LEARNING OBJECTIVE: Recognize the different types of wounds, and determine management and treatment procedures for open and internal soft-tissue injuries.
The most common injuries seen by the medical technician in a first aid setting are soft tissue injuries with the accompanying hemorrhage, shock, and danger of infection. Any injury that causes a break in the skin, underlying soft tissue structures, or body membranes is known as a wound. This section will discuss the classification of wounds, the general and specific treatment of soft tissue injuries, the use of dressings and bandages in treating wounds, and the special problems that arise because of the location of wounds.
CLASSIFICATION OF WOUNDS
Wounds may be classified according to their general condition, size, location, the manner in which the skin or tissue is broken, and the agent that caused the wound. It is usually necessary for you to consider these factors to determine what first aid treatment is appropriate for the wound.
General Condition of the Wound
If the wound is fresh, first aid treatment consists mainly of stopping the flow of blood, treating for shock, and reducing the risk of infection. If the wound is already infected, first aid consists of keeping the victim quiet, elevating the injured part, and applying a warm wet dressing. If the wound contains foreign objects, first aid treatment may consist of removing the objects if they are not deeply embedded. DO NOT remove objects embedded in the eyes or the skull, and do not remove impaled objects. Stabilize impaled objects with a bulky dressing before transporting the victim.
Size of the Wound
In general, since large wounds are more serious than small ones, they usually involve more severe bleeding, more damage to the underlying organs or tissues, and a greater degree of shock. However, small wounds are sometimes more dangerous than large ones since they may become infected more readily due to neglect. The depth of the wound is also important because it may lead to a complete perforation of an organ or the body, with the additional complication of entrance and exit wounds.
Location of the Wound
Since a wound may involve serious damage to the deeper structures, as well as to the skin and the tissue immediately below it, the location of the wound is important. For example, a knife wound to the chest may puncture a lung and cause interference with breathing. The same type of wound in the abdomen may result in a dangerous infection in the abdominal cavity, or it might puncture the intestines, liver, kidneys, or other vital organs. A knife wound to the head may cause brain damage, but the same wound in a less vital spot (such as an arm or leg) might be less important.
Types of Wounds
When you consider the manner in which the skin or tissue is broken, there are six general kinds of wounds: abrasions, incisions, lacerations, punctures, avulsions, and amputations. Many wounds, of course, are combinations of two or more of these basic types.
ABRASIONS.—Abrasions are made when the skin is rubbed or scraped off. Rope burns, floor burns, and skinned knees or elbows are common examples of abrasions. This kind of wound can become infected quite easily because dirt and germs are usually embedded in the tissues.
INCISIONS.—Incisions, commonly called cuts, are wounds made by sharp cutting instruments such as knives, razors, and broken glass. Incisions tend to bleed freely because the blood vessels are cut cleanly and without ragged edges. There is little damage to the surrounding tissues. Of all classes of wounds, incisions are the least likely to become infected, since the free flow of blood washes out many of the microorganisms (germs) that cause infection.
LACERATIONS.—These wounds are torn, rather than cut. They have ragged, irregular edges and masses of torn tissue underneath. These wounds are usually made by blunt (as opposed to sharp) objects. A wound made by a dull knife, for instance, is more likely to be a laceration than an incision. Bomb fragments often cause lacerations. Many of the wounds caused by accidents with machinery are lacerations; they are often complicated by crushing of the tissues as well. Lacerations are frequently contaminated with dirt, grease, or other material that is ground into the tissue. They are therefore very likely to become infected.
PUNCTURES.—Punctures are caused by objects that penetrate into the tissues while leaving a small surface opening. Wounds made by nails, needles, wire, and bullets are usually punctures. As a rule, small puncture wounds do not bleed freely; however, large puncture wounds may cause severe internal bleeding. The possibility of infection is great in all puncture wounds, especially if the penetrating object has tetanus bacteria on it. To prevent anaerobic infections, primary closures are not made in the case of puncture wounds.
AVULSIONS.—An avulsion is the tearing away of tissue from a body part. Bleeding is usually heavy. In certain situations, the torn tissue may be surgically reattached. It can be saved for medical evaluation by wrapping it in a sterile dressing and placing it in a cool container, and rushing it—along with the victim–to a medical facility. Do not allow the avulsed portion to freeze, and do not immerse it in water or saline.
