Force Injuries


Blunt Force Injuries
  1. Abrasions (scratch)
    • Superficial injury to the skin
    • Epidermis is removed by friction
    • Examples
      • Fingernail scratches
      • Skin dragged over rough surface
         
  2. Bruises (contusion)
    • Blood vessels are damaged
      • Petechial bleed - small amount of bleeding
      • Hematoma - large amount of bleeding
    • Affected by
      • Age of patient
      • Underlying disease
        • Hemophilia
        • EtOH use
        • Liver disease
        • Anticoagulant use
    • Pattern contusions
      • Slap marks with digits delineated
      • Looped or flat contusions
        • From belts or cords
      • Circular contusions
        • From fingertip pressure
        • Often found on medial upper arm
      • Parallel contusions with central clearing from linear objects
      • Contusions from shoe heels and soles
      • Semicircular contusions and abrasions
        • Often from bite marks
    • Bruise Aging
      • Time since occurrence vs. bruise color
      • The following are approximations:
        • 0-2 hours: no discoloration, possibly swollen and/or tender
        • 1-2 days: reddish blue
        • 3-5 days: blue-purple
        • 5-7 days: green
        • 7-10 days: yellow
        • 10-14 days: brown
        • 14-28 days: resolved
      • Varies by:
        • Location
        • Patient age
        • Co-morbidities
        • Medications
  3. Laceration (tear)
    • Goes through epidermis and dermis
    • Differs from a cutting (incised) wound
      • Edges are irregular, crushed, abraded
      • Often see unique "tissue bridges"
        • Strands of tissue connecting dermis to deeper layers
      • Less bleeding (generally)

       

Sharp Force Injuries

  1. Caused by sharp instruments
    • Edged instruments
      • Knives, blades
    • Glass
  2. Both epidermis and dermis are violated
  3. Essentially no indirect injury occurs
    • Tissue is directly cut / torn
  4. Wound types
    • Incised wound (slash wound)
      • Wound length > wound depth
        • Razor slash
    • Penetrating wound
      • Wound depth > wound length
      • May be deeper than weapon length
        • Skin indented at time of impact
  5. Stab wound circumstances
    • Homicidal stab wounds
      • Common locations
        • Trunk, neck
        • Upper arms, head
      • Usually multiple wounds
      • Usually widely spread over patient
      • Often see defensive injuries
        • Palms, fingers
        • Volar forearms
    • Suicidal stab wounds
      • Rare
      • Usually involve
        • Heart
        • Epigastrium
        • Neck
      • Usually see hesitation punctures
      • Clothes often parted to expose target body area
    • Accidental stab wounds
      • Usually single wound
        • Unless patient falls on multi-pronged implement
      • Can affect any part of body
      • Victim often found in situ

General Treatment

  1. Key to success is rapid diagnosis and treatment
  2. Follow ATLS ABCs
  3. Wound evaluation
    • If patient stable
      • May explore wound locally under anesthesia
      • Measure the size of all wounds accurately
      • Note any areas of bruising or grazing
      • Assess wound depth.
        • If bleeding restarts, delay until treatment
      • Look for foreign bodies / contamination
      • Look for signs of infection (local / systemic)
    • Many wounds require no further evaluation
    • Wounds that need further evaluation
      • Crush injuries
      • Fractures
      • Radio-opaque foreign bodies
      • Ask radiology for foreign body views
      • Penetration of a joint
      • Abdominal or thoracic injuries
      • Hand and face injuries
         
  4. Tetanus prophylaxis
  5. Antibiotics
    • Decide on a case-by-case basis
    • Almost always for:
      • Abdominal / chest injuries
      • Joint involvement
      • Dirty wounds