Soft Tissue Injury Soft Tissue Injury
Nov 14, 2014
Soft Tissue InjurySoft Tissue Injury
Scenario
You are caring for a woman who punched You are caring for a woman who punched out a second-story window and jumped out a second-story window and jumped into some bushes to escape a fire. She into some bushes to escape a fire. She has a laceration on her hand, with fatty has a laceration on her hand, with fatty tissue exposed that is bleeding briskly. tissue exposed that is bleeding briskly. Her face is badly scraped and is oozing Her face is badly scraped and is oozing red fluid. A branch punctured her leg red fluid. A branch punctured her leg and is protruding through the other and is protruding through the other side. She is developing a “goose-egg” side. She is developing a “goose-egg” bruise on her forehead.bruise on her forehead.
DiscussionDiscussion Which skin layers have been injured?Which skin layers have been injured?
How will you control the bleeding?How will you control the bleeding?
What risk factors for wound infection are What risk factors for wound infection are present?present?
How will you manage her injuries?How will you manage her injuries?
What type of dressing will you place on each What type of dressing will you place on each wound?wound?
Incidence/Morbidity/Incidence/Morbidity/MortalityMortality
40 million people 40 million people each year seek each year seek medical care for medical care for soft tissue traumasoft tissue trauma
Causes:Causes: FallsFalls Motor vehicle Motor vehicle
accidentsaccidents Blunt traumaBlunt trauma Penetrating traumaPenetrating trauma
Incidence/Morbidity/Incidence/Morbidity/MortalityMortality
Most soft tissue Most soft tissue trauma is not life-trauma is not life-threateningthreatening
73,000 died in 73,000 died in 20012001
Anatomy & Physiology of Anatomy & Physiology of the Skinthe Skin
Largest Organ – 16% Largest Organ – 16% of body weightof body weight
Layers:Layers: Epidermis, outer layerEpidermis, outer layer
WaterproofWaterproof Dermis, inner layerDermis, inner layer
Connective tissueConnective tissue
Elastic fibersElastic fibers
Blood vesselsBlood vessels
Lymph VesselsLymph Vessels
Motor & Sensory fibersMotor & Sensory fibers
Hair, nails, sebaceous Hair, nails, sebaceous and sweat glands and sweat glands
Anatomy & Physiology of Anatomy & Physiology of the Skinthe Skin
Role:Role: ProtectionProtection Temperature Temperature
maintenancemaintenance Storage of Storage of
nutrientsnutrients Sensory receptionSensory reception Excretion & Excretion &
secretion secretion
Pathophysiology of Wound Pathophysiology of Wound HealingHealing
HomeostasisHomeostasis VasoconstrictionVasoconstriction Formation of a clot Formation of a clot
plugplug CoagulationCoagulation Fibrous tissue Fibrous tissue
developmentdevelopment
Pathophysiology of Wound Pathophysiology of Wound HealingHealing
HomeostasisHomeostasisVasoconstrictionVasoconstriction
Slows blood flowSlows blood flow
May last as long as 10 May last as long as 10 minutesminutes
Formation of a Formation of a platelet plugplatelet plug1.1. Platelets adhere Platelets adhere
to collagento collagen
2.2. Swell, become Swell, become stickysticky
3.3. Secrete Secrete chemicals that chemicals that attract other attract other plateletsplatelets
Pathophysiology of Wound Pathophysiology of Wound HealingHealing
HomeostasisHomeostasis CoagulationCoagulation
Occurs within minutesOccurs within minutes After 30 minutes, clot After 30 minutes, clot
retracts and vessel is retracts and vessel is sealedsealed
Cascade EventCascade Event Prothrombin activatorProthrombin activator Prothrombin → Prothrombin →
ThrombinThrombin Fibrinogen → FibrinFibrinogen → Fibrin Threads capture Threads capture
platelets, blood cells, platelets, blood cells, and plasmaand plasma
Results in a blood Results in a blood clotclot
Pathophysiology of Wound Pathophysiology of Wound HealingHealing
HomeostasisHomeostasis Fibrous tissue Fibrous tissue
developmentdevelopment As wound is As wound is
repaired, replaces repaired, replaces damaged tissue with damaged tissue with new connective new connective tissuetissue
Fibroblasts – Fibroblasts – Collagen synthesisCollagen synthesis
Scar tissue Scar tissue formationformation
Pathophysiology of Wound Pathophysiology of Wound HealingHealing
HomeostasisHomeostasis Other pointsOther points
Disruption of Disruption of clottingclotting
Genetic diseasesGenetic diseases MedicationsMedications
Generally protectiveGenerally protective Sometimes life-Sometimes life-
threateningthreatening AMIAMI StrokeStroke
Pathophysiology of Wound Pathophysiology of Wound HealingHealing
Inflammation – Prepares Inflammation – Prepares wound for healing and wound for healing and clears it of foreign and clears it of foreign and dead tissuedead tissue Capillary dilationCapillary dilation
Heat/rednessHeat/redness Capillary permeabilityCapillary permeability
Swelling/pain/tendernessSwelling/pain/tenderness Accumulate for up to 72 Accumulate for up to 72
hourshours Attraction of leukocytesAttraction of leukocytes
PusPus Systemic response (?)Systemic response (?)
