Page 70 - JSOM Winter 2025

The IV fluid rate is LR at 525mL/h, with total estimated IV • Encouraging coughing and deep breathing hourly and reas-
fluids at 6,142.5mL (~6.1L). Cumulative total UOP is 426mL sess thoracic burns.
(dark), approximately 55mL/h. • Assisting the patient with oral/dental care.

A single episode of vomiting controlled with ondansetron. Time +24 Hours
Now, with increasing pain in upper extremities, the patient is The patient has been maintained on IV fluid resuscitation with
not responding to previous medications. Radial pulses are ab- good urine output. At 14 hours post-burn, IV fluids decreased
sent in right upper extremity and diminished in the left upper to 400mL. However, over the last 90 minutes, HR and RR
extremity. have increased, UOP and BP have started to decrease, and the
patient is complaining of chest wall pain on the right side.
Recommended interventions include the following:
• Possible escharotomy (Figure 2) of the upper extremities The patient’s vital signs are as follows: HR, 119; BP,
15
to resolve limb ischemia (eschar syndrome). Note: this 84/60mmHg; RR, 25–30 breaths/min; SpO 90% on room air;
2
is different than a compartment syndrome requiring a temperature, 37.8°C.
fasciotomy.
• Indications: Restore perfusion to extremity due to eschar The IV fluid rate is LR at 400mL/h, with a cumulative total IV
syndrome and improve ventilation if circumferential burns fluid input of 11,192mL (~11.2L). Cumulative total UOP is
of the chest are limiting thoracic excursion. 1400mL over 24 hours (10mL/h over the last 3 hours despite
o Obtain surgical consultation if able. an increase in the IV fluid rate).
o Expect an increased need for analgesia and sedation.
o Anticipate bleeding. Providers were unable to run more laboratory data because of
o Ideally use electrocautery for escharotomy, if not avail- limited capabilities on DDG.
able use a scalpel.
o Consider changing the dressing to silver-impregnated Extremity pain is well controlled with scheduled acetamino-
nylon dressings. phen and as-needed IV morphine. New bruising is noted on
– The patient should not be dressed in silver sulfadia- the right lateral chest with decreased breath sounds; right-
zine, bacitracin, or gentamicin creams until evaluated sided splinting with pain somewhat worse with deep breaths.
by a surgeon. Covering the patient with a clean bed-
ding sheet or applying Xeroform with loose-fitting Assessment includes the following:
Kerlix may be more appropriate in this setting. En- • Differential diagnosis: Burn shock, progressive pulmonary
sure dressing is not placed circumferentially around failure secondary to inhalation injury, delayed presentation
extremities. of thoracic trauma with hemothorax, infection, delayed
presentation of solid organ injury with bleeding.
FIGURE 2 Escharotomy incisions. • Repeating primary and secondary surveys, including chest
and abdominal ultrasound:
o Ultrasound of the right chest demonstrates large fluid
density. No significant intra-abdominal free fluid identi-
fied on abdominal ultrasound. Note: Ultrasound is not
available on DDG.
o Palpable crepitus of lateral rib tracking to the posterior
chest.

Recommended interventions include the following:
• Arranging telemedicine consultation.
• Treating the likely diagnosis: traumatic hemothorax.
o Placing a chest tube (1400mL of blood returned).
o Activating DDG walking blood bank and transfusing
1–2 units of fresh low-titer O– whole blood and reas-
Adapted with permission from Driscoll IR, Mann-Salinas EA, Boyer
NL, et al. Burn Care (CPG ID:12) Joint Trauma System Clinical Prac- sessing BP (goal is MAP of 65mmHg or greater). Note:
tice Guideline. Published May 11, 2016. Accessed October 31, 2023. Walking blood bank is not a routine capability on the
https://learning-media.allogy.com/api/v1/pdf/9e2f0f44-e42d-4b0f- majority of Role 1–capable warships including DDG.
ab06-6665e31badfb/contents Intermittently, some ships may have the training and
equipment.
Recommended nursing care includes: o Maintaining IV fluids.
• Maintaining the head of the bed elevated >30°. o Monitoring UOP and peripheral pulses.
• Continuing to elevate burned extremities to reduce edema o Checking pH and electrolytes if possible.
even after escharotomy. o Administering 1g of calcium gluconate in conjunction
• Checking BP and pulses every hour or more to ensure ade- with whole blood transfusion. Note: Not available on
quate resuscitation and return of circulation to extremities. DDG.
• Checking IV sites. o Tranexamic acid (TXA) is not indicated because the pa-
• Documenting strict intake and I&Os to track the patient’s tient is more than 3 hours from the initial injury.
fluid status. • Decreasing IV fluid rate to LR at 320mL/h.
• Ensuring the patient is repositioned or ambulates every 2 o Goal UOP: 45mL/h (0.5mL/kg/h).
hours. • Providing oxygen to maintain an SpO of 92% or greater.
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68 | JSOM Volume 25, Edition 4 / Winter 2025