EMT-Basic Exam: The Basics of Trauma - Soft Tissue Damage

EMT-Basics may encounter a variety of soft tissue injuries in the field. Soft tissue injuries can include open and closed injuries and burns. In most cases, these injuries look worse than they actually are and necessitate only minor emergency care.

1. The Skin
In order to properly recognize and treat soft tissue damage, you must have a sound understanding of the skin. The largest organ in the human body, the skin covers the entire surface area of the body and acts as a protective barrier. The skin guards the body against the environment, viruses, bacteria, and other potentially harmful organisms. The skin also acts as the body’s insulation, regulating body temperature by opening and closing pores and releasing or retaining heat. Nerves in the skin allow us to feel heat, cold, touch, pressure, and pain.

The skin has three layers:
- The epidermis, which is the skin’s outermost layer, is a very thin layer of dead skin cells and pores. The majority of superficial injuries occur here. In most cases, epidermal injuries will not result in pain or bleeding.
- The next layer is the dermis, which consists of sweat and subcutaneous glands, hair follicles, small blood vessels, and nerve endings. Injuries to the dermis often result in pain and bleeding.
- The deepest layer of skin is the subcutaneous layer. Subcutaneous skin injuries can cause significant pain and bleeding. Severe subcutaneous skin injuries may include exposure of bones, muscles, or other tissues.

A section of skin with various accessory organs.

2. Closed Injuries
Patients with closed soft tissue injuries will present with fully intact skin and no external bleeding. Because there are no open wounds with these injuries, EMT-Basics do not have to clean or cover the site of the injury.
There are three basic types of closed soft tissue injuries:
- Contusions, also known as bruises, are closed injuries characterized by damaged skin cells and torn blood vessels in the dermis. The site of the injury will become discolored due to internal blood accumulation. Contusions are sometimes accompanied by swelling or pain.
- Hematomas are a more severe form of contusions. Hematomas occur with injuries to larger blood vessels. These injuries lead to a much greater accumulation of blood under the skin. Particularly large hematomas may lead to hypoperfusion, so it is important to assess the patient for symptoms of the early onset of shock.
- Closed crush injuries result from force applied to an area of the body with a blunt instrument. Closed crush injuries in the vicinity of an organ may be an indication of damage to that organ and internal bleeding as a result.

3. Open Injuries
Open soft tissue injuries involve breakage of the skin and, in most cases, external bleeding. Open wounds are at risk of infection and should be cleaned and covered with sterile dressings.
Abrasions are simple scrapes that damage only the epidermis. Pain, oozing blood, and redness are common symptoms of abrasions.
Lacerations are cuts or breaks in the skin of various depths. Lacerations can be linear (regular) or stellate (irregular) and sometimes occur in connection with other soft tissue injuries. In most cases, lacerations are caused by a forceful impact with sharp objects, like knives or shards of broken glass. Severe bleeding may be present based on the location of the wound.
A patient suffers an avulsion when a section of skin or soft tissue is torn partially or fully off the body. These types of injuries can be found anywhere on the body.
Penetration or puncture wounds occur when an object, most commonly a knife or a bullet, is forced into the body. The object may still be in the wound, or it may have exited the body at another area.
An amputation occurs when a limb or appendage is completely severed from the body. Amputations may be accompanied by massive bleeding.
In some cases, crush injuries can cause open soft tissue injuries, along with internal organ damage. Most open crush injuries result in pain, swelling, and deformity. The severity of blood loss may vary in these cases.

4. Treatment of Open and Closed Soft Tissue Injuries
As with most medical emergencies, the first objective in treating a patient with an open or closed soft tissue injury is to ensure a patent airway. Check for spinal injuries and immobilize, if necessary. Because severe bleeding may occur with open injuries, you should carefully monitor the patient for signs of shock and treat accordingly. When attempting to control bleeding, the wound should be exposed and covered with dry sterile dressings.
If the patient is deemed stable and no life threats are found, you should splint any injured extremities before transport. Patients in shock should be transported immediately and splinted en route.
Some wounds require special treatment. For example, penetrating chest wounds require sealed occlusive dressings that don’t allow air to enter or exit the wound. In the event of a sucking chest wound (an injury in which an object penetrates the skin and lung cavity), the dressing should only be sealed on three sides. This allows air to exit but not re-enter the wound.
In some cases, an abdominal injury will result in part of an organ protruding from the skin. This is known as an evisceration. The exposed organ should be covered with a sterile dressing that has been moistened with water or saline. An occlusive dressing should then be applied to prevent the wound from drying.
When you find a patient with a foreign object still in a wound, you should not, in most cases, attempt to remove it. Generally, the only situations in which you should attempt removal are when the object interferes with the airway or your ability to administer chest compressions.
In the event of an amputation, it is important to attend to the severed appendage. If the amputated part is salvageable, wrap it in plastic and keep it cool.

Tip: Never place an amputated body part directly on ice, as this will damage the tissue.
Another injury that requires special consideration is an open neck injury. Open neck injuries should be covered with a sterile occlusive dressing. The carotid artery should not be compressed unless required for control of bleeding, and only one side should be compressed at a time.
When you encounter soft tissue injuries of the face or head, it is important to check for skull or spinal injuries before proceeding with treatment. If there are no skull fractures, dressings and bandages should be applied with direct pressure. If a skull fracture is present, don’t apply direct pressure.
Eye injuries may require flushing. If the patient has an object embedded in the eye, don’t attempt to remove it. Stabilize the object and cover both eyes in order to minimize eye movement as you transport the patient.
Oral injuries may result in airway obstructions due to blood or broken teeth. Secure the airway and use dressings to control bleeding before transport.

5. Burns
Burns are very painful injuries that can cause permanent disfigurement or disability. While burns themselves may not be fatal, the damage they may cause to the airway, respiratory system, and circulatory system can be extremely dangerous. Because burns can result in severe damage to the protective layers of skin, they can also lead to fluid loss, hypothermia, and infection.
The classification of burns is based on the depth of the injury. Burn severity is measured by the depth and location of the burn, the percentage of the body that is burned, pre-existing conditions, and age.
 

There are three burn classifications:
- Superficial burns affect only the epidermis and result in redness and minor pain. The most common form of superficial burn is sunburn.
- Partial-thickness burns affect both the epidermis and the dermis and are characterized by severe pain and blistering. You may also find moist or mottled skin that ranges from white to red in color.
- Full-thickness burns affect the epidermis, dermis, and the underlying tissues. These burns may be deep enough to involve bones or organs, as well. Full-thickness burns will produce dry, leathery skin that feels hard to the touch and may appear white, dark brown, or charred. Pain may be isolated to the edges of the burn because of nerve damage.

The “rule of nines” is the common method used to determine the percentage of body area that has been burned. In adults, the front and back of the head and neck make up 9 percent of the body, the front and back of each arm is 9 percent, each side of the trunk is 18 percent, the front and back of each leg is 18 percent, and the genitalia represent 1 percent. Total percentage can be determined by adding each burned area. These percentages are different in children and infants.

The rule of nines in diagnosing burns.

Critical burns are those affecting the face, hands, feet, or genitalia or those involving respiratory injuries or illness. Full-thickness burns covering more than 10 percent of the body or partial-thickness burns covering more than 30 percent of the body are also considered critical. Burns to a painful, swollen, or deformed extremity or those that encircle an extremity are also critical. Some burns that would be considered moderate in an adult may be critical in children or infants. Ensuring a clear airway and initiating immediate transport to the nearest burn center are the most important early treatments for critical burns.
Moderate burns occur away from critical areas. Moderate full-thickness burns may cover between 2 and 10 percent of the body. Moderate partial-thickness burns may cover up to 30 percent of the body. In turn, moderate superficial burns, such as sunburns, may cover up to 50 percent of the body.
Minor full-thickness burns may cover less than 2 percent of the body and minor partial-thickness burns may cover less than 15 percent of the body.
When treating a burn victim, you should be sure that the patient is kept warm, as burned skin may be unable to properly control body temperature. Because children and infants have a greater surface area in relation to their total body size, they may be particularly susceptible to increased loss of heat and fluids, shock, airway difficulties, and hypothermia.
Never attempt to treat a burn with cold water or ice. Small burns may be cooled with cool water. Larger burns should not be cooled due to the risk of hypothermia.
Certain types of burns require special attention. Airway burns are often the result of inhaling superheated air or chemicals related to combustion. Airway burns may result in swelling, which leads to respiratory difficulty. Patients with airway burns may decline rapidly, requiring advanced airway maneuvers. Indications of airway burns may include facial burns, singed facial hair, burns around the mouth or nose, oral burns or swelling, and a hoarse voice. These types of injuries are most common in patients who have recently been inside a burning building.
Chemical burns may require the use of special protective equipment. Most chemical burns should be cleaned and flushed with water. Dry powder chemicals should be carefully brushed away from the affected area. Exact treatment protocol will depend on the chemical involved.

Tip: When treating a chemical burn, remember to take the necessary body substance isolation (BSI) precautions to protect yourself before treating the patient.
Before treating the victim of an electrical burn, be sure that the patient has been removed from the source. Once the scene is safe, carefully and continually check for signs of respiratory or cardiac arrest. Look for entrance and exit wounds. Injuries resulting from electrical burns may be more severe than they appear, so you should be aware of the possibility of internal damage and cardiac injury. It is also important to look for early signs of shock in these patients.

Related Topics You Should Review:
- Dermatology
- Dressings and bandages
- Shock