FeverFever
Pathophysiology of Wound Pathophysiology of Wound HealingHealing
Epithelialization and Epithelialization and NeovascularizationNeovascularization NeovascularizationNeovascularization
New vessel formationNew vessel formation EpithelializationEpithelialization
Re-establishes the skin layersRe-establishes the skin layers
Pathophysiology of Wound Pathophysiology of Wound HealingHealing
Collagen synthesisCollagen synthesis Structural protein Structural protein
of most body tissueof most body tissue Deposited at injury Deposited at injury
site within 48 hours site within 48 hours after woundafter wound
Alteration of Wound Alteration of Wound HealingHealing
Interference of Interference of healing or delayshealing or delays Medical conditionsMedical conditions
Advanced age, Advanced age, alcoholism, uremia, alcoholism, uremia, diabetes, hypoxia, diabetes, hypoxia, peripheral vascular peripheral vascular disease, malnutrition, disease, malnutrition, advanced cancer, advanced cancer, hepatic failure, and hepatic failure, and C.V. disease C.V. disease
Medications Medications Corticosteroids, Corticosteroids,
NSAIDS, PCN and more NSAIDS, PCN and more
Alteration of Wound Alteration of Wound HealingHealing
High Risk WoundsHigh Risk Wounds Potential for Potential for
infectioninfection LocationLocation Wound cause or Wound cause or
forceforce Immuno-Immuno-
compromised compromised patientspatients
Lots of dead tissue Lots of dead tissue
Alteration of Wound Alteration of Wound HealingHealing
Abnormal Scar FormationAbnormal Scar Formation Keloid – Scar tissue outside the original Keloid – Scar tissue outside the original
woundwound Hypertrophic – Excessive scar tissue Hypertrophic – Excessive scar tissue
within the original woundwithin the original wound Tension linesTension lines
Amount of tension on the skinAmount of tension on the skin Vary from body part to body partVary from body part to body part Knee wound vs. forearm woundKnee wound vs. forearm wound
Alteration of Wound Alteration of Wound HealingHealing
Keloid scar tissueKeloid scar tissue
Alteration of Wound Alteration of Wound HealingHealing
Hypertrophic scar Hypertrophic scar tissuetissue
Types of Open Soft Tissue Types of Open Soft Tissue InjuriesInjuries
AbrasionsAbrasions LacerationsLacerations Major arterial Major arterial
lacerationslacerations AvulsionsAvulsions
Impaled objectsImpaled objects AmputationAmputation IncisionsIncisions Penetrations/Penetrations/
puncturespunctures
Types of Open Soft Tissue Types of Open Soft Tissue InjuriesInjuries
AbrasionsAbrasions Partial thickness Partial thickness
skin injuryskin injury Caused by scraping Caused by scraping
or rubbingor rubbing PainfulPainful High for infectionHigh for infection
Types of Open Soft Tissue Types of Open Soft Tissue InjuriesInjuries
LacerationLaceration A tear, split, or A tear, split, or
incisionincision Can be caused by a Can be caused by a
knife or other sharp knife or other sharp objectobject
Vary in depthVary in depth Can have Can have
significant blood significant blood loss loss
Types of Open Soft Tissue Types of Open Soft Tissue InjuriesInjuries
Major arterial lacerationsMajor arterial lacerations Lacerations involving larger arteriesLacerations involving larger arteries Extensive bleeding possibleExtensive bleeding possible If closed, may develop a hematomaIf closed, may develop a hematoma
Types of Open Soft Tissue Types of Open Soft Tissue InjuriesInjuries
AvulsionsAvulsions Flap of skin is torn or Flap of skin is torn or
cut, not completely cut, not completely looseloose
Tissue may not be Tissue may not be viableviable
Examples:Examples: Ear lobe, nose tip, finger Ear lobe, nose tip, finger
tips, degloving, and scalp tips, degloving, and scalp woundswounds
Seriousness depends Seriousness depends on:on:
CirculationCirculation ContaminationContamination
Types of Open Soft Tissue Types of Open Soft Tissue InjuriesInjuries
Impaled objectImpaled object Instrument that Instrument that
causes injury causes injury remains imbedded remains imbedded in woundin wound
Knives, tree Knives, tree branches…branches…
Types of Open Soft Tissue Types of Open Soft Tissue InjuriesInjuries
AmputationAmputation Complete or partial Complete or partial
loss of a limb by a loss of a limb by a mechanical forcemechanical force