AMPUTATIONS.—A traumatic amputation is the nonsurgical removal of the limb from the body. Bleeding is heavy and requires a tourniquet (which will be discussed later) to stop the flow. Shock is certain to develop in these cases. As with avulsed tissue, wrap the limb in a sterile dressing, place it in a cool container, and transport it to the hospital with the victim. Do not allow the limb to be in direct contact with ice, and do not immerse it in water or saline. The limb can often be successfully reattached.
Causes of Wounds
Although it is not always necessary to know what agent or object has caused the wound, it is helpful. Knowing what has caused the wound may give you some idea ofthe probable size ofthe wound, its general nature, the extent to which it is likely to become contaminated with foreign matter, and what special dangers must be guarded against. Of special concern in a wartime setting is the velocity of wound-causing missiles (bullets or shrapnel). A low-velocity missile damages only the tissues it comes into contact with. On the other hand, a high-velocity missile can do enormous damage by forcing the tissues and body parts away from the track of the missile with a velocity only slightly less than that of the missile itself. These tissues, especially bone, may become damage-causing missiles themselves, thus accentuating the destructive effects of the missile.
Having classified the wound into one or more of the general categories listed, the medical technician will have a good idea of the nature and extent of the injury, along with any special complications that may exist. This information will aid in the treatment of the victim.
MANAGEMENT OF OPEN SOFT-TISSUE INJURIES
There are three basic rules to be followed in the treatment of practically all open soft tissue injuries: to control hemorrhage, to treat the victim for shock, and to do whatever you can to prevent infection. These will be discussed, along with the proper application of first aid materials and other specific first aid techniques.
Hemorrhage is the escape of blood from the vessels of the circulatory system. The average adult body contains about 5 liters of blood. Five hundred milliliters ofblood, the amount given by blood donors, can usually be lost without any harmful effect. The loss of 1 liter of blood usually causes shock, but shock may develop if small amounts of blood are lost rapidly, since the circulatory system does not have enough time to compensate adequately. The degree of shock progressively increases as greater amounts of blood escape. Young children, sick people, or the elderly may be especially susceptible to the loss of even small amounts of blood since their internal systems are in such delicate balance.
Capillary blood is usually brick red in color. If capillaries are cut, the blood oozes out slowly. Blood from the veins is dark red. Venous bleeding is characterized by a steady, even flow. If an artery near the surface is cut, the blood, which is bright red in color, will gush out in spurts that are synchronized with the heartbeats. If the severed artery is deeply buried,
however, the bleeding will appear to be a steady stream.
In actual practice, you might find it difficult to decide whether bleeding is venous or arterial, but the distinction is not usually important. The important thing to know is that all bleeding must be controlled as quickly as possible.
External hemorrhage is of greatest importance to the medical technician because it is the most frequently encountered and the easiest to control. It is characterized by a break in the skin and visible bleeding. Internal hemorrhage (which will be discussed later) is far more difficult to recognize and to control.
Control of Hemorrhage
The best way to control external bleeding is by applying a compress to the wound and exerting pressure directly to the wound. If direct pressure does not stop the bleeding, pressure can also be applied at an appropriate pressure point. At times, elevation of an extremity is also helpful in controlling hemorrhage. The use of splints in conjunction with direct pressure can be beneficial. In those rare cases where bleeding cannot be controlled by any of these methods, you must use a tourniquet.
If bleeding does not stop after a short period, try placing another compress or dressing over the first and securing it firmly in place. If bleeding still will not stop, try applying direct pressure with your hand over the compress or dressing.
Remember that in cases of severe hemorrhage, it is less important to worry too much about finding appropriate materials or about the dangers of infection. The most important problem is to stop rapid exsanguination. If no material is available, simply thrust your hand into the wound. In most situations, direct pressure is the first and best method to use in the control of hemorrhage.
Bleeding can often be temporarily controlled by applying hand pressure to the appropriate pressure point. A pressure point is the spot where the main artery to an injured part lies near the skin surface and over a bone. Apply pressure at this point with the fingers (digital pressure) or with the heel of the hand. No first aid materials are required. The object of the pressure is to compress the artery against the bone, thus shutting off the flow of blood from the heart to the wound.
There are 11 principal points on each side of the body where hand or finger pressure can be used to stop hemorrhage. These points are shown in figure 4-27. If bleeding occurs on the face below the level of the eyes, apply pressure to the point on the mandible. This is shown in figure 4-27A. To find this pressure point, start at the angle of the jaw and run your finger forward along the lower edge of the mandible until you feel a small notch. The pressure point is in this notch.
Figure 4-27.—Pressure points.
