Remote Primary Health Care Manuals

Injuries — soft tissue

Red Flags — Urgent Medical Consult
  • Suspicion of internal haemorrhage
  • Artery injury — spurting blood, large blood loss, bruise rapidly increasing or pulsing
  • Cool, pulseless limbs
  • Swelling or discharge — signs of infection
  • Constant severe pain
  • Penetrating injuries close to a joint, finger or palm of hands 

Table 2.13   Type of injury

Signs and Symptoms Action

Bites or fist cut by teeth

Animal or human bites

Burn

Burn

Stab wound

Spear and knife wounds (Stab wounds)

Significant water exposure — sea, waterholes

Water related skin infections

High pressure injection injuries, usually hands and fingers — may be very severe with only tiny surface injury (accidental injection of fluid from high pressure equipment)

Medical consult

Penetrating injuries to palm side of hands or fingers
  • Palmar spaces can become infected — medical consult
  • Always give antibiotics — Table 2.15
  • Review next day for redness or swelling

 

Necrotising fasciitis

Urgent medical consult

Arterial bleeding 

  • Bruise (haematoma) rapidly increasing in size or pulsing/throbbing
  • Spurting blood, large blood loss, reduced or no pulses, cool limb

Apply pressure straight away — See Injuries — bleeding — urgent medical consult 

Cool, pulseless limbs — bone involvement,  signs of nerve or circulation problems  

Gently straighten limb, apply firm traction until pulse returns — ​See Injuries — limbs — urgent medical consult

Joints move more or less than they should — tendon or joint involvement
  • If penetrating injury close to a joint — medical consult
  • Always give antibiotics — Table 2.15 
  • See Joint sprains

Hand or finger injury

  • Can cause long-term problems if not treated properly. If not sure what to do — always get help or advice

Nail bed injury — can lead to problems with nail growth

See Injuries — fingernails and toenails

Foot injury and known diabetes

Complicated or severe wound — Table 2.15



Necrotising fasciitis

  • Rapidly progressive soft tissue infection — life threatening  — urgent medical consult 
  • Often mismatch between the patient’s appearance and what is visible
    • Pain that is far more severe than expected for what is seen 
    • OR severe soft tissue infection with minimal pain (nerves damaged)

Table 2.14  

Usual signs/symptoms Occasional signs/symptoms
  • Sepsis
  • Constant severe pain or tenderness
  • Bruised appearance at site of infection
  • Localised swelling
  • Discharge — watery, putrid
  • Wound
  • Crepitus
  • Blood blisters
  • Overlying numbness
  • Underlying tissue tender and hard (woody)

Ask

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • Head-to-toe exam — with attention to
    • Involving hand, neck, armpit or groin
    • Neurovascular, tendon, joint or bone involvement
    • Risk of penetrating a body cavity — head, chest, abdomen, buttocks, close to hip or shoulder
    • Crush injury or extensive tissue damage
    • Nerve injury — numbness
    • Contamination — carefully check wound for foreign bodies
    • Infection — localised or systemic features, sepsis
  • Immunisation status — tetanus

Do

  • Clean wound, irrigate with normal saline 
  • If wound very dirty or dead tissue present — medical consult
  • If wound infected or not improving with antibiotics — swab wound 
  • If wound needs to be debrided or gently scrubbed to remove dirt — consider local anaesthetic
    • Lidocaine (lignocaine) 1% injection — up to 0.3mL/kg
    • Lidocaine-prilocaine (lignocaine-prilocaine) cream OR gauze soaked in lidocaine (lignocaine) 2%
    • Takes about 30 minutes to work
  • Give pain relief — back slab often useful
  • If object sticking into body — medical consult 
  • If puncture wound to the sole of foot through footwear — medical consult
  • If injury to finger needs sutures or closer examination — may need nerve block
  • If infection doesn’t get better or gets worse — medical consult
Injuries less than 8 hours old and clean

Complicated injuries — tendon, joint or bone involvement

Severe injuries — crush injury or extensive tissue damage

Injuries less than 8 hours old and dirty OR more than 8 hours old
  • Give antibiotics — Table 2.15 OR if significant fresh or salt water exposure — see Water-related skin infections
  • If complicated or severe — medical consult
  • If not complicated and not severe
    • Clean with normal saline 
    • Debride (cut away dead and badly damaged tissue), trim wound edge
    • If less than 8 hours old and now clean — close
    • If less than 8 hours old and still not clean OR more than 8 hours old — medical consult
    • Do not close, dress wound daily

Table 2.15   Antibiotics for soft tissue injuries by wound type

Mild contamination OR shallow puncture OR mild infection OR more than 8 hours old

  • Dicloxacillin OR flucloxacillin oral — adult 500mg, child 12.5mg/kg/dose up to 500mg — doses — 4 times a day (qid) for 5–7 days
  • OR cefalexin oral — adult 1g, child 25mg/kg/dose up to 1g — doses — twice a day (bd) for 5–7 days
  • If allergy to penicillin — medical consult for trimethoprim-sulfamethoxazole oral — adult 160+800mg, child 4+20mg/kg/dose up to 160+800mg — doses — twice a day (bd) for 5–7 days

Complicated or severe wound OR heavy contamination OR severe infection

Give until evacuated

  • Cefazolin IV — adult 2g, child 50mg/kg/dose up to 2g — doses — every 8 hours (tds)
  • AND metronidazole IV — adult 500mg, child 12.5mg/kg/dose up to 500mg — doses — every 12 hours (bd)
  • If allergy to penicillin — medical consult for clindamycin IV — adult 600mg, child 15mg/kg/dose up to 600mg — doses — every 8 hours (tds)