Digits, lower leg, Digits, lower leg, hand, forearm, and hand, forearm, and footfoot
Fatal bleeding may Fatal bleeding may resultresult
Partial amputation Partial amputation have more severe have more severe bleeding than a bleeding than a complete amputation complete amputation
Types of Open Soft Tissue Types of Open Soft Tissue InjuriesInjuries
IncisionsIncisions Similar to a Similar to a
laceration – wound laceration – wound edges are smooth edges are smooth and not jaggedand not jagged
Caused by a knife, Caused by a knife, razor, glass, or razor, glass, or sharp metalsharp metal
Heal betterHeal better Bleed freelyBleed freely
Types of Open Soft Tissue Types of Open Soft Tissue InjuriesInjuries
Penetrations and Penetrations and puncturespunctures Caused by a Caused by a
pointed or sharp pointed or sharp objectobject
Can cause deep Can cause deep damage to damage to underlying tissueunderlying tissue
Hard to assess in Hard to assess in the fieldthe field
Stab wound, GSWStab wound, GSW
Blast InjuriesBlast Injuries
Is caused by a Is caused by a blast or explosion blast or explosion
Injuries are due to Injuries are due to 3 forces:3 forces: PrimaryPrimary SecondarySecondary TertiaryTertiary
Blast InjuriesBlast Injuries
AssessmentAssessment Scene SurveyScene Survey Initial AssessmentInitial Assessment Rapid Trauma Rapid Trauma
AssessmentAssessment Detailed Detailed
AssessmentAssessment On-Going On-Going
AssessmentAssessment
Blast InjuriesBlast Injuries
ManagementManagement Same principles apply Same principles apply
for trauma for trauma management:management:
ABCsABCs Oxygenation and Oxygenation and
ventilationventilation Stabilize impaled Stabilize impaled
objects, PRNobjects, PRN Rapid transportRapid transport
Fix life threats on-Fix life threats on-scenescene
Trauma center routingTrauma center routing Maintain adequate Maintain adequate
blood pressuresblood pressures
Crush InjuriesCrush Injuries
Crush InjuryCrush Injury Compartment Compartment
SyndromeSyndrome Crush SyndromeCrush Syndrome
Crush InjuriesCrush Injuries
Crush InjuryCrush Injury Occurs when tissue is exposed to a Occurs when tissue is exposed to a
compressive forcecompressive force Interferes with normal tissue structure Interferes with normal tissue structure
and metabolic functionand metabolic function Massive crush injury to vital organs = Massive crush injury to vital organs =
Immediate deathImmediate death Severity depends on:Severity depends on:
Amount of pressure appliedAmount of pressure applied Amount if time the pressure stays in placeAmount if time the pressure stays in place Body region affectedBody region affected
Crush InjuriesCrush Injuries
Crush InjuryCrush Injury Usually involves Usually involves
upper/lower upper/lower extremities, torso, or extremities, torso, or pelvispelvis
Common situations:Common situations: Structural collapseStructural collapse Earth collapseEarth collapse Motor vehicle crashesMotor vehicle crashes Warfare Warfare
incidents/Terrorismincidents/Terrorism Industrial accidents Industrial accidents
Crush Injuries Crush Injuries Compartment Compartment
SyndromeSyndrome A result of a crush A result of a crush
injury (compressive injury (compressive forces)forces)
Muscle groups are Muscle groups are confined within their confined within their tough fibrous sheaths tough fibrous sheaths and not allowed to and not allowed to stretchstretch
Usually below the knee or above the Usually below the knee or above the elbowelbow
Tibial fracture commonTibial fracture common Associated hemorrhage and edema Associated hemorrhage and edema
increase the pressure within the increase the pressure within the closed fascial spaceclosed fascial space
Result in ischemia – More Result in ischemia – More swelling and more pressureswelling and more pressure
Irreversible soft tissue and nervous Irreversible soft tissue and nervous
damage can occurdamage can occur (hours later(hours later))
Crush InjuriesCrush Injuries Compartment Compartment
SyndromeSyndrome S/SS/S
5 Ps – Pain, Paresis, 5 Ps – Pain, Paresis, Parathesia, Pallor, Parathesia, Pallor, PulselessnessPulselessness
Pain is out of proportion Pain is out of proportion of the injury and with of the injury and with passive stretchpassive stretch
SwellingSwelling TendernessTenderness Weakness in affected Weakness in affected
