Emergency Care Textbook Professional Responders PDF

9 Hemorrhage and Soft Tissue Trauma Key Content Infection................................... Dressings and Bandages......... Stitches and Sutures............... Tourniquets............................. External Bleeding.................... Internal Bleeding.................... Open Wounds..............

9 Hemorrhage and Soft Tissue Trauma Key Content Infection................................... Dressings and Bandages......... Stitches and Sutures............... Tourniquets............................. External Bleeding.................... Internal Bleeding.................... Open Wounds......................... Closed Wounds....................... Burns........................................ Major Soft Tissue Trauma....... 170 172 173 174 174 177 178 182 182 191 Most of the human body is made of soft tissues, which is a general category that includes skin, fat, muscle, vital organs, and blood vessels, among others. Soft tissues are generally defined by what they are not: Essentially, soft tissues are all tissues other than bones. These tissues are more susceptible to injury than the denser tissue in the skeleton. Injuries to the soft tissues range from extremely minor (such as a scrape or bruise) to life-threatening (such as an impaled object or gunshot wound). Damage to blood vessels, especially arteries, can be immediately life-threatening. Most soft tissue injuries are not addressed during your primary assessment, as they are typically not as serious as issues affecting the airway, respiration, or circulation, but a hemorrhage must be recognized and cared for as quickly as possible. HEMORRHAGE AND SOFT TISSUE TRAUMA Introduction 169 Soft tissue injuries can be divided into two general categories: open wounds, in which the skin is broken, and closed wounds, in which trauma occurs beneath the skin. Some types of soft tissue injuries, such as crush injuries, may be open, closed, or both, depending on the nature of the specific injury. Others, such as burns, do not fall naturally into either category, so this distinction is more of a guide than a rule. area thoroughly to remove any bacteria that might already be present. Minor wounds that are not hemorrhaging should be washed with water, preferably running water under gentle pressure (as from a tap or hose). If possible, rinse any minor wound for 5 minutes. Because chemicals such as soap and alcohol can cause damage to sensitive tissues under the skin, water alone is recommended for cleaning wounds. STAGES OF WOUND HEALING For wounds that are hemorrhaging or that involve extensive tissue damage, bleeding control and rapid transport are higher priorities than cleaning. These wounds will be cleaned thoroughly in the medical facility as a routine part of the care provided. Do not delay transport to clean a major wound. Healing is the general term used to describe the body’s process of repairing damaged tissues. In the case of wounds, this occurs primarily through the formation of scar tissue. HEMORRHAGE AND SOFT TISSUE TRAUMA First, the edges of a wound are brought together, and a thin layer of blood or plasma forms a clot between them. New tissue cells then grow through the clot, followed by new blood vessels. A new layer of skin then grows over the restored tissues. This process takes 5 or 6 days on average, depending on the size and location of the wound: Areas with good blood supply (such as the face) heal more rapidly than those without (such as the knees). The scar reaches full strength in approximately 17 days but will continue to contract and solidify for about a year. 170 If the edges of the wound are not brought together, healing takes longer, and a larger scar is likely to result. When the gap between the wound’s edges is so large that the wound cannot be closed, healing occurs through granulation, where new tissue grows from the bottom of the wound towards the surface, displaying a rough texture as it develops. Skin then grows slowly over this rough tissue. This is a much slower process, reinforcing the value of closing wounds whenever possible. INFECTION Any open wound is at risk of infection and should be protected from harmful pathogens. The best initial defence against infection is cleansing the When caring for any open wound, you can reduce the risk of infection by using sterile technique. Avoid touching open wounds, and use clean gloves if touching the wound is unavoidable. Take care to keep dirt and debris out of the wound, and avoid letting non-sterile material come into contact with it. When cleaning the area around a wound, always wipe away from the wound, not towards it. Signs of Infection When a wound becomes infected, the surrounding area becomes swollen and red, and the area may feel warm or throb with pain. Some infected wounds have a pus discharge (Figure 9–1, a-b). An infection begins in the wound itself but may spread into the surrounding tissues if untreated. In some cases, the infection can enter the patient’s circulatory system and move throughout the body, resulting in a life-threatening condition called systemic infection. Red streaks on the skin moving away from the wound and towards the heart are one sign that an infection is progressing to the systemic level. Systemic infection can also cause a patient to present with flu-like symptoms (e.g., fever, nausea, and general malaise). Systemic infections are usually treated with antibiotics, so a patient with these signs and symptoms should be examined by a physician as soon as possible. Tetanus produces a powerful toxin that affects the body’s central nervous system and specific muscles. Because it can often cause the jaw and neck muscles to contract, tetanus is sometimes referred to as lockjaw. As a tetanus infection progresses, it can affect other muscles as well. Once the tetanus infection enters the nervous system, its effects are irreversible, so any patient suspected of having a tetanus infection should see a physician as soon as possible. b Figure 9–1, a-b: An infected wound. Tetanus Tetanus is a serious infection caused by the microorganism Clostridium tetani. The spores of this bacterium are commonly found in soil, dust, and the feces of certain animals. Tetanus can cause severe medical problems and can be fatal. Tetanus spores are introduced into the body through a wound caused by a contaminated object. The spores then grow into bacteria inside the body. Because the organism multiplies in an environment that is low in oxygen, puncture wounds and other deep wounds are at the greatest risk for tetanus infection. Signs and symptoms of tetanus include: Difficulty swallowing. Irritability. Headache. Fever. Muscle spasms near the infected area. The best way to prevent tetanus is to be immunized against it. This involves an initial vaccination and periodic booster shots, which help to maintain the antibodies that protect against tetanus. Booster shots are recommended every 5 to 10 years. They are also recommended if a wound has been contaminated by dirt, or whenever a potentially contaminated object, such as a nail in a barn, causes a puncture wound. Most children in Canada receive an immunization known as DPT vaccine (short for diphtheria, pertussis, and tetanus. Consult a physician if you are unsure whether your tetanus immunization or booster is up to date. Infected wounds of the face, neck, and head should receive immediate medical care since the tetanus toxin can travel