Primary Assessment Study Guide for the EMT Test

Chief Complaint and Life Threats: Part 3

Soft Tissue Injuries

It is important to be able to identify and care for patients with soft tissue injuries. The functions, disease, assessment, and management of this type of injury require a comprehensive understanding of the soft tissue anatomy and the procedures used to treat damage to these tissues.

Skin Anatomy and Physiology

Skin is considered an organ. It is, in fact, the largest organ of the body. One can only imagine the potential impact of trauma and/or injury to this organ. The EMT must know details about the skin’s makeup, function, types of skin and soft tissue injuries, and how to identify and manage these injuries.

Here are some terms to know:

epidermis—outermost layer of the skin; provides a protective barrier
dermis—middle layer of skin; located beneath the epidermis
mucous membranes—moist linings of body cavities that open to the outside (mouth, nose, eyes, genitals)
the three types of soft tissue injury—The three types of soft tissue injury include abrasions, lacerations, and avulsions. Abrasions are scrapes or the rubbing away of the top layer of skin (epidermis). Lacerations are cuts or tears in the skin or underlying tissue. Avulsions are portions of skin or tissue that are torn away or pulled completely off.
contusion—bruise caused by blunt trauma that damages small blood vessels without breaking the skin
ecchymosis—bruising
hematoma—localized collection of blood outside of blood vessels
crushing injury—occurs when a body part is subjected to a high degree of pressure, usually from being trapped between two objects
crush syndrome—a life-threatening condition that can occur after a severe crushing injury when damaged muscles release toxins
compartment syndrome—occurs when pressure builds up within a closed muscle compartment, reducing blood flow and potentially causing permanent damage
contamination abrasion—a scrape of the removed top layer of skin that has become exposed to dirt, debris, or bacteria
laceration—cut or tear in the skin and underlying tissue
incision—clean, straight cut in the skin, usually by a sharp object
avulsion—portion of skin or tissue that has been torn loose or completely pulled away
fascia—tough, fibrous layer of connective tissue that surrounds muscles, blood vessels, and nerves; helps support and separate them
amputation—partial or complete removal of a limb, either by trauma or surgery
penetrating wound—when an object pierces the skin and enters underlying tissues
impaled objects—any object that has pierced a patient’s body and remains stuck in the body

Pathophysiology

The skin has several functions. The main functions include temperature regulation, nerve pathway, and shielding to maintain fluids inside the body and keep bacteria out. Understanding these functions will help during the treatment of skin injuries.

Open and Closed Injuries

These injuries are two of the three types of soft tissue injuries, the third being burns. A competent EMS (Emergency Medical Services) worker is well-versed in the identification of this type of injury and knows the importance of assessment and appropriate management. Knowing how to handle these emergencies will help prevent common complications related to shock, infections, and bleeding.

Critical points to consider involve the difference in presentation of the closed versus open injury. Open wounds are more obvious and can be difficult to triage, as even a simple and small exposed surface area is at risk for bleeding and contamination. Paying attention to a closed wound with high acuity symptoms is critical for preventing hypovolemic shock and other critical complications.

Burns

Burns occur when there is exposure to heat, radiation, toxins, chemical substances, and/or electricity. Injuries of this type not only include burns, but also burn-related exposure injuries. Burns are classified according to the degree of severity.

Pathophysiology

The disease potential of a burn is multifaceted. Depending on the type and severity of the burn, there can be increased capillary permeability, which creates plasma leakage in and around tissue. This increases the risk of edema, impact to blood volume, and cardiac output concerns.

Complications

The impact from burns breaches the protective barrier between external exposures and the skin. Complications from this breach may include: pain, infection, dehydration, neurovascular compromise, compartment syndrome, body temperature irregularity, shock, and even airway issues.

Severity

The degree of severity includes five factors that help to guide assessment and emergency treatment regimens. Another consideration about the degree of severity relates to the trauma level of the hospital to which the patient will be transported.

Bleeding

Loss of blood, whether internal or external, can have a severe impact on bodily functions. External blood loss is more evident, but equal damage can be done when the bleeding is internal, which is more difficult to diagnose.

External Bleeding

It is critical to understand the characteristics and significance of external bleeding. In addition, knowledge of total blood volume and the body’s ability to handle acute and profuse blood loss is important.

Here are some terms and concepts to know:

hemorrhage—uncontrolled or excessive bleeding
hypovolemic shock—a life-threatening condition that occurs when the body loses a significant amount of blood or fluids
hemophilia—genetic disorder in which a person’s blood does not clot properly, leading to excessive bleeding
vasoconstriction—narrowing of blood vessels, reduces blood flow
coagulation—process by which blood forms a clot, helps to stop bleeding after an injury
the characteristics and significance of external bleeding—External bleeding occurs when blood is visible outside the body and is often caused by some type of injury. The amount and rate of external bleeding can vary depending on the type of blood vessels involved. Arterial bleeding results in bright red, spurting blood with each heartbeat. Venous bleeding results in dark, steady blood flow. Capillary bleeding is slow, oozing, and easily controlled. The significance of the type of bleeding is attributed to its level of severity. Uncontrolled bleeding can lead to hypovolemic shock and even death.

Internal Bleeding

Internal bleeding is just that: bleeding inside the body with no significant visible bleeding outside. This makes detection much more difficult. There are, however, physical signs and symptoms that are important to know for early detection and treatment. Understanding the nature of the illness, identifying signs and symptoms, and knowing the mechanism of injury (MOI) are key to providing appropriate care.

Here are some terms and concepts to know:

contusion—a bruise caused by blunt trauma; damages small blood vessels under the skin without breaking the skin
ecchymosis—bruising
hematuria—blood in the urine
hematemesis—vomiting blood
melena—black, tarry, foul-smelling stools, usually caused by gastrointestinal bleeding
signs and symptoms of internal bleeding in trauma and medical patients—Common signs and symptoms in trauma patients include pain at the injury site, swelling or distention, bruising over the injured area, signs of shock (cool, pale, clammy skin), rapid pulse, and low blood pressure. In medical patients, these signs include weakness, dizziness, fainting, abdominal pain/distension, blood in stool, urine, or vomit, and signs of shock without apparent external injury.