Soft Tissue Injuries & Burns

Anatomy and Physiology Review

• The skeleton and muscle groups
• The skin

Pathophysiology

• Open soft tissue injuries occur when trauma breaks the barrier of the skin (the skin is open). Tissue in the pathway of the offending trauma is torn, displaced or destroyed. Open wounds include:
  • Abrasions: Superficial scratches (although often widespread) that occur as a result of scraping or grinding against an uneven surface (as in road rash). Minimal bleeding, primarily from capillaries. High risk of infection.
  • Lacerations: Slicing of the skin that can affect deeper and larger blood vessels. Bleeding can be severe.
  • Avulsions: Trauma that tears away large pieces of soft tissue or creates an attached but displaced flap of tissue.
  • Amputation: The traumatic removal or a digit or appendage (such as an arm or leg).
  • Penetrating injuries: Occur when an offending object is inserted into the body, often with significant energy. These injuries can range from manual penetration (as in stabbing) to high-velocity penetration (as with gunshot wounds or fragmentation from a blast injury). Penetrating trauma is often difficult to assess, because external injuries may be minimal while internal injuries are severe.
• Closed soft tissue injuries occur when trauma exerts energy on the body but does not break the barrier of the skin. In these cases, blunt force trauma exerts energy on not only the skin but also on underlying muscle and organs. Trauma can compress, rupture and destroy structures. Closed soft tissue injuries include:
  • Contusions: Occur when trauma ruptures small blood vessels beneath the skin. Contusions are characterized by swelling and discoloration secondary to the presence of blood below the skin.
  • Hematomas: Similar to contusions, caused by ruptured blood vessels at the area of the injury, but unlike contusions, result from more significant tissue damage and rupture of larger blood vessels. They are characterized by large amounts of blood beneath the skin, collected at the area of the injury, and significant swelling.
• Crush injuries occur when a large or heavy object smashes a portion of the body. This force can result in both open and closed injuries. In both cases, the damage is often significant but not always apparent by looking at the external surfaces of the skin.
• Blast injuries result from the rapid expansion of energy secondary to a chemical reaction. They can be divided into four categories:
  • Primary blast injury occurs from the initial expansion of energy and results in blunt force trauma. This energy frequently causes closed blast injuries but also can cause open injuries.
  • Secondary blast injury results from fragmentation as pieces of the explosive device or particles from the surrounding area are blown outward. These objects penetrate and cause open, penetrating trauma.
  • Tertiary blast injury results from the victim’s being thrown by the blast energy, or by the collapse of structures onto the victim. These injuries can cause both closed (blunt force) injuries and open injuries (such as impalement).
  • Quaternary blast injury results from forces other than the blast energy. Such injuries include burns, secondary illnesses and the effects of weapons of mass destruction, such as radiological or chemical side effects.
• Burns typically are caused by one or more of four sources:
  • Thermal (heat)
  • Electrical (direct and alternating current, or intense light burning the eyes)
  • Chemical (such as strong acids or bases)
  • Radiation
• A burn injury is also classified by the depth of the skin it affects:
  • Superficial burns affect the epidermis and cause reddening and pain.
  • Partial thickness burns affect the epidermis and dermis and cause reddening, mottling, pain and blisters.
  • Full thickness burns affect all the layers of the skin and cause charring and/or a leathery, white appearance of the skin. Although full thickness burns do not themselves cause pain, they often are surrounded by partial thickness burns that do cause pain.
• The damage and life threat from a burn also are related to the extent of body surface area involved and the location where the burn occurs.
  • Burns occurring over large surface areas are extremely dangerous.
  • Burns occurring over the face, hands, feet, genitalia, or joints, or those extending around the circumference of the thorax or an extremity, potentially are critical.
  • Burns that involve secondary injury (such as fractures or other trauma) or that occur in patients with underlying illnesses (such as COPD) pose a much higher risk than those that do not.

Signs and Symptoms

• When assessing the patient for injuries, always consider the mechanism of injury and review the velocity and energy exerted on the patient. Although an assessment does not guarantee that you will locate the injury, it can help predict where injury is likely and help determine the potential extent of injury.
• Open injuries often are the most visible type of trauma, since they result in violation of the skin. Look for traumatic injuries as described above, as well as for bleeding. Beware, however, that penetrating trauma can demonstrate little external damage while at the same time causing massive internal damage.
  • Beware high-pressure injection injuries, because these will result in minimal external trauma but significant internal damage that occurs over time.
  • Beware internal bleeding from damaged internal organs, even if external bleeding is minimal. Look for signs of shock.
• Closed injuries often result in contusions or hematomas and swelling. The patient commonly will complain of localized pain at the site of the trauma.
  • Beware of internal bleeding. Always look for signs of shock.
• Determine the cause of a burn. Remember that some causes may result in more extensive burns than others.
  • Swelling after thermal burns is a significant risk. Beware burns that may include the airway, such as burns of the chest, face and/or neck. Look for signs such as a hoarse voice, stridor or difficulty speaking. These findings indicate airway involvement.
  • Electrical burns can cause extensive internal injuries. Beware the potential for cardiac dysrhythmias.
  • Chemical burns may include inhalation and ingestion injuries. Beware the potential for chemicals on the skin to be absorbed and also cause toxicological emergencies.
  • Radiological burns include significant risk of long-term injury.
• Determine the extent of a burn using the rule of nines or the palmar method.
  • The rule of 9s is designed as an easy to remember method for determining the percentage of body surface area burned. Each area is numbered by 9 or 18 as follows:
    