muscle groupsmuscle groups Diagnosis – History, MOI Diagnosis – History, MOI
and Index of Suspicionand Index of Suspicion
Crush InjuriesCrush Injuries
Crush SyndromeCrush Syndrome Life-threatening conditionLife-threatening condition Caused by prolonged immobilization or Caused by prolonged immobilization or
compressioncompression Destruction and necrosis of tissueDestruction and necrosis of tissue Rare – Occur when extrication or rescue Rare – Occur when extrication or rescue
is prolonged > 4-6 hoursis prolonged > 4-6 hours
Crush InjuriesCrush Injuries Crush SyndromeCrush Syndrome
PathophysiologyPathophysiology Vascular integrity disturbedVascular integrity disturbed Loss of cell structure and membraneLoss of cell structure and membrane Survival until compressive force is removedSurvival until compressive force is removed Harmful processes:Harmful processes:
Oxygen rich blood returns to damaged (ischemic) tissue Oxygen rich blood returns to damaged (ischemic) tissue (Reperfusion)(Reperfusion)
Results in pooling of blood and shockResults in pooling of blood and shock Toxic substances and waste picked up from damaged siteToxic substances and waste picked up from damaged site
Returns to systemic circulation – Metabolic acidosis Returns to systemic circulation – Metabolic acidosis and electrolyte imbalanceand electrolyte imbalance
Rhabdomyolysis – Myoglobin from damaged muscle Rhabdomyolysis – Myoglobin from damaged muscle filtered by kidneysfiltered by kidneys
Renal failureRenal failure
Crush InjuriesCrush Injuries
Crush Syndrome Crush Syndrome TreatmentTreatment Difficult to Difficult to
diagnose and treatdiagnose and treat VariablesVariables
Extent of tissue Extent of tissue damagedamage
Duration and force Duration and force of crushof crush
Patient’s general Patient’s general healthhealth
Other injures?Other injures?
Crush InjuriesCrush Injuries
Crush Syndrome TreatmentCrush Syndrome Treatment Oxygenation and VentilationOxygenation and Ventilation Maintain body temperatureMaintain body temperature Aggressive hydrationAggressive hydration Sodium bicarbonate - Hyperkalemia and acidosisSodium bicarbonate - Hyperkalemia and acidosis Insulin and dextrose – HyperkalemiaInsulin and dextrose – Hyperkalemia Mannitol – Kidney hydrationMannitol – Kidney hydration Arterial tourniquets (?) before releasing Arterial tourniquets (?) before releasing
compressive forcecompressive force Amputation (?)Amputation (?) Consider hospitals with hyperbaric oxygenation Consider hospitals with hyperbaric oxygenation
facilitiesfacilities
Hemorrhage Control Hemorrhage Control TechniquesTechniques
Direct pressureDirect pressure ElevationElevation Pressure dressingPressure dressing
Pressure pointPressure point Tourniquet Tourniquet
applicationapplication SplintingSplinting
Hemorrhage Control Hemorrhage Control TechniquesTechniques
Arterial bleed – Bright red, spurtingArterial bleed – Bright red, spurting Venous bleed – Dark reddish-blue, Venous bleed – Dark reddish-blue,
oozingoozing Capillary bleed – Bright red, oozingCapillary bleed – Bright red, oozing
Apply PPE and take BSI precautionsApply PPE and take BSI precautions
Hemorrhage Control Hemorrhage Control TechniquesTechniques
Direct pressureDirect pressure Hemorrhage control by apply direct Hemorrhage control by apply direct
pressure at the injury sitepressure at the injury site Applied for 4-6 minutesApplied for 4-6 minutes
Manual or via bandageManual or via bandage Never remove pressureNever remove pressure
Continued bleeding?Continued bleeding? Second pressure dressing on top of firstSecond pressure dressing on top of first
Hemorrhage Control Hemorrhage Control TechniquesTechniques
ElevationElevation Elevate injury site above the heart, as Elevate injury site above the heart, as
possiblepossible A supplement to direct pressureA supplement to direct pressure
Hemorrhage Control Hemorrhage Control TechniquesTechniques
Pressure PointPressure Point Used when direct Used when direct
pressure and pressure and elevation does not elevation does not get the job doneget the job done
Compression of an Compression of an artery (over a bone) artery (over a bone) proximal to the proximal to the injury siteinjury site
Pressure should be Pressure should be maintained for maintained for about 10 minutesabout 10 minutes
Hemorrhage Control Hemorrhage Control TechniquesTechniques
