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Scenario
You are caring for a woman who
punched out a second-story window
and jumped into some bushes to
escape a fire. She has a laceration on
her hand, with fatty tissue exposed
that is bleeding briskly. Her face is
badly scraped and is oozing red fluid.
A branch punctured her leg and is
protruding through the other side.
She is developing a “goose-egg”
Discussion
Which skin layers have been injured?
Homeostasis Formation of a
Vasoconstriction platelet plug
Slows blood flow 1. Platelets adhere
May last as long as 10 to collagen
minutes 2. Swell, become
sticky
3. Secrete
chemicals that
attract other
platelets
Pathophysiology of Wound
Healing
Homeostasis
Coagulation
Occurs within
minutes
After 30 minutes,
clot retracts and
vessel is sealed
Cascade Event
Prothrombin
activator
Prothrombin →
Thrombin
Fibrinogen → Fibrin
Threads capture
platelets, blood
Pathophysiology of Wound
Healing
Homeostasis
Fibrous tissue
development
As wound is
repaired, replaces
damaged tissue with
new connective
tissue
Fibroblasts –
Collagen synthesis
Scar tissue
formation
Pathophysiology of Wound
Healing
Homeostasis
Other points
Disruption of clotting
Genetic diseases
Medications
Generally protective
Sometimes life-
threatening
AMI
Stroke
Pathophysiology of Wound
Healing
Inflammation –
Prepares wound for
healing and clears it of
foreign and dead
tissue
Capillary dilation
Heat/redness
Capillary permeability
Swelling/pain/tenderne
ss
Accumulate for up to
72 hours
Attraction of leukocytes
Pus
Systemic response (?)
Pathophysiology of Wound
Healing
Epithelialization and
Neovascularization
Neovascularization
New vessel formation
Epithelialization
Re-establishes the skin layers
Pathophysiology of Wound
Healing
Collagen synthesis
Structural protein of
most body tissue
Deposited at injury
site within 48 hours
after wound
Alteration of Wound
Healing
Interference of
healing or delays
Medical conditions
Advanced age,
alcoholism, uremia,
diabetes, hypoxia,
peripheral vascular
disease,
malnutrition,
advanced cancer,
hepatic failure, and
C.V. disease
Medications
Corticosteroids,
NSAIDS, PCN and
Alteration of Wound
Healing
High Risk Wounds
Potential for
infection
Location
Wound cause or
force
Immuno-
compromised
patients
Lots of dead tissue
Alteration of Wound
Healing
Abnormal Scar Formation
Keloid – Scar tissue outside the original
wound
Hypertrophic – Excessive scar tissue
within the original wound
Tension lines
Amount of tension on the skin
Vary from body part to body part
Knee wound vs. forearm wound
Alteration of Wound
Healing
Keloid scar tissue
Alteration of Wound
Healing
Hypertrophic scar
tissue
Types of Open Soft Tissue
Injuries
Abrasions Impaled objects
Lacerations Amputation
Major arterial Incisions
lacerations Penetrations/punct
Avulsions ures
Types of Open Soft Tissue
Injuries
Abrasions
Partial thickness
skin injury
Caused by scraping
or rubbing
Painful
High for infection
Types of Open Soft Tissue
Injuries
Laceration
A tear, split, or
incision
Can be caused by a
knife or other sharp
object
Vary in depth
Can have significant
blood loss
Types of Open Soft Tissue
Injuries
Major arterial lacerations
Lacerations involving larger arteries
Extensive bleeding possible
Continued bleeding?
Second pressure dressing on top of first
Hemorrhage Control
Techniques
Elevation
Elevate injury site above the heart, as
possible
A supplement to direct pressure
Hemorrhage Control
Techniques
Pressure Point
Used when direct
pressure and
elevation does not
get the job done
Compression of an
artery (over a bone)
proximal to the
injury site
Pressure should be
maintained for
about 10 minutes
Hemorrhage Control
Techniques
Tourniquet
application
Has little or no
indication in the
emergency
management of
hemorrhage
Associated with
nerve, vessel, and
eventual limb loss
Last resort only
Hemorrhage Control
Techniques
Tourniquet application
Guidelines:
Select site – Need a 2 inch wide site
Place tourniquet over artery to be
compressed, use wide material (BP cuff?)
Place pad over artery to be compressed
If using a bandage, encircle extremity twice
(pad), tie knot over pad
Tie a windlass with a square knot
Tighten windlass until bleeding stops.
Secure it
Document tourniquet – Mark forehead –
Never loosen
Hemorrhage Control
Techniques
Splinting/Pneumatic Pressure Devices
Uniform direct pressure
Over a dressed would only after
bleeding is controlled
Types of Bandages and
Dressings
Bandage – Any material used to
secure a dressing
Dressing – A sterile or non-sterile
cover that aids in hemorrhage
control and prevents further damage
or contamination.
Types of Bandages and
Dressings
Sterile
Non-sterile
Occlusive
Non-occlusive
Adherent Non-
adherent
Complications of
Improperly Applied
Dressings and Bandages
Discomfort
Too loose - Do not control bleeding
Too tight – Can cause ischemia,
structural damage to vessels, nerves,
tendons, muscles, and skin
Unclean - Infection
Wound Infection
Common complication of soft tissue injury
Can cause systemic infection sepsis
Causes:
Time (Should be cleaned and repaired within 8-
12 hours)
Mechanism (GSW, knife, crush injury)
Location (foot, hand, perineum)
Severity (More tissue damage = more
infection)
Contamination (Soil, saliva, and/or feces)
Preparation (Cleanliness)
Cleansing (Normal saline and high-pressure
syringe)
Technique of repair (Some need to be left
open, other closed)
Wound Infection
S/S of infection
Pain, swelling, and
redness at the site
Purulent discharge
(yellow or green)
Foul odor
Red streaks from
wound – directed
towards the heart
Fever, chills, sweats
Related Protocols
Amputation
Pain management
PAIN MANAGEMENT
PROTOCOL
PAIN MANAGEMENT
PROTOCOL
Pain Management Basic Level
Assess and support ABCs. Offer
Inclusion Criteria: This comfort and reassurance.
guideline applies to Patient positioning:
patients suffering from Initiate patient positioning and spinal
severe pain or discomfort, movement restrictions, as needed.
If no spinal injury suspected, place
including isolated the patient in a position of comfort.
extremity injuries, If evidence of shock, place the patient
supine with the feet elevated and
musculoskeletal or soft monitor airway closely. Treat shock
according to the Shock Guidelines.
Guidelines.
tissue injuries, flank pain Administer oxygen, as needed to
due to suspected kidney maintain an SpO2 of at least 96%.
stone, sickle cell crisis, Splint injured extremities and apply
labor, and other causes. cold packs.
Once advanced level care arrives on
scene, give report and transfer
care.
Advanced Level
6. If the patient can cooperate, have
the patient self-administer
nitrous oxide.
PAIN MANAGEMENT
PROTOCOL
Amputation