If bleeding is in the shoulder or in the upper part of the arm, apply pressure with the fingers behind the clavicle. You can press down against the first rib or forward against the clavicle; either kind of pressure will stop the bleeding. This pressure point is shown in figure 4-27B.
Bleeding between the middle of the upper arm and the elbow should be controlled by applying digital pressure to the inner (body) side of the arm, about halfway between the shoulder and the elbow. This compresses the artery against the bone of the arm. The application of pressure at this point is shown in figure 4-27C. Bleeding from the hand can be controlled by pressure at the wrist, as shown in figure 4-27D. If it is possible to hold the arm up in the air, the bleeding will be relatively easy to stop.
Figure 4-27E shows how to apply digital pressure in the middle of the groin to control bleeding from the thigh. The artery at this point lies over a bone and quite close to the surface, so pressure with your fingers may be sufficient to stop the bleeding.
Figure 4-27F shows the proper position for controlling bleeding from the foot. As in the case of bleeding from the hand, elevation is helpful in controlling the bleeding.
If bleeding is in the region of the temple or the scalp, use your finger to compress the main artery to the temple against the skull bone at the pressure point just in front of the ear. Figure 4-27G shows the proper position.
If the neck is bleeding, apply pressure below the wound, just in front of the prominent neck muscle. Press inward and slightly backward, compressing the main artery ofthat side of the neck against the bones of the spinal column. The application of pressure at this point is shown in figure 4-27H. Do not apply pressure at this point unless it is absolutely essential, since there is a great danger of pressing on the windpipe, thereby choking the victim.
Bleeding from the lower arm can be controlled by applying pressure at the elbow, as shown in figure 4-27I.
As mentioned before, bleeding in the upper part of the thigh can sometimes be controlled by applying digital pressure in the middle of the groin, as shown in figure 4-27E. Sometimes, however, it is more effective to use the pressure point of the upper thigh, as shown in figure 4-27J. If you use this point, apply pressure with
the closed fist of one hand and use the other hand to give additional pressure. The artery at this point is deeply buried in some of the heaviest muscle tissue in the body, so a great deal of pressure must be exerted to compress the artery against the bone.
Bleeding between the knee and the foot may be controlled by firm pressure at the knee. If pressure at the side of the knee does not stop the bleeding, hold the front of the knee with one hand and thrust your fist hard against the artery behind the knee, as shown in figure 4-27K. If necessary, you can place a folded compress or bandage behind the knee, bend the leg back, and hold it in place by a firm bandage. This is a most effective way of controlling bleeding, but it is so uncomfortable for the victim that it should be used only as a last resort.
You should memorize these pressure points so that you will know immediately which point to use for controlling hemorrhage from a particular part of the body. Remember, the correct pressure point is that which is (1) nearest the wound, and (2) between the wound and the main part of the body.
It is very tiring to apply digital pressure, and it can seldom be maintained for more than 15 minutes. Pressure points are recommended for use while direct pressure is being applied to a serious wound by a second rescuer. Using the pressure-point technique is also advised after a compress, bandage, or dressing has been applied to the wound, since this method will slow the flow of blood to the area, thus giving the direct pressure technique a better chance to stop the hemorrhage. The pressure-point system is also recommended as a stopgap measure until a pressure dressing or a tourniquet can be applied.
The elevation of an extremity, where appropriate, can be an effective aid in hemorrhage control when used in conjunction with other methods of control, especially direct pressure. This is because the amount of blood entering the extremity is decreased by the uphill gravitational effect. Do not elevate an extremity until it is certain that no bones have been broken or until broken bones are properly splinted.
Another effective method of hemorrhage control in cases of bone fractures is splinting. The immobilization of sharp bone ends reduces further tissue trauma and allows lacerated blood vessels to clot. In addition, the gentle pressure exerted by the splint helps the clotting process by giving additional support to compresses or dressings already in place over open fracture sites.
Later in this chapter we will go into the subject of splinting in greater detail.
A tourniquet is a constricting band that is used to cut off the supply of blood to an injured limb. Use a tourniquet only as a last resort and if the control of hemorrhage by other means proves to be difficult or impossible. A tourniquet must always be applied above the wound (i.e., toward the trunk), and it must be applied as close to the wound as practical.
Basically, a tourniquet consists of a pad, a band, and a device for tightening the band so that the blood vessels will be compressed. It is best to use a pad, compress, or similar pressure object, if one is available. The pressure object goes under the band and must be placed directly over the artery or it will actually decrease the pressure on the artery, allowing a greater flow of blood. If a tourniquet placed over a pressure object does not stop the bleeding, there is a good chance that the pressure object is in the wrong place. If placement is not effective, shift the object around until the tourniquet, when tightened, will control the bleeding.
