TRAINEE GUIDE HCB 102 UNIT 8 AND 9

TRAINEE GUIDE

FOR

HOSPITAL CORPSMAN BASIC (HCB)

B-300-0010

HCB 102 – BASIC HOSPITAL CORPSMAN SCOPE OF CARE

UNIT 8 – MUSCULOSKELETAL SYSTEM

UNIT 9 – DERMATOLOGY SYSTEM

REVISED FOR

MEDICAL EDUCATION AND TRAINING CAMPUS

3176 CPL JOHNSON ROAD
FORT SAM HOUSTON TEXAS 78234

NOVEMBER 2018

FOR TRAINING USE ONLY

TRAINEE GUIDE HCB 102 UNIT 8 AND 9

TABLE OF CONTENTS

Contents Page

Title Page ............................................................................................................................................ i

List of Effective Elements ................................................................................................................. ii
Change Record ................................................................................................................................. iii
Security Awareness Notice................................................................................................................ v
Safety/Hazard Awareness Notice ..................................................................................................... vi
Terminal Objectives ....................................................................................................................... viii
Course Master Schedule ................................................................................................................... ix

Unit 8 –Musculoskeletal System

Lesson 1 – Assess and Treat Musculoskeletal Conditions
Lesson 2 –Prepare Patient for Transportation
Outline Sheet 102.8.1-1 Musculoskeletal System ................................................................... 10

Unit 9 –Dermatology System

Lesson 1 – Assess and Treat Dermatological Conditions
Outline Sheet 102.9.1-1 Dermatology System ........................................................................ 78

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SECURITY AWARENESS NOTICE

This course does not contain any classified material in any class or practical work session.

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TRAINEE GUIDE HCB 102 UNIT 8 AND 9

SAFET/HAZARD AWARNESS NOTICE

Any time a trainee or instructor has apprehension concerning his or her personal safety or that of
another, he or she shall signal for a "Training Time Out" to clarify the situation or procedure and
receive or provide additional instruction as appropriate. "Training Time Out" signals, other than verbal,
shall be appropriated to the training environment.
Instructors are responsible for maintaining situational awareness and shall remain alert to signs of
trainee panic, fear, extreme fatigue or exhaustion, or lack of confidence that may impair safe
completion of the training exercise, and shall immediately stop the training, identify the problem, and
make a determination to continue or discontinue training. Instructors shall be constantly alert to any
unusual behavior, which may indicate a trainee is experiencing difficulty, and shall immediately, take
appropriate action to ensure the trainee's safety.
The safety precautions contained in this course are applicable to all personnel. They are basic and
general in nature. Personnel who operated and maintain equipment in support of METC must be
thoroughly familiar with all aspects of personnel safety, and strictly adhere to very general as well as
specific safety precaution contained in operating and emergency procedures and applicable governing
directives.
All personnel must have a comprehensive knowledge of emergency procedures which prescribe
courses of action to be followed in the event of an equipment failure or human error as stated in the
Pre-Mishap Plan. Strict adherence to approved and verified operating, emergency and maintenance
procedures in clinic are MANDATORY.
As a minimum, each individual is responsible for knowing, understanding, and observing all safety
precautions applicable to the command, school, course, their work and their work areas. In addition,
you are responsible for observing the following general safety precautions:
A. Each individual shall report to work rested and emotionally prepared for the tasks at hand.
B. You shall use normal prudence in all your functions, commensurate with the work at hand
C. You shall report any unsafe conditions, or any equipment or material which you consider to be
unsafe, and any unusual or developing hazards.
D. You shall warn others whom you believe to be endangered by known hazards or by failure to
observe safety precautions, and of any
E. Unusual or developing hazards.
F. You shall report to the school staff any accident, injury, or evidence of impaired health
occurring in the course of your work or during non-training environment.
G. You shall wear or use the protective clothing and/or equipment of the type required, approved,
and supplied for the safe performance of your work.
All personnel in the immediate vicinity of a designated noise hazardous area or noise hazardous
operation shall wear appropriate hearing protective devices (NDSTC Instruction 6260.6 series).

A Training Time Out (TTO) may be called in any training situation where a student or instructor
expresses concern for personal safety or requests clarification of procedures or requirements. TTO is
also an appropriate means for a student to obtain relief if he or she is experiencing pain, heat stress or
other serious physical discomfort. A TTO may be signaled by displaying a "T" sign with your hands. If
the signal is not acknowledged, the signaler shall shout "Training Time Out." The instructor shall
attempt to relieve and remove the student from the possible hazardous environment. If an adequate

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SECURITY AWARENESS NOTICE

number of instructors are available to allow training to continue safely, the lead instructor may elect to
do so.

However, if this is not practical, training will be stopped until the situation is corrected.

ORM
A decision making tool used by people at all levels to increase operational effectiveness by
anticipating hazards and reducing the potential for loss, thereby increasing the probability of a
successful mission. (OPNAVINST 3500.39 series)

MISHAP
Any unplanned or unexpected event or series of events that result in damage to DoD property;
occupational illness or injury to on-duty DoD military or civilian personnel; or damage to public and
private property or injury and illness to non-DoD personnel caused by DoD operations. (OPNAVINST
5102.1 series)

NEAR MISS
A condition might exist which, if allowed to go unchecked or uncorrected, has the potential to cause a
mishap; or an act or event might result in a near mishap in which injury or damage was avoided merely
by chance. (OPNAVINST 5102.1 series)

UNSAFE CONDITION
Any unsafe or unhealthful working conditions that can cause harm, damage or loss to personnel,
equipment or facilities. Report unsafe conditions in accordance with OPNAVINST 5100.23 series,
Chapter 10.

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TRAINEE GUIDE B-300-0010

OUTLINE SHEET 102.8.1-1

MUSCULOSKELETAL SYSTEM

102.8.1 Perform a musculoskeletal system assessment

102.8.2 Assist in treating musculoskeletal abnormalities

102.8.3 Document musculoskeletal encounter in a SOAP Note

102.8.4 Prepare patient for transportation

102.9.1 Perform a dermatology system assessment (SPL2)

102.9.2 Assist in treating dermatology abnormalities (SPL2)

102.9.3 Document dermatology encounter in a SOAP Note (SPL2)

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OUTLINE SHEET HCB 102.8.1-1

MUSCULOSKELETAL SYSTEM

A. INTRODUCTION

Unlike many other systems, the musculoskeletal system extends into all parts of the body. The
musculoskeletal system provides the stability and mobility necessary for physical activity.
Physical performance requires bones, muscles and joints that function smoothly. Because the
musculoskeletal system serves as the body’s main line of defense against external forces, injuries
are common. Moreover, numerous disease processes affect the musculoskeletal system and can
ultimately cause disability.

B. ENABLING OBJECTIVES

[Link] Define terms related to musculoskeletal system (KPL1)

[Link] Define the anatomy and physiology associated with assessing and treating
musculoskeletal system conditions (KPL1)

[Link] Obtain history from patient with common orthopedic disorders (SPL2)

[Link] Explain concepts and principles for assessing musculoskeletal conditions (KPL2)

[Link] Assess patients for spinal cord injuries (SPL2)

[Link] Assess patients for musculoskeletal conditions (SPL2)

[Link] Examine a patient for orthopedic disorders (SPL2)

[Link] Perform orthopedic examination (SPL2)

[Link] Explain concepts and principles for treating musculoskeletal disorders (KPL 1)

[Link] Assist in the treatment of musculoskeletal disorders (SPL1)

[Link] Assist in treatment of spinal cord injuries (SPL1)

[Link] Apply orthopedic devices (SPL1)

[Link] Remove orthopedic devices (SPL1)

[Link] Document musculoskeletal encounter in SOAP note (SPL 2)

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OUTLINE SHEET HCB 102.8.1-1

MUSCULOSKELETAL SYSTEM (CONT)

[Link] Describe the basic facts in regards to patient evacuation (KPL1)

[Link] Prepare patients for evacuations (SPL1)

[Link] Perform patient carrying techniques (SPL1)

[Link] Describe the basic facts in regards to patient transport (KPL1)

[Link] Prepare patients for transport (SPL1)

[Link] Stabilize patients for transport (SPL1)

C. HCB 102.8.1-1 MUSCULOSKELETAL SYSTEM TOPIC OUTLINE

1. Introduction - Unlike many other systems, the musculoskeletal system extends into all parts of
the body. The musculoskeletal system provides the stability and mobility necessary for
physical activity. Physical performance requires bones, muscles and joints that function
smoothly. Because the musculoskeletal system serves as the body’s main line of defense
against external forces, injuries are common. Moreover, numerous disease processes affect the
musculoskeletal system and can ultimately cause disability.

2. Case Study - Seaman Rose is a 32-year-old male currently working in Supply aboard the USS
CARON (DD-970). Seaman Rose reported to the sick call after experiencing a sharp pain in his
back after being assigned to offload supplies during an extended Replenishment At Sea (RAS).
In addition, he complained that it is hard for him to walk or to bend down.

3. Terms related to the Musculoskeletal System

a. Abduction – Movement of the limb away from the midline of the body.

b. Adduction – Movement of the limb toward the midline of the body.

c. Angulated fracture – Fracture in which the broken bone segments are at an angle to each
other.

d. Articulation- Where two bones meet

e. Atrophy – Decrease in size or wasting away of a body part or tissue.

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f. Bursa – A small serous sac between a tendon and a bone.

g. Bursitis – Inflammation of the connective tissue structure surrounding a joint.

h. Cartilage – Tough tissue that covers the joint ends of bones and helps form certain body parts,
such as the ear.

i. Closed extremity injury – An injury to an extremity with no associated opening in the skin.

j. Comminuted fracture – A fracture in which the bone is broken in several places.

k. Compartment syndrome – Injury caused when tissues such as blood vessels and nerves are
constricted within a space as from swelling or from a tight dressing or cast.

l. Crepitus – A grating or crackling sound or sensation (as that is produced by the fractured ends
of a bone moving against each other).

m. Dislocation – The disrupting or “coming apart” of a body part (joint) from its normal position.

n. Edema – The abnormal accumulation of fluid in interstitial spaces of tissue (also known as
swelling).

o. Effusion – The escape of fluid, such as from blood vessels as a result of rupture or seepage.

p. Erythema – Redness or inflammation of the skin or mucous membranes.

q. Fracture – Any break in the bone or tooth.

r. Greenstick fracture – A fracture of the bone, occurring typically in children in which one
side of the bone is broken and the other only bent.

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MUSCULOSKELETAL SYSTEM (CONT)

s. Gait – A manner of walking or moving on foot.

t. Gout – A form of arthritis, is a disorder of purine metabolism that results from an elevated
serum uric acid level.

u. Mechanism of Injury (MOI) – Method by which damage (trauma) to skin, muscles, organs
and bones happens. Medical providers use MOI to help determine how likely it is that a
serious injury occurred.

v. Orthopedics– Branch of medicine concerned with the prevention or correction of disorders of

the musculoskeletal system.

w. Paralysis – Loss of muscle function through injury, disease, or damage to its nerve supply.
Most paralysis is due to stroke or spinal cord injury.

x. Periosteum – Tough connective sheath that covers the bone.

y. Range of Motion (ROM) – Extent of movement of a joint, measured in degrees of a circle.

z. Sprain – The stretching or tearing of ligaments that causes pain and disability.

aa. Strain – Muscle or tendon injury resulting from violent contraction or excessive force.

bb. Tendonitis – Inflammation of a tendon usually from a strain

4. Anatomy and Physiology of the Musculoskeletal System

a. Anatomy

i. There are three types of muscles:

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MUSCULOSKELETAL SYSTEM (CONT)

1. Voluntary – Known as skeletal muscle, is under conscious control of the brain via the
nervous system.

a. form the major muscle mass of the body

2. Involuntary – Known as smooth muscle, is found in the gastrointestinal system, lungs,

blood vessels, and urinary system.

3. Cardiac – A specialized form of involuntary muscle, is found only in the heart.

ii. Skeletal system:

1. Skull – The bony structure that forms the head. It supports the structures of the face and
provides a protective cavity fort the brain.

a. Cranium – Top portion of the skull that protects the brain which includes the
following bones:

i. Frontal

ii. Parietal

iii. Occipital

iv. Temporal

v. Sphenoid

vi. Ethmoid

b. The bones of the anterior cranium connect to facial bones

i. Mandible (lower jaw)

ii. Maxillae (fused bones of the upper jaw)

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MUSCULOSKELETAL SYSTEM (CONT)

iii. Nasal bones (which provide some of the structure of the nose)

c. Face is the front of the skull

2. Hands and Wrists

a. The wrist consists of eight small bones firmly bound in two rows of four bones each
called carpals.

b. The hand consists of five bones called metacarpals.

c. The fingers consists of 14 bones called phalanges.

3. Elbow – The joint of the arm that connects the upper and lower bones.

a. Humerus (upper arm) – The bone between the shoulder and the elbow.

b. Radius and ulna (lower arm) are the two bones between the elbow and the hand.

i. Radius – Extends from the lateral side of the forearm from the elbow to the
thumb side of the wrist and runs parallel to the ulna.

ii. Ulna – Extends from the medial side of the forearm from the elbow to the
smallest finger and runs parallel to the radius. It is the largest and longer bone in
the forearm.

4. Shoulder – The joint where the humerus fits into the scapula, like a ball and socket. It is
one of the largest and most complex joints of the body.

a. Clavicle – Known as collarbone, is located anteriorly

b. Scapula – Known as shoulder blade, is located posteriorly

i. Acromion process of the scapula is the highest portion of the shoulder

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MUSCULOSKELETAL SYSTEM (CONT)

5. Vertebral column – Commonly referred to as the backbone or spine. It provides structure

and support for the body and houses and protects the spinal cord.

a. There are 33 vertebrae which are divided into five sections:

ii. Cervical

1. Neck

2. 7 vertebrae

iii. Thoracic

1. Thorax, ribs, upper back

2. 12 vertebrae

iv. Lumbar

1. Lumbar Lower back

2. 5 vertebrae

v. Sacral

1. Back wall of pelvis

2. 5 vertebrae

vi. Coccyx

1. Tailbone

2. 4 vertebrae

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MUSCULOSKELETAL SYSTEM (CONT)

6. Pelvis – Contains bones that are fused together

b. Ilium – Is the superior bone that contains the iliac crest

vii. Wide bony wing that can be felt near the waist

c. Ischium is the inferior, posterior portion of the pelvis

d. Pubis is formed by the joining of the bones of the anterior pubis

e. The pelvis is joined posteriorly to the sacral spine

7. Hips – The joint where the femur (thigh bone) and pelvis join

a. Consists of the acetabulum (the socket of the hip joint) and the ball at the proximal
end of the femur

8. Legs and Knees

a. Femur – Commonly referred to as the thigh bone. It is both the longest and strongest
bone in the body extending from the hip to the knee.

b. Patella – Commonly referred to as the kneecap. It is a small, freestanding bone that

rests between the femur and the tibia.

c. Tibia – Also known as the shin bone, is the medial and larger bone of the lower leg.
Shin splints are the most common lower leg injury incurred in the tibia often caused
by running or other athletics.

d. Fibula – The lateral and smaller bone of the lower leg. This is a common site for
stress fractures.