rapidly to the brain. Gangrene Like tetanus, gangrene is caused by bacteria that thrive in the absence of oxygen. It may also be caused by a loss of blood supply to the affected tissue. Gangrene causes a sudden onset of pain and swelling, with local tissue discoloration and a brownish, foul-smelling watery discharge that is highly infectious (Figure 9–2). A patient may also have a low-grade fever and present with signs of shock. HEMORRHAGE AND SOFT TISSUE TRAUMA a 171 © 2012 MICHAEL ENGLISH, M.D. - Custom Medical Stock Photo. All Rights Reserved. a Figure 9–2: Gangrene causes a sudden onset of pain and swelling, with local tissue discoloration and a brownish, foul-smelling watery discharge that is highly infectious. While rare, gangrene may lead to necrotizing fasciitis, which is a rapidly progressive and very painful infection sometimes referred to as flesheating disease. The most definitive characteristic is the presence of crackling (crepitus) beneath the skin due to tiny air bubbles. Any patient with gangrene should be seen by a medical professional and may require urgent transportation to do so. Monitor the patient for signs of shock during transport. HEMORRHAGE AND SOFT TISSUE TRAUMA DRESSINGS AND BANDAGES 172 Once an open wound has been cleaned, it must be protected against the intrusion of additional pathogens. This is done by covering the wound with a dressing, which is the general term for any material that is placed over a wound to cover and protect it. A dressing can also help to absorb blood and other fluids. A bandage is a piece of material (usually cloth or elastic) used to hold a dressing in place. Bandages can also be used to support an injured body part. Wrapping a bandage snugly can create pressure on a wound, helping to control bleeding. This is referred to as a pressure bandage. b Figure 9–3, a-b: a, Dressings come in various sizes; b, different types of bandages are used to hold dressings in place, apply pressure to control bleeding, help protect a wound from dirt and infection, and provide support to an injured body part. A wide variety of dressings and bandages are commercially available (Figure 9–3, a-b). Sometimes, a dressing and a bandage will be combined into a single product. When possible, choose the option that is best suited to the wound, taking into account the size, type, and location of the injury (see Table 9–1). Applying a Roller Bandage To apply a roller bandage, follow these general guidelines: First, secure one end of the bandage in place (Figure 9–4, a). Wrap the bandage around the body part until the dressing is completely covered and the bandage extends several centimetres beyond the dressing (Figure 9–4, b). Tie or tape the bandage in place (Figure 9–4, c). If applying roller gauze to an extremity, apply it distally-toproximally to facilitate venous return. If blood soaks through the bandage, leave the bandage and dressings in place and apply additional dressings and another bandage on top. TABLE 9–1: COMMON TYPES OF BANDAGES AND DRESSINGS DESCRIPTION EXAMPLES OF USE Occlusive dressings Air- and water-tight dressings that completely block a wound Covering an intravenous (IV) site Gauze Can be sterile or non-sterile Some types are non-stick Open wounds; non-stick variety is commonly used for burns Burn dressings Sterile, non-stick sheets or packs Some have non-stick material on one surface and sterile gauze on the reverse, others may have a gel or other substance incorporated to speed burn cooling Burn care Trauma dressings Large sheets of sterile, absorbent material Usually placed over a layer or more of gauze Large open wounds Abdominal dressings Similar to trauma dressings, but smaller in size Abdominal wounds, other large open wounds Pressure dressings (field dressings) Layers of gauze and other absorbent material attached to a roller bandage Allows a dressing and bandage to be applied simultaneously Hemorrhage control, especially on extremities Skin closures (butterfly closures) Small adhesive strips used to hold together edges of an open wound Lacerations Small adhesive dressings Small, adhesive pad or strip with an attached sterile pad Available in a variety of sizes and shapes for different applications Small minor wounds Eye dressings Small, sterile oval of thick absorbent material placed over the eye socket Protecting an injured eye from additional damage or foreign material, and absorbing fluid Triangular bandages Triangular sheet of soft material, typically cotton Supporting injured extremities, holding dressings in place, securing splints Elastic roller bandage (tensor bandage) Long strip of elastic material that can be wrapped around an injury to provide continuous pressure, supporting the area and reducing swelling Supporting injured extremities, caring for sprains and sprains Gauze roller bandage Long strip of absorbent material. May be self-adhesive. Can be folded for use as a dressing or compress Holding dressings in place, stabilizing impaled objects, holding cold packs in place Leave the fingers or toes uncovered if possible: This can help you assess sensation and circulation to ensure that the bandage’s pressure is appropriate (Figure 9–4, d). Check sensation and circulation before and after applying the bandage. If the fingers or toes show signs of impaired circulation or sensation after applying the bandage, loosen the bandage slightly and reassess. Comparing the injured extremity to the corresponding one on the other side of the body can help you determine the patient’s normal levels of sensation and circulation. STITCHES AND SUTURES Stitches or sutures are needed when a wound might not otherwise heal cleanly. Stitches and sutures speed the healing process, help to prevent infection, and reduce the appearance of scars. A wound should be stitched or sutured within the first few hours after the injury. The following may require stitches or sutures: A hemorrhaging wound A wound with jagged edges A wound more than 2.5 cm (1 in.) long A wound on the face or head HEMORRHAGE AND SOFT TISSUE TRAUMA TYPE 173 a c b d Figure 9–4, a-d: When applying a bandage: a, secure the end of the bandage in place; b, wrap the bandage around the body part until the dressing is completely covered; c, tie or tape the bandage in place; and d, ensure the bandage is not too tight by checking distal circulation. A  wound that gapes widely or shows the muscle or bone A wound on a joint or on the hands or feet A large or deep puncture A large or deeply embedded object A human or animal bite HEMORRHAGE AND SOFT TISSUE TRAUMA TOURNIQUETS 174 A tourniquet is a tight band placed around an extremity to constrict blood vessels and stop blood flow. It is used to treat a hemorrhage when all other interventions are impossible or have been ineffective (Figure 9–5, a). Because the tourniquet completely blocks blood flow to the extremity for the entire time that it is in place, it can have serious complications for the patient and should only be used if it is absolutely necessary. A bandage and dressing should be used in addition to a tourniquet whenever possible to assist with blood clotting. A variety of commercially manufactured tourniquets are available. You should consider applying a tourniquet for initial care during situations when you are unable to use standard hemorrhage control. Such situations may include a mass casualty incident, an injury in an environment that becomes unsafe, or a patient hemorrhaging blood from a wound that cannot