“That Others May Live”


General Evaluation of Chest



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General Evaluation of Chest:

 Get history of breathing difficulties


 Expose chest and abdomen. Observe for: Respiratory rate, depth and symmetry.

 Examine anterior and posterior chest for injuries.

 Auscultate breath sounds in all lung fields to include axillae.

Listen for: Symmetry, wheezes, rales and rhonchi



If breath sounds are not equal: Percuss to determine different tones (hyperresonance-vs-hyporesonance).

Note: All severe chest injuries require urgent evaluation with special consideration for aeromedical evacuation.

Caution: In cases of abdominal and chest trauma, the role of fluid resuscitation in the pre-hospital environment is controversial. In cases of uncontrolled internal hemorrhage, administering large amounts of IV fluids prior to surgical control of bleeding may make things worse. In these cases, fluid resuscitation should be rendered with great care. Monitor the patient closely: A patient with suspected internal hemorrhage that is awake, alert and oriented, and producing urine does not necessarily need fluid resuscitation to a higher BP. If the patient is unconscious: Titrate the BP to between 90-100 systolic.

Specific Injuries and Treatment
Fractured Ribs or Sternum

Signs and Symptoms: Localized chest pain aggravated by breathing or coughing. Often there is decreased motion on the affected side. May be ecchymosis, localized tenderness to palpation; crepitus. Normal symmetrical breath sounds bilaterally.

Treatment: Semi-Fowler's (Semi-reclining position with head and torso inclined to 45-60 degrees, legs/knees extended). Encourage deep breathing and coughing. Pain medication PRN. O2 if condition deteriorates (suspect more serious problem). Evacuate.

Caution 1: Do not tape or strap fractured ribs in absence of paradoxical motion (flail chest). This contributes to pooling of secretions, atelectasis and pneumonia.

Caution 2: Fractures of lower three ribs may accompany splenic or hepatic injury with subsequent internal bleeding.

Caution 3: Numerous complications can accompany chest injury. Continuous re-evaluation is imperative.
Flail Chest

Signs and Symptoms: Localized chest pain aggravated by breathing or coughing. Rapid shallow respirations with compromised air exchange. Localized area of paradoxical chest movement.

Treatment: Immediately immobilize flail segment by placing hand over area to prevent further motion. Immobilize flail segment with tape (midline to midline). Note: If tape does not stick, immobilize flail segment with hand, sandbags, etc. or roll patient onto affected side. Semi-Fowler's position if there are no contraindications (Semi-reclining position, with head and torso inclined to 45-60 degrees, legs/knees extended). Oxygen and pain medication as required.

Note: Definitive treatment is usually intubation with mechanical ventilation.

Caution 1: Monitor respirations closely. Monitor for underlying problems: Pulmonary contusion, cardiac

contusion, abdominal injuries or hemopneumothorax.



Caution 2. May need to assist ventilations with BVM. Intubation may be required.

Caution 3. Limit hydration. Over hydration may increase the incidence/severity of pulmonary contusion.
Pulmonary Contusion

Signs and Symptoms: MOI usually within last 24 hours (e.g., steering wheel trauma, deceleration injury, concussion waves following explosion) and history of progressive respiratory distress. Decreased breath sounds. Dullness to percussion over affected area. Hypoxia can occur leading to coma and death.

Treatment: Positive pressure oxygen. May require intubation. Suction secretions. Prevent fluid overload: IV TKO. Pain control. Caution: DO NOT use CNS depressants (narcotics).

Pneumothorax

Signs and Symptoms: May or may not have history of injury (spontaneous-vs.-traumatic). Chest pain. Diminished breath sounds on affected side. Hyperresonance to percussion. Decreased movement on the affected side.

Treatment: In absence of severe symptoms, observe and O2 only. O2. Evacuate.

Note: In the presence of severe symptoms a thoracentesis or chest tube insertion is indicated.
Open Pneumothorax

Signs and Symptoms: History of penetrating injury. Rapid and/or gasping respirations. May hear sucking sound or see blood froth escaping from wound.

Treatment: Immediately seal wound with hand or available material. Replace temporary seal with a saline gauze dressing or Ascherman Chest Seal. Sterile saran wrap is an excellent material for making an occlusive chest dressing. Note: When taping dressing, leave one edge undone to function as a flap valve. Semi-Fowler's position. Oxygen. Evacuate.