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OUTLINE SHEET HCB 102.8.1-1

MUSCULOSKELETAL SYSTEM (CONT)

9. Feet and Ankles

a. Ankle

i. Two distinct landmarks

1. Lateral malleolus (at the lower end of the fibula).

2. Medial malleolus (at the lower end of the tibia).

ii. Consists of bones called tarsals

b. Feet

i. Calcaneus – The heel bone. A common site for stress fractures caused by
jumping sports such as basketball.

ii. Metatarsals – A group of five long bones in the foot that connect the ankle to the
toes. They help with balance when standing or walking and are the most
common sites for stress fractures caused by sprinting, running or jumping and
other athletics.

iii. Phalanges – Bones of the toes. There are generally three phalanges for each digit
except for the large toe (four).

10. Joints – Formed when bones connect to other bones.

a. Types of joints

i. Ball-and-socket joint – An articulation in which the rounded head of a bone fits

into a cuplike cavity of the other and allows multidirectional movement and
rotation. These joints include: shoulders and hips.

ii. Hinge joint – Formed between two or more bones where the bones can only
move to flex or extend. These joints include: elbows, knees and ankles.

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MUSCULOSKELETAL SYSTEM (CONT)

b. Physiology

i. The musculoskeletal system has five main functions:

1. Provide support. Structural support for the entire body. Individual bones or
groups of bones provide a framework for the attachment of internal organs.

2. Protect internal organs. Many soft tissues and organs are surrounded by
skeletal elements. For example, the rib cage protects the heart and lungs,
the skull protects the brain, the vertebrae protect the spinal cord and the
pelvis protects reproductive organs.

3. Provides leverage and movement. Bones function as levers that can change
the strength and direction of the forces generated by muscles.

4. Produce blood cells. Red blood cells, white blood cells and other blood
elements are produced in the red marrow which fills the internal cavities of
the bones.

5. Store minerals and lipids. Calcium is the most abundant mineral in the
body (99% of the body's calcium is found in the skeleton). The bones also
store energy reserves as lipids (fats) in areas filled with yellow marrow.

ii. Muscles – Three types: visceral, skeletal and cardiac

1. Visceral – Found inside organs such as the stomach, intestines and blood
vessels. The weakest of all muscle tissues, visceral muscle makes organs
contract to move substances through the organ. Visceral muscle cannot be
controlled consciously therefore it is an involuntary muscle.

2. Skeletal – The only voluntary muscle tissue in the body, it is controlled

consciously. The function of the skeletal muscle is to contract to move
parts of the body closer to the vone that the muscle is attached to. Most

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MUSCULOSKELETAL SYSTEM (CONT)

skeletal muscles are attached to two bones across a joint which serves to
move parts of those bones closer together.

3. Cardiac – Found only in the heart, also referred to as Myocardium - it is

responsible for pumping blood throughout the body. Cardiac muscle tissue
cannot be controlled consciously therefore it is an involuntary muscle.

iii. Skeleton – The bones of the body that form its framework.

1. Skull – Encloses and protect the brain.

2. Spine – Is essential for movement, sensation, and vital functions, injuries

have the potential to damage the cord, possibly resulting in paralysis or
death.

5. Basic Assessment and Treatments of the Musculoskeletal System

a. Prehospital orthopedic assessment considerations – Primary assessment

i. History of Present Illness

1. Joint pain can be caused by injury or disease affecting any of the ligaments, bursae or
tendons surrounding the joint. Injury or disease can also affect the ligaments, cartilage
and bones within the join leading to pain. Pain is also a feature of inflammation
(arthritis) and infection.

a. Associated events: time of day, activity, specific movements, injury, strenuous

activity, weather

b. Temporal factors: change in frequency or character of episodes, better or worse as

day progresses, nature of onset (slow versus rapid)

c. Characteristics: Stiffness or limitation of movement, change in size or contour,

swelling or redness, constant pain or pain with particular motion, unilateral or
bilateral involvement, interference with daily activities, joint locking, clicking or
giving way.

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OUTLINE SHEET HCB 102.8.1-1

MUSCULOSKELETAL SYSTEM (CONT)

d. Mechanism of injury: direct trauma, overuse, sudden change of direction, forceful

contraction, overstretch.

e. Efforts to treat: exercise, rest, weight reduction, physical therapy, heat, ice, braces
or splints

f. Medications: nonsteroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen

(aka Motrin)

2. Muscle pain is most commonly caused by tension, stress overuse and minor injuries.
This type of pain is usually localized, affecting just a few muscles or a small part of the
body.

a. Character: limitation of movement, weakness or fatigue, paralysis, tremor, tic,

spasms, clumsiness, atrophy, aching or pain

b. Precipitating factors: injury, strenuous activity, sudden movement, stress

c. Efforts to treat: rest, ice, elevation and compression (RICE), heat, stretching

d. Medications: NSAIDs such as Ibuprofen

3. Skeletal injuries (also known as fractures) involve a complete or partial break in the
bone. In more severe cases, the bone may be broken into several places. Fractures may
be the result of high force impact or stress, or minimal trauma injury as a result of
certain medical conditions that weaken the bone.

a. Character: difficulty with gait or limping; numbness, tingling, or pressure

sensation; pain with movement, crepitus; deformity or change in skeletal contour.

b. Mechanism of injury: high force (and/or direct) trauma, overuse, sudden change of
direction, forceful contraction or crushing.

c. Associated event: injury, recent fractures, strenuous activity, sudden movement,

stress; postmenopausal

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MUSCULOSKELETAL SYSTEM (CONT)

d. Efforts to treat: rest, elastic bandage, splint, orthopedic cast and traction splint

e. Medications: Analgesics such as Tylenol

ii. Past Medical History (determine if the patient had/has)

1. Trauma: nerves, soft tissue, bones, joints; residual problems; bone infection

2. Surgery on joint or bone; amputation, arthroscopy

3. Chronic illness: cancer, arthritis, sickle cell disease, hemophilia, osteoporosis, renal or
neuralgic disorder

4. Skeletal deformities or congenital anomalies

iii. Family History

1. Congenital abnormalities of hip or foot

2. Scoliosis or back problems

3. Arthritis

4. Genetic disorders

iv. Personal/Social History

1. Employment: past and current, lifting and potential for unintentional injury, repetitive
motions, typing/ computer use, safety precautions, use of spinal support, chronic stress
on joints

2. Exercise: extent, type, and frequency; weight bearing; stress on specific joints

3. Functional abilities: personal care (eating, bathing, dressing, grooming, elimination);

other activities (housework, walking, climbing stairs, caring for pet); use of prosthesis

4. Weight: recent gain, overweight or underweight for body frame

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MUSCULOSKELETAL SYSTEM (CONT)

5. Height: maximum height achieved, any changes

6. Nutrition: amount of calcium, vitamin D, calories, and protein

7. Tobacco or alcohol use

v. Equipment for inspection, palpation, ROM, muscle tone/strength

1. Skin-marker pencil

2. Goniometer (instrument used for measurement of angles)

3. Tape Measure

4. Reflex Hammer

vi. Inspection

1. Inspect the anterior, posterior, and lateral aspects of the patient's posture.

2. Observe the patient's ability to stand erect, symmetry of body parts, and alignment of
the extremities.

3. Note any abnormal curvature of the spine.

4. Inspect the skin and subcutaneous tissues overlying the muscles, cartilage, bones, and
joints for discoloration, swelling, and masses.

5. Observe the extremities for symmetry and deformities.

6. Muscle wasting occurs after injury as a result of pain, disease of the muscle, or damage
to the motor neuron.
vii. Palpation

1. Palpate any bones, joints, and surrounding muscles if symptomatic. Palpate inflamed
joints last.

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MUSCULOSKELETAL SYSTEM (CONT)

2. Note any heat, tenderness, swelling, crepitus, pain, and resistance to pressure.

3. No discomfort should occur when you apply pressure to bones or joints.

4. Muscle tone should be firm, not hard or doughy

viii. Range of Motion and Muscle Tone

1. Examine both the active and passive range of motion for each major joint and its
related muscle groups.

2. ROM and muscle tone are often evaluated simultaneously.

3. Allow adequate space for the patient to move each muscle group and joint through its
full range.

4. Instruct the patient to move each joint through its active range of motion as detailed in
specific joint and muscle sections.

5. Note limitations due to pain, joint instability, and deformity which suggest a problem
with the joint, related muscle group, or nerve supply.

6. Ask the patient to relax and allow you to passively move the same joints until the end
of the range of motion is felt.

7. Do not force the joint if there is pain or muscle spasm.

8. Muscle tone may be assessed by feeling the resistance to passive stretch.

9. During passive range of motion, the muscles should have slight tension.

10. Passive range of motion often exceeds active range of motion by five degrees.

11. Range of motion with active and passive maneuvers should be equal between joints.

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12. Discrepancies between active and passive range of motion may indicate true muscle
weakness or a joint disorder.

13. No crepitation or tenderness with movement should be apparent.

14. Note the specific location of tenderness when present.

15. When a joint appears to have an increase or limitation in its range of motion, a
goniometer is used to precisely measure the angle.

16. Begin with the joint in the neutral position, and then flex/extend the joint as far as
possible.

17. Measure the angles of greatest flexion and extension, comparing these with the
expected joint flexion and extension values

ix. Muscle Strength

1. Evaluating the strength of each muscle group is considered part of the neurologic
examination. However, it is usually integrated with the examination for
musculoskeletal conditions. Thus the provider must define the character of symptoms,
including location, time of occurrence, precipitating factors and associated
signs/symptoms.

2. Ask the patient first to contract the muscle you indicate by extending or flexing the
joint and then to resist as you apply force against that muscle contraction.

3. Alternatively, tell the patient to push against your hand to feel the resistance.

4. Compare the muscle strength bilaterally.

5. Expect muscle strength to be bilaterally symmetric with full resistance to opposition.

6. Full muscle strength requires complete active range of motion.

7. Variations in muscle strength are graded from no voluntary contraction to full muscle
strength, using the scale in the table below.
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8. Weakness may result from disuse atrophy, pain, fatigue, or overstretching.

9. Muscle strength should be graded on a scale of 0/5 to 5/5 using the below scale:

Muscle Function Level Grade

No evidence of movement 0
Visible muscle contraction with no or trace of movement 1
Full range of motion, but not against gravity 2
Full range of motion against gravity but not against resistance 3
Full range of motion against gravity and some resistance 4
(supplied by the provider or object), but weak
Full range of motion against gravity, full resistance 5

6. Perform orthopedic examination

a. Hands and Wrists

i. Inspect the dorsum and palm of hands for the following:

1. Position

2. Shape

3. Number and completeness of digits.

ii. Palpate each joint in the hand and wrist.

iii. Test range of motion by the following maneuvers:

1. Flexion and extension of the joints of the hand and fingers

2. Thumb opposition

3. Forming a fist

4. Finger adduction and abduction

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5. Wrist flexion and extension

6. Radial deviation

7. Ulnar deviation

iv. Test muscle strength by the following maneuvers:

1. Wrist flexion and extension.

2. Hand grip

b. Elbow

i. Inspect the elbows

ii. Palpate the elbow and surrounding areas

iii. Test range of motion by the following maneuvers:

1. Flexion

2. Extension

3. Pronation and supination

iv. Test muscle strength by the following maneuvers:

1. Elbow flexion and extension.

2. Pronation and supination

c. Shoulder

i. Inspect shoulders and shoulder girdle for contour, edema, ecchymosis, erythema &
deformities.

ii. Palpate the joint spaces and bones of the shoulders.

iii. Observe the patients’ face for grimace (sign of pain)

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iv. Test range of motion by the following:

1. Shrugging the shoulders.

2. Forward flexion

3. Extension

4. Abduction

5. Adduction

6. Internal and external rotation

v. Test muscle strength by the following maneuvers:

1. Shrugged shoulders.

2. Abduction with forward flexion.

3. Medial rotation.

4. Lateral rotation.

d. Cervical Spine

i. Inspect the neck for:

1. Alignment

2. Symmetry of skinfolds and muscles.

3. Step-off sign – a step-like central defect, typical of sickle cell anemia or fracture
where the bones are not lined up properly. This can be seen and/or felt during the
examination.

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ii. Range of motion:

1. Forward flexion

2. Extension

3. Lateral bending

4. Rotation

5. Test muscle strength by the following maneuvers:

a. Flexion against resistance

b. Extension with resistance

c. Rotation with resistance

e. Thoracic and Lumbar spine

i. Inspect the spine for alignment.

ii. Palpate the spinal processes and muscles for deformities and tenderness.

iii. Test range of motion by the following:

1. Forward flexion

2. Extension

3. Lateral bending

4. Rotation

f. Hips

i. Inspect the hips for symmetry.

ii. Palpate hips and pelvis for the following:

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1. Instability

2. Tenderness

3. Crepitus

iii. Test range of motion by the following maneuvers:

1. Flexion

2. Extension

3. Adduction

4. Abduction

5. Internal rotation

6. External rotation

iv. Test muscle strength of hips with the following maneuvers:

1. Flexion and extension

2. Abduction and adduction

3. Internal external rotation

g. Legs and Knees

i. Inspect the knees.

ii. Palpate the knee.

iii. Test range of motion with the following maneuvers:

1. Flexion

2. Extension

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iv. Test the strength of muscles in flexion and extension.

7. Assist in treatment of musculoskeletal disorders

a. Spinal Injury

i. Pathophysiology:

1. Bones, ligaments, and cartilage of the spinal column are damaged, the spinal cord
can be damaged as well.

2. Specific injuries to the spinal column include:

a. Fractures with and without bone displacement

b. Dislocations

c. Muscular strains

d. Disk injury including compression

3. These injuries can occur without injury to the spinal cord, but when displaced
fractures or dislocations occur, the cord, disk, and spinal nerves can be severely
injured.

4. The spinal cord itself can be lacerated, contused or impinged on resulting in

permanent damage (e.g. paralysis).

