Epidermis
Tough, external layer that forms a watertight covering of the body.
How are old epidermis cells replaced?
They are replaced by cells that are pushed to the surface when new cells form in the germinal layer at the base of the epidermis.
Dermis
Inner layer of skin that lies below the germinal cells of the epidermis.
What does the dermis layer contain?
Hair follicles
Sweat glands
Sebaceous glands
Function of sweat glanfs
Help cool the body by releasing sweat onto the surface of the skin through small pores that pass through the epidermis.
Function of sebaceous glands
Produces sebum which is the oily material that waterproofs the skin and keeps it supple.
Which layer of the skin does the blood vessels provide the skin with nutrients and oxygen?
Dermis
Three layers of the skin
Epidermis
Dermis
Subcutaneous tissue
What orfices in the body are lined with mucous membranes?
Mouth, nose, anus, and vagina
Difference between mucous membranes and skin?
Both are a protective barrier, however the mucous membrane secretes a watery substance to lubricate the opening while skin is dry.
The skins many functions :
Protects body from pathogens and keeps fluids in.
Nerves in the skin reports to the brain on the environment and many sensations.
Regulating temperature
What is a tension line?
Skin is arranged over the body structures in a manner that provides tension.
Lacerations occurring ___ to the skin tension lines may remain ___ with little or no intervention.
parallel; closed
Dynamic tension
Tension lines found in areas that lie over muscle. Tension varies according to the contraction of the underlying muscle and subsequent movement of the skin.
Why doe injuries to dynamic tension lines interfere with healing?
The injury disrupts the clotting process and the tissue repair cycle, resulting in slowed healing and a tendency toward abnormal scar formation.
Closed soft-tissue injuries are characterized by :
Hx of blunt trauma
Pain at the injury site
Swelling
Discoloration
What is a contusion?
Torn small blood vessels and cellular damage within the dermis.
Ecchymosis
Bruising or discoloration associated with bleeding within or under the skin.
Hematoma
Large blood vessel is damaged and bleeds rapidly. Usually associated w/ extensive tissue damage.
Crush syndrome
Metabolic derangement that can result in renal failure and death. It develops when crushed extremities or other body parts remain trapped for prolonged periods of time.
Pathophysiology of crush syndrome.
When tissues are crush, muscle cells die and release harmful substances into surrounding tissues. The oppressing force prevents blood from returning to the injured body part, so the harmful substances are released into the circulation AFTER the limb is freed and blood low is returned.
Compartment syndrome
Develops when edema and swelling result in increased pressure within a closed soft-tissue compartment.
What should you assess continuously when a crush injury is suspected? Why?
Skin color, temperature, and distal pulses. Looking for signs of compartment syndrome.
Abrasion
Wound of the superficial layer of the skin caused by friction when a body rubs or scrapes across a rough or hard surface.
Laceration
Jagged cut in the skin caused by a sharp object or blunt force that tears the tissue.
Difference between a laceration and incision?
Lacerations is a jagged cut. Laceration is a sharp, smooth cut.
Avulsion
Injury that separates layers of soft tissue resulting in complete detachment or hangs as a flap.
What layers of the skin are usually involved in avulsions?
Subcutaneous layer and fascia.
Management of complete and incomplete avulsion..
Complete : wrap separated tissue in sterile gauze and bring it to the ED.
Incomplete : Replace the flat avulsed flap to its original position as long as it is not visibly contaminated.
Which bacteria account for most bacterial skin infections?
Staphylococcus and Streptococcus.
Visible clues of infection include :
Erythema Pus Warmth Edema Local discomfort
What is lymphangitis? What is a sign of lymphangitis?
Inflammation of the lymph channels. Red streaks adjacent to the wound.
Gangrene
Dead tissue caused when blood supply to that tissue is interrupted or stopped.
When should you suspect gangrene?
Patient has chronic risk factors including DM, smoker, PVD, and there is numbness, coolness, or swelling of an extermity.
What are late signs of gangrene?
Discoloration of the limb to black, blue, or red.
Which gangrene bacteria causes a foul-smelling gas?
Clostridium perfingens
Tetanus
A disease caused by spores that enter the body through a punctured wound contaminated with animal feces, street dust, or soil or that can enter through contaminated street drugs.
What does tetanus do to the body?
It causes the body to produce a potent toxin, which results in painful muscle contractions strong enough to fracture bones.
What is the first sign of tetanus?
Muscle stiffness in the jaw and neck which then progresses down the remainder of the body.
