Emergency Medical Training Services Emergency Medical Technician – Paramedic Program Outlines Outline Topic: Tissue and Burn Injuries Revised: 11/2013
SOFT TISSUE and BURN CHAPTER OUTLINE COMBINED
DEFINITIONS
• Hemorrhage – is the loss of blood from within. Bleeding.
• Compartment syndrome – Defines as; tissue pressure rising above perfusion pressure resulting in
ischemia to muscles. Edema (fluid or blood) to an area that makes the tissue so tight it is cutting off
blood flow like a tourniquet. Bleeding abdomen or interstitial tissues swelling of a broken ankle. Also
can develop when the body is placed under extreme pressure.
• Ecchymosis – black and blue.
• Keloid - excessive accumulation of scar tissue that extends past the wound.
What happens with hemorrhage and hemostasis (remember back to the shock lecture)
First 10 minutes is vasoconstriction. Is a rapid but temporary response to trauma. Platelets adhere to collagen in the injured tissue. Swell and become sticky. Prothrombin activator stimulates prothrombin into thrombin which converts fibrinogen into fibrin threads. Threads trap platelets/blood cells/plasma to form a clot. This chemical action takes place within 1 to 2 minutes of injury. In 3 to 6 minutes clot is formed. Within 30 minutes the vessel is sealed shut. Note: Problems which interrupt the clotting process; hemophilia, liver disease. Aspirin decreases platelet activity. Warfarin suppressed ability of the liver to make certain clotting factors. Capillaries ooze because they cannot contract to control bleeding. Major concern is not blood loss but rather infection.
Inflammatory Response
Remember back to the shock lecture of hemostasis. The capillary sphincters shut and then pool also results in fluid leaking out of the cells. This is inflammation and it continues up to 72 hours. Most injured tissue will not regain its full strength until 4 months after the insult. What can delay healing; corticosteroids, anti-inflammatory drugs (Motrin, aspirin), penicillin, anticoagulants, and others.
SKIN
• Skin is the largest organ of the body. 20 sq feet making up 16% of total bodyweight.
• Skin regulates temperature, protective barrier, detects environmental dangers (sensory nerves).
• Epidermis – 20 layers of dead cells with keratin which acts as a waterproofing protein.
• Dermis – hair follicles, sweat glands, sebaceous glands, nerves. Maintains fluid balance and protection
against bacteria.
• Subcutaneous (sub-dermis) – fatty tissue. Insulation, cushion, and caloric reserve.
CATEGORY OF INJURIES • Open Injuries – skin is penetrated.
• Closed Injuries – skin is intact.
• Crushing Injuries can be open or closed.
• Burn Injuries can be open or closed.
CLOSED INJURIES
• Contusion – is blood that has collected under the skin. Also known as a bruise. Can occur 24 to 48 after
the injury.
• Hematoma – is a larger vessel under the skin that bleeds and more blood collects faster and raises the
area.
• A contusion to the torso may indicate massive bleeding. We say that if it takes one fist to cover the
contusion they lost about 10% of their blood volume.
OPEN INJURIES
• Abrasion – Shearing forces that damage the epidermal layer. Friction burn, wind burn, gravel burn (road
rash). Painful and high risk of infection.
• Laceration – Jagged cut through the skin. Cut by a device not designed to cut or cut smooth. A piece of
glass, metal, jagged cutting knifes, etc… • Incision - Is a cut through the skin. Cut by a device designed to cut fine lines. Examples are scalpel, razor
blades, smooth cut knifes.
• Puncture Wound – Sharp, pointed objects. Needle, knife stab, gunshot. Object was pushed through the
skin leaving smooth edges and no tissue flaps. Increased risk of deep infection.
• Amputation – Is a partial or complete removal from normal position. Must contain a bone.
• Avulsion – Is a partial or complete removal from normal position. Only contains soft tissue and no bone.
Example, ear lobe, penis, etc…
• Evisceration – Internal organs coming outside the body.
• Bites - bite pressure can be greater than 400 PSI. All bites should seek physician evaluation.
OPEN/CLOSED WOUNDS
• Burns and crushing wounds can fall under both open or closed wounds. It depends on if the skin is
intact or exposed.
HEMORRHAGE
• Injury to deep tissues can cause severe blood loss.