be accessed. Apply the tourniquet 5 to 10 cm (2 to 4 in.) above the injury and just above any joint in this range (Figure 9–5, b). Tighten the tourniquet until the bleeding stops, and secure it in place (Figure 9–5, c). Continue to apply direct pressure to the wound if possible. Document the time that the tourniquet was applied. A patient with a tourniquet applied should always be in the rapid transport category. EXTERNAL BLEEDING Most open wounds will have some bleeding, but the body’s clotting response will usually stop minor bleeding within 10 minutes, especially if pressure is applied. A hemorrhage, however, will overwhelm the body’s responses and can rapidly cause a patient to go into hemorrhagic shock. For this reason, it is crucial that you learn to differentiate minor bleeding from hemorrhaging. You should check for external hemorrhaging during the rapid body survey in your primary assessment and provide care for it immediately if it is found. Each type of blood vessel bleeds differently. Bleeding from arteries is often hemorrhagic (rapid, profuse, and life-threatening). This is because arterial blood is under direct pressure from the heart, so it usually spurts from the wound, making it difficult for clots to form. For this reason, arterial bleeding is harder to control than bleeding from veins and capillaries. Arterial blood has a bright red colour due to its high concentration of oxygen. a Veins are damaged more often than arteries because they are closer to the skin’s surface. Venous blood is under less pressure than arterial blood, and flows from the wound at a steady rate without spurting. Due to the lower pressure, venous bleeding is easier to control than arterial bleeding. Only damage to veins deep in the body, such as those inside the trunk or thighs, produces hemorrhages that are hard to control. Because it is oxygen-poor, venous blood is a dark red or maroon colour. b External bleeding is life-threatening when significant quantities of blood are spurting or flowing freely (hemorrhaging) from a wound. Care for External Bleeding To control minor to moderate amounts of bleeding, apply pressure with your gloved hand directly on the wound. This is called applying direct pressure. Pressure on the wound compresses the blood vessels, restricting the blood flow, and allows clotting to occur. You can maintain pressure on a wound by applying a dressing and pressure bandage to the injured area. If the patient is responsive, he or she may be able to maintain direct pressure on the dressing while you apply the bandage. c Figure 9–5, a-c: a, If a hemorrhage cannot be controlled through other interventions: b, apply a tourniquet 5 to 10 cm (2 to 4 in.) above the injury; and c, tighten the tourniquet until bleeding stops, and secure it in place. HEMORRHAGE AND SOFT TISSUE TRAUMA Capillary bleeding is usually slow because the vessels are small and the blood is under low pressure. It is often described as oozing from the wound. Clotting occurs easily with capillary bleeding. The blood from capillaries is usually dark red in colour. 175 Direct pressure alone may not be enough to control a hemorrhage, or it may be impossible (for example, if a patient’s leg is inaccessible but is hemorrhaging). If so, apply a tourniquet to control the bleeding. a To control external bleeding, follow these general steps: 1. Place the patient in a seated or recumbent position. 2. Place direct pressure on the wound with a gloved hand. 3. Apply a sterile dressing. Place your gloved hand over the dressing and apply firm pressure (Figure 9–6, a). 4. Apply a bandage over the dressing to maintain direct pressure (Figure 9–6, b) and hold the dressing in place. If blood soaks through, add additional dressings and bandages. Do not remove any blood-soaked dressings or bandages. 5. If bleeding continues, and the wound is on a limb, apply a tourniquet above the injury (Figure 9–6, c). While painful, this is necessary to save the patient’s life. EPISTAXIS (NOSEBLEED) HEMORRHAGE AND SOFT TISSUE TRAUMA b 176 Epistaxis (usually referred to as a nosebleed) is often caused by blunt force trauma to the nose. High blood pressure or changes in altitude can also cause epistaxis. If the MOI suggests more severe injuries, ensure that those are identified and cared for. Initiate spinal motion restriction protocols if indicated. In most cases, you can control the bleeding by having the patient sit with the head slightly forward while pinching the nostrils together (Figure 9–7). Applying an ice pack or cold compress to the bridge of the nose can also help slow blood flow and assist in the clotting process. Once you have controlled the bleeding, instruct the patient to avoid rubbing, blowing, or picking his or her nose since this could restart the bleeding. c Figure 9–6, a-c: To control external bleeding: a, place direct pressure on the wound; b, apply a pressure bandage; and c, apply a tourniquet if bleeding continues and the wound is on a limb. If you suspect that the nosebleed is caused by a foreign body lodged in the nostril or nasal passage, refer the patient to a physician (unless it can be easily removed without the risk of Internal hemorrhaging usually occurs in injuries caused by a violent blunt force, such as when a driver is thrown against the steering wheel in a motor vehicle collision. An internal hemorrhage may also occur when a sharp object, such as a knife, penetrates the skin and damages internal structures, or when a fractured bone ruptures an organ or blood vessels. further injury). If the patient’s history includes hypertension or blood-thinning medication, epistaxis can become life-threatening: If the bleeding cannot be quickly controlled, these patients may require rapid transport. If the bleeding cannot be controlled within 10 to 15 minutes or repeatedly stops and recurs in a short period, this is an example of uncontrollable bleeding: The patient should be transported to a medical facility. If the patient loses responsiveness, place him or her in the recovery position to allow blood to drain from the nose. INTERNAL BLEEDING Internal bleeding is the escape of blood from arteries, veins, or capillaries into spaces inside the body. Capillary bleeding is just beneath the skin and is usually not serious; it is usually indicated by mild bruising. Internal bleeding involving arteries and veins, however, can result in severe blood loss and can be life-threatening. Major fractures, such as those involving the pelvis, femur, or lower ribs, can puncture organs or arteries and cause significant internal bleeding. The signs and symptoms of possible internal bleeding are not always obvious and may take time to appear. They include: Discoloration of the skin (bruising) in the injured area. Soft tissues that are tender, swollen, or firm. Anxiety or restlessness. Rapid breathing (tachypnea). Skin that feels cool or moist or looks pale or bluish. Nausea and vomiting. Excessive thirst. Declining level of responsiveness. A rapid, weak pulse. A drop in blood pressure. The body’s inability to adjust to internal hemorrhaging will eventually result in shock. Shock is discussed in Chapter 8. HEMORRHAGE AND SOFT TISSUE TRAUMA Figure 9–7: To control epistaxis, have the patient lean forward while pinching the nostrils together. Because internal bleeding is more difficult to recognize than external bleeding, you should always suspect internal bleeding when the MOI indicates the potential for a serious injury. For example, if you find a motorcycle rider who has been thrown from a bike, you may not see any external hemorrhaging, but the violent forces involved indicate that serious internal injuries are likely. 