5. Injuries that occur immediately and as a result of direct force are called primary
injuries.

6. Secondary injuries to the spinal cord occur after the initial insult, but can cause the
same and even more harm.

7. Assessment must account for the possibility of spinal involvement in any traumatic
injury.

8. Remember: not every trauma patient has a spinal injury.

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9. Assessment should evaluate physical findings and MOI to make appropriate

decisions regarding the risk of potential spinal damage.

10. Identifying a potential spinal injury results from an assessment of both MOI and the
physical condition of the patient.

11. The spine is most often injured by energy that forces movement of the spine beyond
its normal range of motion.

a. Flexion and extension injuries are common.

b. Sometimes the spine is over rotated, as in a twisting sports injury or excessively

compressed.

c. When the spine is excessively pulled, as in a hanging, it can cause a

“distraction” injury.

d. Penetrating trauma can also cause destruction of vertebrae and damage to the
spinal cord.

12. The cervical and lumbar vertebrae are most susceptible to injury because they are
not supported by other bony structures.

13. Certain medical conditions also make the spine more vulnerable to injury (i.e.
Osteoporosis, spina bifida, scoliosis)

14. Other patients have conditions where the spine cannot move the way it normally
would such as fused vertebrae

15. Certain MOI are associated with a high risk for spinal injury.

a. Falls from greater than 1 meter (roughly 3 feet) or down more than 5 stairs

b. Axial loading (compression injuries) such as those that occur in diving injuries

c. High-speed motor-vehicle crashes, especially with rollover or ejection of the

patient

d. Motorized recreational vehicle (ATV) crashes

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e. Bicycle collisions

16. Maintain a high degree of suspicion of a potential spine injury when your patient is
a victim of a motor-vehicle or motorcycle collision, was struck by a vehicle,
received blunt injury to the spine or above the clavicles, was involved in a diving
incident, was found hanging by his neck, or was found unconscious from trauma.

ii. Pre- Hospital/Inpatient/Outpatient Considerations

1. Subjective:

a. Pain with movement (Do not ask the patient to move.)

b. Pain in the area of the injury

c. Significant MOI along with contributing signs and symptoms

d. Impaired breathing

2. Objective / Illness / Injury:

a. Physical assessment for spine and spinal cord injury

b. Mechanism alone does not identify injury.

c. Assessment, especially in times of high-risk mechanism of injury should

specifically look for the physical indicators of spinal injury.

d. Pain and tenderness, particularly in the area of the spine will be important
findings.

e. Motor and sensory deficits.

f. Symptoms of spine injury

g. Paralysis of extremities--the most reliable sign of spinal cord injury in conscious

patients

h. Tenderness anywhere along the spine

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i. Priapism- a persistent erection caused by excessive blood flow into the penis as
a result of trauma or injury to the pelvis or perineum.

j. Loss of bowel or bladder control

k. Neurogenic shock

3. Assess for the need for Spinal Precautions-Selective Spinal Immobilizations

a. Many systems use formal spinal assessment algorithms to identify the likelihood
of spinal injury and to indicate the need for spinal precautions.

b. Most algorithms have their roots in the National Emergency X Radiography

Utilization Study (NEXUS)

c. Evidence based framework for assigning risk of spinal injury

d. Key elements of the NEXUS algorithm are as follows:

i. Reliable patient

ii. Any pain along the midline spine would signify a high risk of spinal injury

iii. NEXUS associated tenderness with spinal injuries. Practitioners must

palpate 33 vertebrae to assess for any pain on palpation. Any painful
response to palpation would be considered a positive finding

iv. Neurological function must be fully intact

e. It is reasonable then to use these best practices to formalize spinal assessment

iii. Assessment: Spinal Trauma

1. Differential Dx:

a. Osteoporosis

b. Posterior rib fracture

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iv. Plan / Treatment:

1. Pre-Hospital

a. Assess and treat any life threatening injuries

b. Maintain spinal immobilization via the application of a cervical collar (C-collar)

c. Place patient on a long spine board to protect from further injury and to keep
them immobilized

2. Inpatient/Outpatient

a. Maintain spinal immobilization

b. Assist in administering pain medication

c. Assist in performing imagery (x-ray, CT, MRI)

v. Document encounter.

b. Shoulder Dislocation

i. Pathophysiology / MOI / NOI:

1. Caused by pressure or force pushing the bone out of the joint; usually occurs in the
setting of acute trauma.

2. The shoulder is a very dynamic joint, prone to injury.

3. Anterior Dislocations are the most common

ii. Pre-Hospital/Inpatient/Outpatient Considerations

1. Subjective Data / Signs and Symptoms:

a. Severe pain in the affected shoulder.

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b. Repeat injury

2. Objective Data / Injuries or Illness:

a. Deformity and inability to use extremity or joint as usual.

b. Anterior Dislocation:

i. Shoulder is squared off

c. Prominent acromion process

d. Arm is held in slight abduction and external rotation

3. Assessment: Shoulder dislocation

a. Differential Dx:

i. Fracture of the Humeral head

ii. Acromioclavicular joint injury

iii. Scapular Fracture

iv. Cervical Spine Injury

4. Plan / Treatment:

a. Pre-Hospital - Splint utilizing a sling and swathe

b. Inpatient/Outpatient

i. Assist in administering pain control medication

ii. Assist in reduction of dislocation

iii. Assist in obtaining imagery (x-ray, CT, MRI)

iv. Document encounter

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c. Wrist Fracture

i. Pathophysiology / MOI / NOI:

1. From trauma (direct, indirect, twisting, or crushing).

2. The scaphoid is the most commonly fractured carpal bone.

3. As the wrist is forcibly hyperextended (beyond its normal limits), the palm side of
the scaphoid fails in tension and the dorsal side fails in compression resulting in a
fracture.

4. Mechanism of injury is commonly referred to Fallen on Outstretched Hand

(FOOSH)

ii. Pre-Hospital/Inpatient/Outpatient Considerations

1. Subjective Data / Signs and Symptoms:

a. Pain, limited movement, swelling

b. Felt a pop or snap with injury

c. Can occur more easily in patients with bone disorders.

2. Objective Data / Injury Illness:

a. Deformity

b. Maximal pain and tenderness in the anatomic snuffbox

c. Decreased range of motion of the wrist and thumb

d. Loss of function

e. Color changes

f. Paresthesia

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3. Assessment: Wrist Fracture

a. Differential diagnosis:
i. Wrist sprain
ii. Distal radius or ulnar fracture

4. Plan / Treatment:

a. Pre-Hospital

i. Apply a SAM splint to immobilize the wrist

ii. Immobilize the arm by applying a sling and swathe

b. In-Patient/Out-Patient

i. Assess mechanism of injury and point of maximal tenderness

ii. Exam with special attention to skin integrity and neurovascular status

iii. Assist in administering pain control medications

iv. Assist in obtaining imagery (x-ray, CT, MRI)

5. Document encounter

d. Ankle Sprain-Inversion

i. Pathophysiology / MOI / NOI

1. Injuries to the lateral ligaments that support the ankle due to being stretched too
much.

2. The ankle joint is a hinge joint composed of the tibia, fibula, and talus.

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3. Injuries may range from stretching with microscopic damage (grade I) to partial
disruption (grade II) to complete disruption (grade III).

4. 85-90% of ankle sprains involve lateral ligaments.

ii. Pre-Hospital Considerations

1. Subjective / Signs and Symptoms:

a. History from the patient to include:

i. Time of injury

ii. MOI

iii. Treatments attempted prior to care

iv. Presence of a “pop” or “crack”

v. History of previous trauma

vi. Ability to bear weight after the injury occurred

vii. Pain

2. Objective / Injuries or Illness

a. Joint instability

b. Pain on the lateral aspect of the ankle with palpation

c. Swelling

d. Ecchymosis

3. Assessment: Inversion ankle sprain

a. Differential Dx:

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i. Achilles tendon injury

ii. 5th Metatarsal fracture

4. Plan / Treatment:

a. Splint/Immobilize the ankle

b. Prevent further injury: avoid weight bearing

c. Rest, Ice, Compression, Elevation (RICE)

iii. In-Patient/Out-Patient Considerations

1. Subjective: Same as Pre-hospital

2. Objective:

a. Assess for joint laxity-Initial assessment for laxity may be difficult due to pain,
swelling, and muscle spasm. Repeat exam ~5 days after injury may improve
sensitivity

b. Difficulty bearing weight

c. Check pulse, motor, sensory of the area surrounding and distal to the injury.

3. Assessment: Inversion ankle sprain

a. Differential Dx;

i. Fracture and/or dislocation of the ankle/foot

ii. Nerve injury

4. Plan / Treatment

a. Assist with obtaining Radiographs of the ankle if deemed necessary.

b. Most lateral ankle sprains can be managed conservatively-RICE

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c. Rest: Initially, activity as tolerated. Early mobilization and physical therapy

speed recovery/reduce pain:

i. Weight bearing, as tolerate

ii. Consider crutches if unable to bear weight.

iii. Exercises should be initiated as early as tolerated and limited to pain-free

range of motion.

iv. Patients can start mobilization by tracing the alphabet with the foot in the air.

v. Resistance exercises with an elastic band

vi. Protection/compression: For grade I/II sprains, lace-up bracing is superior to

air-filled/gel-filled ankle brace, which is superior to elastic bandage/taping to
provide support and decrease swelling. Grade III sprains should have short-
term immobilization (10 days)

vii. Ice: Ice for first 3 to 7 days for pain reduction and decrease recovery time

viii. Elevation: Elevate ankle to decrease swelling.

ix. Assist with administration of pain medication

5. Document encounter

e. Low Back Pain

i. Pathophysiology / MOI / NOI:

1. Low back pain (LBP) is extremely common and includes a wide range of symptoms
involving the lumbosacral spine and pelvic girdle.

2. LBP can be characterized by duration or associated symptoms.

a. Duration:

i. Acute (<6 weeks)

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ii. Subacute (>6 weeks but <3 months)

iii. Chronic (>3 months)

3. A specific cause is not found for most patients with LBP. Most cases resolve in 4 to
6 weeks.

4. Rule out "red" flag symptoms indicating the need for immediate intervention. Red
flags:

a. Recent trauma

b. Neurologic deficits

c. Bowel/bladder incontinence or urinary retention

d. Saddle anesthesia

e. Weakness, falls

f. Night pain, sweats, fever, weight loss

g. Age >70 years with or without trauma

h. Age >50 years with minor trauma

i. History of cancer

j. Osteoporosis

5. System(s) affected: musculoskeletal, neurologic

6. Synonym(s): lumbago, lumbar sprain/strain, low back syndrome

7. Risk Factors:

a. Age

b. Activity (lifting, sudden twisting, bending)

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c. Obesity

d. Sedentary lifestyle

e. Physically strenuous work

f. Psychosocial factors—anxiety, depression, stress

g. Smoking

ii. Subjective / Signs and Symptoms

1. Localized/nonspecific "mechanical" low back pain

2. Back pain with lower extremity symptoms

3. Systemic and visceral symptoms

4. On set of pain (sudden or gradual)

5. Referred pain to the groin, buttocks, or extremities

a. Irritation, impingement, or compression of lumbar and sacral nerve roots often

results in more leg pain than back pain

b. Pain from the L1-L3 nerve roots radiates to the hip and/or thigh, whereas pain
from the L4-S1 nerve roots radiates below the knee

iii. Prehospital Considerations

1. Objective Injury / Illness:

a. Pain is worse with extension

b. Unilateral pain/numbness down one extremity without signs of bowel/bladder

dysfunction

c. Abnormal gait

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2. Assessment: Low Back Pain

a. Differential Dx:

i. Renal Calculi

ii. Abdominal Aortic Aneurysm

3. Plan / Treatment:

a. Pre-Hospital

i. Reassure patients that pain is usually self-limited; treatment should relieve

pain and improve function

ii. Rule out pregnancy in female patients

b. In-Patient/Out-Patient

1. Prevention Measures:

i. Maintain normal weight

ii. Adequate physical fitness and activity

iii. Stress reduction

iv. Proper lifting technique and good posture

v. Smoking cessation

2. Assist with administration of pain control medication

3. Assist with obtaining imagery (x-ray, CT, MRI)

4. Document encounter

f. Chondromalacia Patella (Patellofemoral Pain Syndrome-PFPS)

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i. Pathophysiology / MOI / NOI:

1. Pain in or around the patella that increases after prolonged sitting, squatting,
kneeling, and stair climbing

2. Most frequently diagnosed condition in patients <50 years old with knee complaints

3. High incidence in physically active populations

4. Direct relationship with hip weakness and poor functional control of the femur
during weight-bearing tasks

5. Risk factors:

a. Weak quadriceps

b. Female sex

c. Limited quadriceps and gastrocnemius flexibility. Decreased hamstring

flexibility

d. Increased medial patellar mobility

ii. Subjective:

1. Anteromedial knee pain exacerbated by physical activity

2. Anterior knee pain when descending/ascending stairs, ambulating over uneven

surfaces, or running

3. Pain often exacerbated when squatting

4. Pain after activity as well as during activity

iii. Objective:

1. Apprehension sign: Compress the patella against the femur and ask the patient to
contract quadriceps muscles; pain upon contraction is consistent with patellofemoral
pain syndrome, although pain may be present in normal individuals as well

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2. Compression test: reproduction of pain with compression of patella against the

femur

iv. Assessment: PFPS

1. Differential Dx:

a. Iliotibial band syndrome

b. ACL, PCL, and meniscal disruption

v. Plan:

1. Stretching and strengthening exercises, especially hip strengthening

2. Taping and bracing

3. NSAIDs for pain management

4. Ice packs after activity improve clinical symptoms

vi. Document encounter

g. Medial Tibial Stress Syndrome (Shin Splints)

i. Pathophysiology:

1. It is aching pain along the inner edge of the tibial shaft that develops when the
musculature and/or periosteum in the (lower) leg become irritated by repetitive
activity. The condition is part of a continuum of stress-related injuries to the lower
leg. MTSS does not encompass pain from ischemia (compartment syndrome) or
stress fractures.

