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34-1
Chapter 34
Bleeding and
Soft Tissue Trauma
Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display.
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Objectives
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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
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Bleeding
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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Impaled Object in the Eye
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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
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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
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Burns
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Burn Types
• Thermal (exposure to heat)– Examples: flame, scald, flash
• Chemical– Examples: acids, alkalis
• Electrical (including lightning)
• Radiation
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Burn Severity
• Depth• Extent• Location• Patient age• Conditions present
before the burn• Associated factors
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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
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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
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Full-Thickness (Third-Degree) Burn
• Destroys epidermis, dermis
• Skin color varies
• Looks dry, waxy, or leathery
• Numb – nerve endings destroyed
• Rapid fluid loss
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Full-Thickness (Third-Degree) Burn
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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
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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
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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
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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
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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
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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
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Infant / Child Considerations
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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
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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
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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
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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
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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
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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
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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
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Care for Electrical Burns
• Make sure the power is off!• Contact additional resources if needed
before entering the area
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Care for Electrical Burns
• Manage ABCs
• Stabilize cervical spine if needed
• Watch closely for respiratory and cardiac arrest– Make sure an AED
is available
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Care for Electrical Burns
• Treat other injuries if present• Look for entrance and exit wounds
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Dressing and Bandaging
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Dressing and Bandaging
• Dressing– Absorbent material placed directly over a
wound
• Bandage– Used to secure a dressing in place
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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
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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
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Types of Dressings
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Sterile Gauze Pads
• Loosely woven material
• Classified by size in inches– 2 x 2– 4 x 4
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Trauma Dressing
• Thick dressing• Various sizes• Two layers of gauze
with absorbent cotton in center
• Uses– Large wounds– Pad injured limb
inside a splint
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Occlusive Dressing
• Made of nonporous material• Used to cover open wound and make
airtight seal– Chest wound– Neck wound
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Nonadherent Pads
• Gauze pads with special coating• Used to cover leaking open wound but not
stick to it
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Eye Pads
• Uses:– Cover eyes after minor eye injury– Cover small wound, such as a puncture
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Bandages
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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
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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
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Roller Bandage
• Soft, slightly elastic material• Available in various widths
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Elastic Bandage
• Do not use to secure a dressing in place• May act as a tourniquet if injured area swells
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Triangular Bandage
• Large piece of muslin • When folded, can be used as a
bandage or sling
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Self-Adherent Wrap
• Elastic wrap coated with self-adhering material
• Often used as a pressure bandage
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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
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Applying a Roller Bandage
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Applying a Roller Bandage
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Applying a Roller Bandage
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Applying a Roller Bandage
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Head or Ear Bandage
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Upper Arm Bandage
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Elbow Bandage
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Wrist or Forearm Bandage
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Knee Bandage
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Foot or Ankle Bandage
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