Note: An alternative treatment is to apply an occlusive dressing without a flap, then IMMEDIATELY perform a needle throracentesis followed by chest tube insertion.
Tension Pneumothorax

Signs and Symptoms: May or may not be from penetrating trauma. Chest pain. Difficulty breathing. Extreme dyspnea. Cyanosis. Hypotension. Diminished or absent breath sounds on affected side. Hyperresonance on affected side. Affected side may appear more prominent and move less with respiration. The following may or may not be found:

 Distended jugular veins

 Subcutaneous emphysema

 Tracheal shift



 Displaced apex beat of heart

Treatment: Needle thoracentesis. High flow oxygen. Evacuate while monitoring ventilation closely.
Massive Hemothorax

Signs and Symptoms: May or may not be due to penetrating trauma. Patient may be anxious and confused. S/S of hypovolemic shock. Respiratory distress. Decreased breath sounds on affected side. Dull to percussion on affected side.

Treatment: Secure airway. High concentration oxygen. IV x NS or NS. (hypovolemic shock). Close observation for developing tension hemopneumothorax. Decompress only if tension hemopneumothorax is suspected. Evacuate.
Additional Notes (Chest Trauma):

ABDOMINAL TRAUMA
Guidelines and Considerations
History: Symptoms in a conscious patient could include, but are not limited to: Nausea, vomiting, cramps, and localized pain. In some cases pain may seem to arise in an area or point other than at its origin (referred pain). Example, injury of the diaphragm is often manifested by pain in the shoulder.
Physical Exam: Examine for wounds, bruises, abrasions and abdominal distention (late finding). Any penetrating wound from the neck to the knees may involve the abdomen (dependant on trajectory, ricochet, missile fragmentation, etc.). Any chest or groin injury may involve abdominal contents. Auscultate all four quadrants for bowel sounds. Listen to chest during this exam (bowel sounds in the chest are indicative of ruptured diaphragm). Palpate for tenderness and rigidity. Perform genital and rectal examination.

Caution: In cases of abdominal and chest trauma, the role of fluid resuscitation in the pre-hospital environment is controversial. In cases of uncontrolled internal hemorrhage, administering large amounts of IV fluids prior to surgical control of bleeding may make things worse. In these cases, fluid resuscitation should be administered with great care. Monitor the patient closely: A patient with suspected internal hemorrhage who is awake, alert and oriented; and producing urine does not necessarily need fluid resuscitation to a higher BP. If the patient is unconscious: Titrate BP to between 90-100 mmHG.

Specific Injuries
Penetrating Abdominal Injury

Signs and Symptoms: Patient may have multiple complaints or no complaints. May see very small to very large penetrating wound. Remember to look for additional wounds (such as exit wounds).

Treatment: Control external bleeding. Large-bore IV's NS or LR (see page 47 for cautions). Note: Large bore saline lock is an excellent alternative to an IV. Keep patient N.P.O. Insert an NG tube. Urinary catheterization (proceed gently due to possible bladder trauma, but only if rectal exam is normal, there is no blood at uretheral meatus and no scrotal hematoma). ASAP evacuation. If evacuation is delayed greater than 2-4 hours, initiate antibiotic therapy.


Blunt Trauma & Blast Injury

Signs and Symptoms: Patient may have any number of physical complaints. May or may not see evidence of trauma. Do full abdominal exam. Much of the time you will have no idea the extent of damage, only that something is wrong.

Treatment: Monitor patient closely and treat symptomatically. Evacuate ASAP


Evisceration

Signs and Symptoms: Any protrusion of abdominal contents through a wound.

Treatment: Control hemorrhage. Large bore IV's NS or LR (see page 47 for cautions). Saline lock is acceptable. Sterile wet (saline) dressing, then cover with saran wrap. Keep patient NPO. NG tube. Urinary catheterization if rectal/penile/scrotal exam is negative. ASAP transport. If wound is grossly contaminated and evacuation delayed, dilute (1:10 dilution with normal saline) betadine solution may be used to soak the wound for 20 minutes, then replace with saline/saran wrap dressing. Initiate antibiotic therapy.

Injury to the Kidney

Signs and Symptoms: May be either penetrating or blunt. Pain (may confuse kidney pain with muscle pain). May have gross blood in urine.

Treatment: Normal wound care. IV NS or LR and titrate appropriately. Urinary catheterization.


Urethral Injury

Signs and Symptoms: Blunt or penetrating trauma to the suprapubic area. May or may not be blood at the urethral meatus. Signs of other injury. Assessment is based on whole patient. Note: Urethral injury is usually secondary to other types of trauma.

Treatment: If possible, catheterize carefully. DO NOT attempt catheterization if any blood at the meatus, high-riding prostate, and blood in the rectum or obvious trauma to the urethra. If unable to catheterize, decompress bladder with suprapubic-needle-cystotomy. Additional treatment per findings.

Note: Wounds of the external genitalia are dressed and bandaged. Avulsed tissue is transported with patient.
Additional Notes (Abdominal Trauma):
EXTREMITY TRAUMA
Guidelines and Considerations

General Treatment: A hazardous environment or situation may alter or prevent any of these steps.

