Page 67 - JSOM Winter 2025

that, when closed, may improve casualty survivability during o It is important to prevent the patient from getting hypo-
distributed maritime operations (DMOs). thermia. Therefore, cover the patient with warm blan-
kets as soon as possible. If possible, be sure to warm any
intravenous (IV) solutions.
Scenario
Setting The secondary survey should be a complete head-to-toe phys-
A U.S. Navy Arleigh Burke–class guided-missile destroyer ical exam, including passive and active range of motion of all
(DDG) with a crew of 314 is conducting solo arctic operations joints.
approximately 72 hours away from advanced medical care.
Current medical capabilities include standard Role 1 DDG Point-of-care ultrasound is incredibly useful in evaluating in-
personnel and equipment including one Independent Duty jured patients. It can identify free intra-abdominal, pericardial,
Corpsman, two junior Corpsmen, and two total (stacked) and pleural fluid, which can be concerning for hemorrhage or
ward beds. Basic point-of-care labs are available including cardiac injury after explosion and blunt injury. Note: there is
rapid complete blood count (CBC) using QBC star, dipstick no current ultrasound capability on a DDG.
urinalysis (UA), finger-stick glucose using a glucometer, and
fecal occult blood testing. There is no ultrasound, electrocar- Significant findings on primary and secondary surveys include:
10
diogram, or x-ray capability. No external signs of hemorrhage. He is speaking clearly with a
GCS of 15 (E4, M6, V5); alert and oriented to person, place,
11
Patient and time. He has full recollection of the event without any
A 28-year-old man was brought to DDG Main Medical after a memory gaps. No evidence of soot in the oropharynx; voice is
transformer exploded in a confined space while he was work- normal. The patient’s clothing was completely removed while
ing on the ship’s electrical system. He was not in contact with maintaining c-spine stabilization. No midline, cervical, tho-
an electrical power source when the incident occurred; however, racic, or lumbar spine tenderness to palpation. Breath sounds
he was not wearing his fire-retardant coveralls correctly as they clear throughout, with some pain and splinting with deep
were “half-mast” tied around his waist, with only a t-shirt pro- breathing on the right side of his chest. Strong but rapid pal-
tecting his torso. His shirt caught fire, requiring swift action from pable pulses distally in all four extremities. Abdomen is soft,
the response team. He was quickly removed from the site of the non-tender, and non-distended. Pelvis is stable and non-tender
explosion, but no medical treatment was given during transport. to lateral compression. No obvious long bone deformities. On
Upon arrival to Main Medical, his shirt is charred, and he is now the anterior chest, a combination of erythema, edema, blisters,
experiencing pain, hearing loss, and difficulty breathing. and charred skin consistent with 2nd and 3rd-degree burns
is identified. The posterior torso has minimal blistering and
The patient’s medical history is notable for a 10-pack-year erythema. On both upper extremities, he has circumferential
smoking history and having previously recovered from a erythema, edema, pink-white skin, and charred burns concern-
COVID-19 infection within the last 12 months; no hospitaliza- ing for 2nd and 3rd-degree burns.
tion had been required. He is not on any current medications.
The patient’s diagnosis is severe burn injury of the torso with
Time 00 Minutes circumferential upper extremity involvement concerning for
The patient’s presenting vital signs are as follows: heart rate second- and third-degree burns.
(HR), 130bpm; blood pressure (BP), 189/65mmHg; respi-
ratory rate (RR), 30 breaths/min minute; peripheral oxygen Initial Burn Treatment Principles include: 8,11–17
saturation (SpO ), 92%; temperature, 37°C; weight, approx- 1. Following TCCC treatment guidelines and performing a
2
imately 90kg. complete primary and secondary trauma survey to identify
any potential concomitant traumatic injuries.
During physical examination he appears alert, oriented to per- 2. Assessing the airway initially and with serial exams. Main-
son, place, time, and has full recall of the incident. He is com- taining a high index of suspicion for the development of
plaining of significant pain in his arms and chest, with obvious airway obstruction from either inhalation injury or airway
burns to the bilateral upper extremities. The patient’s face is edema. Smoke inhalation injury can occur with burns or
free of burns and there is no soot seen in the oropharynx. explosions in closed spaces. Generalized total body swell-
ing during resuscitation can cause airway edema and ob-
Recommended interventions are to treat the patient as a struction, particularly in patients with >40% total body
trauma patient first: perform a full primary and secondary sur- surface area (TBSA) burns.
vey evaluating for traumatic injury in addition to assessing and 3. Keeping the patient euthermic (maintaining body tempera-
managing his burn injuries. ture), and avoiding wet dressings to prevent hypothermia.
4. Determining the extent of the burn and beginning initial
The primary survey should: resuscitation. (The initial burn calculation can be estimated
• Assess the airway and consider cervical-spine immobiliza- using the rule of nines [Figure 1]).
tion due to history of explosion. 5. Arranging early telemedicine consultation. While both pic-
• Assess breathing and ventilation. tures and videos can provide the consultant with significant
• Assess pulses with hemorrhage control if encountered. data, this may be challenging given the limited bandwidth
• Assess neurologic status to include: in the deployed maritime environment. Depending on
o Level of consciousness via Glasgow Coma Scale (GCS) mission, location, and situation, email and telephone are
o Pupillary size and reaction typically available. The U.S. Army Institute of Surgical Re-
• Expose the patient completely and examine the entire body search (USAISR) Burn Center can be reached at:
for injury. • DSN 312-429-2876 (429-BURN)

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