Any long flat material may be used as the band. It is important that the band be flat: belts, stockings, flat strips of rubber, or neckerchiefs may be used; however, rope, wire, string, or very narrow pieces of cloth should not be used because they can cut into the flesh. A short stick may be used to twist the band, tightening the tourniquet. Figure 4-28 shows the proper steps in applying a tourniquet.
Figure 4-28.—Applying a tourniquet.
To be effective, a tourniquet must be tight enough to stop the arterial blood flow to the limb. Be sure, therefore, to draw the tourniquet tight enough to stop the bleeding. Do not make it any tighter than necessary, though, since a tourniquet that is too tight can lead to loss of the limb the tourniquet is applied to.
After you have brought the bleeding under control with the tourniquet, apply a sterile compress or dressing to the wound and fasten it in position with a bandage.
Here are the points to remember about using a tourniquet:
MANAGEMENT OF INTERNAL SOFT-TISSUE INJURIES
Internal soft-tissue injuries may result from deep wounds, blunt trauma, blast exposure, crushing accidents, bone fracture, poison, or sickness. They may range in seriousness from a simple contusion to life-threatening hemorrhage and shock.
Visible indications of internal soft-tissue injury include the following:
More often than not, however, there will be no visible signs of injury, and the medical technician will have to infer the probability of internal soft-tissue injury from other symptoms such as the following:
There is little that a medical technician can do to correct internal soft-tissue injuries since they are almost always surgical problems. The Hospital medical technician’s goal must be to obtain the greatest benefit from the victim’s remaining blood supply. The following steps should be taken:
SPECIAL CONSIDERATIONS IN WOUND TREATMENT
There are special considerations that should be observed when treating wounds. The first of these is immediate treatment to prevent shock. Next, infection should be a concern: Look for inflammation and signs of abscess. medical technicians should be aware of these conditions and have the knowledge to treat them.
Shock is likely to be severe in a person who has lost a large amount of blood or suffered any serious wound. The causes and treatment of shock are explained earlier in this chapter.
Although infection may occur in any wound, it is a particular danger in wounds that do not bleed freely, in wounds in which torn tissue or skin falls back into place and prevents the entrance of air, and in wounds that involve the crushing of tissues. Incisions (in which there is a free flow of blood and relatively little crushing of tissues) are the least likely to become infected.
Wounds incurred in transportation accidents and natural disasters are especially likely to become infected. They present the problem of devitalized (dead or dying) tissue; extravasated blood (blood that has escaped its natural boundaries); foreign bodies such as missile fragments, bits of cloth, dirt, dust; and a variety of bacteria. The devitalized tissue proteins and extravasated blood provide a nutritional medium for the support of bacterial growth and thus are conducive to the development of serious wound infection. Puncture wounds are also likely to become infected by the germs causing tetanus.
COMMON INFECTION-CAUSING BACTERIA.— There are two types of bacteria that commonly cause infection in wounds: aerobic and anaerobic. Aerobic bacteria live and multiply in the presence of air or free oxygen, while anerobic bacteria live and multiply only in the absence of air.
Aerobic Bacteria.—The principal aerobic bacteria that cause infection, inflammation, and septicemia (blood poisoning) are streptococci and staphylococci, some varieties of which are hemolytic (destroy red blood cells). The staphylococci and streptococci may be introduced at the time of infliction, or they may be introduced to the wound later (at the time of first aid treatment or in the hospital if nonsterile instruments or dressings are employed).
Anaerobic Bacteria.—Anaerobic bacteria are widespread in soil (especially manured soil). While not invasive, anaerobic bacteria contribute to disease by producing toxins and destructive enzymes, often leading to necrosis and/or gangrene of the infected area.
MINOR WOUND CLEANING AND DRESSING.—Wash minor wounds immediately with soap and clean water; then dry and paint them with a mild, nonirritating antiseptic. Apply a dressing if necessary. In the first aid environment, do not attempt to wash or clean a large wound, and do not apply an antiseptic to it since it must be cleaned thoroughly at a medical treatment facility. Simply protect it with a large compress or dressing, and transport the victim to a medical treatment facility. After an initial soap and water cleanup, puncture wounds must also be directed to a medical treatment facility for evaluation.
Inflammation is a local reaction to irritation. It occurs in tissues that are injured, but not destroyed. Symptoms include redness, pain, heat, swelling, and sometimes loss of motion.Treatment for furuncles and carbuncles includes the following: