34-1 chapter 34 bleeding and soft tissue trauma copyright (c) the mcgraw-hill companies, inc....

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

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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

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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

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Types of BleedingArterial

• Arterial bleeding– Life-threatening– Bright red, oxygen-rich blood– Spurts from the wound

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Types of BleedingVenous

• Venous bleeding– Flows as a steady stream– Dark red or maroon

• Oxygen-poor blood

– Usually easier to control than arterial bleeding

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Types of BleedingCapillary

• Capillary bleeding– Oozes slowly from the wound– Dark red blood– Usually not serious– Often clots and stops by itself

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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

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External Bleeding

• External bleeding is bleeding that you can see– Blood flows through an

open wound

• Control bleeding manually until bleeding stops

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Emergency Care of External Bleeding

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Scene Size-Up

• Make sure the scene is safe to enter

• Evaluate mechanism of injury / nature of illness

• Personal protective equipment (PPE)

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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

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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)

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Direct Pressure

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Pressure Bandage

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Pressure (Air) Splint

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Pneumatic Antishock Garment

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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

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Tourniquet

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Tourniquet

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Tourniquet

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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

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TourniquetsPrecautions

• Do not remove or loosen the tourniquet unless directed to do so by a physician

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TourniquetsPrecautions

• Be sure the tourniquet is in open view– Do not cover it with a bandage, a sheet, or

the patient’s clothing

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TourniquetsPrecautions

• Never apply a tourniquet directly over a joint

• Place it as close to the injury as possible

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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

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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

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Internal Bleeding

• Most common causes of internal bleeding:– Injured or damaged internal organs– Fractures

• Femur• Pelvis

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Internal Bleeding

• Sites where major bleeding is most likely to occur:– Abdominal cavity– Chest cavity– Digestive tract– Tissues surrounding broken bones

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Internal Bleeding

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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

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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

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Soft-Tissue Injuries

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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

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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

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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

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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

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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

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Closed Soft-Tissue Injuries

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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

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Compartment Syndrome

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“5 P’s” of Compartment Syndrome

• Pain on passive stretching of the muscle

• Paralysis (or weakness)

• Paresthesias

• Increased pressure

• Diminished peripheral pulses

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Crush Syndrome

• Mine cave-ins

• Trench collapse

• Motor vehicle crash (MVC)

• Landslide, avalanche, rockslide

• Rubble from war, earthquake

• Pinning under heavy objects

• Severe beatings

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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

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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

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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

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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

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Closed WoundsManagement

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

• Contact medical direction for instructions

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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

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Open Soft-Tissue InjuriesTypes

• Abrasions

• Lacerations

• Punctures

• Avulsions

• Amputations

• Open crush injury

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Abrasion

• Outermost skin layer damaged by rubbing or scraping

• Little or no

bleeding

• Infection primary

concern

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Laceration

• Cut or tear– May occur by itself or with other

soft-tissue injuries

• Types– Linear (regular)– Stellate (irregular)

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Laceration

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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

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Puncture Wound

• Severity depends on:– Location of injury– Depth of wound– Size of penetrating object– Forces involved in creating the injury

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Impaled Object

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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

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Avulsion

• Piece of skin or tissue is torn loose or pulled completely off

• Bleeding varies with extent and depth of injury

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Amputation

• Separation of a body part from the rest of the body

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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

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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

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Special Considerations

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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

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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

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Penetrating (Open) Chest Injuries

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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

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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

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Evisceration

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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

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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

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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

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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

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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

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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.

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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

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Foreign Body in the Eye

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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

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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

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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

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Mouth Injuries

• Can result in airway obstruction

• Signs and symptoms:– Tenderness– Bruising– Swelling

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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

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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

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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

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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

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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

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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%

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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

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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

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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

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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?

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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

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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

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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