EMS Lecture - Soft Tissue Injuries: BURNS, AVPU & SAMPLE

Chapter 5: Soft Tissue Injuries and Burns

Overview of Skin Anatomy

• The skin consists of three layers that EMTs must know: the epidermis (outer layer), dermis (middle layer containing blood vessels, hair follicles, nerves, and sweat glands), and subcutaneous tissue (fat layer).

Types of Internal Injuries

• A contusion, commonly referred to as a "black and blue" mark, occurs when small blood vessels (capillaries) burst under the skin due to trauma.

• A hematoma is a larger collection of blood that forms a swelling; it can be described as resembling a ball or grapefruit.

• Contusions go through four stages of healing: red, purple/blue, brownish-purple, and yellow. The color change indicates the healing process.

Closed vs. Open Injuries

Closed Injuries

• Patients can experience significant internal bleeding without visible signs; this is critical in cases involving pelvic girdle injuries.

Open Injuries

• An abrasion is a superficial scrape that typically involves only the outer layer of skin with minimal capillary bleeding.

• A laceration refers to a cut through the skin where bleeding varies based on depth; arterial bleeds are characterized by spurting while venous bleeds pour out.

Severe Open Wounds

• An avulsion involves tearing away flesh or muscle but remains partially attached; it often results in severe bleeding.

• A puncture wound, such as from stabbing or gunshot wounds, is defined as deeper than wide. Other examples include needle punctures.

Definitions for EMT Understanding

• Key definitions include:

• Amputation: Removal of a body part.

• Evulsion: Skin peeled back with potential serious bleeding.

• Puncture: Deep wound caused by sharp objects like needles.

• Abrasion: Least severe injury type—just scraping the skin surface.

• Laceration: General term for any cut in the skin.

Treatment Considerations

Understanding Impaled Objects and Emergency Response

Managing Impaled Objects

• When dealing with impaled objects, do not remove them as they may be holding blood vessels together. Removal should only occur in an operating room.

• Impaled objects are classified under penetrating injuries; if the object is still embedded, it is considered impaled rather than removed.

• If the impaled object does not obstruct the airway, it should remain in place during transport to avoid further injury.

Stabilization Techniques

• Stabilizing an impaled object is crucial; movement can exacerbate injury. Use bulky dressings and roller gauze to secure the object tightly.

• In cases where emergency services are needed, they will assist in managing the situation for safe transport without removing the object.

Eye Injuries Protocol

• For eye injuries involving an impaled object, do not remove it unless it blocks the airway. Bandage both eyes to prevent further damage.

• Small debris in the eye should be flushed from medial (nose side) to lateral (outer side), ensuring proper technique during treatment.

Understanding Epistaxis (Nosebleeds)

• The medical term for a nosebleed is epistaxis. It can be caused by various factors and often appears more severe than it is.

• Treatment involves keeping calm, having the patient lean forward, pinching their nostrils together across the bridge of their nose to control bleeding effectively.

Complex Cases: Neck Injuries

• Stabbing or shooting injuries to the neck pose significant risks due to large arteries that supply blood to the brain. Immediate attention is required for potential bleeding and air embolism risks.

Occlusive Dressings and Chest Injuries

Understanding Occlusive Dressings

• An occlusive dressing is an airtight bandage applied to stop bleeding, particularly in large open neck wounds.

• Disposable sterile plastic packaging from medical equipment can be repurposed as occlusive dressings by cutting it to size.

• The primary concern with open neck wounds is air embolism; thus, applying an occlusive dressing is crucial to prevent air from entering the bloodstream.

Techniques for Bandaging

• Compressing a carotid artery can stop bleeding but risks cutting off blood flow to the brain, which could be fatal.

• Various techniques will be discussed for effectively bandaging chest injuries, especially those resulting from gunshot or stab wounds.

Anatomy of the Lung

• The anatomy of the lung includes key structures such as the trachea, bronchi (right and left), and bronchioles leading to alveoli where gas exchange occurs.

• Alveoli are surrounded by pulmonary capillaries that facilitate oxygen absorption into the blood and removal of carbon dioxide.

Pleura: Protective Membrane of Lungs

• The pleura is a protective membrane surrounding the lungs, consisting of two layers: visceral pleura (inner layer) and parietal pleura (outer layer).

• Between these layers lies the pleural cavity filled with surfactant, which acts as a lubricant preventing friction during breathing.

Types of Thoracic Injuries

• Key terms include pneumothorax (air in thorax), hemothorax (blood in thorax), and hemopneumothorax (both air and blood present).

• Tension pneumothorax is life-threatening due to increased pressure on lungs; understanding this condition is critical for emergency response.

Consequences of Chest Trauma

• A stab wound creates a hole in both chest wall and parietal pleura, allowing air to rush into the thoracic cavity—leading to potential lung collapse.