177 Care for Internal Bleeding Lacerations The care for internal bleeding depends on the severity and site of the bleeding. For minor internal bleeding, such as a contusion (bruise) on an arm, apply ice or a chemical cold pack to the injured area to help reduce pain and swelling. Place something such as a gauze pad or towel between the cold source and the skin to avoid freezing the tissues. A laceration is a cut, usually caused by a sharp object (e.g., a knife or broken glass). The cut may have either jagged or smooth edges (Figure 9–9, a-b). A laceration can also result when a blunt force splits the skin. This often occurs in areas where bone lies directly under the skin’s surface (e.g., the eyebrow). Deep lacerations can affect the layers of fat and muscle, damaging both nerves and blood vessels. Lacerations usually bleed freely and, depending on the structures involved, can hemorrhage. Because the nerves may also be injured, lacerations may or may not be immediately painful. If you suspect internal hemorrhaging, you must obtain advanced medical care for the patient immediately. There is little you can do to control internal hemorrhaging effectively: The patient must be transported to the hospital as soon as possible. Monitor the patient for signs and symptoms of shock. The patient will often require immediate surgery to correct the problem. OPEN WOUNDS There are four main types of open wounds: 1. Abrasions 2. Lacerations 3. Avulsions 4. Punctures The care for all of them is generally the same: Control any external bleeding, protect against infection, and check for internal injuries. a HEMORRHAGE AND SOFT TISSUE TRAUMA Abrasions 178 An abrasion is the most common type of open wound. It occurs when skin is rubbed or scraped away (Figure 9–8, a-b). Rug burn and road rash are common terms for types of abrasions. Because the removal of the outer skin layers exposes sensitive nerve endings, an abrasion is often painful. Because abrasions are usually superficial, the capillaries are the only blood vessels affected. Bleeding is typically not severe. Infection is a serious concern with abrasions, as dirt and other matter can easily become embedded in the skin during the injury. Cleaning the wound and monitoring for signs of infection are important steps. b Figure 9–8, a-b: An abrasion. Bleeding control is usually your primary concern with a laceration, though infection is also a risk. If the wound is deep, damage to underlying tissues can cause internal bleeding: Monitor the patient’s condition closely and watch for signs of shock, especially if the laceration is on the torso. Avulsions completely torn away (Figure 9–10, a-b). A partially avulsed piece of skin may remain attached but hang like a flap. Because avulsions often involve deeper layers of soft tissue, bleeding is usually significant. Bleeding and infection control are usually your priorities when caring for an avulsion. a a b b Figure 9–9, a-b: A laceration. Figure 9–10, a-b: An avulsion. HEMORRHAGE AND SOFT TISSUE TRAUMA An avulsion is a type of injury in which a portion of the skin and other soft tissue is partially or 179 Punctures A puncture wound results when the skin is pierced with a pointed object such as a nail, a splinter, or a knife (Figure 9–11, a-b). A bullet wound is also classified as a puncture wound. Because the skin usually closes around the penetrating object, external bleeding is generally not severe. However, internal hemorrhages can occur if the penetrating object damages major blood vessels or internal organs. An object that remains in the open wound is called an impaled object (Figure 9–12, a-b). An object may also pass completely through a body part, making two open wounds: one at the entry point and one at the exit point. Although puncture wounds generally do not hemorrhage, they are still potentially dangerous as they have a high risk of infection. Objects penetrating the soft tissues carry micro-organisms that cause infections (e.g., tetanus), and these micro-organisms often prefer low-oxygen environments, such as those found deeper within the body. To combat the risk of infection, both major and minor puncture wounds should be cleaned thoroughly. a HEMORRHAGE AND SOFT TISSUE TRAUMA a 180 b Figure 9–11, a-b: A puncture wound. b Figure 9–12, a-b: An impaled object. BALLISTICS INJURIES Injuries caused by firearms are considered puncture (or penetrating) wounds, and the care is generally the same as for any other open wound. If you encounter a patient who has been injured by a firearm, look for both an entry and an exit point for the bullet. If no exit point is found, the bullet may still be inside the patient’s body. You may also find burns on the skin caused by gunpowder, especially if the bullet was fired at close range. The location of the entry point (and exit point, if present) can give an indication of the internal injuries that may have occurred based on which structures or organs the bullet may have damaged after penetrating the skin. It is not always possible to assess the patient’s internal injuries merely by examining the entry (and/or exit) point, however. a The scene of a firearms injury is often a crime scene. Ensure that the scene is safe and that law enforcement personnel have been contacted, and follow the protocol for responding to a crime scene. Impaled Objects Stabilize the object with bulky dressings (Figure 9–13, a), then bandage the dressings in place around the object to limit movement and control bleeding (Figure 9–13, b). REMOVING SLIVERS A sliver is a thin piece of material that has penetrated the skin. There are three common types of sliver: 1. Wood: These are often difficult to see against the patient’s skin. To find a wood sliver, wet the area with a coloured antiseptic solution b Figure 9–13, a-b: a, Use bulky dressings to support an impaled object; b, control bleeding and hold the dressing in place by applying a bandage. (e.g., iodine) for 30 seconds. Gently wipe away the remaining liquid; the sliver will have likely soaked up some of the liquid, making it easier to see. 2. Metal: These are generally easy to see and remove. 3. Glass: These are usually invisible and difficult to remove. Soak in warm, diluted antibacterial detergent for 20 minutes. HEMORRHAGE AND SOFT TISSUE TRAUMA If the object that caused an injury is still in the wound, it is referred to as an impaled object. Small objects (such as slivers and fish hooks) can usually be removed without any risk for the patient (see below), but larger impaled objects (such as a shard of glass or metal rebar) should be left in place unless they interfere with the patient’s airway or respiration. Moving an impaled object can damage internal structures and cause or exacerbate bleeding. 181 To remove a sliver: 1. Determine the angle at which the sliver entered the skin (Figure 9–14, a). 2. Grasp the sliver with disinfected forceps (tweezers) and draw it out at the same angle (Figure 9–14, b). 3. Treat the wound as a puncture or laceration. REMOVING FISH HOOKS Do not remove an impaled fish hook if there is a chance that removing it might injure vital structures (e.g., muscles or nerves around the eye). In these cases, immobilize the fish hook until it can be removed at a medical facility. If the fish hook can be removed without risk to underlying tissues, take it out using one of the following methods, and then treat the resulting puncture wound. Method 1 1. With  one hand, press down on the back of the hook shank (by the eye of the hook) to push the barb away from any tissue. 