2. Overuse injuries causing or limited by micro trauma from repetitive motion leading
to periosteal inflammation

3. Pathogenesis: theorized to be due to persistent repetitive loading, which leads to

inadequate bone remodeling and possible micro fissures causing pain without
evidence of fracture or ischemia

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4. Risk Factors:

a. Female sex

b. Leaner calf girth

c. Lack of physical fitness

d. Inexperienced runners and rapid increase in mileage

ii. Subjective:

1. Patients typically describe dull, sharp, or deep pain along the lower leg that is
resolved with rest.

2. Patients are often able to run through the pain in early stages

3. Pain is commonly associated with exercise (also true with compartment syndrome),
but in severe cases, pain may persist with rest

iii. Objective:

1. Tenderness to palpation is typically elicited along the posteromedial border of the

middle-to-distal third of the tibia

2. Pain with plantar flexion

3. Ensure neurovascular integrity of the lower extremity, examining distal pulses,

sensation, reflexes, and muscular strength

iv. Assessment: MTTS/Shin Splints

1. Tibial Stress Fracture

a. Typically, pain persists at rest or with weight-bearing activities.

b. Focal tenderness over the anterior tibia

2. Compartment Syndrome-Emergency condition

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a. Pain without direct tenderness on exam

b. Pain increases with exertion and resolves at rest.

c. Pain is described as cramping or squeezing.

d. Pain with possible weakness or paresthesia on exam

v. Plan:

1. Use ancillary service to rule out fracture (x-ray, bone scan)

2. Activity modification with a gradual return to training based on improvement of

symptoms

3. Patients should maintain fitness with low-impact activities such as swimming and
cycling

4. Continue activity modification until patients are pain-free on ambulation.

5. Supportive footwear

6. Ice therapy

7. NSAIDs

8. Stretching

vi. Document encounter

h. Mid-Shaft Femur Fracture

i. Pathophysiology:

1. Usually requires major, high-energy trauma

2. Patients are mostly young

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3. Adults with high-energy injuries (motor vehicle accidents [MVAs], gunshot wounds
[GSWs], falls).

4. Complications include compartment syndrome, fat embolism, hemorrhage

5. Fractures are classified according to location, geometry (i.e. transverse, spiral), and
extent of soft tissue injury (open, closed)

ii. Subjective:

1. Extreme pain

2. MOI

3. Cannot walk

iii. Objective:

1. Thigh deformity, swelling, and shortening

2. Commonly presents as multi-trauma:

a. Chest, abdominal, pelvic, hip, knee injury, including dislocation.

3. Patient may be hypotensive due to hemorrhage into the thigh.

4. Patient may have impaired circulation in the distal leg due to vascular compromise
or compartment syndrome.

iv. Assessment: Femur Fracture

1. Hip dislocation

2. Thigh contusion

v. Plan:

1. Pre-hospital

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a. Treat life-threatening injuries

b. Monitor BP continuously for signs of hemorrhagic shock.

c. Obtain IV access

d. Immobilization of the extremity

e. Application of a traction splint can be important for tamponade of further blood

loss into the thigh.

2. In-Patient/Out-Patient

a. Maintain lower extremity stability.

b. Under medical direction remove splint and clothing

c. Assist in administering pain control medications

d. Femur fractures with diminished or absent distal pulses, an expanding

hematoma, or a palpable pulsatile mass require immediate surgery

e. Traction should be maintained or applied if the patient will not go to the OR

immediately

vi. Document Encounter

8. Apply a Cervical Collar - A collar is a device that wraps around the neck and provides rigid
form to help prevent movement.

a. Apply a rigid cervical collar to any patient who may have an injury to the spine based on
mechanism of injury, history, or signs and symptoms.

b. Rigid cervical collars, or extrication collars, are frequently used to aid in the spinal motion
restriction of the cervical spine.

c. Collars must be properly sized. A wrong sized collar may do more harm than good by
hyperextending the neck if it is too large or allowing flexion if it is too small.

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d. The collar is not applied in a way that will obstruct the airway. Maintain manual
stabilization even after the collar is in place until the patient is secured to a backboard.

e. Rigid extrication collars are designed to limit flexion, extension, and lateral movement
when combined with an immobilization device such as a long backboard, vacuum mattress,
or a vest-style device.

f. Once cervical spinal movement is restricted, it is important to establish a baseline for

sensory, motor, and circulatory function in four extremities.

i. Ensure that at least two people are available to place a cervical collar; one maintains
cervical spine alignment while the other applies the collar.

ii. Remove protective headgear if indicated

iii. Return the patient’s head to a neutral position (unless contraindicated).

iv. Remove jewelry from the ears, neck, face, and tongue before collar placement

v. Measure with the hand and adjust the collar until the sizing line is the correct distance
from the lower plastic edge of the collar

vi. Push down on the safety buttons to lock the collar

vii. Slide the back of the collar under / behind the patient's neck.

viii. Bring the front of the collar around the front of the patient's neck. Ensure that the collar
is laying on the shoulder, chest, and the chin rest is under the chin.

ix. While holding positive control of the collar in front, ensure not to press down on the
collar, and bring the securing strap around and secure the collar. Do not secure the
collar too tightly or too loosely as this will cause the collar to be ineffective.

x. Do not remove the collar. Only a medical officer can remove device.
9. A sling is a triangular bandage used to support the shoulder and arm.

a. Once the patient’s arm is placed in a sling, a swathe can be used to hold the arm against the
side of the chest.

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b. Remember to assess distal pulse, motor function, and sensation both before and after
immobilizing or splinting an extremity

c. Do not tie a sling around the patient’s neck if there is possible cervical-spine injury

10. Apply a SAM Splint

a. Utilize least injured side to measure and form split

b. Make sure to extend past joints on either side of injury to reduce movement

c. Secure split to extremity with ace bandage or any available pliable material

11. Applying a traction splint:

a. Perform hand hygiene before patient contact and don gloves.

b. Assess A-B-C-Ds, including central and distal pulses, and provide cervical spine
precautions as indicated.

c. Obtain vital signs and oxygen saturation via pulse oximetry and connect the patient to a
cardiac monitor. Assess vital signs frequently.

d. Remove the patient's clothing, jewelry, and any constrictive bulky material that would lay
under the splint. Remove or cut off footwear.

e. Perform a focus assessment of the extremity using the 8 Ps: pain, pallor, pulses, paresthesia,
paralysis, puffiness, position, and pressure. Notify the practitioner immediately of any
abnormalities.

f. If skin integrity is disrupted, consider it to be an open fracture; notify the practitioner

immediately.

g. Inspect all wounds and covered them with a sterile dressing.

h. Unbuckle the stirrup and fasten the ankle hitch snugly above the ankle and just below the
calf.

i. Buckle the stirrup again and pull the green tab to eliminate slack.

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j. Slide the male end of the upper thigh strap buckle underneath the knee and up toward the
groin. Position the thigh pad around the upper inner thigh. Fasten the buckle.

k. Tighten the thigh strap while positioning the pole receptacle high along the lateral hip, near
the belt line.

l. Put together the traction pole, then place the pole alongside the leg with at least one pole
section extending past the foot. Fold the proximal pole end back on itself to achieve the
correct splint length.

m. Seat the traction pole in the receptacle and secure the pole to the knee.

n. Attach the yellow loop of the ankle hitch to the anchor point. Feed the strapping through
with one hand while pulling the red tab with the other until traction was approximately 10%
of the patient's body weight or a maximum of 6.8 kg (15 lb) of force.

o. Feed the thigh and lower leg straps underneath the knee and slide them into place.

p. Reassess distal motor and neurovascular status.

q. Monitor vital signs and oxygen saturation.

r. Assess, treat, and reassess pain.

s. Continue to reassess distal motor and neurovascular status of the foot; notify the
practitioner immediately of any changes.

t. Elevate the extremity as indicated and prescribed.

u. Apply cold packs or ice packs as indicated or prescribed.

v. Administer tetanus immunization as indicated and prescribed.

w. Administer antibiotics as prescribed.

x. Prepare the patient for operative intervention or the insertion of a pin for skeletal traction.

y. Discard supplies, remove PPE, and perform hand hygiene.

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z. Document the procedure in the patient's record

12. Lesson 2 – Prepare Patients for Transport

13. Protecting Yourself: Body Mechanics - refers to the proper use of your body to prevent injury
and to facilitate lifting and moving.

a. Things to consider before lifting a patient

i. The objects

ii. Your imitations

iii. Communication

b. Rules to prevent injury

i. Position your feet properly.

ii. Use your legs.

iii. Never turn or twist.

iv. Do not compensate when lifting with one hand.

v. Keep the weight as close as possible to your body.

vi. Use a stair chair when carrying a patient on stairs whenever possible.

c. It is almost always safer and more efficient to move patients over distances on a wheeled
device rather than carry a patient.

d. When lifting a patient-carrying device, use an even number of people if possible.

i. Power lift

1. Squat rather than bend at the waist.

2. Keep the weight close to your body.

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3. Keep feet a comfortable distance apart and flat on the ground with weight primarily
on the balls of the feet or just behind them.

4. Keep your back locked-in.

5. Use the reverse order to lower a patient.

ii. Power grip

a. As great an area of your fingers and palms as possible should be in contact with the
object.

b. All of your fingers should be bent at the same angle.

c. If possible, keep your hands at least 10 inches apart.

iii. Reaching

1. Keep your back in a locked-in position.

2. Avoid twisting while reaching.

3. Avoid reaching more than 20 inches in front of your body.

4. Avoid prolonged reaching when strenuous effort is required.

iv. Pushing or pulling

a. Push, rather than pull, whenever possible.

b. Keep your back locked-in.

c. Keep the line of pull through the center of your body by bending your knees.

d. Keep the weight close to your body.

e. If the weight is below your waist level, push or pull from a kneeling position.

f. Avoid pushing or pulling overhead.

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g. Keep your elbows bent and arms close to your sides

14. Patient Carrying Techniques

a. One-Rescuer Assist:

i. Place the patient’s arm around your neck, grasping his/her hand in yours.

ii. Place your other arm around the patient’s waist.

iii. Help patient walk to safety.

iv. Be sure to communicate with the patient about obstacles, uneven terrain, and so on.

b. Cradle Carry

i. Place one arm across the patient’s back with your hand under his/her arm.

ii. Place your other arm under his/her knees and lift.

iii. If the patient is conscious, have him/her place his/her near arm over your shoulder.

c. Pack Strap Carry

i. Have the patient stand.

ii. Turn your back to him/her, bringing his/her arms over your shoulders to cross your
chest.

iii. Keep his/her arms as straight as possible, with his/her armpits overs your shoulders.

iv. Hold the patient’s wrists, bend and pull him/her onto your back.

d. Fireman’s Carry

i. Place your feet against the patient’s feet and pull him/her toward you.

ii. Bend at your waist and flex your knees.

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iii. Duck and pull him/her across your shoulder, keeping hold of one of his/her wrists.

iv. Use your free arm to reach between his/her legs and grasp his/her thigh. This way, the
weight of the patient falls onto your shoulders.

v. Stand-up.

vi. Transfer your grip on his/her thigh to the patient’s wrist.

e. Piggyback Carry

i. Assist the patient to stand.

ii. Place his/her arms over your shoulder so they cross your chest.

iii. Bend over and lift the patient.

iv. While he/she holds on with his/her arms, crouch and grasp each leg.

v. Use a lifting motion to move him/her onto your back.

vi. Pass your forearms under his/her knees and grasp his/her wrists.

f. Two-Rescuer Assist

i. Place the patient’s arms around the shoulders of both rescuers.

ii. They each grip a hand, place their free arms around the patient’s waist, and help
him/her walk to safety.

g. Fireman’s Carry With Assist

i. Place your feet against the patient’s feet and pull him/her toward you.

ii. Bend at your waist and flex your knees.

iii. Duck and pull him/her across your shoulder, keeping hold of one of his/her wrists.

iv. Use your free arm to reach between his/her legs and grasp his/her thigh. This way, the
weight of the patient falls onto your shoulders.

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v. Stand up.

vi. Transfer your grip on his/her thigh to the patient’s wrist.

vii. The second rescuer helps to position the patient.

h. Extremity Carry

i. Place the patient on his/her back with knees flexed.

ii. Kneel at the patient’s head.

iii. Place your hands under his/her shoulders.

iv. The second HM kneels at the patient’s feet, grasps the patient’s wrists, and lifts the
patient forward.
v. At the same time, slip your arms under the patient’s armpits and grasp his/her wrists.

vi. The second HM can grasp the patient’s knees while facing, or facing away from the
patient.

vii. Direct the second HM, so both move to a crouch, and stand at the same time.

viii. Move as a unit when carrying a patient.

ix. If the patient is found sitting, crouch and slip your arms under the patient’s armpits and
grasp hi/her wrists.

x. The second HM crouches, then grasps the patient’s knees.

xi. Lift the patient as a unit.

15. Moving The Casualty To Safety - In an emergency, there are many ways to move a casualty to
safety. Ranging from one-person carries to stretchers and spine boards. The casualty’s
condition and the level of danger will dictate the appropriate method. Give all necessary first
aid BEFORE moving the casualty.

a. Protecting Your Patient:

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i. Emergency Moves - If the patient is in immediate danger, you may have to move the
patient before assessing the patient, immobilizing the patient’s spine, or moving a
stretcher into position.

ii. Urgent moves are required when the patient must be moved quickly for treatment of an
immediate life threat.

iii. Non-urgent moves when there is no immediate threat to life.

b. The military uses a number of standard stretchers. When using a stretcher, the HM should
consider a few general rules:

i. Use standard stretchers when available and be ready to improvise safe alternatives.

ii. When possible, bring the stretcher to the casualty

iii. Always fasten the casualty securely to the stretcher

iv. Always move the casualty FEET FIRST so the rear stretcher bearer can watch for signs
of breathing difficulty.

16. Patient-carrying devices - this lesson has dealt with methods used to move an injured person
out of danger and into a location to facilitate first aid being administered. Casualties should not
be moved before the type and extent of injuries are evaluated and the required emergency
medical treatment is given. The exception to this occurs when the situation dictates, i.e. a fire.
The situation will dictate the urgency of casualty movement

a. Stretcher or other device designed to carry the patient safely to the ambulance and/or to the
hospital. Know how to properly use a device and its rating (how much weight it will hold
safely). Be sure to regularly maintain and inspect a device.

b. Types of stretchers

i. Manual stretchers are lifted by Corpsman or litter carriers.

1. Stokes stretcher – The Navy service litter most commonly used for transporting sick
or injured persons is the Stokes stretcher.

a. It is a wire basket supported by iron rods.