How is necrotizing fasciitis transmission?
Vectors such as insect bites or jellyfish stings.
s/s of necrotizing fasciitis
Erythema and warmth at the site Fever Night sweats Chills Vomiting Diarrhea
Which conditions require transport even if the injuries seem minor?
Compromise of : nerves, vessels, muscles, tendons or ligaments.
FB or cosmetic complications
Heavy contamination
Necrotizing fasciitis
Death of tissue from bacterial infection.
Primary survey of soft tissue injuries
Rapidly determine life threats -XABCD.
Control bleeding quickly.
Address life threats.
Perform manual immobilization if needed.
Check responsiveness w/ AVPU.
Administer high-flow oxygen as needed.
NRB at 15 L/min or BVM if inadequate perfusion or ventilations.
Assess circulatory status for signs of shock.
Perform 60-to-90 second rapid full body scan. Apply c-collar if indicated.
Determine whether patient needs immediate transport or stabilization at scene.
History taking of soft tissue injuries
SAMPLE
OPQRST
Last tetanus vaccination
Medications and OTC to determine interference with hemostasis.
What should be included in your communication and coumentation?
Description of MOI
Position in which the patient was found upon arrival
Estimate amount of blood lost
Location and description of any soft-tissue injuries or other wounds
Treatment of closed soft-tissue injury
RICES : Rest Ice Compression Elevation Splinting
What is an occlusive dressing and when should you use one?
Dressing made from petroleum gauze, aluminum foil, or plastic that prevents air and liquids from entering or exiting a wound.
Use on open chest wounds, abdominal eviscerations and penetrating wounds above umbilicus, penetrating back wounds, and open neck injuries.
What are the primary functions of dressings and bandages?
Control bleeding
Protect wound from further damage
Prevent further contamination and infection
Management of amputation
Complete : control the bleeding. If it involves large area of muscle mass, will most likely require tourniquet and treatment of shock.
Partial : immobilize the part with bulky compression dressings and splint to prevent further injury.
Emergency treatment for bites
Control bleeding and apply a dry, sterile dressing
Consider irrigation w/ sterile water if grossly contaminated
Immobilize area w/ splint or bandage if extremity
Provide transport to the Ed for surgical cleansing
Management of abdominal wounds
Cover wound w/ sterile gauze compressed moistened w/ sterile saline solution and secure with an occlusive dressing
Management of open neck wounds
Cover the wound w/ an occlusive dressing
Apply manual pressure, but do not compress carotid arteries
Secure pressure dressing over the wound w/ roller gauze loosely wrapped around the next and then firmly around opposite axilla.
Burn process may results in :
Renal failure
Liver failure
Dysrhythmias
Heart failure
Which hormones are secreted in response to pain and stress from a burn?
Catecholamines - epinephrine and norepinephrine
Hypovolemic shock occurs because of the two types of injuries that result from burns :
Fluid loos across damaged skin
Volume shifts w/in the rest of the body
How does the body respond during shock when the BP decreases?
It responds with tachycardia and vasoconstriction, which limits blood flow further and continues the cycle.
Complications that can result from a burn injury :
Infection
Hypothermia
Hypovolemia
Shock
Loose mucosa in the hypopharynx can swell and rapidly result in complete airway obstruction.
Circumferential burns to chest can compromise breathing.
Circumferential burns of an extremity can result in compartment syndrome.
Burns are described in three pathologic progressions, what are they?
Zone of coagulation
Zone of stats
Zone of hypothermia
Zone of coagulation
Central area of skin that suffers the most damage. There is little or no blood flow to the injured tissue.
Zone of stasis
Peripheral area surrounding the zone of coagulation which has decreased blood flood and inflammation.
In which burn zone with necrosis develop in 24 to 48 hours after injury?
Zone of stasis
Zone of hypothermia
Least affected by the thermal injury.
Typically how long does it take the cells in the zone of hypothermia to recover?
7-10 days
What is the main priority of burn treatment?
Salvage as much injured as possibly by improving perfusion.
When should you suspect substantial airway burns?
Signs of singed hair w/in nostrils, soot around the nose and mouth, hoarseness, or hypoxia.
Superficial burns
Involve epidermis only
Skin turns red but does not blister or burn into next layer
Burn site painful
Ex : sunburn
Partial-thickness burns
Epidermis and portion of dermis No damage to subcutaneous tissue Skin typically moist, mottled, and white to red Presence of blisters Intense pain
Full-thickness burns
All layers of skin including subcutaneous layers, muscle, bone, or internal organs.