2. With the other hand, quickly jerk out the hook. Method 2 a 1. Move  the hook in a curve so that the barbed tip exits through the skin. 2. Clip off the barbed tip and remove the remainder of the hook by pulling it back the way it entered. This avoids forcing the eye of the hook through tissue. CLOSED WOUNDS HEMORRHAGE AND SOFT TISSUE TRAUMA A closed wound is generally defined as any wound that occurs without breaking the skin. While infection is less of a concern with closed wounds, they often involve damage to internal structures and the risk of internal bleeding. Like open wounds, closed wounds range from extremely minor to life-threatening. 182 Abscesses An abscess is a significant localized collection of pus within tissues, usually in hair-bearing areas (Figure 9–15). It is also referred to as a boil. b Figure 9–14, a-b: To remove a sliver: a, determine the angle at which it entered the skin; and b, with disinfected forceps, grasp and withdraw it at the same angle. If the abscess involves the face, neck, groin, or buttocks, or if it is very painful, the boil should preferably be treated by a physician. The abscess may drain naturally if left alone. Draining can be hastened by applying hot and warm compresses alternately until the pus begins Subungual Hematomas To care for a subungual hematoma, begin by cleaning the area. Ensure that the patient’s hand is on a firm surface. Use a nail drill to create a small hole in the nail above the fluid pocket. If there is no nail drill available, heat the end of a paperclip until it is red-hot and use it to create the hole. Because there are no nerve endings in this area, the procedure should be painless. Clean the area and apply a dressing. If pressure builds over time, the hole may need to be reopened. If releasing the fluid does not stop the pain, perform a focused exam on the affected digit to check for a possible fracture or other damage to internal structures. Myocardial Contusions Myocardial contusion (also referred to as cardiac contusion) is a bruising of the heart’s muscle tissue. It is usually caused by blunt chest trauma and therefore is frequently suspected in patients involved in a motor vehicle collision or a fall. Cardiac contusion can cause life-threatening arrhythmias and cardiac failure. Because of nonspecific symptoms, myocardial contusion is difficult to identify. Common symptoms include pain in the chest (from the blunt force) and the feeling that the heart is racing. Any patient with serious chest trauma should be rapidly transported to a medical facility for assessment. Figure 9–15: An abscess. Dermatitis Dermatitis is a general term for an inflammation of the skin. Most cases of dermatitis result either from direct contact with a chemical irritant or from an allergy. Dermatitis is not contagious, but it can spread if left untreated. If you encounter a patient with dermatitis, ask whether he or she has had a reaction to a skin irritant in the past. Signs and symptoms of dermatitis include: Redness, irritation, or swelling (Figure 9–16). Itchiness or pain. Possible thickening and cracking of the skin. Possible blisters. To care for dermatitis: Avoid further contact with the irritant. Protect the skin with a suitably sized dressing. Advise the patient to seek additional medical attention if the irritation persists for more than 3 days. Figure 9–16: Dermatitis. HEMORRHAGE AND SOFT TISSUE TRAUMA A subungual hematoma is a collection of blood or fluid between the nail bed and the fingernail. Subungual hematomas result from direct trauma to the fingernail, most commonly after a crushtype injury. The pressure of the fluid causes the fingernail to throb, often resulting in intense pain. If the blood is released, the patient will feel some relief. Photo. All Rights Reserved. © 2012 Science Photo Library - Custom Medical Stock to discharge. Avoid squeezing the abscess, as this is likely to spread the infection. Clean the area and apply dry dressings once the abscess has begun to reduce in size. The dressings will continue to absorb the remaining fluid from the wound. Change the dressings if they become saturated with fluid. Continue to cleanse the area periodically, watching for signs of infection. 183 BURNS Severity of Burns A burn is a soft tissue injury caused by heat, chemicals, electricity, or radiation (see Table 9–2). While all types of burns have similar characteristics, the care that is indicated for a patient can vary based on how the burn occurred. Interventions indicated for a thermal burn may not be indicated for a chemical burn, and so on. When burns occur, they affect the epidermis (outer layer of skin) first. If a burn progresses, it can also damage the dermis and other underlying tissues (including muscle and bone). Burns that break the skin can cause infection, fluid loss, and loss of temperature control. The severity of a burn depends on the following factors: Intensity of the source (e.g., the temperature of steam or concentration of a chemical) Length of exposure to the source Location of the burn Extent of the burn Patient’s age Patient’s underlying medical conditions HEMORRHAGE AND SOFT TISSUE TRAUMA In general, patients under the age of 5 and over the age of 60 have thinner skin and burn more severely. Patients with acute trauma (e.g., fractures) or chronic medical problems (e.g., heart or kidney conditions, diabetes) tend to have more complications resulting from burns; burns are often more severe in these patients, and they are more vulnerable to dehydration as a result of burn injuries (increasing the risk of shock). 184 In addition to being broken down by their causes (heat, chemicals, electricity, or radiation), burns are classified by their depths. The deeper the burn, the more types of tissue are affected, and the more severe the burn is. Generally, three depth classifications of burns are used: 1. Superficial 2. Partial-thickness 3. Full-thickness SUPERFICIAL BURNS A superficial burn (sometimes referred to as a firstdegree burn) involves only the top layer of skin (Figure 9–17, a-b). The burnt skin is red and dry, the burn is usually painful, and the affected area may swell. Superficial burns generally heal in 5 to 6 days without permanent scarring. a TABLE 9–2: CAUSES OF BURNS CAUSE DESCRIPTION EXAMPLES OF SOURCES Thermal Caused by exposure to heat Steam, fire, boiling water Chemical Caused by exposure to caustic chemicals Battery acid, drain cleaner Electrical Caused by exposure to powerful electrical currents Charged electrical wires, lightning Radiation Caused by exposure to radiation Sunlight, nuclear radiation b Figure 9–17, a-b: A superficial burn. FULL-THICKNESS BURNS A partial-thickness burn (sometimes referred to as a second-degree burn) involves both the epidermis and the dermis (Figure 9–18, a-b). These burns appear red and have blisters that may open and weep clear fluid, making the skin appear wet. The skin may also appear blotchy in the area around the burn. These burns are usually very painful. Minor partial-thickness burns may heal in a few weeks without in-hospital burn care, but more severe partial-thickness burns can be life-threatening. Scarring can occur from partialthickness burns. A