This chapter discusses soft-tissue trauma, including the anatomy, pathophysiology, assessment, and management of soft-tissue injuries. It covers the layers of the skin, blood vessels, and muscles. Common soft-tissue injuries are described such as abrasions, lacerations, punctures, and avulsions. Complications like hemorrhage, infection, and impaired healing are addressed. Assessment techniques like inspection, palpation, and focused examination are outlined. The objectives and considerations for wound dressings and bandaging different body areas are presented.

1. Paramedic Care:
Principles & Practice
Volume 5
Trauma Emergencies

2. Chapter 5
Soft-Tissue Trauma

3. Topics
Introduction to Soft-Tissue Injuries
Anatomy and Physiology of
Soft-Tissue Injuries
Pathophysiology of Soft-Tissue Injury
Dressing and Bandage Materials
Assessment of Soft-Tissue Injuries
Management of Soft-Tissue Injury

4. Introduction to
Soft-Tissue Injuries

5. Introduction to
Soft-Tissue Injuries
Skin is the largest organ
16% of total body weight
Function:
– Protection
Body fluids in
Bad stuff out (pathogens)
– Sensation
– Temperature regulation

6. Introduction to
Soft-Tissue Injury
Epidemiology
– Open wounds
– Closed wounds
More common
Contusions, sprains, strains
– Risk factors for soft-tissue wounds
Age
Alcohol and drug abuse
Occupation
– Prevention

7. Anatomy and Physiology of
Soft-Tissue Injuries

8. Anatomy and Physiology of
Soft-Tissue Injuries
Layers of the Skin
– Epidermis
– Dermis
– Subcutaneous

9. Anatomy and Physiology of
Soft-Tissue Injuries
Blood Vessels
– Arteries
– Arterioles
– Capillaries
– Venules
– Veins
Layers
– Tunica intima
– Tunica media
– Tunica adventitia
Click here to view the anatomy of blood
vessels.

10. Anatomy and Physiology of
Soft-Tissue Injuries
Muscles
– Beneath skin layers
– Fascia
Thick, fibrous, inflexible membrane surrounding muscle
that aids in binding muscle groups together

11. Anatomy and Physiology of
Soft-Tissue Injuries
Tension Lines
Lacerations across the
tension lines have a
tendency to be pulled
apart.
Lacerations parallel to the
tension lines tend to gape
very little.

12. Pathophysiology of
Soft-Tissue Injury

13. Pathophysiology of
Soft-Tissue Injury

14. Pathophysiology of
Soft-Tissue Injury
Closed Wounds
– Contusions
Blunt, nonpenetrating
injuries that crush and
damage small blood
vessels
Characterized by
erythema and
ecchymosis
© Edward T. Dickinson, MD

15. Closed Wounds
Hematoma – ‘HEMATOMATA’
– Blood separates tissue and pool in a pocket
Dangerous in head injuries
Some may cause hypovolemia

16. Pathophysiology of
Soft-Tissue Injury
Open Wounds
– Abrasion
Typically the most minor
of injuries
Carries the danger of
serious infection
– Laceration
Penetrates more deeply
into the dermis than an
abrasion
Endangers the deeper
and more significant
vasculature, nerves,
muscles, tendons,
ligaments, and organs
© Charles Stewart, MD

17. Open Wounds
Incision
– A surgically smooth
laceration
Puncture
– A small entrance
wound with damage
that extends into the
body’s interior
– A puncture
additionally carries
an increased
danger of infection

18. Open Wounds
Impaled Object
– A wound
complication often
associated with a
puncture or
laceration
– May cause
worsening damage
if withdrawn © Charles Stewart, MD

19. Open Wounds
Avulsion
– A flap of skin,
although torn or cut,
is not torn
completely loose
from the body
– Degloving injury
Ring injury

20. Open Wounds
Amputations
– Partial or complete
severance of a digit or
limb
– Hemorrhage associated
with the amputation may
be limited
– Care is used to ensure
that the stump will be as
functional as possible © Mark C. Ide

21. Pathophysiology of
Soft-Tissue Injury
Hemorrhage
– Arterial
– Venous
– Capillary
The nature of the soft-tissue wound may be
more important than the size or type of vessel
involved
– Clean lacerations and amputations generally do
not bleed profusely

22. Pathophysiology of
Soft-Tissue Injury
Wound Healing
– Hemostasis
Vessels have a muscular layer that reflexively constricts
the vessel in response to local injury
Platelets begin the clotting process
Stick to the vessel wall and to one another forming a plug
Proteins activate a complicated series of enzyme
reactions
Coagulation

23. Wound Healing
Inflammation
– Involves a host of elements
Various kinds of white blood cells
Proteins involved in immunity
Hormone-like chemicals that signal other cells to
mobilize
– Chemotactic factors
Recruit cells
Granulocytes and macrophages
Phagocytosis

