Page 69 - JSOM Winter 2025

always be taken for concerns of hypotension, apnea, and o Morphine 2–4 mg IV every 3–4 hours as needed for pain
allergic reactions. control.
o If pain persists and patient is able to tolerate oral medi-
Initial wound care includes the following: 14 cation, give the following instead of acetaminophen:
o Use a clean sheet or dry gauze (recommended). It is – Acetaminophen/oxycodone (Percocet; 5mg): 1–2 tabs
important not to disturb any blisters. To prevent hypo- by mouth every 4–6 hours as needed. Note: Only ac-
thermia, avoid wet and or moist dressings. Refrain from etaminophen/codeine available on DDG.
applying cool compresses or dressings to the burn, as – Acetaminophen/codeine: 1–2 tabs by mouth every
they can lead to hypothermia. However, a brief applica- 4–6 hours, as needed.
tion of cold water as first aid immediately after injury is – Gabapentin 300mg by mouth every 8 hours. Note:
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beneficial, especially for small burns. not available on DDG.
o Cleanse the wounds and debride loose, dead skin if • Venous thromboembolism (VTE) prophylaxis, if no ev-
evacuation is anticipated to take longer than 24 hours. idence of solid organ or traumatic brain injury and in
Washing the skin with antibacterial soap (preferably conjunction with a burn, trauma, or critical care expert.
chlorhexidine gluconate) in clean water, and dressing Providing a patient with potential traumatic brain injury or
wounds with any available dry dressings will decrease solid organ injury VTE prophylaxis with heparin or enoxa-
burn wound infection risk. parin may be catastrophic. Given the patient’s normal GCS,
– Cleaning and debriding burn wounds is a resource-in- severe traumatic brain injury is unlikely but possible given
tensive procedure and should only be attempted pro- the blast mechanism of injury. Solid organ injury is also
vided appropriate resources are available including possible given the mechanism of injury.
personnel and dressing supplies. Pain control is re- o Better: Heparin 5000U subcutaneous 3 times/day. Note:
quired to permit dressing care. Heparin is not available on DDG. Heparin is preferred
o Silver-impregnated nylon dressings are now available on in patients with renal insufficiency.
cruisers (CG) and DDG. Once placed, they are covered o Best: Enoxaparin (Lovenox) 30mg subcutaneous daily.
with sterile gauze and moistened with sterile water. This Note: Only 10 doses of 30mg injection are available on
type of burn dressing can be left in place for up to 7 DDG. Use with caution in patients with concern for re-
days which is advantageous in the deployed maritime nal impairment and following telemedicine consultation.
environment characterized by limited supplies. This may • Nausea/vomiting
be best used just prior to evacuation. o Consider ondansetron (Zofran) in the following dosages:
– 1–2 tabs sublingual every 4–6 hours, as needed.
Time +90 Minutes – 4mg IV, may repeat one time in 2 hours if nausea/
Having established IV access, with LR being administered at vomiting returns.
420mL/h, the patient’s vital signs are as follows: HR, 120bpm; ◆ Check QT on a cardiac monitor or electrocardio-
BP, 87/55mmHg; RR, 25 beats/min; SpO , 92% on room air; gram before giving, if possible. Note: No electro-
2
temperature, 35.5°C. cardiogram or three-lead cardiac monitoring is
available on DDG.
UOP is 15mL (dark in color). The patient appears alert and • Gastrointestinal prophylaxis medications are indicated in
oriented ×4, answering questions appropriately. White blood this patient because of the extent of burns.
count is 21,000; hemoglobin, 15; hematocrit, 45; and platelet o Minimum: Ranitidine or famotidine by mouth.
count, 485,000. o Better: Omeprazole by mouth.
o Best: Pantoprazole IV or by mouth or H2 blockers IV or
Wounds are dressed with dry gauze initially as described above. by mouth Note: Not available on DDG.
Two mg of morphine is administered with 30mg of ketamine.
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Pulses are present at bilateral wrists. Daily nursing and progress notes should be documented. This
should include full documentation of assessment, along with
Recommended interventions include the following: nursing progress notes for significant events, as needed. See
• Elevating extremities to reduce edema. the nursing care plan in prolonged field care for full details. 21
• Because the UOP is too low, increasing the IV fluid rate by
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25% (0.25×420mL/h); the new LR rate is 525mL/h. Routine nursing care includes the following:
• Arranging a telemedicine consultation with the USAISR • Maintaining the head of bed elevated >30°.
Burn Center, if possible. • Depending on the patient’s ability to move, consider reposi-
• Reassessing the airway and work of breathing. tioning every 2 hours or having the patient ambulate.
• Administering tetanus vaccine, if needed. • Performing frequent neurovascular assessment. Bilateral
• Preventing further hypothermia. upper extremities are at significant risk for compartment
• Checking blood sugar. syndrome given the patient’s circumferential burns.
• Continuing to trend the UOP, lactate, and base deficit for end- • Documenting strict intake and output (I&Os) to track the
points of resuscitation. Note: Only UOP is available on DDG. patient’s fluid status.
• Continued monitoring of the airway, pulse, UOP, and pain
Additional medications should be given for the following control.
indications:
• Pain control Time +12 Hours
o Acetaminophen at a maximum dose of 1g every 6 hours. The patient’s vital signs are as follows: HR, 110bpm; BP,
o Avoid non-steroidal anti-inflammatory drugs (NSAIDs) 98/66mmHg; RR, 25 breaths/min; O saturations 96% on room
2
due to side effects (renal impairment, gastritis). air; temperature, 36.5°C.
Burn Injury on a Destroyer During DMOs | 67