• As more air enters between pleural layers, it causes pneumothorax—a collapsed lung scenario often seen in trauma cases.

Understanding Pneumothorax and Related Conditions

Treatment of Lung Injuries

• Patients can breathe with one lung temporarily, though it may be uncomfortable. They are quickly transported to a trauma center where procedures like chest tube insertion are performed to allow air and blood to escape from the affected lung.

• Surgical intervention is not common for these cases; however, in certain situations, surgery may be necessary depending on the injuries sustained.

Spontaneous Pneumothorax

• Spontaneous pneumothorax typically occurs in tall, skinny males in their early 20s without any apparent cause. Symptoms include sudden difficulty breathing.

• This condition involves air leaking into the pleural space due to a collapsed lung, requiring similar treatment as traumatic pneumothorax through chest tube insertion.

Occlusive Dressing Technique

• An occlusive dressing is applied to manage pneumothorax by preventing air from entering while allowing some air to escape if needed. This helps avoid complications from excessive pressure buildup.

• Leaving a corner of the dressing open can facilitate airflow out of the pleural space, which is crucial for patient comfort and effective treatment.

Tension Pneumothorax

• If air continues to enter the pleural space without being released, it leads to tension pneumothorax. This condition pushes the affected lung against vital structures like the heart and good lung.

• Key indicators include absent breath sounds on one side during examination. Immediate action involves applying an occlusive dressing to prevent further air entry.

Pericardial Tamponade

• Pericardial tamponade occurs when blood accumulates in the pericardial sac surrounding the heart due to trauma or laceration, hindering proper heart function.

• The condition affects systolic and diastolic pressures as they converge due to restricted ventricular filling and contraction capabilities.

Beck's Triad Indicators

• Beck's triad consists of three clinical signs: narrowing pulse pressure (e.g., systolic-diastolic difference decreasing), distended jugular veins (JVD), and muffled heart sounds upon auscultation.

Tension Pneumothorax and Related Injuries

Understanding Tension Pneumothorax

• Tension pneumothorax causes tracheal deviation away from the midline due to air accumulation in the pleural space, leading to lung collapse and pressure on surrounding structures.

• Recognizing tension pneumothorax is critical; paramedics can relieve it by needle decompression, which is life-saving. It’s often referred to as a "sucking chest wound" due to audible air intake.

Signs of Cardiac Tamponade and Flail Chest

• Jugular venous distention (JVD) indicates cardiac tamponade, while flail chest occurs when multiple ribs are fractured in two or more places, causing paradoxical respiration.

• In flail chest, the affected rib segment moves inward during inhalation instead of outward, creating significant respiratory distress.

Sports Injuries: Commotio Cordis

• Commotio cordis can occur in sports when a projectile strikes the chest, potentially leading to cardiac arrest. Immediate defibrillation can restore normal heart rhythm.

Gunshot Wounds and Evisceration Management

Gunshot Wound Characteristics

• Gunshot wounds typically present with small entry wounds and larger exit wounds; internal damage may be extensive but requires careful assessment without delving into specifics.

Evisceration Protocol

• Evisceration refers to organs protruding outside the body; immediate care involves maintaining ABC (Airway, Breathing, Circulation), controlling bleeding, and providing oxygen.

• Do not attempt to replace eviscerated organs. Instead, cover them with a moistened sterile dressing followed by a dry dressing for protection against infection.

Amputation Care Techniques

Managing Amputated Body Parts

• For amputations, use two Ziploc bags: one for ice and another for the amputated part. Ensure that the body part does not come into direct contact with ice during transport.

Understanding Thermal Injuries and Burn Classification

Transporting Thermal Injuries

• When transporting body parts with thermal injuries, place the affected body part in a separate bag, then submerge that bag in ice to preserve the tissue.

Anatomy of the Abdomen

• Familiarity with the four quadrants of the abdomen is crucial; key organs include:

• Right Upper Quadrant: Liver and Gallbladder

• Right Lower Quadrant: Appendix

• Left Upper Quadrant: Stomach and Spleen

Trauma Centers in New York

• New York has several trauma centers, particularly in Brooklyn, Queens, Staten Island, Manhattan, and the Bronx. These centers frequently handle burn injuries.

Classifying Burns

• Burns are classified into three degrees:

• First Degree (Superficial): Characterized by red skin (e.g., sunburn).

• Second Degree (Partial Thickness): Involves blisters; do not pop them.

• Third Degree (Full Thickness): Skin appears charred or blackened; may expose muscle or bone.

Characteristics of Each Burn Type

• First-degree burns present as redness on the skin.

• Second-degree burns show blisters which can be large and white.

• Third-degree burns resemble overcooked meat and require significant heat exposure.

