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Soft tissue injuries can range from minor cuts to serious threats. The most important thing is to ensure a clear airway for the patient. Soft tissue injuries can be caused by different mechanisms such as blunt trauma, penetrating trauma, explosions, and burns. Hemorrhage and infection are the main causes of death related to these injuries. It is important to control bleeding, prevent contamination, and protect the wound. The skin is the body's first line of defense and varies in thickness depending on age and location. It has two main layers, the dermis and epidermis, with various structures and functions. The skin serves as a barrier against infection, regulates body temperature, and maintains fluid balance. There are three types of soft tissue injuries: open, closed, and burns. Cessation of bleeding is the primary concern in wound healing, followed by inflammation, development of new skin cells, and collagen formation. Contusions and hematomas are common types of soft tissue injuries Soft tissue injuries are common from simple cuts and scrapes to serious slight threat injuries. Now we already talked about bleeding and things like that, so some of this is going to be kind of a review for you. Do not be distracted by open traumatic means, right? Patients, they've got to do gloving and we can see right down to the bone, remove that school and all the bleeding, but again, what's going to kill the patient first and foremost? Airway. So make sure the patient has a good, clean airway. Soft tissue injuries can be issued through a variety of mechanisms. Blunt trauma, penetrating trauma, barotrauma, explosions and things, and burns, which we'll talk about. So soft tissue trauma is a common form of injury. Death is often related to hemorrhage or infection. We don't see death from infection. That takes time, but we can sure keep that from happening or minimize it by properly bandaging and sealing the wound. And of course, hemorrhage, we do see it and we can fix that. Soft tissue injuries can be prevented by simple protective actions. Remember, the vast majority of trauma is preventable. The number one, the words that go along with that is, hold my beer and watch this, right? Those are the words that keep us in business. So the skin is the body's first line of defense. The integumentary system, it is the largest organ of the body, 20 to 40 kilograms, and it is a defense against external forces and infection. The inside of our body, underneath our epidermis, our dermis and below, is a pristine environment. It's no bacteria. When you get bacteria, you get an infection, a pimple or cyst or something like that. The skin is relatively tough but susceptible to injury. If you break the tensile strength of the skin or expose it to too much heat or chemicals exposure, you're going to have a burn or an injury. Brazing, bruises and abrasions to lacerations and amputations. In all instances, you must control the bleeding. And remember, the patient could have internal bleeding. So your job is to stop the external because it can have a potentiating effect with the internal. No matter how little it is, stop the external bleeding. Prevent further contamination to decrease the risk of infection. Protect the wound from further damage. And then we apply dressings and bandages to do that on various parts of the body. This is the three reasons we bandage, dress and bandage wounds. In order, stop the bleeding, prevent further contamination and protect the wound from further damage. Skin varies in thickness. In the very young, in the very old, it is thinner. You see those elderly patients, those 80, 90 year olds, you can see right through the skin. Right? The skin is so thin. And when it cuts, they don't cut, it just tears like paper. And then you try and suture that. It's like suturing wet paper. It's thinner on the eyelids, lips and ears. Thickest part of the, the thickest skin of the body is on the skull. But also the back and the soles of the feet have thick skin as well. Skin has two principal layers, the dermis and epidermis. And we've gone through this. We know that. We talked about, let's say this white part is the bone. Then we have a fascia, which keeps the bone from adhering to the muscle. Then you have the muscle. Then you have the fascia again. That's that tough white fibrous stuff in between the muscle and the skin. And of course, then you have the skin. And this is the dermis, which is the true and the living skin. This is the subcutaneous layer. Subcutaneous fat that's used as an energy store and an insulating effect. Skin cells are made here. The dermis is the true skin. The living skin, as it's called, with its different structures. We have the sensory nerves. You have nerves that