1. Control hemorrhage and treat for shock.

2. Remove tight clothing, jewelry and footgear prior to splinting. Note: Femur fractures require a traction splint.

3. Unless fracture is significantly angulated, do not manipulate if good circulation and nerve supply is present.

4. If there is neurovascular compromise of the limb or significant angulation of the fracture:

 Stabilize the proximal portion of the fracture and use gentle long-axis traction to align the fracture

(exact anatomic reduction is not necessary at this stage). Perform CSM check after any

manipulation or splinting



5. If evacuation is delayed: Debride wounds by irrigation and scrubbing.

6. Pack and dress wounds with bulky sterile dressing. Immobilize joint above and joint below fracture.

7. Neurovascular check: Perform neurovascular check before splint application, after application and

q. 15-30 min thereafter.



8. Consider analgesics for pain if not contraindicated.

9. Elevate and apply cool compresses during the first 12 hours (if able).

10. Consider antibiotics for open wounds if evacuation delayed over 4 hours.
Note: Open fractures have a high incidence of infection and must be treated aggressively in the field. In all cases of open fracture or suspected open fracture the use of IV antibiotics should be considered:
In cases where evacuation to higher level care will take 4 hours or longer, treat as above, plus:

 Administer antibiotics. Rocephin, Cefotan or Mefoxin are acceptable antibiotics.

 If the skin over a fracture is abraded, clean the abrasion with betadine solution, irrigate with saline and dress the wound.

 If bone is visible in the wound and there is neurovascular compromise, re-alignment of the fracture in the field may be required. Irrigate the bone ends with a minimum of 1 liter of normal saline before re- alignment. Do not delay re-alignment for more than 5 minutes for irrigation. If normal saline is not available, use any other sterile fluid for irrigation.


In cases where evacuation to higher level care will take 12 hours or longer, treat as above, plus:

If there is a laceration with no bone visible: Irrigate the wound with medium-pressure technique, using a minimum of 1 liter of normal saline (preferably 2 -3 liters).

If bone is visible in the wound: Irrigate as above and cover with a moist sterile dressing.

 If dirt or other debris is impacted into the bone: Clean out as best as possible before irrigation.


Specific Injuries
Clavicle

Signs and Symptoms: Pain and tenderness over clavicle. Difficulty moving adjacent arm without discomfort.

Treatment: Sling and Swathe. Pain medication as needed. A “Figure 8” splint used to be the treatment of choice for this injury: It is currently out of favor for definitive care. However, use of a Figure 8 splint may provide better functionality in the field. Use of a Figure 8 splint is allowable, if it provides for better functionality of the patient.

Note: Sharp or displaced loose fragments can damage underlying nerves, vessels, or lung. Always check neurological function in an upper extremity and examine closely for a pneumothorax.
Humerus (Proximal, Middle and Distal Shaft)
Proximal Fractures of the Humerus: Pain of upper arm and shoulder. Swelling and ecchymosis may be present. Angulation may be noted. May have appearance of dislocation or shoulder may appear normal with arm hanging loosely at side or held across the chest. Shortening of upper arm may be evident. Virtually the entire length of the humerus can be palpated by palpating from the axilla to the medial aspect of the elbow. Significant pain and/or crepitation on palpation is strongly suggestive of fracture.

Treatment: Loose sling and swathe (with no pressure under the elbow). Keep patient in seated position, if practical. Note: Fractures of the neck of the humerus can accompany shoulder dislocations.
Mid-Shaft Fractures of the Humerus: May have damage to the radial nerve, which spirals around the bone. Damage to the nerve is indicated by inability to lift the hand (wrist drop) and loss of sensation on the back of the hand.

Treatment: Loose sling and swathe (with no pressure under the elbow). Keep patient in seated position, if practical.
Fractures of the Distal Humerus: Fractures of the lower humerus can be difficult to differentiate from fracture/dislocations of the elbow in the field. If there is swelling, pain and crepitation on palpation around the elbow, it is best to assume a fracture and splint, sling and swath the arm with the elbow in 90 degrees of flexion.

Shoulder Dislocations

Signs and Symptoms: Anterior/Inferior dislocations are most common (95% of shoulder dislocations). Pain to shoulder region. Loss of contour of deltoid muscle when compared to unaffected side. Palpable defect where the humeral head should be. Test for loss of sensation in the deltoid region: This indicates injury to the axillary nerve and needs to be documented prior to any treatment. Patient will usually hold the affected arm away from the body and supported by the unaffected arm. Recurrent dislocations are common. Frequently the victim will be able to tell you what the problem is.