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b. Even if the stretcher is tipped or turned, the casualty can be held securely in
place, making the Stokes adaptable to a variety of uses.

c. This stretcher is particularly valuable for transferring injured persons to and

from boats. As mentioned before, it can also be used with flotation devices to
rescue injured survivors from the water.

d. Can be used for direct ship-to-ship transfer of injured persons. Fifteen-foot

tending lines are attached to each end.

e. Placement of patient in stretcher.

i. The rescuer at the head takes charge.

ii. Log-roll the patient as a unit.

iii. Gently roll patient (Again as a unit), into centered position on stretcher.

iv. Pad with three blankets: two of them should be placed lengthwise so that one
will be under each of the casualty s legs), and the third should be folded in
half and placed in the upper part of the stretcher to protect the head and
shoulders.

v. The straps go OVER the blanket or other covering, thus holding it in place.

vi. Handling lines and patient securing straps will NOT be placed on Stokes
stretchers located in the hangar bay and flight deck areas. These stretchers
are used for mass casualty situations and, based on the "scoop and run"
theory, these lines and straps are not utilized and could present a hazard.

2. Reeves stretcher – is designed for rapid immobilization of spinal and neck injuries
in tight places.

a. It is constructed of lightweight vinyl-coated polyester that is easily washed with

soap and water.

b. It has one vertical lift point and four horizontal lift points for helicopter hoist
capability allowing the sleeve to hoist patients from any angle.

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c. For head and cervical support, it includes removable Velcro head-securing

blocks, adjustable head- and chin-securing straps, a chest- and arm-securing flap
with Velcro, a leg-securing flap with Velcro and a spine board compartment for
added strength and rigidity.

d. Six chest and six leg straps with buckles and a yellow "fail-safe" strap are used
for security. This stretcher has a load capacity of over 1,000 lbs.

e. The steps to use a Reeves Sleeve are:

i. Open vests and straps

ii. While maintaining manual traction, apply cervical collar

iii. The rescuer at the head takes charge. While maintaining cervical traction,
log-roll the patient as a unit.

iv. Slide Reeves Sleeve under patient as far as possible

v. Continue to maintain cervical traction. Gently roll patient (Again as a unit),

into centered position on reeves sleeve

vi. Position head panels around head. Secure forehead strap. Chin strap may be
used, as long as airway is not compromised.

vii. Place upper vest as high under arm pits as possible allowing no space in arm
pit. Wrap upper and lower vests around patient and secure Velcro.

viii. Secure all straps snugly. Patient’s arms are outside the black straps, and
place inside the yellow strap. TUCK ALL EXCESS STRAPS.

3. Miller board - is constructed of an outer plastic shell with an injected foam core of
polyurethane foam. It is impervious to chemicals and elements. It can be used in
virtually every confined-space rescue and vertical extrication. It provides for full
body immobilization.

a. Harness system, including a hood and two-point contact for the head (forehead
and chin) to stabilize the head and cervical spine

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b. The narrow design allows passage through hatches and crowded passageways.

c. It fits within a Stokes (basket) stretcher and will float a 250-pound person.

ii. Power stretchers lift the patient from the ground level to the loading position or lower a
patient from the raised position.

iii. Bariatric stretchers are constructed to transport obese patients.

iv. Wheeled stretcher

1. Device in the back of all ambulances that transports a patient in a reclining position

2. When moving the patient, safest level is closest to the ground.

3. Ideal for level surfaces

4. Remember to use proper body mechanics when moving the stretcher in and out of
the ambulance.

5. A stretcher can be carried by four carriers, one at each corner (especially over rough
terrain).

c. Spine board - is equipment used in the immobilization of suspected or real fractures of the
spinal column. They are made of fiberglass or exterior grade plywood.

i. Two types: short and long

ii. Used for patients who are found lying down or standing and who must be immobilized

iii. Made of a material that resists absorbing blood and body fluids

iv. Short spine boards are primarily used for removing patients from vehicles when a neck
or spine injury is suspected.

v. Utilize a Long Spine Board

1. Ensure that one team leader and at least three assistants are available.

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2. The team leader maintains alignment of the head; the second person positions the
backboard

3. The tallest remaining team member places his or her hands behind the patient’s
shoulder and lower hip area

4. The last remaining team member places his or her hands on the patient’s upper hip
area and the knee and thigh area.

5. On the team leader’s count, the team rolls the patient on his or her side while
maintaining spinal alignment. If possible, avoid rolling the patient onto an injured
extremity.

6. The second person places the board underneath the patient.

7. When the board or mattress is in optimum position, the team returns the patient to
the supine position on the board. The team leader maintains manual immobilization
of the head until immobilization is complete.

8. Place padding underneath the head if necessary to maintain neutral alignment.

9. Secure the torso and legs to the board with regular or spider straps.

10. Stabilize the head bilaterally with a foam block or towel rolls.

11. Place a foam strap or adhesive tape directly on the skin across the patient’s
forehead, across the blocks or towel rolls, and onto the board. Avoided taping across
the hair or eyebrows.

12. Discontinue manual stabilization of the head after taping or strapping is complete.

d. Moving patient onto carrying devices - Choose a move based on the position is in when it is
time to move him to a carrying device and whether or not the patient is suspected of having
a spine injury.

i. Patient with suspected spine injury

1. Perform manual stabilization of the head and neck

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2. Apply a cervical collar.

3. Maintain manual stabilization until the patient is immobilized to a spine board.

ii. If patient is seated in a vehicle, immobilize him with a short spine board or vest and
then on a long spine board.

iii. If patient is lying down or standing, move him directly to a long spine board.

iv. Patient with no suspected spine injury

1. Extremity lift – Used to carry a patient to a stretcher or stair chair or lift a patient
from the ground or sitting position

2. Direct ground lift – Used to lift a patient from the ground to a stretcher

3. Draw-sheet method – Used along with direct carry method during transfers between
hospitals and nursing homes or when a patient must be moved from a bed at home
to a stretcher

4. Direct carry – Used to move a patient from a bed or from a bed-level position to a
stretcher

e. Patient positioning

i. Place unresponsive patients with no suspected spine injury in the recovery position (on
side).

ii. Place responsive patients with no suspected spine injury in a position of comfort.

iii. The semi-sitting position (Fowler’s or semi-Fowler’s position) aids patients with
breathing complaints.

iv. Continuously monitor the patient’s airway and level of responsiveness, and place
patient in the recovery position at the first sign of a decreased level of responsiveness.

v. Place patients who are believed to be in shock in the supine position.

vi. Place patients who have experienced trauma on a spine board at level position and
immobilize to prevent injury.

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17. Summary and Review

[Link] Define terms related to musculoskeletal system (KPL1)

[Link] Explain landmarks associated with the musculoskeletal system (KPL2)

[Link] Obtain history from patient with common orthopedic disorders (SPL2)

[Link] Explain concepts and principles for assessing musculoskeletal conditions (KPL2)

[Link] Assess patients for spinal cord injuries (SPL2)

[Link] Assess patients for musculoskeletal conditions (SPL2)

[Link] Examine a patient for orthopedic disorders (SPL2)

[Link] Perform orthopedic examination (SPL2)

[Link] Explain concepts and principles for treating musculoskeletal disorders (KPL 2)

[Link] Assist in the treatment of musculoskeletal disorders (SPL1)

[Link] Assist in treatment of spinal cord injuries (SPL1)

[Link] Apply orthopedic devices (SPL1)

[Link] Remove orthopedic devices (SPL1)

[Link] Document musculoskeletal encounter in SOAP note (SPL2)

[Link] Describe the basic facts in regards to preparing patients for transport (KPL1)

[Link] Prepare patients for transport (SPL1)

[Link] Stabilize patients for transport (SPL1)

[Link] Perform patient carrying techniques (SPL1)

[Link] Prepare patients for evacuations (SPL1)

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Scan 14-3 Applying a Cervical Collar

STIFNECK® SELECT™ (© Edward T. Dickinson, MD) WIZLOC Cervical Collar.

Philadelphia Cervical Collar™ Patriot Adult and Pediatric. NEC-LOC™ rigid extrication collar, opened. Rigid cervical
collars are applied to protect the cervical spine. Do not
apply a soft collar.

Sizing a Cervical Collar

1. Measure the patient’s neck. 2. Measure the collar. The chin piece should not lift the
patient’s chin and hyperextend the neck. Make sure the
collar is not too small or tight, which would make the
collar act as a constricting band.
(continued)

Chapter 14 | The Secondary Assessment 369

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Scan 29-5 Four-Rescuer Log Roll

First Take Standard Precautions.

1. Stabilize the head and neck. Apply a rigid cervical 2. Place the board parallel to the patient.
collar.

3. Have three rescuers kneel at the patient’s side 4. The EMT at the head and neck directs the others to
opposite the board, leaving room to roll the patient roll the patient as a unit.
toward them. Place rescuers at the shoulder, waist,
and knee. One EMT will continue to stabilize the head
while the others reach across the patient to properly
position their hands.

5. The EMT at the patient’s waist grips the spine board 6. Roll the patient as a unit onto the board.
and pulls it into position against the patient. (This can
be done by a fifth rescuer.)

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Scan 29-6 Spinal Precautions for a Supine Patient

First Take Standard Precautions.

1. Place the patient’s head in a neutral, in-line position 2. Apply an appropriately sized rigid cervical collar.
and maintain manual stabilization of the head and
neck. Assess distal CSM.

3. Position an immobilization device. 4. Move the patient onto the device without
compromising the integrity of the spine. Once the
patient is in position, apply padding to voids between
the torso and the board.
(continued)

Pediatric Note
When immobilizing a six-year-old or younger child, provide padding beneath
the shoulder blades to compensate for the child’s large head. Pad from the
shoulders to toes as needed to establish a neutral position.
If you do not carry a pediatric long spine immobilization device, then prac-
tice immobilizing children using adult equipment and lots of towels or blankets
to pad around the child. EMTs are usually very good at improvising. In this
case, however, the first time you improvise should be in the classroom so you
will work quickly in the field!

Chapter 29 | Trauma to the Head, Neck, and Spine 823

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Scan 29-6 Spinal Precautions for a Supine Patient (continued)

5. Secure the patient’s torso to the board first.

6. Secure the patient’s legs (above and below the knee).

7. Pad and immobilize the patient’s head last. 8. Reassess the patient’s distal CSM.

Pediatric Note
Occasionally EMTs are confronted at a motor-vehicle collision with an infant
or young child who was riding in a child safety seat. At one time it was recom-
mended that, if the child did not need immediate resuscitation or need to be
placed supine for any reason, the child could be immobilized in the child
safety seat. Immobilizing a child in a child safety seat is no longer recom-
mended because the integrity of a safety seat may have been compromised
in the collision.
The procedure for rapid extrication from the child safety seat is shown in
Scan 29-7.

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OUTLINE SHEET 102.9.1-1

DERMATOLOGY SYSTEM

A. INTRODUCTION

1. Introduction - Unlike many other systems, the musculoskeletal system extends into all parts of
the body. The musculoskeletal system provides the stability and mobility necessary for
physical activity. Physical performance requires bones, muscles and joints that function
smoothly. Because the musculoskeletal system serves as the body’s main line of defense
against external forces, injuries are common. Moreover, numerous disease processes affect the
musculoskeletal system and can ultimately cause disability.

B. ENABLING OBJECTIVES

[Link] Define terms related to the dermatology system (KPL1)

[Link] Explain anatomy of dermatology system (KPL2)

[Link] Explain concepts and principles for assessing patients for dermatological abnormalities
(KPL1)

[Link] Explain concepts and principles for assessing patients for hazardous substance exposure
(KPL2)

[Link] Assess patients for dermatological abnormalities (SPL1)

[Link] Assess wounds (SPL2)

[Link] Assess patients for thermal injuries (SPL2)

[Link] Perform dermatological examination (SPL2)

[Link] Explain concepts and principles for assisting in treatment of dermatological conditions
(KPL1)

[Link] Explain concepts and principles for assisting in treatment for thermal injuries (KPL2)

[Link] Assist in treatment of hazardous substance exposure (SPL2)

[Link] Prepare patients for medical procedures (SPL1)

[Link] Assist in treatment of dermatological conditions (SPL1)

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[Link] Assist in treatment of thermal injuries (SPL2)

[Link] Perform wound assessment and care (SPL1)

[Link] Irrigate infected areas (SPL1)

[Link] Administer local anesthesia (SPL1)

[Link] Remove external staples (SPL1)

[Link] Remove external sutures (SPL1)

[Link] Report side effects to treatments (SPL2)

[Link] Explain concepts and principles of topical medication administration (KPL2)

[Link] Administer topical Medications (SPL2)

C. HCB 102.9.1-1 DERMATOLOGY TOPIC OUTLINE

1. Introduction - Skin provides an elastic, rugged, self-regenerating, protective covering for the
body. The skin and its accessory structures make up the dermatological system also known as
the integumentary system. This system functions to guard the body’s physical and biochemical
integrity, maintain a constant body temperature, and provide sensory information about the
surrounding environment. In this lesson, we will cover the structures that make up the
dermatological system and how to examine the skin, hair, and nails as part of a focused
examination when the patient presents with a dermatological concern. This lesson plan will
also explains how to document the assessment, treatment, and documentation of care of the
dermatology system within the scope of practice of a Hospital Corpsman

2. Case Study – Gunnery Sergeant Brent Hartzog presents to the Battalion Aid Station
complaining that he cut his left leg. He also complains of redness and swelling at the sight of
the injury and feeling feverish.

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3. Terms related to the Dermatological System

a. Abrasions – An excoriation, or circumscribed removal of the superficial skin layers.

b. Acne – A disorder of the skin caused by inflammation of the skin glands found chiefly
in adolescents and marked by papules especially on the face.

c. Alopecia – Absence or loss of hair.

d. Contact Dermatitis – A cutaneous reaction to an external substance.

e. Avulsion – A tearing away or forcible separation.

f. Bulla – A large vesicle or blister greater than one centimeter.

g. Cancer – General term frequently used to indicate any of various types of malignant
neoplasms, most of which invade surrounding tissues, may metastasize to several sites,
and are likely to recur after attempted removal and to kill the patient unless adequately
treated; especially, any such carcinoma or sarcoma, but, in ordinary usage, especially
the former.

h. Carbuncle – Deep-seated pyogenic infection of the skin and subcutaneous tissues,

usually arising in several contiguous hair follicles, with formation of connecting
sinuses.

i. Cellulitis – Inflammation of subcutaneous, loose connective tissue (formerly called

cellular tissue).
j. Contusion – Any mechanical injury (usually caused by a blow) resulting in hemorrhage
beneath unbroken skin.

k. Crust – Dried serum, blood, or purulent exudates; slightly elevated; size varies; brown,
red, black, tan, or straw colored.

l. Dermatology – The branch of medicine concerned with the study of the skin, diseases
of the skin, and the relationship of cutaneous lesions to systemic disease.