Tourniquet Tourniquet applicationapplication Has little or no Has little or no
indication in the indication in the emergency emergency management of management of hemorrhagehemorrhage
Associated with Associated with nerve, vessel, and nerve, vessel, and eventual limb losseventual limb loss
Last resort onlyLast resort only
Hemorrhage Control Hemorrhage Control TechniquesTechniques
Tourniquet applicationTourniquet application Guidelines:Guidelines:
Select site – Need a 2 inch wide siteSelect site – Need a 2 inch wide site Place tourniquet over artery to be compressed, Place tourniquet over artery to be compressed,
use wide material (BP cuff?)use wide material (BP cuff?) Place pad over artery to be compressedPlace pad over artery to be compressed
If using a bandage, encircle extremity twice If using a bandage, encircle extremity twice (pad), tie knot over pad(pad), tie knot over pad
Tie a windlass with a square knotTie a windlass with a square knot Tighten windlass until bleeding stops. Secure itTighten windlass until bleeding stops. Secure it Document tourniquet – Mark forehead – Never Document tourniquet – Mark forehead – Never
loosen loosen
Hemorrhage Control Hemorrhage Control TechniquesTechniques
Splinting/Pneumatic Pressure Splinting/Pneumatic Pressure DevicesDevices Uniform direct pressureUniform direct pressure Over a dressed would only after Over a dressed would only after
bleeding is controlledbleeding is controlled
Types of Bandages and Types of Bandages and DressingsDressings
Bandage – Any material used to Bandage – Any material used to secure a dressingsecure a dressing
Dressing – A sterile or non-sterile Dressing – A sterile or non-sterile cover that aids in hemorrhage cover that aids in hemorrhage control and prevents further damage control and prevents further damage or contamination.or contamination.
Types of Bandages and Types of Bandages and DressingsDressings
SterileSterile Non-sterileNon-sterile OcclusiveOcclusive Non-occlusiveNon-occlusive Adherent Non-Adherent Non-
adherentadherent
Complications of Complications of Improperly Applied Improperly Applied
Dressings and BandagesDressings and Bandages DiscomfortDiscomfort Too loose - Do not control bleedingToo loose - Do not control bleeding Too tight – Can cause ischemia, Too tight – Can cause ischemia,
structural damage to vessels, structural damage to vessels, nerves, tendons, muscles, and skinnerves, tendons, muscles, and skin
Unclean - InfectionUnclean - Infection
Wound InfectionWound Infection Common complication of soft tissue injuryCommon complication of soft tissue injury
Can cause systemic infection sepsis Can cause systemic infection sepsis Causes:Causes:
Time (Should be cleaned and repaired within 8-12 Time (Should be cleaned and repaired within 8-12 hours)hours)
Mechanism (GSW, knife, crush injury)Mechanism (GSW, knife, crush injury) Location (foot, hand, perineum)Location (foot, hand, perineum) Severity (More tissue damage = more infection)Severity (More tissue damage = more infection) Contamination (Soil, saliva, and/or feces)Contamination (Soil, saliva, and/or feces) Preparation (Cleanliness)Preparation (Cleanliness) Cleansing (Normal saline and high-pressure syringe)Cleansing (Normal saline and high-pressure syringe) Technique of repair (Some need to be left open, other Technique of repair (Some need to be left open, other
closed)closed) General patient condition (Pre-existing conditions, General patient condition (Pre-existing conditions,
age) age)
Wound InfectionWound Infection
S/S of infectionS/S of infection Pain, swelling, and Pain, swelling, and
redness at the siteredness at the site Purulent discharge Purulent discharge
(yellow or green)(yellow or green) Foul odorFoul odor Red streaks from Red streaks from
wound – directed wound – directed towards the hearttowards the heart
Fever, chills, Fever, chills, sweats sweats
Related ProtocolsRelated Protocols
AmputationAmputation
Pain managementPain management
PAIN MANAGEMENT PROTOCOL
PAIN MANAGEMENT PAIN MANAGEMENT PROTOCOLPROTOCOL
Pain Management Pain Management Inclusion Criteria: This
guideline applies to patients suffering from severe pain or discomfort, including isolated extremity injuries, musculoskeletal or soft tissue injuries, flank pain due to suspected kidney stone, sickle cell crisis, labor, and other causes.