Treatment:

1. If within easy transport time/range to higher-level care, splint in the most comfortable position and transport.

2. If higher-level care is distant, early reduction can be attempted:
a) Palpate the entire length of the humerus. The entire shaft of the humerus can be palpated from

the inner aspect of the upper arm. Presence of any significant point tenderness to palpation or

crepitation indicates a fracture-dislocation. Fracture-dislocations are more common in high-speed

injuries and in older persons. Note: DO NOT attempt field reduction if there is any suspicion of a

fracture-dislocation: Splint in position of comfort and transport.



b) Test for sensation over the deltoid area, checking for injury to the axillary nerve. Document prior

to any attempt at reduction.



c) Check circulation and neurological function of the affected arm and hand.

d) There are multiple methods of reducing shoulder dislocations. The key to reduction is to perform it

early before significant muscle spasms can develop, and to do any required manipulation SLOWLY and GENTLY. It is NEVER appropriate to attempt to ‘jerk’ a shoulder back into place.

e) The patient may have to be sedated prior any procedure. Valium, 5-10 mg slow IV is usually

effective and is also a good muscle relaxant.



f) Successful reduction is usually obvious with a sudden return of the shoulder external anatomy to

normal, and significant reduction of pain.



g) Reassess the neuro/vascular status of the arm and hand, then sling/swath.

Scapular Manipulation Method: Have the patient is sit upright or lay face down. If sitting, the affected arm is supported straight out from the body. If lying prone the arm will be straight down. Apply 5-10 pounds of long-axis traction to the arm. The operator stands behind the patient and grasps the tip (inferior portion) of the scapula rotating it inward (towards the spine) and superior (towards the head). Slow, gentle and continuous motion is maintained.


Scapular Manipulation Method of Shoulder Reduction

See above for description of technique. Note the tip of scapula is rotated towards the midline and superior.



Hand Fractures

Signs and Symptoms: Usually obvious swelling and deformity of hand/fingers. Do not attempt

re-alignment unless neurovascular compromise or significant angulation is noted.



Treatment: Splint in position of function (beer-can or duckbill splint). Buddy-taping to adjacent fingers can splint isolated finger injuries.

Thumb/Finger Dislocations:

Signs and Symptoms: Usually obvious from deformity of the thumb/finger at the joint.

Treatment: Reduction of phalange dislocation is accomplished by traction applied to the partially-flexed digit while pushing the base of the dislocated phalanx back into place. Reduction of a dislocated metacarpophalangeal joint (knuckle) of an index finger is usually unsuccessful, frequently requiring surgery. After reduction buddy-tape or splint the affected finger. If reduction is unsuccessful, splint the hand in position of function (beer-can or duckbill splint) and transport.





Reduction of phalangeal dislocation

See above for description of technique.




Pelvis

Signs and Symptoms: Pain in the pelvis, hips, groin or back. Pain is elicited when applying pressure to iliac crests or suprapubic area. Patient may be unable to lift legs while supine. The foot on the injured side may be turned outward.

Treatment: Place patient on a long board. MAST will help in stabilizing pelvic fractures and may help tamponade bleeding from pelvic structures. Initiate 2 x LB IV LR/NS or start large-bore saline lock. Pain medication as needed and evacuate.

Note: Foley catheter is contraindicated due to risk of damage to GU structures. It is recommended not to use the log roll technique to move a patient with a suspected pelvic injury.

Femur

Signs and Symptoms: Pain in the upper leg and/or deformity. Foot may be rotated inward or outward. Note: Serious bleeding may occur into the thigh compartments without any visible blood loss.

Treatment: Apply traction splint. A properly applied traction splint will significantly decrease the patient’s pain and help control bleeding. LB IV LR/NS or saline lock, pain control and evacuate.

Knee Dislocations

Signs/Symptoms: Usually obvious, with the tibia/fibula either anterior or posterior to the distal femur.

Treatment: This is a devastating injury, frequently accompanied by vascular damage to the popliteal artery. Assume vascular damage in all knee dislocations even if pulses are present. Knee dislocations will frequently reduce themselves. If it has not, reduce by steady, gentle long-axis traction. Splint carefully and monitor distal pulses frequently.

Ankle Fracture-Dislocations

Signs/Symptoms: Usually obvious, with the foot shifted anterior or posterior on the distal tibia/fibula. Skin over the dislocation is frequently tented. Pulses in the foot may be absent and is a grave sign, requiring immediate reduction of the dislocation. Virtually all ankle dislocations involve fractures.

Treatment: Ankle dislocations should be reduced as soon as possible. Apply gentle and steady traction to the foot while supporting the heel and lower leg until the alignment of the ankle is approximately normal. Exact anatomic reduction is not necessary. No skin should be tented or tight over bone if the ankle has been properly reduced. Splint the ankle with a well-padded posterior and U-splint. Do not allow the patient to put any weight on the ankle or leg.
Ankle Sprains: See Ankle Sprain section in Patrol Medicine, page 79.

Other Lower Extremity Fractures/Dislocations

Signs/Symptoms: Pain, swelling and eccymosis in area of injury.

