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Paramedic Soft Tissue Injury

Nov 14, 2014

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Page 1: Paramedic  Soft Tissue Injury

Soft Tissue InjurySoft Tissue Injury

Page 2: Paramedic  Soft 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.

Page 3: Paramedic  Soft Tissue Injury

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?

Page 4: Paramedic  Soft Tissue Injury

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

Page 5: Paramedic  Soft Tissue Injury

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

Page 6: Paramedic  Soft Tissue Injury

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

Page 7: Paramedic  Soft Tissue Injury

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

Page 8: Paramedic  Soft Tissue Injury

Pathophysiology of Wound Pathophysiology of Wound HealingHealing

HomeostasisHomeostasis VasoconstrictionVasoconstriction Formation of a clot Formation of a clot

plugplug CoagulationCoagulation Fibrous tissue Fibrous tissue

developmentdevelopment

Page 9: Paramedic  Soft Tissue Injury

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

Page 10: Paramedic  Soft Tissue Injury

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

Page 11: Paramedic  Soft Tissue Injury

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

Page 12: Paramedic  Soft Tissue Injury

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

Page 13: Paramedic  Soft Tissue Injury

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

Page 14: Paramedic  Soft Tissue Injury

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

Page 15: Paramedic  Soft Tissue Injury

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

Page 16: Paramedic  Soft Tissue Injury

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

Page 17: Paramedic  Soft Tissue Injury

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

Page 18: Paramedic  Soft Tissue Injury

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

Page 19: Paramedic  Soft Tissue Injury

Alteration of Wound Alteration of Wound HealingHealing

Keloid scar tissueKeloid scar tissue

Page 20: Paramedic  Soft Tissue Injury

Alteration of Wound Alteration of Wound HealingHealing

Hypertrophic scar Hypertrophic scar tissuetissue

Page 21: Paramedic  Soft Tissue Injury

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

Page 22: Paramedic  Soft Tissue Injury

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

Page 23: Paramedic  Soft Tissue Injury

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

Page 24: Paramedic  Soft Tissue Injury

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

Page 25: Paramedic  Soft Tissue Injury

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

Page 26: Paramedic  Soft Tissue Injury

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…

Page 27: Paramedic  Soft Tissue Injury

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

Page 28: Paramedic  Soft Tissue Injury

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

Page 29: Paramedic  Soft Tissue Injury

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

Page 30: Paramedic  Soft Tissue Injury

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

Page 31: Paramedic  Soft Tissue Injury

Blast InjuriesBlast Injuries

AssessmentAssessment Scene SurveyScene Survey Initial AssessmentInitial Assessment Rapid Trauma Rapid Trauma

AssessmentAssessment Detailed Detailed

AssessmentAssessment On-Going On-Going

AssessmentAssessment

Page 32: Paramedic  Soft Tissue Injury

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

Page 33: Paramedic  Soft Tissue Injury

Crush InjuriesCrush Injuries

Crush InjuryCrush Injury Compartment Compartment

SyndromeSyndrome Crush SyndromeCrush Syndrome

Page 34: Paramedic  Soft Tissue Injury

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

Page 35: Paramedic  Soft Tissue Injury

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

Page 36: Paramedic  Soft Tissue Injury

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))

Page 37: Paramedic  Soft Tissue Injury

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

Page 38: Paramedic  Soft Tissue Injury

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

Page 39: Paramedic  Soft Tissue Injury

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

Page 40: Paramedic  Soft Tissue Injury

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?

Page 41: Paramedic  Soft Tissue Injury

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

Page 42: Paramedic  Soft Tissue Injury

Hemorrhage Control Hemorrhage Control TechniquesTechniques

Direct pressureDirect pressure ElevationElevation Pressure dressingPressure dressing

Pressure pointPressure point Tourniquet Tourniquet

applicationapplication SplintingSplinting

Page 43: Paramedic  Soft Tissue Injury

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

Page 44: Paramedic  Soft Tissue Injury

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

Page 45: Paramedic  Soft Tissue Injury

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

Page 46: Paramedic  Soft Tissue Injury

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

Page 47: Paramedic  Soft Tissue Injury

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

Page 48: Paramedic  Soft Tissue Injury

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

Page 49: Paramedic  Soft Tissue Injury

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

Page 50: Paramedic  Soft Tissue Injury

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.

Page 51: Paramedic  Soft Tissue Injury

Types of Bandages and Types of Bandages and DressingsDressings

SterileSterile Non-sterileNon-sterile OcclusiveOcclusive Non-occlusiveNon-occlusive Adherent Non-Adherent Non-

adherentadherent

Page 52: Paramedic  Soft Tissue Injury

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

Page 53: Paramedic  Soft Tissue Injury

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)

Page 54: Paramedic  Soft Tissue Injury

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

Page 55: Paramedic  Soft Tissue Injury

Related ProtocolsRelated Protocols

AmputationAmputation

Pain managementPain management

Page 56: Paramedic  Soft Tissue Injury

PAIN MANAGEMENT PROTOCOL

Page 57: Paramedic  Soft Tissue Injury

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. .

Page 58: Paramedic  Soft Tissue Injury

PAIN MANAGEMENT PAIN MANAGEMENT PROTOCOLPROTOCOL

Page 59: Paramedic  Soft Tissue Injury

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.

Page 60: Paramedic  Soft Tissue Injury

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..