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m. Ecchymosis – The escape of blood into the tissues from ruptured blood vessels, often
red to purple in appearance and variable in size.

n. Erosion – Loss of part of the epidermis; depressed, moist, glistening; follows rupture of
a vesicle or bulla.

o. Erythema – Redness or inflammation of skin or mucus membrane.

p. Fissure – Linear crack or break from the epidermis to the dermis; may be moist or dry.
(Example: Athlete’s Foot)

q. Hazardous Material – Any substance or material in a form that poses an unreasonable

risk to health, safety, and property when transported in commerce or kept in storage at a
warehouse, port, depot, or railroad facility.

r. Karatin – A protein that is the main component of the skin; the main substance of the
hair, skin and nails.

s. Keloid – Irregularly shaped, elevated, progressively enlarging scar; grows beyond

boundaries, caused by excessive collagen formation during healing.
t. Laceration – Cuts, open wounds that sometimes cause significant blood loss.

u. Lichen – Any of several skin diseases characterized by the eruption of flat papules.

v. Lichenification – The process by which the skin becomes hardened and leathery
usually as a result of chronic irritation.

w. Macule – A patch of skin that is altered in color but usually not elevated and is a
characteristic feature of various diseases (i.e. Smallpox).
x. Nodule – A small mass of rounded or irregular shape such as a small abnormal knobby
body protuberance (i.e. tumorous growth or calcification near an arthritic joint).
y. Papule – A small solid usually conical elevation of skin.

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z. Petechia – A minute reddish or purplish mass containing blood that appears in the skin
or mucus membrane as a result of a localized hemorrhage.
aa. Plaque – Elevated, firm, and rough lesion with flat top surface greater than one cm in
diameter.
bb. Pruritus – Itching.
cc. Puncture – To make a hole with a small pointed object, such as a needle.
dd. Pustule – Elevated, superficial lesion; similar to vesicle but filled with purulent fluid.
ee. Rash – Skin eruption.

ff. Serum – A clear, watery fluid, especially that moistening the surface of serous
membranes, or exuded in inflammation of any of those membranes.
gg. Skin Lesion – A pathologic change in the tissues.
hh. Turgor – To swell.

ii. Ulcer – A break in skin or mucus membrane with loss of surface tissue, disintegration
and necrosis of epithelial tissue and/or pus.

jj. Urticaria (Hives) – Reddened elevated patches of skin that are often itchy.
kk. Vesicle – A small abnormal elevation of the outer layer of the skin enclosing a watery
liquid (i.e. blister).
ll. Warts – Mass produced by uncontrolled growth of epithelial skin cells.
mm. Wheal – elevated irregular shaped area of cutaneous edema; solid, transient, variable
diameter.

4. Anatomy and Physiology of the Dermatological System

a. Anatomy

1. Cutaneous Membrane is the technical term for skin. It’s primary role is to help protect the
rest of the body’s tissues and organs from physical damage such as abrasions, chemical
damage (from detergents) and biological damage from microorganisms.
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a. The skin is made up of three distinct layers. Skin cells are layered into sheets creating a
tough and rugged barrier. These layers are the: epidermis, dermis and subcutaneous tissue.

2. Epidermis is the tough, leathery outer surface of the skin ranging from 0.06 to 0.6 mm,
with the thickest portions located on the palms of the hands and the soles of the feet. This
is the layer you see with your eyes when you look at the skin anywhere on the body. It
protects against microorganisms and allows touch sensation.
a. The epidermis is arranged in five layers. From most superficial to deepest are:

i. Stratum Corneum – Composed of dead skin cells that you shed into the
environment. This layer helps to repel water. (Also known as the “horny
layer”).

ii. Stratum Lucidum – Found only in the palms of the hands, fingertips and
soles of the feet.

iii. Stratum Granulosum – Produces karatin.

iv. Stratum Spinosum – Gives skin its strength and flexibility.

v. Stratum Basale – The skin’s most important cells (keratinocytes) are

formed before moving up to the surface of the epidermis and shed into the
environment as dead skin cells.

b. The epidermis has three appendages located within the dermis: hair, glands, and
nails.

i. Hair follicles are present everywhere except in the palms and soles.

1. Hair, composed of soft keratin, helps regulate body temperature by trapping

air between the hair and the skin's surface

a. Each hair follicle contains a sebaceous gland that secretes sebum.

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1. If the more superficial epidermis is damaged, as with an abrasion,

the deeper epidermal cells that line hair follicles serve as a source of
epidermal regeneration.

2. Sebum is an oily substance that lubricates the skin and hair.

3. Sweat is 99% water mixed with some salts and metabolic waste
products.

4. The evaporation of sweat from the skin's surface helps cool the
body.

b. Nails, located at the dorsal tips of the digits, consist of hard keratin

3. Dermis is 4 mm thick. Although its layers are much less defined than those of the
epidermis, the dermis can be described as consisting of two layers.

a. The thin, superficial papillary dermis consists of loosely woven fibers embedded in
a gelatinous matrix called ground substance.

b. The dermis is highly vascular with many capillary beds providing nutrition to both
the dermis and the overlying avascular epidermis.

i. The dermal capillaries provide the dermis with its characteristic color, ranging
from pink to rosy red.

ii. The dermis also contains several types of sensory receptors that provide
information on touch, pressure, vibration and temperature.

4. Subcutaneous tissue, sometimes called the hypodermis, supports the skin. It consists of
adipose tissue and fascia.

Adipose tissue is highly vascular, loose connective tissue that stores fat, which
provides energy, cushioning, and insulation.

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b. Physiology

i. Epidermis

1. Provides a physical and chemical barrier

2. Helps regulate fluid

3. Critical to vitamin D production

4. Contributes to appearance

ii. Dermis

1. Supports and nourishes epidermis

2. Assists with infection control

5. Pre-Hospital Assessment of the Dermatology System:

a. Wounds

i. Ensure scene safety

ii. Standard precautions

1. Protect yourself by donning the proper personal protective equipment (PPE).

iii. Airway, breathing, circulation, and severe bleeding are identified and treated in the
primary assessment.

v. Physical examination is performed during the secondary assessment.

1. Expose the wound.

a. Clothing that covers the soft-tissue injury must be lifted, cut, or split away.

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i. For some articles of clothing, this is best done with trauma shear or scissors.

ii. Do not attempt to remove clothing in the usual manner, which can aggravate
existing injuries and cause additional damage and pain.

iii. Take care in removing clothing if blood or debris has adhered it to the wound.

2. Clean the wound surface.

a. Do not try to pick embedded particles and debris from the wound.

b. Simply remove large pieces of foreign matter from the surface.

c. When possible, use a piece of sterile dressing to brush away large debris while
protecting the wound form contact with your soiled gloves.

d. Do not spend much time cleaning the wound.

e. Control of bleeding is the priority.

3. Control bleeding.

a. Start with direct pressure and elevation

i. It may be important to remember that direct pressure may not be possible in

certain injuries.

b. If direct pressure to an extremity is not appropriate or possible, move directly to the

placement of a tourniquet.

c. Remember also that with penetrating trauma and puncture wounds, bleeding may
be occurring internally without its being visible on the surface of the skin.

4. For all serious wounds, provide care for shock, including administration of high
concentration oxygen (as needed).

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5. Apply a bandage to prevent further contamination.

a. Use a sterile dressing.

b. When none is available, use the cleanest cloth material at the scene.

6. Bandage the dressing in place after you have controlled the bleeding.

a. If an extremity is involved, check for distal pulse to make certain that circulation
has not been interrupted by the application of a tight bandage.

b. With the exception of a pressure dressing, bleeding must be controlled before

bandaging is started.

c. Periodically recheck the bandage to make certain that bleeding has not restarted.

7. Keep the patient lying still. Any movement will increase circulation and could restart
bleeding.

8. Try to keep the patient calm and reassure them.

6. Pre-Hospital Assessment of Patients for Hazardous Substance Exposure/ Burns

a. Ensure strict standard precautions

b. Ensure Scene Safety

c. Airway, breathing and circulation, and severe bleeding are identified and treated in the primary
assessment

d. Secondary Assessment

i. Involves classifying, then evaluating, the burns. Burns can be classified and evaluated in
three ways:

1. By agent and source

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2. By depth

3. By severity

ii. Burns can cause injury to skin, muscles, bones, nerves, blood vessels, respiratory systems
structures. Burns can also cause emotional and psychological problems.

iii. All three are important in deciding the urgency and the kind of emergency care the burn
requires.

iv. Patient assessment should not be neglected to begin immediate burn care.

v. Classifying Burns by Agent and Source

1. Burns can be classified according to the agent causing the burn (e.g. chemicals or
electricity).

2. Noting the sources of the burn (e.g. dry lime or alternating current) can make the
second more specific.

3. You should report the agent and also, when practical, the source of the agent.

4. For example, a burn can be reported as “chemical burns from contact with dry lime.”

5. Always gather information from your observations of the scene, bystanders’ reports,
and the patient interview.

6. Agents and Sources of Burns:

a. Thermal burns: flame; radiation; excessive heat from fire, steam, hot liquids, and
hot objects

b. Chemical burns: various acids, bases, and caustics

c. Electricity burns: alternating current, direct current, and lightning

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d. Light (typically involves eyes) burns: intense light sources; ultraviolet light can
also be considered a source of radiation burns

e. Radiological burns: usually form nuclear sources; ultraviolet light can also be
considered a source of radiation burns

vi. Classifying Burns by Depth

1. Thermal burns are classified according to their depth as first-, second-, and third degree

2. First-Degree Burn (superficial burn)

a. Involves only the epidermis

b. Characterized by reddening of the skin and perhaps swelling

c. Complaints about pain at the site

d. Will heal of its own accord (e.g., sunburn)

3. Second-Degree Burn (partial thickness burn)

a. Epidermis is burned through, and the dermis is damaged.

b. Deep, intense pain, noticeable reddening, blisters, and mottled (spotted) appearance
to the skin

c. Swelling and blistering for 48 hours after the injury

d. When treated with reasonable care, partial thickness burns will heal themselves.

4. Third-Degree Burn (full thickness burn)

a. All the layers of the skin are damaged and possibly subcutaneous tissues, muscle,
bone, and underlying organs.

b. Can be difficult to tell apart from partial thickness burns

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c. Charred black or brown or areas that are dry and white

d. Patient may complain of severe pain or no pain at all (if enough nerves have been
damaged).

e. Requires skin grafting

f. Forms dense scars as it heals

vii. Determining the Severity of Burns

1. When determining the severity of the burn, consider the following factors:

a. Agent or source of the burn

b. Body regions burned

c. Depth of the burn

d. Extent of the burn

2. Agent or source of burn

a. A burn caused by electrical current may cause only small areas of skin injury.

b. A chemical may remain on the skin and continue to burn for hours or even days,
eventually entering the bloodstream

3. Body regions burned

a. Any burn to the face may involve injury to the airway or eyes.

b. Any burn on hands and feet may cause loss of movement of fingers or toes. Take
special care to prevent damaged tissues from sticking to one another.

c. When the groin, genitalia, buttocks, or medial thighs are burned, potential bacteria
contamination can be far more serious than the initial damage to tissues.
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d. Circumferential burns can be very serious because they constrict skin.

e. The burn healing process can be complicated.

5. Extent of the Burn

a. Rule of Nines is used to give a rough estimate of the surface area affected

i. For an adult, each of the following areas represents 9 percent of the body surface:
head and neck, each upper extremity, chest, abdomen, upper back, lower back
and buttocks, the front of each lower extremity, and the back of each lower
extremity. These make up 99 percent of the body’s surface.

ii. The remaining 1 percent is assigned to the genital region

viii. Classifying Burns by Severity

1. Burns must be classified as to severity to determine the order and type of care, to
determine order of transport, and to provide maximum information to the emergency
department.

2. Severity of burn may determine if the patient is to be taken directly to a hospital with
special burn-care facilities.

3. Classifications of Burn Severity:

a. Minor Burns

i. Full thickness burns of less than 2 percent of the body surface, excluding the
face, hands, feet, genitalia, or respiratory tract

ii. Partial thickness burns of less than 15 percent of the body surface

iii. Superficial burns of 50 percent of the body surface or less

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b. Moderate Burns

i. Full thickness burns of 2 to 10 percent of the body surface, excluding the face,
hands, feet, genitalia, or respiratory

ii. Partial thickness burns of 15 to 30 percent of the body surface

iii. Superficial burns that involve more than 50 percent of the body surface

c. Critical Burns

i. All burns complicated by injuries of the respiratory tract, other soft-tissue

injuries, and injuries of the bones

ii. Partial thickness or full thickness burns involving the face, hands, feet,
genitalia, or respiratory tract

iii. Full thickness burns of more than 10 percent

iv. Partial thickness burns of more than 30 percent

v. Burns complicated by musculoskeletal injuries

vi. Circumferential burns

7. Outpatient/ Inpatient Dermatology Assessment Considerations

a. History of Present Illness- For each of the symptoms or conditions discussed in this section,
targeted topics to include in the history of the present illness are listed.

i. Changes in skin: color, redness (erythema), swelling (edema), sores , lumps, rashes,
dryness, itching (pruritus),

ii. Changes in hair color or growth

iii. Changes in nails discoloration, changes in the appearance of the nail

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iv. Remember to use the mnemonic OLDCARTS to describe the history of present illness

v. Ask about recent exposures to drugs, environment or occupational toxins or chemicals;

frequent immersion in water

vi. Any sick contacts

vii. Ask about travel history (within last 30 days)

viii. Ask about current medications, including over the counter (OTC) and supplements.

b. Past Medical History

i. Previous skin problems: sensitivities, allergic skin reactions, allergic skin disorders, sore,
lesions, treatment

c. Family History

i. Current or past dermatologic disorders in family members; skin cancer; allergic skin
disorders; infections

d. Personal and Social History

i. Care habits: soaps, oils, lotions; cosmetics

ii. Use of tobacco, alcohol

iii. Sexual history: sexually transmitted infections (syphilis, gonorrhea, human

immunodeficiency virus (HIV)

iv. General constitutional symptoms: fever, pain, stress or trauma

e. Inspection – the inspection will be focused on the area of the body where the dermatology
abnormality is located or other areas that are affected.

i. Look the for the following characteristics on the skin (adequate exposure of the skin is
necessary) and any deformities that are abnormal:
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1. Color – the range of expected skin color varies from dark brown to light tan with pink or
yellow overtones. Systemic disorders can produce generalized or localized color
changes.

2. Erythema – should be no erythema, usually localized redness often results from an

inflammatory process i.e. infection.