Treatment: Unless grossly angulated or neurovascular compromise is noted, splint fracture/dislocation as it lies. If re-alignment is necessary, prepare to splint, then apply long-axis traction to re-align extremity. Check neurovascular status before and after re-alignment.

Compartment Syndrome: Occurs when bleeding in a closed space exerts pressure in surrounding non-elastic membranes. This pressure is transmitted to blood vessels and nerves, compressing them to the point of circulatory impairment and neurological compromise. This condition is usually found in either the forearm or the lower leg resulting from crushing injuries or fractures, but can manifest itself in the hand, forearm and foot.

Note: Compartment syndrome is addressed here as a complication of extremity trauma. Due to the delays in patient transfer that PJs routinely encounter it is important you are able to make this assessment.

Signs & Symptoms of Compartment Syndrome may include, but are not limited to:

 Pain that is out of proportion to the injury or physical findings. Pain is usually described as: Deep, excruciating, burning and unrelenting. Pain is usually difficult to localize and difficult to control with the normal analgesic regimen.

 Pain increased with passive stretching of the muscle group involved or with active flexion of involved muscles.

 Hyperesthesia or paresthesias of nerves that cross through the affected area.

 Tenderness, tenseness, or sensation of tightness of the compartment.

Caution: Some of the ‘classic signs’ of compartment syndrome (delayed capillary refill, lack of sensation distal to the injury site, paralysis, pallor and puselessness) occur late in the course of the syndrome and are not reliable for early diagnosis. If compartment syndrome is suspected immediate evacuation is required.

Treatment: Treat causative factor. Immobilize extremity. Closely monitor extremity and transport ASAP. Fasciotomy (page 37).

Note: Fasciotomy should only be performed under direct supervision of a physician.

Caution: Elevation of a limb above heart level, wrapping with ace wraps or compression dressings or application of cold packs are NOT an acceptable treatments for compartment syndrome. These procedures may actually exacerbate the situation.

Crush Injuries: Result from a patient being trapped under heavy object and either crushing part of the body or cutting off circulation (usually of the extremities). Crush injuries are usually the result of a structural collapse. Crush injuries of the head, neck and chest are usually rapidly fatal. Crush

injuries/entrapment of the extremities, lower abdomen and pelvis can result in an awake, alert victim trapped in a collapsed structure.


Signs and Symptoms: Patient trapped with a section of the body caught under a heavy object. The patient can be awake, alert and in remarkably little pain, even though damage to the trapped portion is serious. If accessible, the trapped part of the body may be blue, cold and pulseless. Hyperkalemia and rhabomyolysis can result from this syndrome resulting in cardiovascular collapse or renal failure minutes to hours after extraction.
Treatment: This syndrome has a high mortality. Even though the patient may appear stable while trapped, once the entrapment has been released, the victim may go into complete cardiovascular collapse, from both the sudden flow of blood to the formerly entrapped part of the body and from accumulated metabolic waste products being shunted back into the central circulation. If an IV can be started prior to extrication, it is best to give the patient a fluid bolus just prior to release of the entrapped part of the body. If cardiovascular collapse occurs, standard resuscitation should be started. Crushed extremities should be irrigated with normal saline, dressings applied and splinted. Minimal or no debridement should be done at this stage. Rhabdomyolysis (breakdown of muscle tissue) can result from crush injury. The release of myoglobin can cause acute renal failure. Hydration with normal saline to insure brisk urine flow can help avoid this complication. Urine flow can be increased by use of Mannitol, 0.5-1.0 mg/Kg. This may be used if approved by medical control. Compartment syndrome (see above) can also result from crush injury.
Additional Notes (Extremity Trauma):

BURNS
Guidelines and Considerations

1. Stop the burning process.

2. Assure airway and circulation are not compromised. In the event of airway injury (symptoms

include hoarse voice, carbonaceous sputum, and singed nasal hair) early intubation may be necessary to prevent laryngeal edema from closing off the airway. Note: ALL victims inside a burning structure are presumed to have toxic inhalation (carbon monoxide poisoning) in addition to other accompanying injuries they might have. All burn victims should receive supplemental oxygen.



3. Establish baseline vital signs and document accordingly.

4. 2 x 16 gauge IV’s LR/NS.

5. Calculate the amount of fluid resuscitation required:

Note: The 1st 24 hours of fluid resuscitation is crystalloids only.
___Kg(wt) x 4 cc's x_____% BSA burned = Total fluid for first 24 hours.
Note: Rate of IV Administration for 1st 24 hours:

 1/2 total - 1st 8 hrs (from time of burn)

 1/4 total - 2nd 8 hrs

 1/4 total - 3rd 8 hrs


6. Establish an accurate hourly intake and output record (barring renal dysfunction, urinary output

reflects the competency of fluid resuscitation). Insert foley catheter if necessary.



