SOFT TISSUE INJURY

Injuries to the soft tissues – muscles, skin and nerves – are often traumatic but rarely
life-threatening. However, they are serious if they involve large vessels or organs or
lead to airway or breathing compromise, uncontrolled bleeding and shock.

SKIN
It is composed of three layers: epidermis, dermis and subcutaneous. It protects the
body from the environment, bacteria and other organisms, and it helps to regulate the
body’s temperature. It also serves as a receptor organ that senses heat, cold, touch,
pressure, and pain, and it aids in the elimination of water and various salts.

CLOSED SOFT TISSUE INJURY

A wound in which there is no break in the continuity of the skin.

1. Contusion
- or bruise, is an injury to the tissue and blood vessels contained with the
dermis
- cause localized swelling and pain at the injury site
- discoloration at the injury site caused by blood leaking from damaged
vessels and accumulating in the surrounding tissue
- black and blue discoloration is called ecchymosis

2. Hematoma
- similar to contusion, except that is usually involves damage to a larger
blood vessel and a larger amount of tissue
- Characterized by a large lump with bluish discoloration caused by
blood collecting beneath the skin. This blood may also separate tissues
and pool in the pockets they form
- hematoma is size of patient’s fist can be equal to 10% blood loss,
causing minimal assigns and symptoms of shock (hypoperfusion)

3. Crush Injuries
- one in which force great enough to cause injury has been applied to the
body
- severe blunt trauma or crushing force can cause serious damage to the
underlying soft tissues with associated internal bleeding, and may
result in shock (hypoperfusion)

SIGNS & SYMPTOMS

• swelling, pain, discoloration at the injury site
• signs and symptoms of internal bleeding and shock
(hypoperfusion) if the underlying tissues are injured

EMERGENCY MEDICAL CARE

1. Take standardized precautions
a. Wear protective gloves, eyewear and other appropriate personal
protective equipment
2. Assure an open airway and adequate breathing
a. Provide oxygen
 3. Treat for shock (hypoperfusion)
a. If blood loss is suspected, provide EMC based on the mechanism of
injury and the patient’s signs and symptoms
4. Splint suspected fractures (painful, swollen, deformed extremities)
a. Prevent closed injury assoc. with possible bone fracture from
becoming an open injury
b. Reduce bleeding
c. Relieve pain by immobilizing the affected extremity
d. Elevate extremity, if possible

OPEN SOFT TISSUE INJURY

When the continuity of the skin is broken. Patient is at risk for external bleeding and
contamination with dirt and bacteria, which may lead to infection. It is also the first
indicator of a deeper, mores serious injury, such as fracture or ruptured or lacerated
organ.

1. Abrasion
- caused by scraping, rubbing or shearing away of the epidermis, the
outermost layer of the skin
- a superficial injury, but extremely painful because of presence of
exposed nerve endings
- blood will ooze from the wound (capillary bleeding), which can be
controlled easily with direct pressure

2. Lacerations
- a break in the skin of varying depth
- may be linear (regular) or stellate (irregular)
- may bleed more than the other type of open soft tissue injuries,
especially when an artery is involved
• Linear lacerations: caused by knife, razor or broken glass.
Used to heal better than stellate injuries because the wound
has smooth edges
• Stellate lacerations: commonly caused by blunt object. The
edges of the wound will be jagged and healing may
prolonged

4. Avulsion
- loose flap of the skin and underlying soft tissue that has been torn
loose (partial avulsion) or pulled completely off (total or complete
avulsion)
- bleeding may be severe due to blood vessel injury, although some
blood vessels may tamponade (compress) themselves by retracting into
the soft tissue
- healing will be prolonged and scarring may be extensive
- it is the most common result in accidents with industrial or home
machinery and motor vehicles

5. Amputations
- disruption in the continuity of an extremity or other body part
 - result of ripping or tearing forces often associated with industrial,
agricultural, power tool or motor vehicle accidents
- bleeding is massive
- in most cases due to the elasticity of the blood vessels, very little
bleeding occurs
- an incomplete amputation typically bleeds more than the complete
amputation
- always consider shock