• A single femur fracture can bleed 1 to 2 liters of blood
• A pelvis fracture can bleed 2 to 3 liters of blood.
• Pelvis always can bleed more than femur when compared. WOUND CARE ITEMS
• Dressing – Sterile layer should be first. Dressings cover the wound.
• Bandages – Material used to hold a dressing in place.
• Occlusive dressing (Non-Porous Dressing) – Does not allow air to enter. Used on all deep injuries that
might suck in air. Chest injuries and neck injuries. Fastest occlusive dressing is a gloved hand.
HOW TO CONTROL BLEEDING
• Step 1 - Direct pressure to reduce bleeding into the area.
• Step 2 - Elevate to reduce blood flow to the area.
• Step 3 - Pressure point – pressing down on major artery to the area to reduce blood flow. (brachial in
arm and femoral in legs).
• Step 4 - Tourniquet – LAST EFFORT WHEN ALL ELSE FAILS. If I cut my hand off, if I do the first three steps
it will take 45 minutes to bleed to death. You should be able to get to a surgeon by then. You can use a
tourniquet when the body part is stuck in a machine and you cannot do the first three steps. Or you
have a person shot in 10 areas of the body and you cannot plug them all. Tourniquet should be about 4
inches wide (BP cuff is a good thing), labeled as a tourniquet, time it was placed, and placed as close to
wound as possible.
CLOSED SOFT TISSUE INJURY CARE • Direct pressure if extremity, Elevate the injured area if possible, Pressure point.
• Fluff stuff – Ice for swelling, splint to reduce movement to reduce the need for blood.
• Treat for shock if severe bleeding.
OPEN SOFT TISSUE INJURY CARE
• Direct pressure, Elevate the injured area if possible, Pressure point.
• Fluff stuff – Ice for swelling, splint to reduce movement to reduce the need for blood.
• Treat for shock if severe.
• Never put bones back in, unless they go in by themselves.
OPEN CHEST WOUND CARE (thoracic outline will have more info)
• Known as sucking chest wound.
• Air can enter the plural space. Collapsing lungs.
• Transport on left side if possible.
• Think of the hole like your mouth. When you breathe in air will enter the hole. When you exhale the air
will exit the hole.
• Use an occlusive dressing to cover the hole. If breathing gets worse unseal the occlusive when they
exhale and seal before they inhale to let air out. • Dressing types. Tape occlusive dressing on three sides to form a FLUTTER VALVE. By taping only three
sides when the patient exhales air goes out and when they inhale the occlusive will seal. Just like the
flap on a non-rebreather mask.
• Dressing types – Tape occlusive dressing on all four sides. If needed open when they exhale and close
when they inhale.
• On an exam if you have to pick choose three sides (flutter) versus four sides if the choice is not both are
correct.
EVISCERATION CARE (chapter 27 will have more info)
• Do not put organ back in.
• Keep from drying out and keep warn is the goal
• Use a bulking trauma dressing and get it moist and place over evisceration. Then place dry bulking
trauma dressing on top to hold in body heat.
• The use of an occlusive dressing on top is not mandatory. But might keep in more heat.
Crush Wounds Severe cases are (Traumatic Asphyxia)
• Crush wounds have a mnemonic to remember the 5 signs and symptoms; The 5 P's - Pain, Paresis,
Paresthesia, Pallor, and Pulselessness. • Traumatic Asphyxia - Large constant squeezing of the body, like in a dirt cave in to the chest. As soon as
the pressure is released blood pressure will drop. Give lots of fluids, high flow O2, PASG. Medical
control may order Sodium Bicarb due to the buildup of metabolic acidosis. Once the pressure is
released the patient will rapidly deteriorate due to the release of myoglobin from damaged cells.
• As long as the pressure on the body is constant they can maintain for hours and sometimes days. When
the pressure is released they typically deteriorate quickly.
IMPALED OBJECT CARE
• Never remove. Make mound around to stabilize.
• May remove only if; through and through cheek (means that the item went in a straight line through the
cheek) and can see the distal end and interferes with breathing. If breathing is ok do not remove.
• May remove only if; you need to do CPR and a knife is in the chest. Can not do compressions.
• Very rarely do we remove the impaled object even if too large to fit in the ambulance and cannot be cut
down in size. Cut the object near the wound and stabilize it in place.
AMPUTATION CARE
• Treat patient first. Do not delay transport to locate amputated part.