7. Monitor lung fields for indications of fluid overload (pulmonary edema).

8. Monitor patient's vital signs q. 15min-1hr prn. Note: The use of any fluid replacement formula

merely provides an estimate. The amount of fluid given should be adjusted according to the

individual patient's response. Mental alertness, urinary output (30-50 cc/hr), and vital signs reflect

the adequacy of fluid resuscitation.



9. Once the absence of respiratory compromise, head or spinal trauma has been determined,

medicate patient for pain using IV route only. Note: Toradol is NOT recommended for pain control

in burns.

10. Protect patient from the environment. Cover patient appropriately while performing physical

examination.



11. Protect patient from infection with sterile dressings. If unable to evacuate within 24 hours,

contact support for recommendation regarding antibiotics. If the patient requires antibiotic

therapy for other injuries (such as open fractures) treat with the appropriate antibiotic for that

injury if evacuation is delayed over 4 hours.


General Burn Care:

1. Insert foley and record urine output.

2. Depending on patients condition and urine output, adjust fluid resuscitation prn.

3. In presence of paralytic ileus and/or if burn area is over 35% BSA, insert NG Tube.

4. Splint burns of the hand with fingers spread and with hand in the position of function (beer-can

or duckbill splint). Separate fingers by placing kerlex or 4X4’s between the fingers.



5. Keep neck slightly hyperextended when burned.

6. Avoid vigorous scrubbing when cleaning facial burns. Place moist dressings over eyelids.

7. If the patient is able to drink and does not develop ileus, clear liquids can be given by mouth.

Balanced salt solutions, oral rehydration salts or even sports drinks (diluted 50/50 with water),

in small amounts (5-10 cc’s) should be administered frequently. This may help decrease the IV

fluid requirement.



Note: Signs of a functioning GI tract include passing gas, presence of

bowel sounds and ability to drink small amounts of fluid without nausea/vomiting.



8. Record fluid intake (oral & IV), fluid output (urine, emesis or diarrhea) and vital signs (including

temperature) ever 1-4 hours.



9. Do not give antibiotics to burn victims unless directed by medical control. Note: The

exception to this is if the patient has an injury that normally requires antibiotics (i.e. open

fracture). In this case, administer antibiotic and amount you would normally use if the patient

were not burned.



10. Burn victims develop gastric ulcers very rapidly and should be given Zantac, 50 mg IV or IM

q. 6-8 hours to prevent ulcer formation. If the GI tract is functioning, Zantac, 150 mg orally

q. 12 hours can be used instead of the IM/IV preparation.
Burn Treatment (1st, 2nd, & 3rd Degree):
1st Degree: Submerge body part in cool water or apply cool compresses immediately (NOT ice water).

2nd Degree (Superficial): If 10% or less of BSA involved, submerge body part in cool water immediately if possible. Water immersion may intensify shock so it should be applied for only 10-15 min. for pain relief. Note: Do not submerge in ice water. Cover burn with loose, dry, sterile dressing.
If Evacuation is Delayed:

 Leave blisters intact unless they are larger than 2” in diameter. Large blisters should be drained

with a sterile needle/syringe and then unroofed.

 Clean burn area and apply Silvadene. Silvadine dressing can be covered with saran wrap and then

cover with a loose, dry, sterile dressing. Change every 12-24 hrs or as the dressing becomes

saturated with exudates.

 When removing dressings, avoid removing dressings that have adhered to the skin. This can

increase the damage to the underlying tissue. To ease removal of adhered skin, it may be

necessary to soak dressings using sterile saline prior to removal.

 Consider giving analgesia before changing dressings.


Deep 2nd & 3rd Degree:

If Evacuation is Immediate with Rapid Transport Time: Cover burn area with sterile dressing (if

possible). If large area is involved cover with casualty blanket.

If Evacuation is Delayed: Clean burn area with diluted (1:10) betadine solution using 4x4

gauze, then rinse with saline removing loose nonviable tissue during cleaning process. Apply

Silvadine dressing as noted above. Gently clean and reapply Silvadene and fresh dressing every

12-24 hours. If the saran wrap dressing is used, change as the dressing becomes saturated with

exudates. Note: Morphine should be considered prior to performing initial burn wound

debridement. Administer analgesics one half hour before treating patient. However, use of

morphine is contraindicated in head, chest or spinal trauma.


Circumferential Burns: If circulatory compromise or respiratory difficulty develops, be prepared to perform an escharotomy. Note: An escharotomy should be performed under physician control.
Chemical Burns (Acids, Alkalis, etc):

1. Immediately remove agent (brush off if powder, wash off if liquid).

2. Flood area with water.

3. Remove contaminated clothing.
4. Continue water irrigation of burn area as long as possible. Note: Do not attempt to "neutralize"

with other chemicals.