6. Penetrations/Puncture
- result of sharp, pointed object being pushed or driven into the soft
tissues
- the entry wound may appears very small and cause little bleeding
- such injuries may be deep, damaging and can cause severe internal
bleeding. The overall severity of the injury depends on the location, the
size of penetrating object, the depth of the penetration, the forces
involved and the structures of the path involved

7. Crush injuries
- result of blunt trauma or crushing forces
- they may not appear serious
- The only external sign may be an injury site that is painful, swollen
and deformed.
- External bleeding may be minimal or absent
- Expect that may be internal injury and severe internal bleeding in the
presence of crush injuries

SIGNS AND SYMPTOMS

• A break in the skin and external bleeding
• Localized swelling, pain and discoloration at the injury site
• Possible signs and symptoms of internal bleeding and shock
(hypoperfusion)

EMERGENCY MEDICAL CARE

1. Take standard precautions
2. Assure an open airway and adequate breathing
3. Expose the wound
a. To assess the injury site
b. Cut away the clothing
c. If necessary, clear the area of blood and debris with sterile gauze,
dressings or the cleanest material available
4. Control the bleeding with direct pressure
a. Use a pressure point, if not controlled with direct pressure and
elevation
b. Use tourniquet only as a last resort
5. Prevent further contamination
a. Keep the wound clean as possible
b. If there are loose particles of foreign material around the wound, wipe
it away with a sterile gauze or other clean material
c. Always wipe away the wound, never toward it
 d. Never pick out embedded particles
6. Dress and bandage the wound
a. Apply sterile dressing
b. Secure with bandage
c. Check distal pulses both before and after applying the bandage to be
sure it is not too tight
7. Keep the patient calm and quiet
a. Early sign of shock (hypoperfusion): restlessness and anxiety
8. Treat for shock (hypoperfusion)
9. Transport

SPECIAL CONSIDERATIONS
Chest injuries
May prevent adequate respiration by causing the lung to collapse
A. Use an occlusive dressing to prevent air from entering the chest cavity through
the wound (also known as open pneumothorax)
B. If there is no suspected spinal injury, the patient may assume a position of
comfort or any position that allows for easiest chest expansion

Abdominal injuries
May result in evisceration (internal abdominal organs protrude through the wound)
A. Do not touch the abdominal organs or to try to replace the exposed organs
B. Cover the exposed organs
a. Sterile dressing moistened with sterile water
b. Then secure it with occlusive tape (4 sides)
c. Flex the patient’s hips and knees, if they are uninjured and if spinal
injury is not suspected

Impaled objects
An object still embedded in a wound, it should never be removed in the field, unless it
is through the cheek or the neck where it is obstructing air flow through the trachea
A. Manually secure the object
B. Expose the wound area
C. Control bleeding
D. Use a bulky dressing to help stabilize the object

Amputations
It must care for the amputated part, as well as for the patient and the injury site
A. Remove any gross contamination by flushing the part with sterile water or
saline
B. Wrap the part in a dry sterile gauze dressing
C. Wrap or bag the amputated part in plastic
D. Keep the amputated part cool
E. Transport the part with the patient, if at all possible

Large Open-Neck injuries

In addition to severe bleeding from a wound involving the major blood vessels of the
neck, there is the danger of air being sucked into a neck vein and carried to the heart
Major goals is bleeding control and prevention of an air embolism.
 A. Placed a gloved hand over the wound to control bleeding
B. Apply an occlusive dressing
C. Cover the occlusive dressing with a regular dressing
D. Apply only enough pressure to control the bleeding
E. Once bleeding is controlled, apply a pressure dressing
F. If there is a suspected spinal injury, provide appropriate immobilization

Management

Immediately after the injury occurs one should apply the PRICE principle to minimize
the local tissue damage and reduce inflammation.

’P’rotection ’R’est ’I’ce ’C’ompression ‘E’levation

’PROTECTION’ Protect the individual from further injury by preventing them from
moving and keep further hazards away from the individual (Flegel, 2004).