full-thickness burn (sometimes referred to as a third-degree burn) destroys the epidermis, the dermis, and any or all of the underlying structures— fat, muscles, bones, and nerves (Figure 9–19, a-b). They may look brown or charred, and the tissues underneath sometimes appear white. They can be either extremely painful or relatively painless, depending on how much damage is caused to the nerve endings in the skin. Full-thickness burns are often surrounded by painful partial-thickness and superficial burns. Full-thickness burns can be lifethreatening: Because the burns are open wounds, the body loses fluid (reducing blood volume), so hypovolemic shock is a serious risk. Full-thickness burns are also large open wounds, so they make the body highly vulnerable to infection. Severe scarring may occur, and skin grafts are usually required. a a b b Figure 9–18, a-b: A partial-thickness burn. Figure 9–19, a-b: A full-thickness burn. HEMORRHAGE AND SOFT TISSUE TRAUMA PARTIAL-THICKNESS BURNS 185 Identifying Critical Burns A critical burn is a burn that is likely to be lifethreatening, disfiguring, or disabling and requires immediate, advanced burn care. A patient with a critical burn requires rapid transport. Determining whether a burn is critical is not simply a question of determining its depth or cause: A superficial burn that covers large areas of the body or damages certain body parts can be critical. The following are examples of critical burns: A full-thickness burn of any size A partial-thickness burn that covers more than 10% of the body Any partial- or full-thickness burns on a child or an older adult Inhalation injuries causing respiratory difficulty Burns around the mouth or nose, or signs of smoke inhalation Significant burns on the head, neck, hands, feet, or genitals Burns resulting from chemicals, explosions, or electricity Burns that cause a great deal of pain Burns that result in unresponsiveness Estimating the Extent of Burns HEMORRHAGE AND SOFT TISSUE TRAUMA When communicating with medical personnel about a burned patient, you may be asked how much of the body is burned. The Rule of Nines is a common method for estimating the percentage of the body affected by burns (Figure 9–20 and Table 9–3). It is most useful when assessing large burns that cover multiple areas of the body. 186 In an adult, the head equals 9% of the body’s total surface. The anterior and posterior sides of each arm are considered 4.5% each, for a total of 9% per arm. Each leg equals 18%, as does the anterior and posterior side of the trunk. The groin equals 1%. If the front of the trunk (18%) and one entire arm (9%) are burned, you would estimate that 27% of the body’s surface area had been burned. The Rule of Nines is modified when assessing an infant. For an infant, the head equals 18% of the total body surface. As for adults, the anterior and posterior sides of each arm are considered Figure 9–20: The Rule of Nines is one method to help determine how much of the body is burned. 4.5% each, for a total of 9% per arm. Each lower extremity equals 14%, and each side of the trunk (anterior and posterior) equals 18% (Figure 9–21). For an infant with burns to one leg (14%) and the front of one arm (4.5%), you would estimate that 18.5% of the body’s surface area had been burned. TABLE 9–3: RULE OF NINES PERCENTAGE (ADULT AND CHILD) PERCENTAGE (INFANT) 9 18 Left arm (anterior) 4.5 4.5 Left arm (posterior) 4.5 4.5 Right arm (anterior) 4.5 4.5 Right arm (posterior) 4.5 4.5 Torso (anterior) 18 18 Torso (posterior) 18 18 Groin 1 0 Left leg 18 14 Right leg 18 14 AREA Head and neck In simpler cases, or if the Rule of Nines is not practical, communicate how the burn occurred, the body parts involved, and the severity of the burn. For example, “The patient was injured when an overheated car radiator exploded. The patient has partial-thickness burns on his or her face, neck, chest, and arms.” The Rule of Palms is another method used to estimate the percentage of a patient’s body that has been burned. It is generally used when burns are less extensive. The palm of the patient’s hand is roughly equivalent to 1% of his or her body’s surface area, so if the burns cover an area equal to about 4 of the patient’s palms, the burns cover approximately 4% of the patient’s body. Generally speaking, burns are caused by something in a patient’s environment. You should always use caution when responding to a patient with burns to avoid being injured by the same source. Look for fire, smoke, downed electrical wires, and warning signs for chemicals or radiation. If the scene is unsafe and you have not been trained to manage the specific hazards you encounter, request qualified personnel immediately. Interventions and additional care may not be necessary if a burn is superficial: These injuries generally heal on their own in a matter of days with a low risk of complications. Pay special attention to the patient’s airway during the primary assessment to ensure that it has not been affected by inhalation injuries. Regardless of the burn type, you should perform these three basic care steps: 1. Prevent additional damage to tissue. 2. Cover the burned area with dry dressings. 3. Take steps to manage shock. Additional steps may be necessary, depending on how the burn was caused. Figure 9–21: The Rule of Nines is modified when it is used for an infant. PREVENT ADDITIONAL DAMAGE TO TISSUES Burns can continue to worsen over time if steps are not taken to mitigate their effects. A patient who has been burned by boiling water, for example, will continue to experience tissue damage until the area is cooled. A caustic chemical can continue to burn a patient until it is flushed from his or her skin. When caring for a burn, your first priority is to minimize additional damage. If a patient’s eyes have been flash burned, rinse them with saline or water. Have the patient close his or her eyes, and cover them with moist, sterile dressings. COVER THE BURNED AREA Cover the burned area to protect against pathogens and help reduce pain (Figure 9–22), leaving any blisters intact to further reduce the risk of infection. Use dry, non-stick, sterile dressings and loosely bandage them in place. The bandage should not put pressure on the burned area. If the burn covers a large area of the body, cover it with clean, dry sheets (or other large HEMORRHAGE AND SOFT TISSUE TRAUMA Care for Burns 187 pieces of clean, dry cloth). Unlike most burns, small burns (covering less than 10% of the body) may be covered with a moist dressing if this reduces pain for the patient. Do not put ointments or other oils (e.g., butter, cooking oil, commercial salves) on a burn. Instead of relieving pain, these substances tend to seal in heat and cause infections by contaminating open skin areas. TAKE STEPS TO MANAGE SHOCK Pain and fluid loss from full-thickness and large partial-thickness burns can cause shock. Monitor the patient closely and provide care for shock (see Chapter 8). Patients with burns tend to lose body heat easily, so it is important to manage the temperature of the environment as much as possible to help the patient maintain a normal body temperature. ADDITIONAL CONSIDERATIONS BY CAUSE Thermal Burns Thermal burns are caused by exposure to heat. This may be direct (e.g., touching steam or a hot stove) or radiant (e.g., being exposed to the heat from a forest fire). HEMORRHAGE AND SOFT TISSUE TRAUMA When caring for a thermal burn, it is essential to cool the affected areas immediately. Even after the source of heat has been removed, soft tissue will continue to burn for several minutes, causing further damage. 