Assessing Burn Severity

Estimating Burn Area Using "Rule of Nines"

• To assess how much of a patient's body is burned:

• The head accounts for 9% of total body surface area.

• Each arm also represents 9% each.

Body Regions Breakdown

• Thorax (front & back): 18% total (9% each).

• Abdomen (anterior & posterior): Also contributes to overall percentage calculations.

Legs Assessment

• Each leg consists of an anterior and posterior section contributing to a total of 18% for both legs combined.

Critical Areas for Burns

Identifying Critical Areas

• Four critical areas where burns are particularly concerning:

• Hands

• Feet

• Face

• Genitals

Importance of Location in Treatment Decisions

• Burns located in these critical areas necessitate specialized care at burn centers due to their impact on quality of life.

Why Does Burn Classification Matter?

Implications for Treatment

Burn Treatment and Burn Centers in New York City

Overview of Burn Centers

• In New York City, there are limited burn centers; Brooklyn does not have one. Residents from South Brooklyn (Borough Park, Bensonhurst) would go to Staten Island for treatment.

• For those in North Brooklyn (Red Hook, Green Point, Williamsburg), Cornell Medical Center is the designated facility. Central Brooklyn residents can choose between nearby options due to similar distances.

Understanding Burn Severity

• A first-degree burn becomes critical when it covers more than 75% of body surface area (BSA), which is rare and typically results from extreme sun exposure.

• Second-degree burns are critical if they cover more than 30% BSA. Key areas include the face, hands, feet, and genitals. Burns affecting the respiratory tract also require immediate attention.

• Circumferential burns—those that wrap around a body part—can necessitate treatment at a burn center even if they don't meet the percentage criteria.

Treatment Protocol for Burns

• The primary treatment for burns is cool running water; this should be applied immediately regardless of where the injury occurs.

• Clothing stuck to burns should not be forcibly removed; jewelry near the burn site should also be taken off carefully. Moist dressings are recommended for less than 10% BSA burns while dry dressings are used for larger areas.

Special Considerations for Different Types of Burns

• Electrical burns can cause severe internal damage and may result in entry and exit wounds. Serious electrical injuries often occur with voltages above 220V.

• Chemical burns require irrigation for at least 20 minutes without attempting to neutralize chemicals on-site as this could worsen the situation.

Respiratory Issues Related to Burns

• Patients suffering from electrical burns may experience respiratory issues due to inhaling superheated air that damages their airway lining. Intubation may be necessary in severe cases.

Accessing Burn Care Facilities

• There are no dedicated burn centers in Brooklyn or Queens; patients must travel to Manhattan (Harlem Hospital or Cornell). In Bronx or Staten Island emergencies, specific facilities will depend on patient location.

Vital Signs Monitoring

Vital Signs and Mental Status Assessment

Overview of Vital Signs

• The importance of bringing a blood pressure cuff to every skill lab is emphasized, as it is essential for measuring vital signs.

• Key vital signs include skin color, temperature, pulse (rate, rhythm, quality), eye response to light, respiration (rate and quality), and mental status.

Importance of Mental Status

• Mental status is highlighted as one of the most critical vital signs; an example is given involving a 15-year-old girl who suffered a head injury and displayed confusion about her identity and surroundings.

• It’s crucial to assess the patient directly rather than relying on family members for information to ensure accurate evaluation.

Assessing Alertness with Mnemonics

• The mnemonic "Apple" is introduced for assessing alertness: patients must answer three questions correctly regarding person, place, and time.

• Questions should focus on identifying the person present ("Who is that?"), location ("Where are we?"), and temporal context ("What day of the week is it?").

Evaluating Patient Responses

• A patient may be aware of their discomfort but still not be considered alert if they cannot answer the three key questions.

• Different levels of responsiveness are categorized:

• A for alert,

• V for verbal response,

• P for pain response,

• U for unresponsive.

Pain Response Assessment

• If a patient does not respond verbally or fails to answer correctly, pain can be used as a stimulus by pinching above the shoulders or tragus of the ear to check responsiveness.

• The "AVPU" scale helps categorize patients based on their responses to stimuli—alertness being paramount in initial assessments.

Sample History Taking

• The "SAMPLE" acronym outlines six essential questions:

• S: Signs and symptoms (what's bothering you?)

• A: Allergies (to medications or foods)

• M: Medical history (previous conditions)

Understanding Emotional and Social Factors in Health Assessments

Importance of Last Intake Before Emergency Calls

• The speaker emphasizes the need to know what the patient last ate or drank before the 911 call, indicating its relevance in medical assessments.

Emotional and Social Context in Patient Evaluation

• The discussion introduces a framework for evaluating patients that includes emotional (E) and social (L) factors, highlighting their significance in understanding a patient's overall condition.

• The speaker notes that emotional events are crucial to assess, questioning whether the patient is experiencing stress or other emotional challenges.