sense hot, cold, wet, dry, rough, smooth. One ten-thousandth of an ounce of pressure. Very sensitive. We have the hair follicle and the erector pili muscle, which controls that hair standing up. You get that goose flesh, right? The goose bumps. We have the sebaceous gland, which releases sebum. Causes the skin to be moist and supple. It's an oil. It's a collagen-based oil. In the very young, like young kids, you'll get it. They'll have very oily skin. They have overactive sebaceous glands. As we get older, they get less and less active. That's why the elderly patients will have that brittle, thin, paper-thin skin. Because their sebaceous glands don't work as well anymore. You have the capillary beds. This is where we thermoregulate, as well as perfuse the dermis. The hot blood travels up, exchanges gases, and it cools as it evaporates the sweat, and then travels back down cooler to the core of the body. And then, of course, we have the sweat glands. We have E-crime and apocrine sweat glands. E-crime sweat glands are all over the body. That's our standard sweat. That's how we thermoregulate. Your apocrine sweat glands are in your underarms, your groin, and the bottom of your feet, and they give you the pheromones or the scent that is unique to each of us. And then, from there, you hit the germinal layer. We call it the stratum germ of atom. That's where the skin cell dies, and it kind of locks together into a particular pattern to where you get the epidermis. And, of course, we abrade the epidermis over time. Most of it ends up in our bed, and then our new skin cells kind of travel their way up. Skin cells, that's what they sleep in. So, skin covering all the external surfaces of the body. Any openings are lined with mucosal membranes. Our eyes, our nose, our ears, our lips, urethra, anus, vagina, whatever. It all has a protective mucosal lining, this mucus that comes out that keeps it moist, and it provides a barrier against invading infection. Skin serves many functions. It's a barrier against infection. The inside of the skin is a pristine environment. It's a sensory organ. Hot, cold, wet, dry, rough, smooth. Regulates body temperature by thermoregulating and evaporating sweat, and maintains fluid balance by keeping our fluid in us. And breaking the skin may allow bacteria to enter and increases the possibility of infection, fluid loss, or loss of body control, right? Or loss of temperature control. Systemic damage to tissues can affect body temperature control, especially when we talk about burns. There are three types of soft tissue injuries. Open, closed, and burns. A closed, so anytime you have a wound, whether it's open or closed, the pathophysiology is cessation of bleeding is the primary concern. Remember how I told you that blood vessels, when they get cut, they contract? All of our blood vessels are under tension. They contract and they close off that bleeding and then begin the clotting process. The next stage is inflammation. The body rushes fluid to that area to splint it, put pressure there to close off those blood vessels. That's why you have that inflammatory response. It's one of the reasons why we don't use ACE bandages to bandage things because of swelling. A new layer of skin cells is developed over the damaged area and then blood vessels are made. Your body makes blood vessels. They just, when they come together, you can see them under a microscope, they actually move and they clump together and they get made. And then collagen provides the stability on the wound edges. The wound heals from the edges in. So it goes this way. The very center of the wound is the last thing to heal. Supposed injuries. The contusion is bleeding in the skin that does not break and it's capillary bleeding. We've all seen what a bruise is. Somebody comes up, hey, how you doing? Punches in the arm. Ow, what'd you do that for? And you get that bruise, right? Everybody's had a bruise before. Bruises hurt. You go up, somebody says, ooh, that's a bruise, and poke it. Ow, that hurts. Why does it hurt? Because frank blood irritates nerve fiber, nerve tissue. And that's why you get pain. A hematoma is different. A hematoma is a larger blood vessel that produces a puddle of blood underneath the tissue. And that puddle of blood in that cavity causes it to bubble up. Like you get an egg on your head. You whack your head, you get an egg, right? That's called a hematoma. You can get an IV in your hand and it bleeds. You get a hematoma. You get a well that goes up. A well is like a hematoma. A crushing injury occurs when a significant force is applied to the body. So, some closed injuries, you can develop crush syndrome. When an area of the body is trapped longer than four hours, crush syndrome will develop. It's not can. What is crush