3. Edema – should be no edema

4. Ecchymoses – should be no bruising (usually caused by injury.

5. Lesions – skin lesions is a general term that describes any pathologic skin change or
occurrence.

a. Lesions may be primary (i.e., those that occur as initial spontaneous manifestations
of a disease process). Some examples are: petechia, papule, pustule, nodule, bulla,
and vesicles.

b. Lesion may also be secondary (i.e., those that result from later evolution of a disease
or external to trauma to a primary lesion). Some examples are: Serum, fissures,
lichenification, erosions, and ulcers.

c. Take note of the size of the lesion or other findings. You should measure the in mm
with a ruler.

d. Take note of the borders or margins (demarcation) of the lesion. You should note if
the borders are well demarcated or defined, able to draw a line around it with
confidence (discrete) or poorly defined, have borders that merge into normal skin or
outlying ill-defined papules (indistinct).

e. Take note of the color of the lesion.

f. Take note of the location of the lesion.

g. Also, take note of the distribution of the lesion. Is the lesion located in one small
area (localized) or does it appear widely distributed or in numerous areas
(generalized).
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ii. Inspect hair for:

1. Color – may vary from very light blond to black to gray.

2. Distribution – commonly present on the scalp, lower face, neck, nares, ears, chest,
axillae, back and shoulders, arms, legs, toes, pubic area, and around the nipples. Note
hair loss.

3. Quantity – note hair loss, which can be either generalized or localized..

iii. Inspect nails and skin folds for color, erythema, edema, ecchymosis, lesion and other
deformities.

f. Palpation

i. Feel skin for the following:

1. Moisture- minimal perspiration or dampness.

2. Temperature – should range from cool to warm to touch. Use the dorsal surface of
your hands or fingers because these areas are most sensitive to temperature perception.

3. Turgor – the skin should feel resilient, move easily when pinched, and return to place
immediately when released.

4. Tenderness – should be not tenderness.

ii. Palpate hair for the following:

1. Texture – the hair should be shiny, smooth, and resilient.

iii. Palpate the nails for the following:

1. Texture – should feel hard and smooth with a uniform thickness.

2. Tenderness – should be not tenderness.

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g. Documenting and presenting your findings to the medical health provider and assist the
medical health provider in treating the patient.

8. Assisting in the Treatment of Dermatological Conditions

a. At your duty station, you will learn to assist the provider in the treatment of many
dermatological conditions to include administering medication and/or documentation. The
following are some examples of what tasks you may be assigned:

i. Patient education

ii. Assist in administering or applying certain medications

iii. Assist in medical procedures

iv. Assist in providing wound care

b. Administering Topical Medications

i. Many locally applied medications, such as lotions, patches, pastes, and ointments, create
systemic and local effects if absorbed through the skin. A variety of medications are
available as transdermal (skin) patches to protect from accidental exposure, the Hospital
Corpsman should apply these medications using gloves and applicators.

ii. Skin encrustations and dead tissue harbor microorganisms and block contact of medications
with the affected tissues and therefore should be avoided.

iii. The skin or wound must be cleaned thoroughly before applying a new dose of medication;
simply applying new medications over previously applied medications does little to prevent
infection or offer therapeutic benefit.

iv. Ointments, lotions, powders, and patches must be applied as specifically prescribed to
ensure proper penetration and absorption.

c. The six medication rights of medication administration were taught in Unit 3 lesson plan 4
"Introduction to Medication Administration."
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d. Applying Creams, Ointments, and Oil-Based Lotions

i. Place the required amount of medication in the palm of a gloved hand and soften the agent
by rubbing briskly between the hands.

ii. Once the medication is softened, spread it evenly over the skin surface, using long, even
strokes that follow the direction of hair growth. Apply to the thickness specified by the
manufacturer’s instructions. Do not rub the skin vigorously.

iii. Explain to the patient that the skin may feel greasy after application.

iv. Assess for side effects of treatment. Verbalize if patient tolerated procedure well or
reports, treat, and reassess pain as needed.

v. .Discard supplies, remove gloves, and perform hand hygiene.

vi. Document the procedure in the patient’s record.

e. Administering Local Anesthesia

i. Most minor or office procedures are performed after injection of local anesthesia. The use
of local anesthesia can reduce patient discomfort and improve patient satisfaction and the
procedure’s outcome. Injection of local anesthesia is injected by medical health providers.

ii. Hospital Corpsman can apply topical anesthetics painlessly without needles, either alone or
prior to injected anesthetics. They are applied with a cotton-tipped applicator swab or
cotton ball. They also avoid the tissue distortion that occurs with infiltrated anesthetics.

iii. The purpose of anesthesia is to temporarily induce loss of sensation prior to the following
treatments:
1. Suturing of a laceration

2. Removal of an embedded foreign body

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3. Performance of an invasive procedure (e.g., incision and drainage procedure for a skin
abscess or infected paronychia, a lumbar puncture, chest tube insertion)

4. Cleansing or debridement of a wound

5. Insertion of nasal packing or nasal tubes

f. Procedure

i. Perform hand hygiene and don gloves.

ii. Verify the correct patient using two identifiers.

iii. Check accuracy and completeness of the medication order with the medical health provider.

iv. Ensure the six rights of medication safety: right medication, right dose, right time, right
route, right patient, and right documentation.

g. Applying the Topical Local Anesthesia Lidocaine

i. Apply lidocaine topically in any of the available forms such as a liquid, ointment, jelly, or
viscous fluid to the area.

ii. The provider will assess the effectiveness of the anesthetic by testing for a sharp-dull
sensation. The provider will ensure that the anesthesia is adequate before any procedure is
initiated.

iii. Remove the lidocaine from the area before the procedure.

iv. Discard supplies, remove gloves, and perform hand hygiene.

v. Document the procedure in the patient’s record.

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8. Staple and Suture Removal

a. Patient Education

i. Explain the procedure to the patient and family.

ii. Explain that staple or suture removal is usually not painful, but that the patient may feel
pulling or tugging of the skin.

iii. Teach the patient and family how to remove crusting around the staple or suture insertion
site with normal saline as long as skin is intact after staples or sutures are removed.

iv. Teach the patient and family to look for any sign of separation of the wound edges and to
inspect the incision for continued healing.

v. Educate the patient and family about wound closure strips (e.g., butterfly bandages,
adhesive strips).

1. Explain that wound closure strips are used to support the incision after staple or suture
removal.

2. Instruct the patient not to remove the wound closure strips but to allow them to fall off
on their own.

3. Instruct the patient to take showers rather than soak in the bathtub because submersing
the strips in water may cause them to fall off prematurely and can increase the risk of
incisional site infection.

vi. Instruct the patient to keep the insertion sites clean and dry.

vii. Encourage the patient to use sunscreen on healing tissue and healed scar tissue.

viii. Encourage the patient to use vitamin E on healing tissue because it may aid the healing
process.

ix. Teach the patient and family the correct method for changing dressings if they will be
needed after the patient is discharged.
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x. Encourage the patient to avoid contamination by keeping the area covered when working
in an outdoor or industrial environment.

xi. Encourage questions and answer them as they arise

1. Preparation for staple and suture removal

a. Provide privacy for the patient.

b. Position the patient comfortably while exposing the staple or suture line.

c. Ensure direct lighting on the staple or suture line to aid visibility.

d. Arrange the necessary supplies at the bedside. Place a cuffed, waterproof

disposal bag within easy reach.

2. Removing sutures

a. Gather equipment needed - suture removal kit, antiseptic swabs, gauze, and
forceps.

b. Position patient for procedure.

c. Remove dressing carefully and discard into disposal bag.

d. Inspect wound and incision line verbalize any separation, dehiscence,

evisceration, bleeding or purulent drainage.

e. Clean sutures and healed incision with antiseptic swabs.

f. Place gauze a few inches from suture line. Grasp scissors in dominant hand and
forceps in non-dominant hand.

g. Grasp knot of suture with forceps, and gently pull knot up while slipping tip of
scissors under suture near skin.

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h. Snip suture as close to skin as possible at end distal to knot.

i. Grasping knotted end with forceps, pull suture through from the other side in one
continuous smooth action. Place removed on gauze.

j. Continue above steps until all remaining sutures are removed.

k. Inspect incision, report any abnormal areas, if any.

l. Wipe with antiseptic wipes to remove any debris and clean wound.

m. Document the procedure.

3. Removing Staples
a. Gather equipment needed - staple removal kit, antiseptic swabs and gauze.

b. Position patient for procedure.

c. Remove dressing carefully and discard into disposal bag.

d. Inspect wound and incision line verbalize any separation, dehiscence,

evisceration, bleeding or purulent drainage.

e. Clean sutures and healed incision with antiseptic swabs.

f. Place and control the staple extractor carefully, place lower tip under first staple,
close handles to extract staple.

g. Once both sides of staple are pulled away from skin surface, move staple away
from skin and place on gauze.

h. Continue above steps until all remaining staples are removed.

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i. Inspect incision, verbalize any abnormal areas, if any. Wipe with antiseptic wipes
to remove any debris and clean wound.

j. Document the procedure.

9. Wound Assessment / Care.

a. Verify the correct patient using two identifiers.

b. Perform hand hygiene and don gloves.

c. Assess patient for pain.

d. Carefully remove the soiled dressing.

e. Examine the dressing for color and quantity of drainage.

f. Discard the dressing in a disposable waterproof biohazard bag.

g. Assess the wound for the anatomical location of the wound on the body.

h. Assess the wound for type of wound.

i. Assess the wound for extent of tissue involvement: superficial, partial thickness or full-
thickness.

j. Assess whether the color of the wound is red, yellow, or black.

k. Assess the length of the wound: Place measuring guide or ruler over the wound at the point of
greatest length in the direction of patient head to patient feet.

l. Assess the width of the wound: Place measuring guide or ruler over the wound and measure
from side to side.

m. Determine the amount of wound drainage.

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n. Determine the color of wound exudate.

o. Determine the consistency of the wound exudate.

p. Assess the periwound skin color.

q. Assess the periwound skin texture.

r. Assess the periwound skin temperature.

s. Remove gloves, perform hand hygiene

10. Wound Irrigation

a. Don sterile gloves.

b. Fill a 35-ml syringe with irrigation solution.

c. Attach a 19-gauge angiocatheter to syringe

d. Hold the syringe above the upper end of the wound and over the area being irrigated.

e. Using continuous pressure, flush the wound until the solution draining into the basin is clear.

f. Dry the wound edges with gauze.

g. Reassess the wound, noting whether the color of the wound is red, yellow, or black.

h. Apply Dressing to Wound

i. Don clean gloves

ii. Apply a layer of gauze over the wound as the contact layer or primary dressing

iii. Apply additional layers of gauze, as needed

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iv. Apply tape to the dressing edges in a window-pane fashion, ensuring sufficient contact
with both the intact skin and dressing.

v. Discard supplies, remove personal protective equipment (PPE), and perform hand hygiene

vi. Assess for patient pain and report to medical health provider if worse than the beginning of
procedure

vii. Document the procedure in the patient’s record

11. Wound Debridement

a. Verbalize donning sterile gloves

b. Wash the injured area: Begin washing the injured area by gently pouring water in the center
and working toward the margins of the affected area. Use the cleansing solution and sterile
gauze to gently clean the affected area. Then repeat washing the injured area.

c. Dry the wound by gently drying the wound with gauze

d. Verbalize “I will not debride intact blisters”

e. Verbalize “I will debride devitalized tissue by using the forceps to elevate loose devitalized
tissue and then use the fine-tipped scissors to remove it”

f. Verbalize removing gloves and performing hand hygiene, then donning sterile gloves

g. Wound Dressing

i. Apply silver sulfadiazine by using a sterile-gloved hand to apply cream to affected area.
Then use a sterile tongue depressor to spread a thin and smooth layer of cream over the
affected area

ii. Apply a layer of sterile gauze over the wound as the contact layer or primary dressing

iii. Apply additional layers of gauze, leaving a margin that extends onto the unburned skin

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iv. Secure dressing with a gauze roll e.g. Kerlix, hold the primary dressing in place with non-
dominant hand, then use the dominant hand to hold the gauze roll as you begin layering
the gauze roll with the non-dominant hand distally to the injured area, first ensuring to
begin with two circular turns to anchor the bandage. Continue to transfer the gauze roll to
the dominant hand while wrapping the bandage from distal to proximal covering 50% of
the bandage as you layer the gauze roll on top of itself

v. Secure the gauze roll by ending the gauze roll with two circular turns and securing the
gauze roll by applying tape

vi. Discard supplies, remove gloves, and perform hand hygiene

vii. Reassess for pain and report findings to medical health provider

h. Document the procedure in the patient’s record

12. Assessment and Treatment of the Dermatological System

a. Abrasion - simple scrapes and scratches in which the outer lay of skin is damaged but not all
the layers are penetrated.

i. Abrasions can range in severity.

ii. There may be no detectable bleeding or only a minor ooze of blood from the capillary
beds.
b. Lacerations- a cut. The borders of the laceration may be smooth or jagged. This type of
wound is often caused by an object with a sharp edge, such as a razor blade, broken glass, or
a jagged piece of metal
i. Pre-Hospital Treatment

1. Reduce wound contamination

2. Control bleeding using direct pressure

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3. Do not pull apart the edges of the wound.

4. Most abrasions and lacerations can be cared for by bandaging a dressing in place.

5. Do not underestimate the effects of a laceration; serious infection or scarring could

result.

6. Check pulse, as well as motor and sensory function, distal to the injury.

c. Avulsions - Flaps of skin and tissues torn loose or pulled off completely.

i. Include when the tip of the nose or external ear is cut or torn off

ii. Degloving avulsion occurs when the hand is caught in roller and the skin is stripped off
like a glove

iii. Include an eye pulled from its socket (extruded)

iv. When tissue is avulsed, it is cut off from its oxygen supply and will soon die

v. Pre-Hospital Treatment

1. Treatment

a. Flaps of skin have been torn loose, but not off

i. Clean the wound surface.