188 Hot grease poses a high risk of critical burns because it is slow to cool and difficult to remove from the skin. Burns that involve hot liquid or flames contacting clothing will also be serious since the clothing keeps the heat in contact with the skin. Some synthetic fabrics can melt and stick to the skin when exposed to heat and may take longer to cool than the body’s soft tissues. Although the severity of thermal burns may seem low at first, they can continue to worsen over time if they are not cooled thoroughly. Cool thermal burns with cool or cold potable water (Figure 9–23). Flush or immerse the area using whatever clean sources of water are available (e.g., a tub, shower, or garden hose). Figure 9–22: Cover a burned area to protect against pathogens and help reduce pain. If possible, immerse the burn in water (instead of using running water) to reduce the risk of tissue damage. Ensure that any water used stays cool: You may need to add more cool water to maintain an appropriate temperature. You can apply soaked cloth compresses to areas that cannot be immersed or are too painful to immerse. Continue adding water regularly to keep these compresses cool until the burn site has been cooled completely. Allow adequate time for the burned area to cool, usually at least 10 minutes. If pain continues after 10 minutes, additional cooling may help to relieve it. If a partial- or full-thickness burn covers more than 10% of the body, cool only a small area at a time. Cooling a large area increases the risk of cold stress and hypothermia. Do not use ice or ice water because they can cause critical body-heat loss. Care should be taken to monitor for hypothermia when cooling large burns. This is particularly important in children, who have a higher susceptibility to hypothermia. If the patient starts to shiver, stop cooling his or her burns immediately and monitor for additional signs of hypothermia and shock. If possible, remove any jewellery early in the cooling process. When the burn is cool, remove any remaining clothing from the affected area by carefully peeling or cutting the material away. Do not remove any clothing that sticks to the burn. Inhalation Injuries The presence of soot, thermal burns around the mouth or nose, singed hair, and/or singed eyebrows may signal that a patient’s air passages or lungs have been burned (Figure 9–24). Burns that result from a fire in an enclosed, confined space are likely to involve inhalation injuries of the airway and lungs. Usually, only the upper airway is vulnerable to inhalation injuries. If possible, move the patient to a well-ventilated area. If you suspect a burned airway or burned lungs, place the patient in the rapid transport category. Airway management, assisted ventilations, and supplemental oxygen may be indicated. Figure 9–23: It is important to cool a thermal burn with large amounts of cool water. Chemical Burns The severity of a chemical burn depends on the strength of the chemical and the duration of the chemical’s contact with the body. The chemical will continue to burn as long as it is on the skin. You must remove the chemical from the skin as quickly as possible and then place the patient in the rapid transport category. Before providing care for a chemical burn, ensure that you have taken the proper steps to protect yourself from any possible hazardous chemicals by donning the appropriate personal protective equipment. Ask the patient whether he or she Figure 9–24: Burns to the face may indicate an inhalation injury. HEMORRHAGE AND SOFT TISSUE TRAUMA Chemical burns are caused by exposure to caustic chemicals. These substances are more common in industrial settings but also occur in the home. Cleaning solutions (such as household bleach), oven or drain cleaners, toilet bowl cleaners, paint strippers, and lawn or garden treatments are common sources of caustic chemicals. Typically, burns result from chemicals that are strong acids or alkalis (bases). 189 touched any tools, equipment, etc. after being contaminated by the chemical (as this could contaminate others as well). You should also ask whether anyone else may have been exposed in the same incident. Flush the burn continuously with large amounts of cool, running water. If the chemical is in the form of a powder or granules, brush the chemical from the skin before flushing the area. Continue flushing for at least 20 minutes. Have the patient remove contaminated clothing, including clothing that became wet during flushing. Chemical Burns to the Eye Chemical burns to the eyes can be extremely traumatic. Flush the affected eye for at least 20 minutes (Figure 9–25). Take care to avoid contaminating any unaffected areas of the patient: Flush the affected eye from the nose outward, and angle the patient’s head to avoid washing the chemical into the other eye or onto unaffected skin. Figure 9–25: Flush a chemical burn to the eye for at least 20 minutes. HEMORRHAGE AND SOFT TISSUE TRAUMA Electrical Burns 190 The human body is an effective conductor of electricity. When a person makes contact with an electrical source, the electricity is conducted through his or her body. Some body parts, such as the skin, resist the electrical current. Resistance produces heat, which can cause electrical burns along the path of the current (Figure 9–26). The severity of an electrical burn depends on the circumstances of the contact with the source, the current’s path through the body, and the duration of the contact with the electrical current. Ensure that any electrical current is turned off before approaching a patient with suspected electrical burns. Some areas have specific lock-out procedures for de-energizing electrical systems. Figure 9–26: An electrical burn. Although electrical burns may look superficial, the underlying tissues may be severely damaged. Some electrical injuries will be marked by characteristic entry and exit burns that indicate where the current has entered and left the body (Figure 9–27). Look for two burn sites during the secondary assessment. If a patient has been electrocuted (especially by a lightning strike), you should suspect life-threatening conditions such as respiratory or cardiac arrest. Because of the powerful forces involved, you should also suspect spinal injuries and other fractures. Figure 9–27: An electrical exit wound. Radiation Burns Radiation from the sun and other sources can cause radiation burns, which are similar to thermal burns. The most common radiation burn is a sunburn, which is caused by exposure to the natural ultraviolet radiation of the sun. These burns are usually mild, but they can be painful (Figure 9–28). Occasionally, radiation burns may be partial-thickness and blister. Care for a sunburn as you would a thermal burn: Cool the burn and protect the area from further damage by avoiding exposure to sunlight. MAJOR SOFT TISSUE TRAUMA Amputations An amputation occurs when a body part is completely or partially severed from the rest of the body (Figure 9–29). This can cause damage to many types of soft tissue simultaneously (e.g., skin, fat, muscle, and blood vessels), as well as to bones and other tissues. Figure 9–28: A radiation burn. Crush Injuries Crush injuries occur when the body is subjected to intense blunt force. If a patient is trapped under a heavy object