• Make sure body part goes to same facility as patient. • EXAMPLE Finger – place finger in plastic bag and float in cool water (some ice cubes in water is ok). The
ice keeps the water cool and the water keeps the ice from freezing the finger
• If a tooth – place in a glass of milk or care for like the finger.
NECK WOUND CARE (More info in chapter 24)
• Bleed a lot. Lots of dressing needed.
• Occlusive for deep cuts that might suck in air.
• Direct pressure to control bleeding is OK if needed but don’t do bilateral carotid pressure. Only one side
at a time.
• Transport on left side if possible.
• Air under the skin is subcutaneous emphysema. Snap, crackle, pop sound of trapped air under the skin.
• Air can get sucked into the vessels and cause air embolism (traveling clot).
Tetanus Vaccine
• Tetanus is serious and at time fatal. Disease of CNS caused by infection.
• Booster needed every 5 to 10 years.
• Results for wound infections from dirt, contaminants, metals etc...
BURNS
Causes of burns:
• Thermal - flames, scalds, frostbite, friction, hot air, etc... At 185 degrees it take 1 second to burn skin.
At 111 degrees it takes 6 hours to burn skin.
• Chemical burns.
• Electrical burns.
• Radiation burns (small percent of burn injuries).
Jackson's (Michael) thermal wound theory (local reaction)
• Three zones if injury like a bull's eye pattern
1. Central area of burn is - zone of coagulation. Dead tissue area.
2. Zone of stasis - surrounds the critical injured area. Vasoconstrict and clotting take place to isolate the
damage. Cells die in 24 to 48 hours after injury.
3. Furthest away from the central injury area is the zone of hyperemia. Increased blood flow as a result
of normal swelling just like in a cut. Tissue recovers in 7 to 10 days.
Systemic response to a burn • Hypovolemic shock from burns is called burn shock.
• Burn shock is described as a decrease in venous return, decreased cardiac output, increase of vascular
resistance (afterload).
• The greatest loss of intravascular fluid occurs in first 8 to 12 hours. It continues for another 12 to 16
hours. After about 24 hours leaking from the cells greatly diminishes. If the burn victim survives the
first 24 hours the condition might be upgraded.
Fluid Replacement for Burns
• Within minutes of major burn all capillaries loose the ability to retain fluid. This allows a major fluid shift
including colloids (large molecules) to pass.
• Start Lactated Ringer or Normal Saline and follow the Parkland Consensus burn formula.
Step 1: calculate only the 2nd and 3rd degree burn areas.
Step 2: First 24 hours give 4mL/kg times the amount of burned BSA as follows; 50% over the first 8 hours. 25%
over the second 8 hours, 25% over the third 8 hour period.
Classification of Burns • Superficial (1st degree) – Epidermis layer – Sunburn. Severe and possibly life threatening if burned 50-
70% or greater with underlying health conditions. Sun poisoning and cannot control temperature.
Sunburn takes about 4 to 7 days to heal.
• Partial thickness (2nd degree) – Dermis layer – Blisters that are closed initially. So some sunburns can be
1st and 2nd. Caused by hot liquids, grease. 2 to 4 weeks healing period.
• Full thickness (3rd degree) – Subcutaneous layer – Nerves don’t sense pain. 3rd degree area dose not
hurt because nerves have been denatured. 3rd degree is defined as charred, burn skin or blisters open
immediately after the burn. Skin grafts needed.
• What goes to burn center; burns to hands, feet, groin, chest, face, lungs. Circumferential burns (all the
way around). Burns to under 5 years of age and over 55 years of age. 2nd degree burns to over 15%
BSA, and 3rd degree burns to 5% BSA. High voltage electrocution, inhalation injuries, progressing
chemical burns.
• Circumferential burns may develop to compartment syndrome. Escharotomy are cuts into burned
tissue to relieve underlying pressure on tissues.
Burn Severity
• Minor 1st degree <50% 2nd degree <15% 3rd degree <2%
• Moderate
1st degree >50% 2nd degree <30% 3rd degree <10%
• Critical
2nd degree >30% 3rd degree >10% Hands, feet, joints, genitals, face Inhalation burns
Body Surface Area (BSA)
• Rules of nine – adult (Most accurate after 10 years a older) – Entire arm total 9%, Entire leg total 18%,
Chest 9%, Abdomen 9%, Entire back 18%, Groin 1%, Entire head 9%.