‘REST’ Rest the individual from any activity that causes pain. If simple movements
such as bending, straightening or walking are causing pain ‘’rest’’ means
immobilizing the injury by splinting or preventing weight bearing with crutches
(Flegel, 2004). If walking does not cause any pain, continue to walk for short
distances as comfort allows (Lindsay, Watson, Hickmott, Broadfoot & Bruynel,
1994).

’ICE’ During the first 72 hours following an injury ice can help minimize pain and
control swelling caused by bleeding and fluid loss from the injured tissue (Flegel,
2004). Icing is recommended for 15minutes every 4 hours to help control the swelling
and pain (Subotnick, 1991).

‘COMPRESSION’ Compression is the application of pressure over the injured area

with the use of a bandage, elastic wrap or compression tape (Lindsay et al., 1994).
This is to control the initial bleeding of joint or limb tissues, or to reduce residual
swelling (Flegel, 2004). It is vital that compression is applied within the first few
minutes following the injury to see the benefits (Lindsay et al., 1994).

‘ELEVATION’ Used in combination with ice and compression, elevation can also
minimize initial tissue bleeding and swelling. Elevate the injured part above the level
of the heart as much as possible for the first 72hours, or longer of the swelling
persists. (Flegel, 2004).

HEAD INJURY
This involves the scalp, skull, brain or combination of these

TYPES OF HEAD INJURIES

1. Scalp Injuries
 - May be injured in the same way as any other soft tissue; it may be
contused, lacerated, abraded or avulsed
- Tend to bleed heavily because of rich in supply blood vessels
- The underlying fascia may be torn while the skin stays intact
- Bleeding occurs under the skin and may be confusing at first as you try
to assess the patient
2. Skull Injuries
- it is deformed only if trauma is extreme
- it can be open (a break in the continuity in the skin and bone) or closed
(with the scalp intact)
- the deformity does not cause disability or death; rather, it is the
underlying damage to the brain that leads to serious consequences
- the deformity presents no danger if it is not accompanied by brain
injury, hematoma, cerebrospinal fluid leakage or subsequent infection
3. Brain Injuries
- injury can cause swelling of brain tissue or bleeding within the skull.
Both can cause increased pressure in the skull
- it may be direct (from penetrating trauma), indirect (from a blow to the
skull), or secondary (example, from a lack of oxygen, build-up of
carbon dioxide, or change in BP)
- Closed head injury: scalp is lacerated but the skull remains intact and
there will be no opening to the brain
- Open head injury: a break in the skull, such as that caused by impact
with a windshield or by an impaled object. It involves direct local
damage to the involved tissue, but it can be a result in brain damage
due to infection, laceration of the brain tissue or punctures of the brain
by objects that invade the cranium after penetrating the skull

SIGNS & SYMPTOMS:

1. Altered metal status – disorientation to unresponsiveness
2. Decreasing mental status
3. Irregular breathing pattern (severe)
4. Increasing BP and decreasing pulse
5. Obvious signs of injury (contusions, lacerations, or hematomas to the scalp or
deformity of the scalp
6. Visible damage to the skull
7. Pain, tenderness, or swelling of the site
8. Discoloration around the eyes in the absence of trauma (raccoon sign – very
late)
9. Discoloration behind the ears, the mastoid process (Battle’s sign – very late)
10. Nausea or vomiting
11. Diplopia – double vision
12. Possible seizures
13. Amnesia (Retrograde & Anterograde)

EMERGENCY MEDICAL CARE

1. Take standard precautions
2. Take manual in-line spinal stabilization
3. maintain a patent airway, adequate breathing and oxygenation
4. Monitor airway, breathing, pulse and mental status for deterioration
 5. Control bleeding
6. Be prepared to provide emergency care for seizures
7. Transport immediately

CONCUSSION
- normally causes some disturbance in brain function ranging from
momentary confusion to complete loss of responsiveness and it usually
causes headache
- mild diffuse axonal injury where there is stretching, tearing and
shearing of brain tissue
- present altered mental status that progressively improves then
worsened or it deteriorates from when you arrived on the scene