25. Wound Healing
Inflammation (cont.)
– Lymphocytes and immunoglobins
– Histamine dilates precapillary blood vessels
Increases blood flow to affected area
Brings much-needed oxygen and more phagocytes to
the injured area

26. Wound Healing
Result of the inflammatory stage
– Clearing away of dead and dying tissue
– Removal of bacteria and other foreign substances
– Preparation of the damaged area for rebuilding

27. Wound Healing
Epithelialization
– Epithelial cells migrate over the surface of the
wound
Restores a uniform layer of skin cells along the edges of
the healing wound
– The new epithelial layer is not a perfect facsimile
of the original, undamaged skin
Usually quite functional and cosmetically similar

28. Wound Healing
Neovascularization
– New growth of capillaries in response to healing
– Neovascularized tissue is very fragile and has a
tendency to bleed easily
Collagen Synthesis
– Fibroblasts: Cells that form collagen
– Remodeling

29. Wound Healing Process

30. Pathophysiology of
Soft-Tissue Injury
Infection
– serious complication of open wounds
– Delay healing
– Spread to adjacent tissues
– Systemic infection: sepsis
– Presentation
Pus: WBCs, cellular debris, and dead bacteria
Lymphangitis: visible red streaks
Fever and malaise
Localized fever

31. Infection
Risk factors
– Host’s health and pre-existing illnesses
Diabetics, the infirm, the elderly, and individuals with
serious chronic diseases
– Wound type and location
Well-vascularized areas such as the face and scalp are
very resistant to infection
Distal areas such as extremities heal more slowly
– Associated contamination
– Treatment provided

33. Infection
Infection management
– Antibiotics and keep wound clean
Gangrene
– Deep space infection of anaerobic bacteria
– Bacterial gas and odor
Tetanus
– Lockjaw
– Uncommon with the exception of third-world
country immigrants

37. Pathophysiology of
Soft-Tissue Injury
Other Wound Complications
– Impaired hemostasis
Medications can interfere with hemostasis and the
clotting process
Aspirin, anticoagulants, fibrinolytics, and penicillins
Abnormalities in proteins involved in the fibrin formation
cascade may result in delayed clotting
Hemophilia

38. Other Wound Complications
Re-bleeding
– Re-bleeding is possible from any wound
Movement of underlying structures
Hemorrhage continues in large wounds unnoticed
Postoperative wounds
Delayed healing
– Patients at risk include:
Diabetics, the elderly, the chronically ill, and the
malnourished

39. Main Concepts of this Chapter
Crush Injury
Compartment Syndrome
Crush Syndrome
Rhabdomyalosis

40. Crush Injury
A body part is
compressed, injuring
muscles, blood vessels,
bones, and other
internal structures
© Edward T. Dickinson, MD

41. Pathophysiology of
Soft-Tissue Injury
Crush Injury
– Body tissues subjected to severe compressive
forces
– A crush injury disrupts the body’s tissues
Creates an excellent growth medium for bacteria
– Tissue hypoxia and acidosis may result in muscle
rigor

42. Crush Injury
Associated Injury
– Additional fractures
– Open or closed soft-tissue injuries
– Direct injury
Blunt and penetrating
– Dehydration and hypothermia

44. Compartment Syndrome
Extremity injury causes
significant edema and
swelling in the deep
tissues
Pressure in the
compartment will rise
Results in decreased blood
flow and ischemia

45. Care of Specific Wounds
Compartment Syndrome
– Likely 4–8 hours post-injury
– 30 mmHg
– Symptom
Severe pain out of proportion with physical exam findings
6 Ps
Pain
Paresthesia- numbness
Pallor
Pressure
Paralysis
Pulses
Normal motor and sensory function

46. Care of Specific Wounds
Compartment Syndrome (cont.)
– Management
Care of underlying injury
Splint and immobilize all suspected fractures
Cold packs to severe contusions:
Most effective prehospital management
Reduces edema
Prevents ischemia

49. Pathophysiology of
Soft-Tissue Injury
Crush Syndrome
– Body is entrapped for >4 hours
– Crushed muscle tissue becomes necrotic
Resultant release of metabolic byproducts
traumatic rhabdomyolysis
– By-products of cellular destruction
Myoglobin
Phosphate and potassium
Lactic acid
Uric acid

50. Care of Specific Wounds
Crush Syndrome
– Anticipate problems
– Victims of prolonged entrapment
– Ensure that scene is safe
– Greater the body area compressed, the longer the
entrapment, the greater the risk of crush
syndrome
– Once body part is freed, toxic by-products of
crush injury are released into systemic circulation
– General management for soft tissue and
musculoskeletal injury