syndrome? So, I'm walking somewhere and something falls and my arm gets trapped and it crushes my arm, right? So, my arm now gets no blood flow. After about four hours, usually sooner than four hours, I can develop three phases. Well, the first stage is the ischemic phase. That's where the cells turn to anaerobic metabolism for not getting that continuous blood flow. So, my body starts burning fats instead of oxygen with the sugar and they start producing lactic acid. And that starts damaging other tissues and you start having cellular decay. So, then after a while, once you've burned up the oxygen that's left in that, you get what they call the stagnant phase. That means that the cells are no longer burning any oxygen and they're only doing anaerobic metabolism and everything stagnates. And then, if you release that extremity after a couple hours, three hours, you get what you call the washout phase. You release that limb and all the blood flow rushes into that area and washes out all those toxins. And where do those toxins end up? In your crush of heart, crush of cardiac arrest, crush of liver, crush of liver failure, crush of kidneys, crush of kidney failure. If we come up to a crush injury, first thing I'll do is put a tourniquet on if I can. So, when we release it, the blood flow doesn't go right to that area and cause that washout. I'm also going to give the patient sodium bicarb, which is a base. So, it'll neutralize that acidosis that's building up and give you IV fluid and probably give you fentanyl. Fentanyl, IV fluid, sodium bicarb and probably put a tourniquet there. It gets you to the hospital so when the doctor releases that, you're not just going to go and die from the acidosis. Does that make sense? So, remember the three phases. You've got the ischemic, stagnant and then the washout phase. Now, in crush injuries or significant upper extremity, your body has compartments. This is a compartment. This is a compartment. This is a compartment and this is a compartment, which means blood, if you have a significant bleed, it gets stuck in this area. It gets trapped in this compartment. It doesn't eke its way here. It ends up staying here. And so what happens is it swells and swells and swells and the skin can only swell so much and then the pressure goes inward and it starts compressing the nerves and blood vessels inside and that's called the compartmental syndrome and it can be limb threatening. Okay? So, you have a patient with a crush injury. Most commonly, we see it in the forearm or the lower extremity, the tip fin or the radius ulna in children. You can see it in adults, too. It can happen in sports and things like that. It doesn't happen immediately. It's usually about 46 hours or so after the injury, especially like a crush injury when you allow blood to flow back from the tissues. But what happens is that swelling gets so much that it compresses inside and you can lose the limb. And what we end up with, one of the classic tell-tale signs is pain that's outside of what you'd expect to see. So, I have a patient that's in excruciating pain eight hours after the fracture. All of a sudden, the pain's gotten worse. Well, it shouldn't do that. And then you get passive stretching pain. So, if I have a fracture of my radius ulna and I take my middle finger and I bend it up, it'll hurt a little. I could go, ow, that hurts. But if I do that to a patient with compartmental syndrome, they're going to scream, bloody murk, in pain. I shouldn't see that. Same with the second toe. If you lift the second toe, or just bend the second toe back, and the patient goes, ow, my god! That's a classic compartmental syndrome. So, a significant fracture or crush injury that happens six to eight hours previously. The hand would be white and waxy with little to no pulse. And you have that passive stretching pain outside of what you'd expect to see. Those are classic compartmental syndrome signs and symptoms. That is limb threatening. If I were in Gardner and I saw that, I would call Life Flight. Life Flight will transport a compartmental syndrome because it's time sensitive. So, open injuries, there are four types of abrasions, lacerations, evulsions, and penetrations. So, this is an abrasion. We call this road rash. If you look at that, you can see how the epidermis has been abraded away, and you're looking at the dermis. See that liquid that's coming out of that? What is that liquid? That's plasma. The skin is not going to abrade away enough to expose the blood, but the plasma can go through the dermis and come out. The red blood cells will not, but the plasma will. We call it a weeping wound. There's a little bit of blood there. Basically, you will abrade it away the surface of the skin. The problem with this is the dermis is