5. If chemicals splash into the eye, irrigate the eye with a MINIMUM of 1 liter of fluid, but preferably

several liters. Caution: If an alkali, such as lye or ammonia, is splashed into the eyes, continue

irrigation for at least 60 minutes or until told to stop by medical control.
White Phosphorous (WP) Burns: WP will continue to burn as long as it is exposed to oxygen. The key to treating WP burns is to cut off oxygen to any WP fragments in the body and then remove them as soon as possible.

1. Completely submerge body part in water. Otherwise cover with wet dressing.

2. If possible, move patient to dark area and remove remaining particles (WP fragments glow faintly

in the dark and should show up very well using NVG’s). If unable to debride particles out of

tissue, keep wounds covered with wet dressings during transport.

3. A copper sulfate solution can be used to “extinguish” WP fragments in tissue, however it can

occasionally result in copper toxicity. A freshly made solution of 5% sodium bicarbonate, 3%

copper sulfate and 1% hydroxyethyl cellulose will allow soaking of a WP wound for 20 minutes

without copper toxicity developing. Thoroughly rinse the solution off after use. Copper sulfate

will cause the WP fragments to turn black, cutting off oxygen and allowing for easier identification

and debridement.



4. WP fragments glow under ultraviolet light allowing easy debridement.

Burn Supplies: Burn victims use a large amount of medical supplies in a very short period of time. When planning for a mission involving a burn victim the amount of extra supplies that may be needed should be taken into account. For example, in planning for a mission involving a 3-day transport of a 90 Kg victim with 30% BSA burns, the following should be taken into account:
 72-hour transport with dressing changes q. 8-12 hours = 6-10 dressing changes.

Silvadine: 5-7 grams per % BSA burned per dressing change = 150-210 grams per change

Kerlex: 3-4 rolls per dressing change.

Morphine: 15-20 mg IVP q. 4 hours

Normal Saline:

 11 liters of IV in first 24 hours

 5-10 liters IV NS per day after the first 24 hours

 1 liter NS irrigation per dressing change

Zantac: 50 Mg IV q. 8 hours.

Sterile gloves: 2 pair per dressing change.

Plastic Wrap/Saran Wrap: 6-8 feet of per dressing change.

Planning for this victim’s care would then include at least the following amount of supplies:

Silvadine: 1500-2000 grams

Kerlex: 30-40 rolls

Normal Saline: 25-30 liters for IV use and 8-10 liters for irrigation

Morphine: 360 mg (36 tubex’s)

Zantac: 450 mg

Sterile gloves: 20 pairs

Plastic wrap: 60-80 feet
Additional Notes (Burns):

Burn Nomogram: The burn nomogram is designed to assist with determining the amount of Body Surface Area (BSA) is involved in a burn. Counting only the second and third degree burn areas, add up the total area (use age modifiers if necessary) to determine the total burn area.

Note: The size of the patients’ palm is approximately 1% of their body surface area.



Rule of Nines (Adults only) Relative Percentage of Area Affected by Growth

Age in Years 0 1 5 10 15

A: ½ of head 9.5 8.5 6.5 5.5 4.5

B: ½ of thigh 2.75 3.25 4.0 4.25 4.5

C: ½ of leg 2.5 2.5 2.75 3.0 3.5

% Second Degree Burn______ +% Third Degree Burn________= % Total Burn__________
Example of Burn Area Modification for Age: 1 year old child, ½ half of head burned, all of left thigh burned: Head BSA= 8.5%, thigh = 3.25% and 3.25%. Total BSA = 15%


MEDICAL PROCEDURES
AIRWAY (Management and Control)
Guidelines and Considerations:

 Indicated when airway is partially or completely obstructed/compromised.

 Cervical spine injury is assumed with: Deceleration trauma, blast injury and unconscious patients.  Always evaluate the mechanism of injury (MOI) in unconscious patients to determine or rule out possible injuries.
Jaw Thrust: Method of choice for trauma pt.

Procedure:

1. Place hands on either side of pt's neck to stabilize.

2. Use thumbs to push up at the angles of the jaw.

3. Secure airway with adjunct.

4. Use index finger to assess carotid pulse.
Chin Lift: Two rescuers required: One to stabilize neck and one to open airway.

Procedure:

1. Stabilize pt’s head

2. Use thumb to grasp chin below lower lip while fingers are placed underneath the anterior chin.

3. Gently lift chin.

4. Secure airway with adjunct.

Naso-pharyngeal Airway (NPA): For use on conscious, unconscious, & semi-conscious pts.

Note: NPA is the preferred initial airway adjunct.

Caution: Never force the airway.

Equipment List:

 NPA & Water-soluble lubricant


Procedure:

1. Lubricate with water-soluble lubricant.

2. Insert the airway through the larger nostril, advance into the posterior pharynx.

3. If unable to insert through the larger nostril, attempt to place through the smaller nostril.
Oral-Pharyngeal Airway (OPA): For use on patients with NO intact gag reflex. Note: Patients who tolerate an OPA require intubation to protect their airway. Be prepared to handle vomiting during insertion of OPA.

