34-1 chapter 34 bleeding and soft tissue trauma copyright (c) the mcgraw-hill companies, inc....
TRANSCRIPT
34-1
Chapter 34
Bleeding and
Soft Tissue Trauma
Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
34-2
Objectives
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 BleedingArterial
• Arterial bleeding– Life-threatening– Bright red, oxygen-rich blood– Spurts from the wound
34-10
Types of BleedingVenous
• 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 BleedingCapillary
• Capillary bleeding– Oozes slowly from the wound– Dark red blood– Usually not serious– Often clots and stops by itself
34-12
Types of Bleeding
Arterial VenousVenous CapillaryCapillary
CCoolloorr Bright redBright red Dark red, Dark red, maroonmaroon Dark redDark red
Blood Flow
Spurts with each heart beat
Flows steadily Oozes slowly
Bleeding Control
Difficult to control 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 wear PPE during every patient contact
• 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
Severity of Blood Loss
Normal Blood Volume
Severe Blood Loss
Adult 5000 to 6000 mL Loss of 1000 mL or more
Child 2000 mL Loss of 500 mL or more
Infant 800 mL 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
TourniquetsPrecautions
• Always use a wide bandage
• Do not use:– Wire– Rope– A belt– Any material that may cut into skin and
underlying tissue
34-30
TourniquetsPrecautions
• Do not remove or loosen the tourniquet unless directed to do so by a physician
34-31
TourniquetsPrecautions
• Be sure the tourniquet is in open view– Do not cover it with a bandage, a sheet, or
the patient’s clothing
34-32
TourniquetsPrecautions
• 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 SyndromePossible 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
• Pain on passive stretching of the muscle
• Paralysis (or weakness)
• Paresthesias
• Increased pressure
• Diminished peripheral pulses
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 WoundsManagement
• 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 WoundsManagement
• 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 InjuriesTypes
• 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
34-70
34-year-old with a
traumatic amputation caused by
a gear
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
Open InjuriesManagement
• Scene size-up
• 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
34-76
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.
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
EyeChemical 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 InjuriesJaw 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 BurnKey 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 BurnRule 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 BurnRule of Nines
Body Area Adult Child Infant
Head and neck 9% 18% 18%
Front of trunk 18% 18% 18%
Back of trunk 18% 18% 18%
Each arm (shoulder to fingertips)
9% 9% 9%
Each leg (groin to toe) 18% 13.5% 13.5%
Genitals 1% 1% 1%
34-110
Extent of BurnRule of Nines
34-111
Extent of BurnRule 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