Basic Level Basic Level Assess and support ABCs. Offer Assess and support ABCs. Offer
comfort and reassurance. comfort and reassurance. Patient positioning: Patient positioning:
Initiate patient positioning and spinal Initiate patient positioning and spinal movement restrictions, as needed. movement restrictions, as needed.
If no spinal injury suspected, place the If no spinal injury suspected, place the patient in a position of comfort. patient in a position of comfort.
If evidence of shock, place the patient If evidence of shock, place the patient supine with the feet elevated and supine with the feet elevated and monitor airway closely. Treat shock monitor airway closely. Treat shock according to the according to the Shock GuidelinesShock Guidelines. .
Administer oxygen, as needed to Administer oxygen, as needed to maintain an SpO2 of at least 96%. maintain an SpO2 of at least 96%.
Splint injured extremities and apply Splint injured extremities and apply cold packs. cold packs.
Once advanced level care arrives on Once advanced level care arrives on scene, give report and transfer scene, give report and transfer care. care.
Advanced Level Advanced Level 6. If the patient can cooperate, have 6. If the patient can cooperate, have
the patient self-administer the patient self-administer nitrous oxidenitrous oxide. .
PAIN MANAGEMENT PAIN MANAGEMENT PROTOCOLPROTOCOL
Amputation Amputation
Inclusion CriteriaInclusion Criteria: : Patients with isolated amputation of any Patients with isolated amputation of any extremity. EMS personnel may also need to extremity. EMS personnel may also need to
refer refer to to Shock GuidelinesShock Guidelines. .
Basic Level Basic Level Assess and support ABCs. If the initial Assess and support ABCs. If the initial
assessment is abnormal, minimize assessment is abnormal, minimize scene time. Continue treatment scene time. Continue treatment guidelines enroute. guidelines enroute.
Initiate spinal movement restrictions, as Initiate spinal movement restrictions, as needed. If no spinal injury is needed. If no spinal injury is suspected, place the patient in a suspected, place the patient in a position of comfort. If evidence of position of comfort. If evidence of shockshock, place the patient supine with , place the patient supine with the feet elevated and monitor airway the feet elevated and monitor airway closely. Treat shock according to the closely. Treat shock according to the Shock Treatment GuidelinesShock Treatment Guidelines. .
Administer oxygen as needed to Administer oxygen as needed to maintain an SpO2 of at least 96%. maintain an SpO2 of at least 96%.
Control any obvious external bleeding Control any obvious external bleeding with any combination of direct with any combination of direct pressure, pressure points or pressure, pressure points or elevation. EMS personnel may apply elevation. EMS personnel may apply a tourniquet only as a last resort. a tourniquet only as a last resort. Care of the amputated part: Care of the amputated part:
Remove gross contaminants by Remove gross contaminants by rinsing with saline. rinsing with saline.
Wrap in moistened saline gauze Wrap in moistened saline gauze and place in plastic bag or and place in plastic bag or container (sterile, if available). container (sterile, if available).
Seal the container tightly and Seal the container tightly and place in solution of ice water, if place in solution of ice water, if available. available.
All parts should be brought to the All parts should be brought to the hospital, regardless of the hospital, regardless of the condition of the part. condition of the part.
If the part cannot be located If the part cannot be located immediately, transport the immediately, transport the patient and instruct other patient and instruct other field providers search for and field providers search for and transport the part as soon as transport the part as soon as possible. possible.
Amputation Amputation
Begin transport as soon Begin transport as soon as possible. as possible.
Advanced Level Advanced Level Consider establishing IV Consider establishing IV
access at a TKO rate access at a TKO rate or use a saline lock. or use a saline lock.
Consider ECG and Consider ECG and ETCO2 monitor. ETCO2 monitor.
Follow Follow Pain Management GuiPain Management Guidelinesdelines..