• Rules of nine – child - Entire arm total 9%, Entire leg total 14% (13.5% exact), Chest 9%, Abdomen 9%,
Entire back 18%, Groin 1%, Entire head 18%.
• Smaller burned areas use the Palm Rule for BSA – Patients palm equals about 1% of BSA. The rules of
nine works best for large area burns.
• Note: Torso is defined as chest and abdomen. 18%.
THERMAL BURN CARE • Stop the burning if not already done.
• Protect airway. Use humidified oxygen high flow. If intubation is needed perform early with the correct
size ET Tube.
• Remove clothing. If stuck cut around.
• Remove jewelry.
• Wrap with burn sheet or something without fibers.
• Wrap loose.
• If less than 9-10% BSA can use local cooling through burn sheet bandage and dressing. If over 9-10%
leave dry.
• Separate finger and toes if not stuck already.
• Major burns morphine is given or nitrous oxide. Monitor BP.
• If the victim survives the first several days after the burn the major risk of death shifts to infection.
CHEMICAL BURN CARE
• Brush of chemical if powder before flushing for 20 minutes.
• If the eye is involved; flush affected eye only. open eye lids unless fused together.
• Flush for 20 minutes even of it feels better. You have to dilute the chemical in the pores. • DRY LIME AND SODA ASH AND PHENOL (these chemicals will have a ”w” with a line through it indicating
no water) – activates with water. If the persons perpetration activated the chemical flush with lots of
water for 20 minutes to dilute. Once activated use water to flush if nothing else available per
manufacturer of chemical.
• American Burn Association says that no agent had been found better to flush wounds that just plain
water.
Petroleum burns - Gasoline burns may look superficial but go deep. Cause CNS problems and possible lead poisoning. Hydrofluoric Acid - most corrosive material known. Acid cleans metal, fabrics, glass etching. Kills cells in the body. Deep painful burns. Care: Flush with water, SubQ injection of calcium gluconate into burn site. Phenol - from coal tar - cleaning agent. Also used for explosives, fertilizers, dyes, plastics. Signs: Painless but severe. CNS depression. Care: Flush with water, and cleaned with glycerol, vegetable oil, soap and water to bond with the poison to stop absorption. Ammonia - irritating gas. Strong alkali that burns. Ammonia and bleach is a bad combination that will evacuate a building fast. Care: flush injured tissue and get to fresh air. Sodium and potassium metals. Ignite spontaneously. Water is generally contraindicated. Cover with oil is usually the best treatment. If burning contact medical control to see if large amounts of water need to be used and removal of the impaled metal.
ELECTRICAL BURN CARE
• Main concern is what happened internally between the entrance and exit wounds. • Prognosis is good if immediate interventions are conducted by EMS. (Statement excludes a direct
lightning strike. Lightning strikes usually travel on the outside of the body on the skin.)
• Stay away unless trained. One dead person instead of two.
• Can cause small entrance wounds and larger exit wounds. Cooks them from the inside out. Like a
microwave. Major internal damage. Respiratory and Circulatory collapse it likely.
• V-FIB most common after being shocked. Get AED.
• Pathways of electrocution: Hand to hand, Hand to leg, or leg to leg paths.
• Nerve damage common.
• If indicated aggressive airway management is needed with C-spine precautions.
Radioactive Burns
• Alpha - Stopped by paper or clothing or outer layers of skin. Travel only a few feet from source.
• Beta - More energy than alpha. Can penetrate subcutaneous skin. Travel 6 to 10 feet from source.
• Gamma - x-ray. most dangerous. Lead shields.
• Severity depends on duration, distance and shielding.
Carbon Monoxide Poisoning
• Colorless, odorless, tasteless gas from incomplete burning of fuels.
• Does not harm lungs but does displace oxygen. • CO is 200 to 250 times the attraction to hemoglobin than oxygen.
• Care is get to fresh air, ABC, high flow O2.
• Half-life of CO is 4 hours. With ETT oxygen can be reduced to 30 to 40 minutes. A hyperbaric chamber
will not separate the bond of CO to hemoglobin but will promote the uptake of oxygen by the
hemoglobin that is still available.
• Other Gasses: Cyanide and hydrogen sulfide (chapter 36 discusses more)