51. Crush Sydrome
Hypovolemia
Hyperkalemia
Hypocalcemia
Acidosis
Renal Failure

52. Care of Specific Wounds
Crush Syndrome
– Management
IV: 20–30 mL/kg of NS or D51/2 NS
AVOID LR or K+ based solutions
After bolus, continuous infusion of 20 mL/kg/hr
Consider sodium bicarbonate
Consider calcium chloride:
500 mg IVP
Counteracts hyperkalemia
Consider diuretics:
Mannitol (Osmotrol)
Furosemide (Lasix)

53. Care of Specific Wounds
Crush Syndrome
– Management
IV: 20–30 mL/kg of NS or D51/2 NS
AVOID LR or K+ based solutions
After bolus, continuous infusion of 20 mL/kg/hr
Consider sodium bicarbonate
Consider calcium chloride:
500 mg IVP
Counteracts hyperkalemia
Consider diuretics:
Mannitol (Osmotrol)
Furosemide (Lasix)

55. Rhabdomyolysis
Breakdown of muscle cells
Liberation of injured muscle into circulation

58. Rhabdomyolysis
Muscle stretching
– Influx of Ca++ and Na+
– Cells swell up
Ischemia
Anaerobic metabolism
May be due by electrical current

59. Pathophysiology of
Soft-Tissue Injury
Injection Injury
– High-pressure line
bursts
– Injects fluid or other
substance into skin
and into
subcutaneous tissue

60. Dressing and
Bandage Materials

61. Dressing and
Bandage Materials
Sterile and Non-sterile Dressings
– Sterile: direct wound contact
– Non-sterile: bulk dressing above sterile
Occlusive/Non-occlusive Dressings
Adherent/Non-adherent Dressings
– Adherent: stick to blood or fluid
Absorbent/Non-absorbent
– Absorbent: soak up blood or fluids

62. Dressing and
Bandage Materials
Wet/Dry Dressings
– Wet: burns, postoperative wounds (sterile NS)
– Dry: most common
Self-adherent Roller Bandage
– Kerlex/Kling
Multi-ply, stretch: 1–6”
Gauze Bandage
– Single-ply, non-stretch: 1–3”
Adhesive Bandages
Elastic (Ace) Bandages
Triangular Bandages

63. Assessment of
Soft-Tissue Injuries

64. Assessment of
Soft-Tissue Injuries
Scene Size-up
– Rule out or eliminate
any threats to yourself
or fellow care providers
– Determine the
mechanism of injury
– Standard Precautions

65. Assessment of
Soft-Tissue Injuries
Initial Assessment
– Establishing manual cervical in-line immobilization
– Form a general impression
– Assess the airway, breathing, and circulation
– Correct any immediate threats to the patient’s life

66. Assessment of
Soft-Tissue Injuries
Focused History and Physical Exam
– Significant MOI
Rapid trauma assessment
Perform a swift evaluation of the patient’s head, neck,
chest, abdomen, pelvis, extremities, and posterior body
Confirm the decision either to transport the patient
immediately with further care provided en route to the
hospital

67. Assessment of
Soft-Tissue Injuries
Focused History and Physical Exam
– No significant MOI
Focused trauma assessment
Use the examination techniques of inquiry, inspection,
and palpation to evaluate the injury and the surrounding
area
Check the distal extremity for pulses, capillary refill, color, and
temperature
Transport Decision

68. Assessment of
Soft-Tissue Injuries
Detailed Physical Exam
– Detailed exam should follow a planned and
comprehensive process
– The detailed physical exam is usually performed
during transport
Never delay transport to perform it

69. Assessment of
Soft-Tissue Injuries
Assessment Techniques
– Inquiry
The mechanism of injury, any pain, pain on touch or
movement, and any loss of function or sensation specific
to an area
– Inspection
Carefully observing a particular body region
– Palpation
Palpate the body’s entire surface

70. Assessment of
Soft-Tissue Injuries
Ongoing Assessment
– Reassess the patient’s mental status, airway,
breathing, and circulation
– Inspect any interventions you have performed
– Perform at least every 5 minutes with unstable
patients
– Perform at least every 15 minutes with stable
patients

71. Management of
Soft-Tissue Injury

72. Management of
Soft-Tissue Injury
Objectives of Wound Dressing and
Bandaging
– Hemorrhage control
Direct pressure
Elevation
Pressure points
Consider
Ice
Constricting band
Tourniquet

73. Management of Soft-Tissue
Injury - Tourniquet
Do
– Apply in a way that
will not injure tissue
beneath it
– Use something at
least 2” wide
– Consider using a
blood pressure cuff
– Write TQ and time
placed on patient’s
forehead
Don’t
– Use unless you
cannot control the
bleeding via other
means
– Use rope or wire
– Release it once
applied

