Stormwind Medical Handbook: Soft Tissue Wounds

Stormwind
Medical Handbook
1. Medical Theory & Anatomy
2. Medical Duties
3. **Soft Tissue Wounds**
4. Bone Fractures
5. Head & Eye Injuries
6. Chest & Abdominal Injuries
7. Shock
8. Temperature Related Illness
9. Toxins & Poisons
10. Magical Wounds

The **Soft Tissue Wounds** chapter of the Stormwind Medical Handbook covers the terminology and treatment of common soft tissue wounds. All medical staff should be able to identify and treat these wounds and determine triage based on the severity.

**Disclaimer:** The information edited here has been adjusted to suit the lore of World of Warcraft, and is not meant to be used as real-life saving techniques. Techniques utilized, and information contained in this document may not be best practice.

## Terminology

Common Tissue Wound Terminology will be defined and explained below.

### Blunt Trauma

Blunt Trauma is a broad category of injury where body tissue is bruised, torn, or otherwise damaged by impact with another body that does not penetrate the tissue. Blunt trauma is typically sustained by falls, attacks by blunted weaponry, or high speed collisions. While blunt trauma does not penetrate flesh, it may tear tissue apart by force.

### Penetrating Trauma

Penetrating Trauma is the category of injury where a foreign object pierces the skin and enters the body tissue, causing damage in the process by means of cavitation (separating the tissues). Penetrating trauma is typically sustained with projectile wounds, attacks by sharp weaponry, or collisions with sharp objects. Penetrating trauma always creates an open wound.

### Abrasion Wounds

An Abrasion Wound is a form of blunt trauma in which the upper layers of the skin are grazed or scraped off. Abrasion wounds are typically sustained by falls or collisions with rough surfaces. Abrasion wounds are typically non-life threatening themselves, but may become infected if proper care is not taken in the healing process. They should be cleaned and dressed with bandages as soon as possible.

### Laceration Wounds

A Laceration Wound is one where flesh and skin are torn by blunt trauma. Laceration wounds may be jagged or linear along the victim’s flesh. They are typically sustained by high impact from blunt weaponry or high speed collision. Blood loss from torn flesh should be stanched as soon as possible to maintain the balance of the humours. If an organ is injured with an open wound, cloth should be stuffed into the wound in attempt to stanch bleeding. The wound should be cleaned and dressed until magical healing may be applied.

Once the bleeding is under control, the wound should be cleaned. Stitching the tissue back together may be required for proper healing if the wound is large enough. The wound should be dressed with bandages to prevent further damage to the tissue.

### Incision Wounds

An Incision Wound is a form of penetrating trauma in which a sharp object cuts through the skin and any number of layers of tissue beneath. Incision wounds are visibly different from laceration wounds in that while tissue may bridge the torn flesh of laceration wounds, the tissue of incision wounds is usually cut cleanly apart. Incision wounds are typically sustained by attacks by sharpened weaponry or shrapnel. Blood loss from cut flesh should be stanched as soon as possible to maintain the balance of the humours. Once the bleeding is under control, the wound should be cleaned. Stitching the tissue back together may be required for proper healing if the wound is large enough. The wound should then be dressed with bandages.

### Avulsion Wounds

An Avulsion Wound is one in which flesh is detached from the body by force, either by ripping or slicing the tissue off. Avulsion wounds are typically sustained by animal attacks or in melee combat, where extremities like the ears, nose and fingers may be torn off. Blood loss from torn flesh should be stanched as soon as possible to maintain the balance of the humours. Once the bleeding is under control, the wound should be cleaned to remove debris. Flesh that is torn off of the body can not be reattached without extensive healing magic. The open wound should be stitched closed if possible and dressed with bandages.

### Puncture Wounds

A Puncture Wound is a form of penetrating trauma in which an object pierces the skin and creates a hole or cavity in the flesh. They are typically sustained as animal bites, stab wounds, or collisions with sharp objects. Puncture wounds do not typically cause excessive bleeding unless they rupture a major vein or artery. Once bleeding is stanched, the wound should be cleaned and stitched back together if necessary. The wound should then be dressed with bandages to prevent further debris from entering the cavity.

A Puncture Wound is a form of penetrating trauma in which an object pierces the skin and creates a hole or cavity in the flesh. They are typically sustained as animal bites, stab wounds, or collisions with sharp objects. Puncture wounds do not typically cause excessive bleeding unless they rupture a major vein or artery. Once bleeding is stanched, the wound should be cleaned and stitched back together if necessary. The wound should then be dressed with bandages to prevent further debris from entering the cavity.

### **Projectile Wounds**

A Projectile Wound is one in which a foreign object pierces the skin and either lodges in tissue or exits after passing through tissue. Projectile wounds are typically sustained as arrows, bullets, or shrapnel fire. In any case of a projectile wound, the bleeding should first be stanched around the wound before any attempt to remove the projectile. If the projectile is still embedded in the flesh or bone, one must carefully determine if it is safe to extract or not.

If the victim is struck with an arrow, the arrow should not be pulled by the shaft. Most arrowheads are barbed and will tear flesh if yanked after impact. Furthermore, the arrow shaft will soften in the presence of bodily fluids, and yanking the arrow by the shaft may detach the arrowhead and leave it behind in the victim. Each arrowhead must be located in the body and extracted, for a wound will fester and corrupt if an arrowhead is left within the flesh. If the shaft is still attached to the arrowhead, one must make an incision to broaden the wound and then carefully pull the arrowhead out intact. If the shaft is separated from the arrowhead, multiple incisions may be made in order to find the arrowhead buried in the flesh. If the arrowhead is embedded in bone, significant force will be required to yank it out of the wound. Forceps are recommended. Arrows lodged in the lungs, stomach, or other major organs in the torso are typically fatal wounds unless treated with extensive healing magic. Extracting arrowheads causes a significant amount of bleeding that must be stanched. Once all arrowheads are extracted, the wounds should be cleaned, stitched, and dressed.

If the victim is struck with a bullet, one must carefully determine whether it is safe to remove the projectile. Bullets may become deeply embedded in bone or tissue and difficult to find without causing further trauma. The bullet should be extracted if it is accessible and not lodged in bone. Bullets that are deeply lodged in tissue or bone may be left in tissue, as bullets typically do not agitate flesh as much as arrowheads. Again, bullets lodged in the lungs, stomach, or other major organs in the torso are typically fatal wounds unless treated with extensive healing magic. Regardless of extraction, the wound should be cleaned, stitched, and dressed in order to avoid infection.

## Complications

### Infection

An Infection is defined as the invasion of body tissue, usually surrounding an open wound or sore, by disease causing miasma and the body's reaction to the toxins it creates. Infected tissue is typically reddened and may excrete pus. Infections and the manifestation of miasma are often the direct result of squalid or dirty conditions, poor hygiene, diet that disrupts the humours, lack of access to proper medical care, and necrotizing toxins, or any combination or individual cause therein. Infections severely imbalance the body’s humours and can progress to fatal complications. Without cleansing magic, infected flesh may be amputated in order to save the rest of the body. The victim should be given plenty of fluids to drink in order to rebalance their humours.

### Necrosis

Necrosis is the death of tissue that has been infected or cut off from the humours. Flesh that has died is typically black or green in color and leathery in texture. Necrotic flesh must always be amputated from living tissue as an infection will quickly spread throughout the body sourced from it. A surgeon should be careful to extract all of the necrotic flesh from a wound, for leaving any may well lead to further infection and tissue death. Maggots may be introduced to help eat away the dead tissue. Any bleeding sustained by amputation should be stanched. The wound should be thoroughly cleaned and dressed in order to prevent further infection. The victim should be given plenty of fluids to drink in order to rebalance their humours.

### External Bleeding

External Bleeding is self explanatory; the condition in which blood escapes the body through wounds. Bleeding should be controlled and stanched as soon as possible, as the loss of too much blood will imbalance the humours and result in patient illness and death.

### Internal Bleeding

Internal Bleeding is the condition in which blood escapes the circulatory system and pools within the body, such as inside the skull, lungs, stomach, other organs, or their surrounding cavities. Internal bleeding is typically caused by high impact collisions that rupture blood vessels inside the body without necessarily showing external injury. Internal bleeding is often hard to identify and only recognized when the victim goes into shock due to the imbalance of humours. Blood in one’s stool or urine may be signs of internal bleeding and should be treated seriously. Untreated, internal bleeding is a condition that often proves fatal unless the victim is treated with healing magic.

## Assessment

The medical personnel will perform the following acts in the following order, this is a simplified version for the sake of basic instruction to all personnel. Interventions are to be done by trained medics:

**This part constitutes the primary assessment:**

* Determine mechanisms of injury
* Determine number of patients
	+ Consider if contacting additional medical personnel is necessary and if patient requires their spine to be braced with rods, boards, or a neck attachment.
* Determine the level of responsiveness of the patient and their Level of Consciousness
	+ Patient is either Aware, responsive to verbal stimulation, responsive to pain stimulation, or unresponsive.
	+ Ask general close ended questions to determine patients awareness to things such as person, place, time, and event. “What year is it?”, “Where are you?”, “What happened to you?” “What day is it?”
* Determine immediate life threats and/or chief complaint.
	+ Address these issues immediately if apparent and critical.
	+ Treat for shock
* Assess patient ability to breath/make use of air (ABC’s)
	+ Airway: Open the patient's mouth by grasping the patient’s cheeks from a position above their head and place fingers under the chin, open their mouth as you lift the chin up and depress the crown of their head down. Otherwise known as a head tilt/chin lift.
		- If a neck injury is suspected in any way, do not manipulate the patient’s neck.
	+ Breathing: Ensure adequate ventilation. If needed, place adjuncts in the airway (see section below: interventions)
	+ Circulation: Control major bleeding, determine a pulse, ensure skin looks healthy
		- Pink (or appropriate colour as per patient species), warm, and dry are to be considered ‘normal’ skin signs.
		- Apply tourniquets at this stage if appropriate injuries uncovered (see section below: interventions)
* Determine any pertinent history of the patient; ask if they have any allergies to common medicines or herbs, do they regularly ingest any herbs, potions, or other substances (harmful or otherwise). And when they last ate anything.

**Begin a detailed secondary assessment here:**

* If immediate life threats are noted in the initial assessment, address those issues and ensure patient stability before doing this section.
	+ The medic shall prioritizing deformities, contusions, abrasions, punctures, burns, lacerations, instability, swelling, tenderness, or crepitus (crunchy feeling).
* Inspect the patient's head
	+ The medic shall be looking for darkening about the eyes and dark colouring/blood behind the ears to rule out breaking of the orbital (eye) bones and skull fractures.
	+ The medic shall inspect the patients scalp for bleeding or tears.
* If the patient is suspected to have taken significant cranial trauma and is wearing a tight fitting helmet, do not remove the helmet and secure patients neck.
	+ Inspect the patient's neck
	+ The medic shall inspect the jugular vein and carotid artery for bulging.
	+ The medic shall inspect the position of the trachea (cartilaginous structure around the windpipe in the center of the neck).
	+ The medic shall ensure the spine is stable if trauma is suspected.
* Inspect the patient’s chest
	+ The medic shall place his or her hands upon the ribs of the patient and hold them there for the duration of one breath in and out, as to ensure equal rise of both sides of the chest at once and feel for
	+ The medic shall search the ribs for sections which move paradoxically. Paradoxical movement is defined as sections of rib that have suffered two fractures and created a ‘floating’ segment which presses in during inhalation and puffs out during exhalation.
	+ The medic shall listen to the patient's lungs via their own device and listening for gurgling or other noises. Absence of sound shall be addressed below in Interventions.
* Inspect the patient's pelvis and abdomen
	+ The medic shall press on all four quarters of the abdomen to determine if any one in particular hurts, is tender, has swollen, is distended, or is hardened.
	+ The medic shall assess the stability of the patient's pelvis by placing their hands on the patients hips and moving the hips back and forth, this is to inspect the intact or broken nature of the pelvic bones.
	+ The medic shall inspect the patient's genitals if applicable.
* Inspect the patient’s extremities.
	+ The medic shall inspect the patient's arms and legs and asses the patient's ability to move their hands and feet up and down, grip or resist movement, and press upon the nails to drain them of colour and observe if they return to normal colour. (see; Interventions)
* Inspect the patients back and buttocks
	+ The medic shall inspect the spine for deformities or step offs (spine bones are misaligned)
	+ The medic shall inspect the patient's buttocks if appropriate to check for the prioritized conditions if applicable.
	+ The medic shall now perform secondary interventions as appropriate and reassess every 5 minutes until patient is released to doctors.

## Interventions

***As a disclaimer, non-trained personnel should not attempt these interventions unless specifically instructed to do so by a trained medic and under the guidance of said medic.***

* If a patient is unable to breath appropriately due to obstructed airway without a neck injury, tilt the head back and lift the chin. If the patient is conscious or semiconscious and still cannot control their airway, place a nasal adjunct tube into their nostril with the bevel facing the septum.
* If a patient is unable to breath appropriately due to obstructed airway without a neck injury, tilt the head back and lift the chin. If the patient is conscious or unconscious and still cannot control their airway, place an oral airway adjunct into their mouth, with the curvature meant to go down their throat facing the roof of their mouth, twist it 180 degrees once past the tongue.
* Patients wearing armor should have the armor cut off and chainmail removed over all pertinent sections.
	+ If major bleeding is encountered on the patient, address this concern first. Do so by placing a tourniquet on the wound site towards the body. If the wound is on the bicep, place it toward the shoulder, if on the thigh, place towards the genitals. Do not place a tourniquet on a joint or below the injury site.
	+ If a patient has been shot by a bullet or firearm, determine first if the patient has an exit wound.
	+ If there is an exit wound, compress the hole together if able, and bandage in heavy occlusive/bulky dressing.
* Repeat for the entrance wound, being sure to control bleeding via compression.
	+ If the patient has been shot by an arrow in the torso or an extremity, determine how deep it is and if it is perforating any vital organs or viscera. If it is, presume internal bleeding. Depending on the depth of the arrow, it may be possible to push the arrow through, snap off the arrow head, then draw out the arrow shaft. This is not recommended if an arrow has punctured the area around the heart or large blood vessel.
	+ If other arrows are found nearby and they are found to have large barbs or points, do not push the arrow through. If the arrow is perforating the liver, lungs, or heart. Do not push the arrow through. Evacuate the patient for surgery. Stabilize the arrow with bulky dressing and pads.
* Broken arms should be splinted, as should legs.
	+ Depending on the type of break (aside from compound), long bones may require traction before splinting. The medic shall pull on the misaligned broken bones as to return them to their normal alignment relatively, and then splint with the aid of a second medic or persons. Particularly in the case of a femur break.
* If the patient is bleeding from a significant laceration, bandage tightly with bulky dressing. Apply disinfecting potions if possible.
* If a flap of skin has been torn away incompletely due to an avulsion, do not remove the flap, press it back into place where it was torn from as best as possible.Bandage tightly.
* If a patient suffers an object in the eye such as an arrow, knife, fork, or other blade, stabilize the object for surgical removal later. Both eyes are to be covered tightly as to not cause movement due to the patients free eye moving and causing the damaged eye to move.
* If upon listening to the lungs and by feeling ribs, one side of the chest is not breathing, check for bulges on the left and right side of the patient's neck. If bulging is present, breath sounds are absent, and patient is experiencing significant trouble breathing due to short bounding gasps, suspect a pneumothorax (air leaking into chest from lungs).
* If no external wound is present, insert a small gauge needle beneath the clavicle (front shoulder bone). Do not stick the needle into the heart. Do not perform this procedure if patient is sitting up. Do not place the needle at the lower edge of a rib to avoid neurovascular bundles.
	+ Once the needle is in place, instruct the patient to take a deep breath once the decompression is complete.
* If the patient has suffered significant blunt crushing trauma to the ribs and previous signs and symptoms are present, suspect a hemothorax (blood blocking lungs from inflating).
* The medic shall cut an incision below the sixth or seventh rib into the chest cavity where pertinent, and insert a drainage tube if possible. Instruct the patient to take a deep breath when decompression is complete.
* Do not pick bullets out of the wounds.

## Treatment

Common **Treatment Methods** for soft tissue wounds are defined and explained below.

### Sterilization

Most open flesh wounds must be sterilized as soon as possible in order to avoid corruption. One should first rinse the wound with water and remove all foreign debris. Honey or ground silver may be applied to a wound to prevent infection. When faced with an infection in the field, it must be treated based on how developed or recent the infection is. Severe infections will require special holy treatments or amputation. Minor to moderate infections can often be temporarily treated with a brief cleaning and a wrap of sterile bandage.

