes, ears, feet, or genitals Circumferential burns of the torso or extremities Any third-degree burn in a child All inhalation injuries Electrical burns, including lightning injury All burns complicated by fractures or other trauma All burns in high-risk patients including older adults, the very young, and those with preexisting conditions such as diabetes, asthma, and epilepsy 34-113

Care for Thermal Burns

• • •

If patient still in area of heat source, move to safe area If clothing is in flames – stop, drop, and roll Remove smoldering clothing and jewelry

–

Cut around areas where clothing is stuck to skin 34-114

Primary Survey

•

Stabilize cervical spine if needed

•

Was the patient in a confined space and exposed to smoke, flames, or steam?

– – –

How long was he exposed?

Did he lose consciousness?

Were hazardous chemicals involved?

–

Be alert for potential airway problems 34-115

Inhalation Injury

• • • • • • •

Facial burns Soot in the nose or mouth Singed facial or nasal hair Swelling of lips or inside mouth Coughing Inability to swallow secretions Hoarse voice 34-116

Physical Examination

•

Check pulses in all extremities

–

Circumferential burn can act as a tourniquet

•

After all immediate life-threats have been managed, care for the burn itself 34-117

Physical Examination

• • • •

Quickly determine burn severity Vital signs Medical history Questions related to the burn:

–

How long ago did the burn occur?

–

How did it occur?

–

What was done to treat the burn before you arrived?

34-118

Treat the Burn

• • • • • • •

Cool the burn with cold water Cover burned area with a dry dressing or sheet Keep patient warm

–

Cover with clean, dry sheets Remove all jewelry Look for other injuries

–

Treat and immobilize possible fractures

– –

Treat soft-tissue injuries if present Treat shock if present Keep burned extremities elevated above the heart Transport to closest appropriate facility 34-119

Treat the Burn

•

Do not apply ice, butter, oils, sprays, lotions, or ointments to a burn

•

If a blister has formed, do not break it

–

Loosely cover the blister with a sterile dressing

•

Do not place ice or wet sheets on a burn

•

Do not transport a burn patient on wet sheets, wet towels, or wet clothing 34-120

Infant / Child Considerations

• • • •

Larger BSA than adults in relation to total body size

–

Greater fluid and heat loss More likely to develop shock or airway problems than adults Consider possibility of abuse when treating a burned child Report all suspected cases of abuse to appropriate authorities 34-121

Infant / Child Considerations 34-122

Older Adult Considerations

• – – – – – –

Mechanisms and severity of burn injury related to: Living alone Wearing loose-fitting clothing while cooking Falling asleep while smoking Declining vision, hearing, and sense of smell Slowed reaction time Problems with balance and/or memory 34-123

Chemical Burns

•

Degree of injury is based on:

–

Mechanism of action of the chemical

– – –

Strength of the chemical Concentration and amount of the chemical How long the patient was in contact with the chemical

– –

Body part in contact with the chemical Extent of tissue penetration 34-124

Care for Chemical Burns

•

Scene size-up

–

Gloves, eye protection, other PPE as necessary

–

Additional resources may be needed before you can safely enter the area 34-125

Care for Chemical Burns

•

General impression / primary survey

–

Manage airway and breathing

–

Stabilize cervical spine if needed

–

Remove patient’s jewelry

–

Remove clothing, including shoes and socks 34-126

Care for Chemical Burns

• •

Stop the burning process

–

Brush off dry chemicals

•

Brush chemical away from the patient

–

Flush the burn with

large

amounts of room temperature water

• •

Use low pressure Flush for

at least

20 minutes Treat other injuries, if present 34-127

Electrical Burns

• – – – – – –

Severity of an electrical injury is related to: Amperage (current flow) Voltage (current force) Type of current (AC/DC) Current pathway through the body Resistance of tissues to current Duration of contact 34-128

Electrical Burns

•

Skin normally resists the flow of electric current into the body

–

Electricity entering the body is converted to heat

–

Current follows paths of least resistance

•

Blood vessels, nerves, muscles 34-129

Care for Electrical Burns

• •

Make sure the power is off!

Contact additional resources if needed before entering the area 34-130

Care for Electrical Burns

•

Manage ABCs

•

Stabilize cervical spine if needed

• –

Watch closely for respiratory and cardiac arrest Make sure an AED is available 34-131

Care for Electrical Burns

• •

Treat other injuries if present Look for entrance and exit wounds 34-132

Dressing and Bandaging 34-133

Dressing and Bandaging

•

Dressing

–

Absorbent material placed directly over a wound

•

Bandage

–

Used to secure a dressing in place 34-134

Dressing and Bandaging

•

Functions of dressing and bandaging wounds:

–

Help stop bleeding

–

Absorb blood and other drainage from the wound

–

Protect wound from further injury

–

Reduce contamination and risk of infection 34-135

Dressings

•

A dressing should be:

–

Lint free

–

Large enough to cover the wound

•

Should extend beyond wound edges

–

Sterile whenever possible

–

Applied directly over the wound

•

Do not slide it in place 34-136

Types of Dressings 34-137

Sterile Gauze Pads

•

Loosely woven material

•

Classified by size in inches

–

2 x 2

–

4 x 4 34-138

Trauma Dressing

• • • •

Thick dressing Various sizes Two layers of gauze with absorbent cotton in center Uses

–

Large wounds

–

Pad injured limb inside a splint 34-139

Occlusive Dressing

• •

Made of nonporous material Used to cover open wound and make airtight seal

–

Chest wound

–

Neck wound 34-140

Nonadherent Pads

• •

Gauze pads with special coating Used to cover leaking open wound but not stick to it 34-141

Eye Pads

•

Uses:

–

Cover eyes after minor eye injury

–

Cover small wound, such as a puncture 34-142

Bandages 34-143

Bandages

•

Applied to keep a dressing in place

•

Does not have to be sterile

•

Before applying to an extremity:

–

Remove patient’s jewelry

–

Check pulse distal to the wound 34-144

Roller Gauze (Kling)

• – –

Secures dressing in place 1-inch roll for fingers 2-inch roll for wrists, hands, feet

– –

3-inch roll for elbows, upper arms 4- to 6-inch roll for ankles, knees, legs 34-145

Roller Bandage

• •

Soft, slightly elastic material Available in various widths 34-146

Elastic Bandage

• •

Do not use to secure a dressing in place May act as a tourniquet if injured area swells 34-147

Triangular Bandage

• •

Large piece of muslin When folded, can be used as a bandage or sling 34-148

Self-Adherent Wrap

• •

Elastic wrap coated with self-adhering material Often used as a pressure bandage 34-149

Pressure Bandage

• • • • •

Applied over a wound site to control bleeding Cover the wound with a dressing Apply direct pressure until the bleeding is controlled Secure the dressing in place with a bandage Assess the pulse distal to a bandage 34-150

Applying a Roller Bandage 34-151

Applying a Roller Bandage 34-152

Applying a Roller Bandage 34-153

Applying a Roller Bandage 34-154

Head or Ear Bandage 34-155

Upper Arm Bandage 34-156

Elbow Bandage 34-157

Wrist or Forearm Bandage 34-158

Knee Bandage 34-159

Foot or Ankle Bandage 34-160

34-161