what protects the skin underneath. So, now that's exposed to the air. There's a potential for infection. This is a laceration. A laceration is a jagged cut. If you have a sharp cut by glass or a knife, we can call it an incision. You can see, look across the knee, that's a pretty significant laceration. You cut right through it. It can go right down to the bone and even through the bone. An avulsion is where skin is torn away. You can see how the skin is torn away in this injury. Is that flopping? The skin is actually torn. It's actually pulled back. It's kind of foiled back. I don't know what happened. I can't really tell. Maybe it's a better picture than this. The diagram, that's what you're looking at. If you have a patient that has a flap like that, the other two we're going to bandage. For this one, we're actually going to put that flap back in anatomical position. If it's grossly contaminated, like you see dirt in it, rinse it off and then put the flap back and bandage it. Put it back into anatomical position. If that flap has been amputated or removed and it's bigger than the patient's thumb, bring it with you to the hospital. If it's the patient's thumb, bring it with you to the hospital. An amputation is an injury in which part of the body is completely severed. We know we have to bring that to the hospital. If somebody has an amputated leg and the leg is still bleeding, like the amputated part is still bleeding, don't worry about it. If you lose all his blood, it doesn't matter. I will bandage it to protect it, but I'm worried about the patient losing blood. So I'll put a tourniquet here and then the part that's amputated, I'll bandage it up. But if it's still bleeding, that's all right. We don't put it on ice. We keep it cool. Don't tell the patient to hold it. Don't tell the patient to hold this while we go and then go to the hospital. A penetrating wound is an injury resulting from a piercing object. That can have a penetration or perforation, which means it goes right through. Stabbings and shootings often result in multiple penetrating injuries. When we know we go to the prison, people don't get stabbed once. They go, and they keep stabbing until they get broken up. Shootings, people get shot sometimes multiple times. Look for entrance and exit wounds all the way around, always. Count the number of penetrating injuries and determine the type of gun that was used, if you can, or what the type of penetrating weapon was. Blast injuries, we talked about this. The primary blast wave is the concussion wave that pops hollow organs, stomach, lungs, ears, right? It can cause blast pulmonary embolisms. Secondary blast injury, that's the shrapnel. That causes soft tissue injuries, like we're talking about, amputations, lacerations, bleeding. The tertiary is when the patient is thrown, right? And 40% of deaths from blast injuries happen in this phase with head trauma, traumatic brain injuries. And then the quaternary, the fourth, is burns, toxic inhalation of gases, building collapse, all that good stuff. So in assessment of closed and open injuries, it's more difficult to assess a closed injury than an open because I can see an open injury. I can see what happens. So that's the thing. With a closed injury, it can be far worse than what you perceive it to be. Especially children. Children, especially small children, their bones are very pliable. As we get older, our bones calcify. So if I get hit in the ribs with a baseball bat, my ribs break, and it takes that force. He's five years old, he gets hit in the ribs with a baseball bat, his bones go whoop and bounce out. So I palpate his ribs, wow, he doesn't have broken ribs, he's doing okay. No, the bones pushed in and damaged his liver or his spleen. So keep that in mind with children. We'll talk about pediatrics. We had a dad that ran over his son accidentally because he jumped out of the car before it completely stopped and he got a spleen laceration. I don't know, like seven years old. And that night I was like, Eli, I swear to God, if you get out of this fucking car before it stops, I'm done. You're next. I'll tell you right now, I've seen it at the other end where it wasn't run over the body, it was run over the head. That's not a good thing to see. So consider the possibility of, he's lucky that he only got a spleen laceration, very lucky. But like I said, I've seen cars run over people and they get up. You see it, YouTube all the time. Runs over a guy's leg, he gets up, he goes, oh, that hurts. He's fine. So consider the possibility of closed injuries when you observe bruising. Bruising is classic. You've ruptured blood vessels, there's an injury underneath. Swelling, any kind of swelling, you have that inflammatory response, there's damage there. Deformity, that's