### Wound Dressing

Wound dressing is the process of applying a material against a wound to act as a barrier against corruption or further injury, thus assisting in the healing process. One may use medicinal oils, herbs, honey, or any variety of medical salves to coat an open wound, then proceed to cover the dressed wound with a clean length of cloth. If no designated medical supplies are available, one may loosely tie any cloth around a wound as a minimal dressing. If a trained surgeon or healer is not present to tend to a wound, the wound should be dressed until it can receive proper care.

### Bloodletting

Bloodletting is the act of allowing or causing a wound to bleed in order to purge corruption and bad blood from the body. Wounds caused by poisoned weapons or by animal bites should be allowed to bleed for some time before stanching in order for the blood to flush as much of the toxin as possible from the flesh.

Despite its benefits, bloodletting should be used sparingly. The loss of too much blood, bad or good, will imbalance the humours and may lead to illness or death. After bloodletting, the patient should be given additional food and water based on their temperament and the needs of their humours. Meat is the best food to fortify one's blood.

### Stanching

External bleeding can be stanched by direct pressure, indirect pressure at the pressure points, elevation, or tourniquet. The most effective way to control external bleeding is by applying pressure directly over the wound. If bleeding continues after having applied direct pressure for 30 minutes, apply a pressure dressing. This will consist of a thick dressing of gauze or other suitable material that is held in place with a tightly wrapped bandage. The dressing should be tight but not so tight that it impairs circulation to the rest of the limb. Once the dressing is applied, do not remove it, even if the dressing becomes blood soaked. Leave the dressing in place for 1 or 2 days, then replace with another dressing. Inspect the wound for signs of infection.

### Tourniquet

A tourniquet is a cloth wrapped tightly around or near a wound in order to stanch bleeding. Use a Tourniquet only when direct pressure over the bleeding point did not control the bleeding. If a tourniquet is left in place too long, the tissue damage can progress to gangrene and the loss of the limb later. An improperly applied tourniquet can also cause permanent damage to nerves and other tissues. To use a tourniquet, place it around the extremity, 5 to 10 centimeters above the wound site. Never place it directly over the wound of fracture. Use a stick to tighten the tourniquet enough to stop blood flow. Bind the free end of the stick to the limb to prevent unwinding.

### Cauterization

Cauterization is the act of using a fire-heated metal implement to sear flesh and exposed veins to stanch bleeding and prevent the corruption of flesh. In cases where limbs or flesh has been torn or sliced from the body, cauterization is highly recommended as external bleeding from those wounds is often severe. Despite its efficiency at stanching bleeding, cauterization should be used sparingly as it severely burns any flesh it is applied to. Flesh that is cauterized should be treated as if it were burned and dressed appropriately.

### Stitching

Stitching is the act of tying sundered flesh back together with surgical sutures in a way that will promote wound closure and healing. Stitching should be done with a steel needle that has been boiled in water. Advanced medical kits will have several types of needles, both curved and straight. The thread for sutures is typically made from silk. One can perform a simple interrupted stitch by pulling two sides of a wound together at one place with silk, tying a surgeon’s knot to secure the closure, and cutting the silk before moving on to the next suture along the wound. Depending on the depth of the wound, multiple layers of stitching may be needed to ensure that all layers of tissue heal properly. In that case, the deepest layer of tissue should be stitched first before moving upwards to the surface layers of tissue. As with any open wound, it should be cleaned and dressed in order to aid the healing process.

Depending on the wound, stitching may require air, and can range to as needed sutures. Stitches are to be kept from 10-14 days, addressed as needed.

### Amputation

Amputation is the removal of flesh, extremities, or limbs that are impossible to treat and would otherwise cause further harm to the rest of the body. Amputation should be considered a last resort after other treatment options are attempted and the part of the body to be amputated is deemed beyond help. In any case of amputation, blood flow to the flesh to be amputated should be restricted through the usage of a tourniquet or applied pressure if possible. If the tissue to be amputated is along a bone, the doomed flesh should be cut out and healthy flesh cut back in sections in order to reveal the bone, cauterizing veins as necessary to stanch bleeding. The bone should then be cut with a bone saw such that healthy flesh may envelop the remaining bone. Any jagged or pointy sections of the remaining bone should be filed smooth before the remaining healthy flesh is pulled around it and stitched closed. As with any open wound, it should be cleaned and dressed in order to aid the healing process.

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