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    • Head 9%
      Anterior torso 18%
      Posterior Torso 18%
      Each arm 9%
      Genitals 1%
      Each leg 18%
    • Partial surface areas may also be determined from this method as the anterior surface of a leg would be 9 (because it is half of the leg) and the anterior chest would be 9% because it is half of the anterior torso.
  • The palmar method refers to the fact that the patient’s palm and fingers represent 1% of his or her body surface area. This method can be used to estimate the body surface area of a burn.
• Remember that soft tissue injury can evolve over time. Secondary swelling can be dangerous, particularly in airway-related areas. Reassessment is key.

Treatment

• Be safe. Traumatic injuries often are caused by unsafe situations. Always ensure safety before entering a scene.
• Examine mechanism of injury. A proper scene assessment can assist with treatment decisions.
• Consider the need for immediate transport to an appropriate destination. Often the most important goal for trauma patients is to get them to surgical intervention.
• With both open and closed injuries, use your knowledge of anatomy and physiology to predict damage to underlying structures. Always assume the worst.
• Stop massive hemorrhage immediately.
• With high-risk injuries or when shock signs are present, treat for shock. Maintain airway, oxygenation and ventilation. Consider high-concentration oxygen in situations of potential hypoxia, and maintain body temperature (even in warm conditions).
• Consider the need for spinal motion restriction, and splint extremities at risk for fracture.
• Use cold packs or ice on localized closed injuries. Beware the risk of hypothermia.
• Cover penetrating injuries to the chest, neck and abdomen with occlusive dressings.
• Use dry, sterile dressings to cover the entire wound and bandages to cover and secure in place the entire dressing.
• Assess and reassess circulation, sensory and motor function after bandaging, and consider leaving the tips of fingers and toes accessible for this assessment.
• With amputations, manage hemorrhage first. If possible, recover the amputated part and transport it in moistened saline gauze. The part should be kept cool if possible. Consider using cold packs. Do not immerse the object in water.
• For avulsions, clean the avulsed tissue with sterile saline. If the tissue is still attached, fold it back to its normal position. If the tissue has been disconnected, treat it as an amputated part as outlined above.
• Do not remove impaled objects. Stabilize the impaled object by applying dressings around it, and transport.
  • If the object is impaled in the eye, cover and bandage both eyes to prevent conjugate movement (one eye moving at the same time as the other).
  • If the object is impaled in the cheek and both ends of the object can be visualized, you may remove the object and treat the soft tissue injury. Beware bleeding into the airway.

Treatment: Burns

• Stay safe. Burns are caused by dangerous situations. Beware electricity. Ensure that the source is shut down before you touch the patient. Contact Haz/Mat resources to manage chemical or radiological burns.
• Examine the mechanism of injury. Attempt to determine the nature and cause of a burn.
• Consider the need for advanced life support.
• Consider the need for immediate transport or air medical resources. Transport to an appropriate destination choice. Burn patients frequently require care at a burn center.
• Always stop the burning process:
  • If you can do so safely, brush dry chemicals away, remove clothing and then use copious amounts of water to flush chemical burns.
  • Cool any thermal burn, even if the burn occurred before your arrival. Use water to stop the burning process.
  • To treat burns to the eye, use a continuous flush of sterile saline (or water if saline is unavailable). Beware flushing water from the affected eye to the unaffected eye. Always flush from the bridge of the nose laterally.
• Treat airway, breathing and circulation. Always look for secondary and underlying injuries.
• Use dressings moistened with sterile saline to cover burns of less than 10% of the body surface area.
• Cover extensive burns with dry sterile dressings. Separate digits and remove circumferential jewelry if possible.

Important Concepts

• Rarely are open and closed injuries isolated. Always assume that damage beyond what is visible has occurred. Very commonly, these injuries cause not only soft tissue damage but also internal bleeding, fractures and other potential life threats.
• The most visually dramatic injury may not be the worst injury. Soft tissue injuries often can distract the EMT from more subtle life threats, such as airway, breathing or shock problems.
• Conduct a thorough patient assessment on all trauma patients. Review all four sides of the patient in your physical examination. Injuries such as penetrating trauma are very difficult to detect, but detection may mean the difference between life and death.
• Use resources. If the rule of nines is a challenge to remember, carry a chart or a memory aid.