Equipment List:

 Oropharyngeal airway

 Tongue blade

 Suction should be immediately available in case of vomiting


Procedure: (2 Methods)

1. Push tongue out of the way with a tongue blade & insert airway under direct visualization.

2. Alternate method of insertion is to insert with the tip towards the roof of the mouth, rotate airway 180 degrees into position when the tip of the airway falls off the hard palate onto the soft palate.

Note: If the airway is in the correct position, the end of the airway should be in front of the teeth, just outside the lips. Confirm proper placement by ventilating patient.

Endotracheal Tube (ETT) Intubation: For protection of the airway and/or as a means of ventilation in the apneic patient.
Equipment:

 Endotracheal tube with stylet, cuff checked for leaks (size 7.0-7.5 for adult)

 Laryngoscope (check operation of blade, bulb and batteries)

 Suction

 Syringe to inflate cuff & tape or other means of securing the ET tube once placed.

Procedure:

1. Hyperventilate patient with 100% oxygen for several minutes prior to intubation.

2. Assemble and test equipment while patient is being ventilated:

a. Inflate cuff off ETT with 5-10cc of air and check for leaks. Remove air from cuff leaving

syringe attached to tube. Insert stylet into ETT ensuring it does not protrude past the distal

end of the ETT. Ensure that the stylet slides out the top of the ETT easily.

b. Check light on laryngoscope.

c. Assure availability of suction.

3. Lubricate distal end of tube with water-soluble lubricant (viscous lidocaine can be used).

4. Stop ventilations.

a. Have an assistant stabilize the pt's head and apply cricoid pressure (Sellick's maneuver) while

counting slowly to 30.



b. Intubator takes a breath, holds it and then directly visualizes cords with laryngoscope. If unable to

visualize chords within 30 seconds or when the intubator has to take a breath, remove

laryngoscope and ventilate the patient for 1 minute. Repeat attempt to visualize the cords.

5. When chords are visualized, advance tube to a depth of 5cm beyond cords. Inflate cuff and ventilate.


  1. Confirm proper tube placement by auscultating over stomach and both lung fields. Re-position or

remove as necessary. Do not release Sellick’s maneuver until proper position of the tube is confirmed

and the cuff is inflated.



  1. Secure tube once proper placement confirmed.

  2. Re-confirm position of tube by auscultation every time the patient is moved.


Nasotracheal intubation: Used when the patient's mouth cannot be opened or when the patient cannot be ventilated by other means or if patient is conscious but requires intubation, i.e. severe head trauma, respiratory distress.

Caution: Do not attempt nasotracheal intubation if there are any signs of basilar skull fracture or cribiform plate fracture (Clear fluid from nose/ears, ‘Raccoon eyes’, Battle sign [bruising behind ears]). Do not use excessive force to pass ETT through nose. Nosebleeds are common with this type of intubation.

Warning: Nasotracheal Intubation is contraindicated in fractures of the cribriform plate, basilar skull, or open skull fractures.
Equipment List:

 Endotracheal tube with stylet, cuff checked for leaks (size 7.0-7.5 for adult)

 Water-soluble lubricant (viscous lidocaine can be used)

 Tape or other means of securing ETT

 Syringe to inflate ETT cuff
Procedure:

1. Follow initial steps as for endotracheal intubation using a 7.0 or 7.5 mm ET tube.

2. With bevel against the floor of the septum of the nasal cavity, slip the ETT distally through the largest

nostril. When the tube reaches the posterior pharyngeal wall, great care must be taken on "rounding the

bend" and then directing the tube toward the glottic opening.
4. Listen and feel for the patient to inhale. When the patient inhales, advance the tube with a single

smooth motion into the trachea



5. Observe neck at the laryngeal prominence:

a. Tenting of the skin on either side indicates catching of the tube in the pyriform fossa. This

is solved by a slight withdrawal and rotation of the tube to the midline.



  1. Bulging and anterior displacement of the laryngeal prominence usually indicates correct

placement.

6. Advance the tube until the balloon is past the vocal chords. Inflate cuff, confirm placement, and secure.

7. Re-check the position of the tube after every movement of the patient.
Lighted Stylet Intubation: Indicated when the need for ETT intubation exists, but a laryngoscope is not available or unable to visualize cords with laryngoscope.
Equipment:

 Endotracheal tube with cuff checked for leaks (size 7.0-7.5 for adult)

 Lighted stylet/ wand, batteries and bulb checked.

 Water-soluble lubricant (viscous lidocaine can be used)

 Syringe to inflate ETT cuff. Tape or other means of securing ETT.




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