or between two objects, then it is likely that crush injuries have occurred. These injuries can be internal or external and affect a variety of tissues. Internal hemorrhaging and the buildup of toxins in the body are likely. If necessary, request specially qualified personnel to assist with extricating the patient. Because of the extensive damage that typically results, patients with crush injuries almost always require rapid transport. Although damage to the tissues is severe, bleeding is often less than would be expected from such a major injury. Initial bleeding is often heavy, but blood vessels usually constrict and retract from the site of the amputation, slowing bleeding and making it easier to control with direct pressure. An amputated body part can often be surgically reattached if it is cared for properly. To increase the chance of successful reattachment, rinse the body part quickly with saline, then wrap the body part in sterile gauze and place it inside a plastic bag. Place this bag inside a larger bag and cool it with ice or chemical cold packs. Label the bag clearly with the patient’s name, the date, and the time. Patients with amputations are usually in the rapid transport category. Figure 9–29: An amputation. HEMORRHAGE AND SOFT TISSUE TRAUMA People who work in special settings, such as certain medical, industrial, or research sites, may be exposed to other types of radiation. These facilities will have systems for responding to this type of incident, so you will be working with internal response teams. Treat radiation burns as you would thermal burns and place the patient in the rapid transport category. 191 CRUSH SYNDROME Crushing forces can impair or eliminate circulation in the affected tissues. If a patient has been subjected to crushing forces for a longer period of time (typically more than 1 hour), the hypoxic tissues begin to function anaerobically (without oxygen), producing a buildup of toxins (e.g., lactic acid). When the crushing object is removed, these toxins are carried through the body, affecting multiple body systems and causing a condition referred to as crush syndrome. Impaired heart function and renal (kidney) failure often result. As with any patient suffering crush injuries, a patient with crush syndrome should receive interventions for life-threatening conditions and be placed in the rapid transport category. Compartment Syndrome HEMORRHAGE AND SOFT TISSUE TRAUMA Compartment syndrome occurs when pressure within the muscle compartment builds up to dangerous levels and blocks circulation to the cells. Within the muscle compartment, swelling and/or bleeding creates pressure on capillaries and nerves. The capillaries collapse when the pressure in the compartment becomes greater than the blood pressure within the capillaries, and this disrupts blood flow to muscle and nerve cells in the area. Without a steady supply of oxygen and nutrients, nerve and muscle cells begin to die within hours. Unless the pressure is relieved quickly, compartment syndrome can cause permanent disability or death. 192 A feeling of tightness or fullness in the muscle. A numbness or paralysis in the area. This means that cell death has begun, and efforts to lower the pressure in the compartment may not be successful in restoring function to the muscle. Acute compartment syndrome is a medical emergency. Place the patient in the rapid transport category. Blast Injuries Blast injuries occur when heat and pressure waves generated by an explosion strike and pass through the body’s surfaces. These waves can also throw debris (shrapnel) against a patient, or throw the patient’s body against other objects (causing injuries similar to those sustained in a fall from a height). Blasts release large amounts of energy in the form of pressure and heat. Injuries can include thermal burns (including inhalation burns), loss of hearing, pneumothorax, internal bleeding, and organ damage. Pressure waves are especially likely to damage hollow structures in the body, such as the lungs, sinuses, and GI tract. The extent of blast injuries may be difficult to identify because sometimes there are no visible external injuries, and indicators of internal injuries may not be apparent. Any patient with suspected blast injuries should be placed in the rapid transport category. Compartment syndrome can be caused by a traumatic injury, such as a fracture of one of the long bones in the body. It can also have other causes, such as a badly bruised muscle, complications after surgery, a crush injury, or anabolic steroid use. Compartment syndrome can affect muscle groups in the arms, hands, legs, feet, and buttocks because they are covered by fibrous membranes that do not readily expand. High-Pressure Injection (HPI) Injuries The classic sign of compartment syndrome is pain, especially when the muscle is stretched. Other signs and symptoms of compartment syndrome may include: Pain that is intensely out of proportion with the injury, especially if no bones are broken. A tingling or burning sensation in the muscle. The only visible sign of injury may be a small puncture wound on the hand, which may be overlooked, but the damage to internal tissues can be significant. If the mechanism of injury suggests an HPI (for example, if the patient was injured while using a paint gun), you should suspect additional internal injuries. Immediate surgical interventions are often necessary. High-pressure injection (HPI) injuries occur when a substance is injected into the body under high pressure. This usually occurs in workplace settings and involves a tool such as a grease gun or pressure washer. The injected substance may be paint, oil, water, grease, or even air. SUMMARY Controlling External Bleeding Applying a Tourniquet 1. Place the patient in a seated or recumbent position. 2. Place direct pressure on the wound with a gloved hand. 3. Apply a sterile dressing. Place your gloved hand over the dressing and apply firm pressure. 4. Apply a bandage over the dressing to maintain direct pressure and hold the dressing in place. If blood soaks through, addadditional dressings and bandages on top. 5. If bleeding continues, apply a tourniquet. 1. Confirm that other hemorrhage control techniques are ineffective for the situation. 2. Apply the tourniquet 5 to 10 cm (2 to 4 in.) above the injury and just above any joint in this range. 3. Tighten the tourniquet until the bleeding stops. 4. Secure the tourniquet in place. 5. Continue to apply direct pressure to the wound, if possible. 6. Document the time that the tourniquet was applied. 7. Ensure that the patient is in the rapid transport category. Care for External Bleeding on a Limb Immediately apply direct pressure with a gloved hand Apply a sterile dressing and maintain firm pressure Apply a bandage If blood soaks through, apply another bandage on top Bleeding continues Bleeding stops Apply a tourniquet and tighten until bleeding stops TYPES OF BURNS Name Tissues Affected Signs and Symptoms Superficial burns Top layer of skin (epidermis) Red, dry affected area Swelling Pain Partial-thickness burns Both layers of skin (epidermis and dermis) Red affected area Blotchy skin around the burn Blisters which may weep clear fluid Pain Full-thickness burns Both layers of skin and underlying tissues (fat, muscle, bone, nerves) Brown, charred area, underlying tissues may appear white Pain may or may not be present HEMORRHAGE AND SOFT TISSUE TRAUMA Reassess patient 193 194