SIGNS
1. Momentary confusion
2. Confusion lasts for several minutes
3. Inability to recall the incident and sometimes, the period just before it and
after it
4. Irrritability
5. Nausea and vomiting
6. restlessness

CONTUSION
- bruising and swelling of the brain tissue, can accompany concussion
- causes bleeding into the surrounding tissues and may or may not
caused increased ICP, often causes open injury
- coup-contrecoup injury, damage at the point of a blow to the head
and/or damage on the side opposite the blow as the brain is propelled
against the opposite side of the skull
- acceleration/deceleration injury, typical car crash, head comes to a
sudden stop but the brain continues to move back and forth inside the
skull, resulting in bruising to the brain

SIGNS AND SYMPTOMS

1. Decreasing mental status
2. Paralysis
3. Unequal pupils
4. Vomiting
5. Alteration of VS
6. Profound personality changes

SUBDURAL HEMATOMA
- collection of blood between the dura mater and the archnoid layer of
the brain
- due to low pressure venous bleeding that results from small bridging
veins that are torn during the impact to the head
- bleeding occurs above the brain
- commonly associated with cerebral contusion

Three types:
 a. acute – signs and symptoms begin almost immediately after the injury
b. subacute – signs and symptoms begin 3-7 days after the injury
c. chronic - signs and symptoms after the injury

SIGNS AND SYMPTOMS

1. weakness or paralysis
2. deterioration in level of responsiveness
3. vomiting
4. dilation of one pupil
5. abnormal respirations or apnea
6. headache
7. seizures
8. confusion

EPIDURAL HEMATOMA
- an extreme emergency
- Occurs from low velocity impact to the head or from deceleration
injury. It is always associated with a skull fracture
- arterial or venous bleeding pools between the skull and the dura
- Bleeding is rapid, profuse and severe. It expands rapidly in a small
space, causing dramatic rise in ICP

SIGNS AND SYMPTOMS

1. loss of responsiveness
2. decreasing mental status
3. severe headache
4. seizures
5. increasing SBP and decreasing HR
6. Apnea

LACERATION
- occurs when an object penetrates the skull and lacerates the braing
- a permanent injury, results to bleeding and can cause massive
disruption of the nervous system

SPINE INJURY
- commonly are automobile crashes

a. Compression – when the weight of the body is driven against the head.
Common in falls, diving accidents, motor vehicle crashes or other accidents
where a person impacts an object head first
b. Flexion – when there is severe forward movement of the head in which the
chin meets on the chest or when the torso is excessively curled forward
c. Extension – when there is severe backward movement of the head in which
the neck is stretched, or when the torso is severely arched backward
d. Rotation – when there is lateral movement of the head or spine beyond its
normal position
e. Lateral Bending – when the body is bent severely from the side
f. Distraction – when the vertebrae and spinal cord are stretched and pulled apart
 g. Penetration – when there is injury from gun shots, stabbings, or other types of
penetrating trauma that involve the cranium or spinal column

SIGNS AND SYMPTOMS

1. tenderness in the area of injury
2. pain associated with movement from spine injury may be localized
3. pain independent of movement or palpation along the spinal column or in the
lower legs
4. obvious deformity of the spine upon palpation
5. soft tissue injuries from trauma to the head and necj are associated with
cervical spine injury
6. numbeness, weakness, tingling, or loss of sensation
7. loss of bowel or bladder control
8. priapism
9. impaired breathing

EMERGENCY MEDICAL CARE

1. take necessary standard precaution
2. establish manual in-line spinal stabilization immediately upon making contact
with the patient
3. when performing the initial assessment, open and maintain the airway with the
jaw-thrust maneuver
4. assess pulse, motor function, and sensation in all extremities
5. assess cervical region and neck before applying the cervical spine
immobilization collar
6. apply a cervical spine immbilization