classic. As well as the patient reporting pain. Again, I'm not talking about the aches and pains of life. I wake up in the morning and go, oh, my back, oh, I'm stiff. That's different. I'm talking about pain that's not expected. So seeing size, I make sure the scene is safe. These could be a lot of bleeding, a lot of fluids, so be aware. Goggles, gloves, masks. Look for mechanism of injury as you assess the scene. Dispatch information and walk up on the scene and look. The mechanism of injury may provide you information that relates to safety, i.e., violence, shootings, stabbings. Not something you just want to walk up to, hey guys, how are you? Evaluate scene safety and call for additional resources. Identify life threats, the X, A, B, C's in your transport priority. You're never going to go wrong high priority transport if you feel the patient is potentially unstable. Form your general impression. So I'm going to do my scene safety BSI, make sure the scene is safe, look overview. Once I know the scene is safe, I'm going to walk up to the patient and I'm going to do my general impression of the patient, my overview of the patient. How do they present? Are they following with their eyes? Are they abundant or responsive? Do I see bleeding? Do I see deformity? That types. Circulation. Significant bleeding is an immediate life threat that must be controlled before airway. If you see a significant bleed, not even an arterial bleed, but if you see a significant amount of bleeding, put a glove can on it, stop that bleeding right away. Some venous bleeding can be very significant. Stop it right away. If the patient is obvious life-threatening external bleeding, control the bleed, airway, and then treat the shock. So, X ABCs. Ensure the patient has a clear and maintained airway. Protect the patient's spine. If there's any kind of trauma, put a collar on them. They cheat easy. Well tolerated. Check the adequacy of breathing. Maybe you have to ventilate them. Maybe you have to put an OPA or an NPA. And inspect and salivate the chest to de-check ETLS because maybe there's injuries in the chest. Immediate transport. These patients, high priority. Once I see this, and some of this I can see right into this, I walk up to them. A poor general impression. I look at the patient and you just look like shit. It doesn't take a trauma surgeon to look at somebody and say you just don't look good. Status post-trauma, you look like that, you need to go. Altered level of consciousness, especially in the presence of trauma. Shortness of breath not corrected with oxygen. Abnormal vital signs, which might present a shock and severe pain. So you've got to use a sample of OPTRS2 and DTAP ETLS for a well-rounded assessment. Sample is your history of the patient. OPTRST is a history of the discomfort. And DTAP ETLS is a mnemonic to remind you what to look for on the body. If the patient is not responsive, you're going to have to get the history from another way. Bystanders, family members, medical charts in the home, anything. Sometimes you don't get anything and you just break the patient the way they are. Chronic medical conditions can complicate soft tissue injuries. Well, chronic medical conditions like, you know, if a patient has, you know, a history of DVTs or PEs or atrial fibrillation, he's going to end up on blood thinners, which is going to exacerbate bleeding. He could be on beta blockers for hypertension, which is going to lower his heart rate, which means his heart will not be able to compensate for blood loss. He might be on diuretics for fluid, which means his blood volume, his fluid volume will be lower to begin with, which means he'll become hypovolemic more rapidly. Secondary assessment is your head-to-toe assessment. And I'll be honest with you, most of the time I do this anyway. It takes 90 seconds to two minutes. So, you know, unless the patient is sitting in the meeting holding his wrist and saying, yeah, I'd fall if my bike, my wrist hurts. Okay, I'll do a focused assessment on that. But somebody with kind of a significant trauma, I'll just check them head-to-toe. Kids, I check kids head-to-toe no matter what. It doesn't matter because they're not good historians anyway. Typically performed in the ambulance en route to the hospital unless you have a delayed extrication. For some reason you're waiting to get the patient in the ambulance, do your assessment and you're going to assess everything head-to-toe. Physical examination. We're going to listen to breath sounds. We IPA the chest. IPA stands for inspect, palpate, and auscultate. I'm going to look at the chest. I'm going to palpate it and then I'm going to listen with my stethoscope. Determine the respiratory rate. We're going to look for rate, rhythm, quality, depth. And