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ii. Fold the skin back to its normal position as gently as possible.

iii. Control bleeding and dress the wound using bulky pressure dressings.

b. If skin or another body part is torn from the body

i. Control bleeding and dress the wound using bulky pressure dressing.

ii. Save the avulsed part and wrap it in a sterile dressing kept moist with sterile
saline.

iii. Label the avulsed part with what it is, patient’s name, date, and time the part
was wrapped and bagged. Records should show the approximate time of
avulsion.

iv. Keep the part as cool as possible (without freezing it). Do not immerse the
avulsed part in ice, cooled water, or saline.

v. Label the container the same as the saved part.

vi. Provide reassurance to your patient.

d. Penetrating Wounds - Object passes through the skin or other tissue

i. Often no severe external bleeding, but internal bleeding may be profuse

ii. Threat of contamination

iii. Can be shallow or deep, but depending on the depth of penetration, may cause devastating
injuries

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iv. If the object causing the injury passes through the body and out again, the exit wound
may be more serious than the entrance wound.

v. Often the most significant damage will occur in the structures beneath the skin

vi. Pre-Hospital Treatment

1. Puncture wound

a. Use caution when caring for puncture wounds; an object may actually go all the
way to the bone.

b. Gunshot wounds are always considered serious puncture wounds; assume that
there is considerable internal injury.

c. Stab wounds should be considered serious, especially when they involve the head,
neck, chest, abdomen, groin, or are inflicted proximal to the knee or elbow.

d. Reassure the patient.

e. Search for additional penetrations, including exit wound (especially gunshot

wound), and provide care to both wounds.

f. Assess the need for basic life support whenever there is a gunshot wound. Care
for shock, administering high-concentration oxygen.

g. Follow local protocols with regard to immobilizing the spine when the patient’s
head, neck, or torso is involved

h. Transport the patient. Take the puncturing object to the emergency department if
the emergency is not a crime scene.

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2. Impaled Object

a. A puncture wound may contain an impaled object (e.g., knife, fence post, shard of
glass).

b. Contact medical provider in charge for specific directions if an impaled object is

too long to make transport possible. Request for assistance from local fire
department or damage control in the fleet.

c. In general, do not remove the impaled object. Removal may cause severe bleeding
when the pressure is released or further injury.

d. Expose the wound area. Do not disturb the object while cutting away clothing.

e. Control profuse bleeding by direct pressure if possible. Position your gloved

hands on either side of the object and exert pressure downward. Do not put
pressure on the object or further injure the patient.

f. While you continue to stabilize the object and control bleeding, have another
trained rescuer place several layers of bulky dressing around the injury site so that
the dressings surround the object on all sides.

g. Continue manual stabilization until the stabilizing dressings are secured in place.

h. Have the other rescuer place folded universal pads or some other bulky dressing
material on opposite sides of the object (towels, blankets, or pillows for large
objects).

i. Remove your hands from under the pads, and place them on top, applying
pressure as each layer is placed in position.

j. The next layer of pads should be placed on opposite sides of the object,
perpendicular to the first layer.

k. Continue this process until as much of the object as possible has been stabilized.

l. Remember that a limited amount of time can be given to stabilizing an impaled

object.
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m. Secure the dressings in place.

n. Sweat and body movements may not allow you to use tape.

o. Apply triangular bandages folded into wide strips (cravats) by tying one above
and one below the impaled object.

p. Care for shock.

q. Keep the patient at rest. Position the patient for minimum stress, and provide
emotional support.

r. Transport the patient carefully and as soon as possible. If object was removed
before you arrived, bring it to the hospital.

s. Reassure the patient.

13. Assess and treat selected dermatological abnormalities and emergencies

a. Thermal Burns – Tissue injuries caused by application of heat, chemicals, electricity, or

irradiation.

i. Pathophysiology

1. Open flame and hot liquid are the most common causes of burns (heat usually
greater than or equal to 45 degrees Celsius): Flame burns are more common in
adults.
.
2. Caustic chemicals or acids may show little signs or symptoms for the first few
days.

3. Electricity may have significant injury with very little damage to overlying skin.

4. Excess sun exposure can also cause burns.

ii. Pre-Hospital/Inpatient/Outpatient Considerations

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1. Subjective

a. History of source of burn

2. Objective

a. First degree: Erythema of involved tissue, skin blanches with pressure, skin may
be tender

b. Second degree: Skin is red and blistered, skin is very tender

c. Third degree: Burned skin is tough and leathery; skin is non-tender.

d. Rules of 9s

i. Each upper extremity: 9%

ii. Each lower extremity: 18%

iii. Anterior trunk: 18%

iv. Posterior trunk: 18%

v. Head and neck: 9%

vi. Groin: 1%

e. Quick Estimate: The rule of palms (palmar surface plus finger) uses the surface
area of the patient’s hand is equal to 1% of the body surface area body surface area
(BSA)

f. Documentation of extent of burn and the estimated depth of burn

g. Check for any signs suggestive of potential airway involvement: singed nasal hair,
facial burns, carbonaceous sputum, progressive hoarseness, inflamed oropharynx,
circumferential burns around the neck, tachypnea

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3. Assessment - Thermal Burns

4. Plan

a. Pre-Hospital considerations

i. Provide high-concentration oxygen.

ii. Do not clear debris. Remove clothing and jewelry.

iii. Burns to hands or feet - Remove the patient's rings or jewelry that may
constrict blood flow with swelling. Separate fingers or toes with sterile gauze
pads.

iv. Burns to eyes - Do not open the patient's eyelids if burned. Be certain the
burn is thermal, not chemical. Apply sterile gauze pads to both eyes to
prevent sympathetic movement. If the burn is chemical, flush the eyes for 20
minutes en route to the hospital.

v. Wrap with dry sterile dressing.

vi. Wrap patient to prevent hypothermia and shock.

vii. Hospitalization for all serious burns

1. Second degree burns greater than 10% BSA

2. Any third degree burn

3. Burns of hands, feet, face, or perineum

4. Inhalation injury

5. Chemical burns

6. Circumferential burn

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b. Inpatient/Outpatient considerations

i. Remove overlying clothing and all jewelry from the affected area or limb,
monitor for swelling.

ii. Assess and monitor pulses and capillary refill distal to the burn. Observe for
worsening pain and any paresthesia.

iii. Assess for pain and provide medication as directed.

iv. Using normal saline, sterile gauze, and a cleansing solution, wash the
injured area gently.

v. Gently dry the wound with gauze.

vi. For a burn on the face, apply an antimicrobial topical agent to the wound
and do not place any dressing over the top.

vii. For a contaminated or large burn apply an antimicrobial topical agent to the
wound.

viii. Covered with a sterile, non-adhering gauze dressing and bandage.

ix. Reassess patient for pain.

b. Contact Dermatitis - A cutaneous reaction to an external substance

i. Pathophysiology
1. Hypersensitivity to plants: poison ivy, poison oak, poison sumac

2. Hypersensitivity to chemicals: nickel: jewelry, zippers, and watches; soaps and

detergents; hair dyes, fur dyes, and industrial chemicals; cleaning agents, polishes,
and waxes

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3. Hypersensitivity to topical medicines: topical antibiotics, cosmetics, shampoos,

and nail enamel

ii. Pre-Hospital/Inpatient/Outpatient Conditions

1. Subjective

a. History of Itchy rash

b. Assess for prior exposure to irritating substance

2. Objective:

a. Acute: papules, vesicles, bullae with surrounding erythema; crusting and oozing;
pruritus

b. Chronic: erythematous base; thickening, scaling, fissuring

c. Distribution: where epidermis is thinner (eyelids, genitalia); areas of contact with

offending agent; linear arrays of lesions

3. Assessment:

a. Contact Dermatitis

4. Plan

a. Remove offending agent: avoidance; work modification; protective clothing;

barrier creams, especially moisturizing creams

b. Topical soaks with cool tap water, Burow solution (1-40 dilution), saline (1 tsp/pt
water), or silver nitrate solution

c. Lukewarm water baths

d. Aveeno oatmeal baths

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e. Emollients (while petroleum, Eucerin)

f. Provider may prescribe the following medications:

i. Topical medications (lotion of zinx oxide, corticosteroids for acute

contact dermatitis)

ii. Calamine lotion for symptomatic relief

iii. Topical antibiotics for secondary infection (bacitracin)

iv. Systemic (antihistamine)

c. Folliculitis - Inflammation and infection of the hair follicle and surrounding dermis. Can
occur anywhere on the body that hair is found. Most frequent symptom is pruritus. Most
common infectious etiology is staphylococcus aureus bacteria.

i. Pathophysiology
1. Risk Factors: Hair removal (shaving, plucking, waxing, epilating agents)

2. Occlusive dressing or clothing

3. Use of hot tubs or saunas

ii. Pre-Hospital/Inpatient/Outpatient Conditions

1. Subjective

a. Onset of papules and pustules associated with pruritus or mild discomfort; may
have pain with deep folliculitis

b. Risk factors: frequent shaving, immunosuppression, hot tubs without adequate

chlorine, occlusive clothing and /or occlusive dressings, exposure to hot humid
temperatures

2. Objective:

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a. Primary lesion: small pustules 1 to 2 cm in diameter that is located over a hair or

sebaceous gland; pustule may be surrounded by inflammation or nodular lesions;
after the pustule ruptures, a crust forms; may have suppurative drainage with deep
folliculitis; any hair bearing site can be affected; the sites most often involved are
the face, scalp, thighs, axilla, and inguinal area

3. Assessment: Folliculitis

4. Plan

a. Lesions usually resolve spontaneously.

b. Avoid shaving and waxing affected areas.

c. Warm compresses may be applied TID.

d. Preventive measures are keys to avoidance of recurrence:

i. Antibacterial soap

ii. Keep skin intact; daily skin care with noncomedogenic moisturizers; avoid
scratching.

iii. Clean shaving instruments daily or use disposable razor, disposing after 1 use.

iv. Change washcloths, towels, and sheets daily.

v. Antiseptic and supportive care is usually enough

vi. The provider may prescribe the following:

a. Topical mupirocin may be used in presumed staphylococcus aureous

(bacterial infection routinely found in the skin) infection.

b. Topical antifungals for fungal folliculitis.

c. Systemic antibiotics
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d. Furuncle (Boil) - A deep-seated infection of the hair and sebaceous gland

i. Pathophysiology:

1. Staphylococcus aureus most common organism

2. Initially, a small perifollicular abscess that spreads to the surrounding dermis and
subcutaneous tissue.

3. May occur singly or in multiples; when infection involves several adjacent follicles, a
coalescent purulent mass or carbuncle forms

ii. Pre-Hospital/Inpatient/Outpatient Considerations

1. Subjective: Acute onset of tender red nodule that becomes pustular.

2. Objective:

a. Skin red, hot, and tender

b. Center of the lesion fills with pus and forms a core that may rupture spontaneously
or require surgical incision.

3. Assessment: Furuncle

4. Plan:

a. Apply Moist, warm compresses (provide comfort, encourage

localization/pointing/drainage) 30 minute up to four times a day’s QID

b. If the a incision and drain procedure is completed by the provider you may need to
perform wounds assessment, irrigation of the wound and dressing change

c. Routine culture is not necessary for localized abscess in nondiabetic patients with
normal immune system.

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d. Sanitary practices: Change towels, washcloths, and sheets daily; clean shaving
instruments; avoid nose picking; change wound dressings frequently; do not share
items of personal hygiene.

e. The provider may:

i. Incise and drain, if pointing or large, then consider packing if large or

incompletely drained.

ii. Prescribe systemic antibiotics usually unnecessary, unless extensive

surrounding cellulitis or fever

e. Tinea - A group of non-candidal fungal infections that involve the statum corneum, nails, or
hair.

1. Pathophysiology:

a. Acquired by direct contact with infected humans or animals; invade the skin and
survive on dead keratin.

b. Lesions usually classified according to anatomic location and can occur on

nonhairy parts of the body (tinea corporis), on the groin and inner thigh (tinea
cruris), on the scalp (tinea capitis), on the feet (tinea pedis), and on the nails
(onychomycosis).

ii. Pre-Hospital/Inpatient/Outpatient Considerations

1. Subjective: May report pruritus

2. Objective

a. Lesions vary in appearance and may be papular, pustular, vesicular,

erythematous, or scaling.

b. Secondary bacterial infection may be present.

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c. Infected nails are yellow and thick and may separate from the nail bed.

d. Microscopic examination of skin scraping with KOH solution shows presence

of hyphae.

3. Assessment: Tinea

4. Plan

a. Careful handwashing and personal hygiene; laundering of towels/clothing of

affected individual; no sharing of towels/ clothes/headgear

b. Avoid predisposing conditions such as hot baths and tight-fitting clothing.

c. Keep areas dry as possible

d. Avoid contact sports (e.g. wrestling) temporarily while starting treatment.

e. The provider may prescribe: topical antifungals.

f. Cellulitis - Diffuse, acute, infection of the skin and subcutaneous tissue.

i. Pathophysiology - Majority of cases caused by the bacteria: Streptococcus pyogenes or

Staphylococcus aureus

ii. Pre-Hospital/Inpatient/Outpatient Considerations

1. Subjective:

a. Break in the skin, such as a fissure, cut, laceration, insect bite, or puncture
wound

b. Pain and swelling at the site

c. May have fever

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2. Objective:

a. Skin red, hot, tender, and indurated

b. Borders of redness are not well demarcated

c. Lymphangitis streaks and regional lymphadenopathy may be present.

3. Assessment: Cellulitis

4. Plan:

a. Immobilize and elevate the involved limb to reduce swelling.

b. Sterile saline dressings or cool aluminum acetate compresses for pain relief

c. Mark the area of cellulitis to monitor progression.

d. The provider may prescribe:

e. Tetanus immunization if needed, particularly if there is open (traumatic) wound

f. Systemic antibiotics

14. Summary and Review

[Link] Define terms related to the dermatology system (KPL1)

[Link] Explain anatomy of dermatology system (KPL2)

[Link] Explain concepts and principles for assessing patients for dermatological
abnormalities (KPL1)

[Link] Explain concepts and principles for assessing patients for hazardous substance
exposure (KPL2)

[Link] Assess patients for dermatological abnormalities (SPL1)

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[Link] Assess wounds (SPL2)

[Link] Assess patients for thermal injuries (SPL2)

[Link] Perform dermatological examination (SPL2)

[Link] Explain concepts and principles for assisting in treatment of dermatological

conditions (KPL1)

[Link] Explain concepts and principles for assisting in treatment for thermal injuries
(KPL2)

[Link] Assist in treatment of hazardous substance exposure (SPL2)

[Link] Prepare patients for medical procedures (SPL1)

[Link] Assist in treatment of dermatological conditions (SPL1)

[Link] Assist in treatment of thermal injuries (SPL2)

[Link] Perform wound care (SPL1)

[Link] Irrigate infected areas (SPL1)

[Link] Administer local anesthesia (SPL1)

[Link] Remove external staples (SPL1)

[Link] Remove external sutures (SPL1)

[Link] Report side effects to treatments (SPL2)

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