Area is dry and leathery and may appear white, dark brown, or charred.
Some burns feel hard to touch.
Clotted blood vessels or subcutaneous tissue may be visible.
May not have feeling in nerve endings are destroyed.
Less severely burned areas may be extremely painful.
Five factors to determine severity of burn?
Depth of burn
Extent of burn
Critical areas involved (face, upper airway, hands, feet, genitalia, circumferential burns)
PMH or other injures that can complicate injury
Younger than 5 years or older than 55 years
Which two factors in determining severity of a burn is considered the most important?
Extent and degree of burn
What are burns to the hands, feet, or joints considered serious?
Potential for loss of function via scarring.
Which areas are considered critical in burn injuries?
Face, upper airway, hands, feet, genitalia, and circumferential.
Rule of nines for infant
Head : 18 Arms : 9 each Chest : 18 Back : 18 Genitalia : 1 Legs : 13.5 each
Rule of nines for child
Head : 12 Arms : 9 each Chest : 18 Back: 18 Genitalia : 1 Legs : 16.5 each
Rule of nines for adult
Head : 9 Arms : 9 each Chest : 18 Back : 18 Genitalia : 1 Legs : 18 each
Why are burns to children considered more serious than adults?
They have more surface area relative to total body mass resulting in greater fluid and heat loss. More likely to experience shock, hypothermia, and airway difficulties because of differences in ages and anatomy.
Signs of airway involvement in a burn patient :
Hoarseness Cough Stridor Singed nasal or facial hair Carbon in the sputum Hx of fire in an enclosed space Heavy amounts of secretions and frequent coughing
During your secondary assessment, what should you look for specifically in the respiratory system?
Soot around the mouth and nose. Singed nasal hairs Breath sounds RR and quality DCAP-BTLS
During your secondary assessment, what should you look for specifically in the musculoskeletal system?
Head : racoon eyes, Battle sign, and/or drainage of blood or fluid from ears or nose; Singes nasal or facial hair, burns or swelling of face or ears, burns or swelling in mouth.
Neck : JVD, tracheal deviation
Chest : check for circumferential burn
Abdomen : palpate all four quadrants for tenderness or rigidity
Extremities : circumferential burns, entry or exit burn wounds of electrical injuries. CMS.
Pelvis : stability
What vital signs should you obtain from a burn patient?
BP, pulse, and skin to asses perfusion.
O2 and CO monitor to quantify oxygenation and circulatory status.
Why should you not immerse burns for longer than 10 minutes?
Longer immersion times can increase risk of infection and hypothermia.
Emergency care of burns
Depending on local protocol, immerse are in cool, sterile water or saline or cover with clean, wet, cool dressings. OR irrigation followed by application of sterile dressing.
High-flow oxygen
Prepare for ventilations and airway adjuncts
Estimate severity of burns. Cover w/ dry, sterile dressing or clean, white sheet if injury is too large.
Establish IV - isotonic crystalloid solution
Keep warm
Positioning
Prompt transport
What are the goals in treating patients?
Stop the burning process
Assess and treat breathing
Support circulation
Provide rapid transport
Consensus formula
2-4 mL x Patient’s weight x Percentage of body SA burned = total fluid in 24 hours
What amounts and when should the fluid boluses be given according to the Consensus formula>
1/2 amount calculated from equation during the first 8 hours.
Other half over the next 16 hours.
What happens if you give fluid too early or too fast in a burn patient?
Compromise of airway devices, vascular access, and can lead to compartment syndrome.
What type of burn is commonly seen in children and handicapped adults?
Scald burn
Scald burn
Contact with hot liquids. Larger surface area as liquids can spread quickly.
Contact burn
Coming in direct contact with hot objects. Rarely deep.
Flash burn
Produced by an explosion exposing patient to very intense heat.
Most deaths from fires are not caused directly by burns, but rather?
Inhalation of toxic gases, upper airway compromise, or pulmonary injury
Cause of death if patient survives initial burn injuris?
Secondary infection
Upper airway damage in fires is usually caused by?
Inhalation of superheated gases
Lower airway damage in fires is usually caused by?
Inhalation of chemicals and particulate matter.
Signs and symptoms of hydrogen cyanide poisoning?
CNS, respiratory, and cardiovascular systems. Faintness Anxiety Abnormal vital signs HA Seizures Paralysis Coma
Severity of chemical burn is related to?
pH level of agent Concentration of agent Length of exposure Volume of agent Physical form of agent