we're going to look for asymmetrical chest wall movement. We want symmetry. Asymmetrical is not right. Paradoxical motion is not right. We're going to assess the neurologic system. We're going to check for our ABPU, ANO, Glasgow Coma Scale, pupillary response with pearls. We're going to check eight points of conjugate gaze. We're going to check peripheral vision. We're going to check CFS. Those are on neurological assessment. We're going to assess the musculoskeletal system with a detailed exam of the entire body. Assessing all endocrine regions. We're going to do all our vital signs. We're going to get them early. We're going to get them often. Every five minutes because that's going to give us trending. We're going to look for signs of hypoperfusion. Things like tachycardia, which is half of rapid heart rate, greater than 100 beats per minute. Tachypnea, rapid breathing, greater than 20 breaths per minute. Oral blood pressure, which is a late sign. We pulse and cool pale white skin as they break this. Repeat your primary assessment. What's the best way of repeating your primary assessment? Doing what? Talk to your patient. Assess the effectiveness of prior treatments and maybe the patient's getting cold. You've got to wrap them up more. Call ALS. Put more oxygen on them. Maybe you're bleeding through a dressing and you need to apply another dressing. You check your interventions. Reassess bandages. Again, you need to add more bandages. Communication and documentation. Describe the mechanism of injury. Draw a good picture for the trauma surgeon. Draw a picture that they can understand. Right? Maybe take pictures of the scene. There's nothing wrong with that. Take your phone and take pictures or have your partner take pictures. See if they're drilling the duct better than you are. You're going to have your partner take pictures. See if they're drilling the duct better than the doctor. This is what the scene looked like when we arrived. I don't recommend afterwards posting them on Facebook. That's a HIPAA violation. But you can attach those photos. You can upload them to your computer and attach them via PCR. Identify which position the patient was found in. Amount of blood loss. Estimate. We've talked about this. Put in an estimate of blood loss. Always be a little bit higher. Location and description of all soft tissue injuries or wounds. Size and depth of the injury and how you treated the injury. Things like closed injuries like small contusions and bruises. There's really no treatment for that. You call me hard. You've got a bruise and you want to go to the hospital. I'll take you to the hospital. It's up to you. The problem is that patients can have say an extensive wound. They can have an extensive wound. Or if they have bleeding disorders like hemophilia or blood thinners you can become hypovolemic from multiple contusions. Watch the area no matter how minor for that swelling. We treat closed soft tissue injuries with the RISIS mnemonic. RISIS stands for rest, ice, compression, elevation and splinting. That's used for closed injuries. We never put ice on an open wound or a cold compress on an open wound. Signs of developing shock. Agitation or anxiety. Changes in mental status. Again, they go from confusion to anxiety to restlessness to you know combativeness, lethargy, oxidation, unresponsiveness. Tachycardia to tachypnea. Diaphoresis is that cold wet sweat. That's the body that's that sympathetic response epinephrine causing the capillary blood the capillary sphincters to close off and shut blood back to the core. So you don't get blood going to the extremity skin. So the skin continues to sweat and get decompensated. This along with changing these right here are late signs. That means the patient is decompensated. Before care for a patient follow standard precautions. Gloves, goggles, masks. If the life threatening bleeding is observed, have somebody put direct pressure on it and then put a pressure dressing. Up to the chest, upper abdomen, upper back with a dressing. From the neck to the umbilicus. Control bleeding using direct even pressure dressing and tourniquets. If you can't stop the bleeding throw on a tourniquet. If you have a wound in the trunk push it in and hold it with your thumb. Until you can't fit any more in. All of the wounds are soon to be contaminated and present the risk of infection. That's why we manage them to reduce the risk of further contamination. Control bleeding by splinting the extremity so the patient can't move that extremity and the bleeding eventually stops. Bleeding is good. Bleeding actually cleans the wound. As I bleed blood comes out of the wound and cleans the wound. Then it begins the healing process. So bleeding is good. That's what it's designed to do. So I'm doing