74. Management of
Soft-Tissue Injury
Objectives of Wound Dressing and
Bandaging
– Sterility
Keep the wound as clean as possible
If wound is grossly contaminated, consider cleansing
– Immobilization
Prevents movement and aggravation of wound
Do not use an elastic bandage: TQ effect
Monitor distal pulse, motor, and sensation

75. Management of
Soft-Tissue Injury
Pain and Edema Control
– Cold packs
– Moderate pressure over wound
– Consider analgesic :
Morphine sulfate
2 mg IVP every 5 minutes up to a total of 10 mg given.
Fentanyl (Sublimaze)
25–50 mcg IVP followed by an additional 25 mcg as needed.
If given too rapidly, chest wall rigidity may ensue leading to
respiratory compromise

76. Anatomical Considerations
for Bandaging
Scalp
– Rich supply of blood vessels
– Rarely account for shock
– Can be severe and difficult to control
– With skull fracture:
Gentle digital pressure around the wound
Pressure on local arteries
– Without skull fracture:
Direct pressure

77. Anatomical Considerations
for Bandaging
Face
– Heavy bleeding
– Assess and protect the airway
– Blood is a gastric irritant
Be alert for nausea and vomiting
Ear or Mastoid
– Cover and collect bleeding
– Do not stop CSF from ears or nose

78. Anatomical Considerations
for Bandaging
Neck
– Consider circumferential bandage
Protect trachea and carotids
C-collar and dressing
– Occlusive dressing if lacerated vessel
Shoulder
– Take care to avoid pressure
Axillary artery
Trachea
Anterior neck

79. Anatomical Considerations
for Bandaging
Trunk
– Minor wounds: Dressing
and tape
– Major wounds:
Circumferential wrap
Ladder splint behind back
and wrap gauze over it
Groin and Hip
– Bandage by following
contours of body
– Movement can increase
tightness of bandage
© Ray Kemp/911 Imaging

80. Anatomical Considerations
for Bandaging
Elbow and Knee
– Circumferential wrap and splint
Splinting reduces movement
Position of function
Half flexion/half extension
Hand and Finger
– Remove jewelry from wrist and fingers
– Bulky dressing
– Position of function
Ankle and Foot
– Circumferential bandage

81. Anatomical Considerations
for Bandaging
Complications of Bandaging
– Always assess before and after:
Pulse
Motor
Sensation
– Developing ischemia:
Pain
Pallor
Tingling
Loss of pulse
Decreased capillary refill

82. Care of Specific Wounds
Amputations
– Patient
Control bleeding
Consider tourniquet
Do not delay transport
– Amputated Part
Dry cooling and rapid
transport
Part in plastic bag
(double bag)
Immerse in cold water
Avoid direct contact
between tissue and
cold water

83. Care of Specific Wounds
Impaled Objects
– Stabilize with bulky dressing in place
– Prevent movement of object
– Consider cutting or shortening large impaled
objects
– Consider removal if:
In cheek and interferes with airway
Interferes with CPR

84. Special Anatomical Sites
Face and Neck
– Potential for airway obstruction or compromise
– Aggressive suctioning and oxygenation
– Consider intubation:
Verify ET tube placement
Ensure tube remains in the airway by using continuous
waveform capnography
If excessive swelling or damage:
Needle or surgical cricothyroidotomy

85. Special Anatomical Sites
Thorax
– Superficial injury can be deep
– Always suspect the worst due to underlying
organs
– NEVER explore a wound internally
– Alert for:
Subcutaneous emphysema
Pneumothorax or hemothorax
Tension pneumothorax
– Consider occlusive dressing sealed on 3 sides

86. Special Anatomical Sites
Abdominal Region
– Always suspect injury to ribs or thoracic organs if
between the level of the 5th and 9th rib
– Damage to hollow or solid organs from blunt or
penetrating trauma
– Signs of symptoms of internal injury may be subtle
and slow to progress
– Supportive treatment unless aggressive care is
warranted

87. Wounds Requiring Transport
Any wound that involves
– Nerves
– Blood vessels
– Ligaments
– Tendons
– Muscles
– Significantly contaminated
– Impaled object
– Likely cosmetic injury

88. Soft-Tissue Treatment and
Refer/Release
Typically requires on-line medical direction
– Evaluate and dress wound
– Inform the patient about:
Preventing infection
Follow-up care with a physician
Inquire about tetanus and inform of risks
– Document treatment, referral, and teaching

89. Summary
Introduction to Soft-Tissue Injuries
Anatomy and Physiology of Soft-Tissue
Injuries
Pathophysiology of Soft-Tissue Injury
Dressing and Bandage Materials
Assessment of Soft-Tissue Injuries
Management of Soft-Tissue Injury