EYE, FACE AND NECK INJURIES

Eye Injuries
A. Foreign Object in the eye
B. Injury to the orbits
a. Diplopia
b. Decreased in vision
c. Loss of sensation above the eyebrow, over the cheek or in the upper lip
d. Tenderness upon palpation
e. Paralysis of upward gaze in the involved eye
C. Chemical Burn to the eye
a. Irritated
b. Redness of the eye
c. Red streak across the surface of the eye
d. Blurred or diminished vision
e. Burned skin around the eye
D. Impaled object in the eye or extruded eye ball

Face Injuries
A. Injury to the mid-face, Upper jaw, or lower jaw
a. Resulted from blunt instrument, blow of a fist, an automobile accident,
or gun shot
i. Numbness or pain
 ii. Distortion of facial features
iii. Irregularities in the facial bones that can be felt before swelling
occurs
iv. Severe bruising and swelling
v. Limited jaw motion
vi. Teeth not meeting normally
vii. Hematoma
viii. Pain around the ears
ix. Mouth open or unable to open mouth

B. Object impaled in the cheek

C. Injury to the nose
D. Injury to the ear

Neck Injuries
SIGNS AND SYMPTOMS
a. Obvious swelling
b. Difficulty speaking
c. Loss of voice
d. Airway obstruction
e. Displacement of the trachea to one side

CHEST INJURIES
Closed: result of blunt trauma applied to the chest cavity, which can cause extensive
damage to the ribs and internal organs

Open: result of penetrating chest wound caused by a knife, gun shot or a wide variety
of other objects such as ice picks, screw drivers, letter openers, nails and car keys

SIGNS AND SYMPTOMS

1. cyanosis of fingernails or fingertips
2. dyspnea
3. breathing rate faster or slower
4. contusions, lacerations, punctures, swelling
5. hemoptysis
6. tracheal deviation
7. paradoxical movement of a segment of the chect wall
8. subcutaneous emphysema
9. distented jugular veins
10. absent or decreased breath sounds
11. failure of chest to expand normally during inhalation

ABDOMINAL INJURIES
Similar to those of the chest injury

SIGNS AND SYMPTOMS

1. Contusions, abrasions, lacerations, punctures
2. tenderness on palpation
3. rigid abdominal muscles
4. patient lies with his legs
 5. distended abdomen
6. discoloration around the umbilicus or the flank (late)
7. nausea or vomiting
8. abdominal cramping
9. pain may radiate to either shoulder due to irritation of the diaphragm
10. weakness

EMERGENCY MEDICAL CARE

1. Maintain an open airway and appropriate spinal protection
2. continue oxygen therapy
3. reassess the breathing status
4. treat for shock (hypoperfusion)
5. control any external bleeding
6. position the patient

Abdominal Evisceration: EMC

1. Expose the wound
2. position the patient
3. prepare a clean, sterile dressing
4. cover the moist dressing with an occlusive dressing
5. administer high-flow oxygen

RIB INJURIES
Conditions that may result to a rib injury:
A. Flail segment
- two or more consecutive ribs have been fractured in two or more
places, producing a freely moving section of the chest wall
B. Pulmonary Contusion
- serious consequence of a flail segment
- it can lead to death
- bleeding occurs in and around the alveoli and into the interstitial space
that separates the alveoli and capillaries
- reduces the exchange of oxygen and carbon dioxide, leading to
hypoxia
C. Pneumothorax
- accumulation of air in the pleural cavity, causing collapse of a portion
of the lung
- either blunt or penetrating
D. Open Pneumothorax
- result from an open wound to the chest created by a penetrating object
- air may be heard escaping or entering through the chest wound,
creating a bubbling or sucking sound
E. Tension Pneumothorax
- life-threatening resulting from a pneumothorax that continues to trap
air in the thoracic cavity with no relief or escape
F. Hemothorax
- thoracicn cavity filled with blood rather than air
G. Traumatic Asphyxia
- severe and sudden compression of the thorax causes a rapid increase
pressure in the chest
H. Cardiac Contusion
- common cardiac injury following severe blunt trauma to the chest
I. Pericardial Tamponade
- blunt or penetrating trauma may cause bleeding into the tough sac that
surrounds the heart
J. Rib Injury
- not life-threatening, it can inly be life threatening damage to other
structures and organs