Page 71 - JSOM Winter 2025

• If applicable, holding chemical VTE prophylaxis and not • Continuing daily burn wound care per protocol versus
restarting it. leaving silver-impregnated dressings on.
• Checking blood glucose. • Assessing for any evidence of infection. No prophylactic
antibiotics are indicated for burns or thoracic trauma.
Recommended nursing care includes the following: • Assessing for evidence of coagulopathy.
• Maintaining the head of the bed elevated >30°. • Continuing pain management.
• Maintaining elevation of burned upper extremities and ra- • Checking blood sugar.
dial pulse checks every hour.
• Checking BP every hour or more frequently. In the austere setting, burn wound care similar to the initial
• Cleansing burns with chlorhexidine, if tolerated, and debridement above unless silver-impregnated dressing were
re-dressing with silver-impregnated nylon dressings if not used. The risk of using silver-impregnated nylon dressings
already done. after initial debridement by those inexperienced in burn de-
• Flushing any unused IV line every 12 hours and checking bridement and wound care puts the patient at risk for burn
the IV site (peripheral edema can inadvertently dislodge the wound sepsis. Given that very few active-duty naval caregiv-
IV catheter). ers routinely manage burn wounds (if at all) as resources and
• Performing urinary catheter care. the operational situation allow, daily wound care as described
• Documenting strict I&Os to track the patient’s fluid status. above should be performed to mitigate the risk of burn wound
• Ensuring the patient is repositioned or ambulates every 2 sepsis. Silver-impregnated nylon dressings can be placed when
hours. ready for MEDEVAC.
• Encouraging coughing and deep breathing hourly when
awake. Recommended nursing care includes the following:
• Assisting the patient with oral/dental care. • Maintaining the head of bed elevated >30°.
• Checking BP and pulse every hour or more frequently as
Time +48 Hours needed.
The patient had been administered 1 unit of warmed fresh • Checking chest tube dressing and connections to an evac-
whole blood 18 hours ago with a good response. The IV fluid uation device.
rate was decreased to 300mL/h at Time +30 hours post-burn • Flushing any unused IV line every 12 hours.
and then 200mL/h at +38 hours post-burn. Over the preceding • Performing urinary catheter care.
12 hours, HR, UOP, and BP improved; however, RR and re- • Documenting strict I&Os to track the patient’s fluid status.
spiratory distress increased. Eight hours previous, the patient • Ensuring the patient is repositioned or ambulates every 2
was started on supplemental oxygen by non-rebreather or face hours.
mask for an SpO of 88%. • Encouraging coughing and deep breathing hourly when
2
awake.
The patient’s vital signs are as follows: HR, 97bpm; BP • Assisting the patient with oral/dental care.
112/78mmHg; RR, 35 breaths/min; SpO , 94% on 10–15L • Maintaining euthermia.
2
non-rebreather or face mask; temperature, 36.5°C.
Time +72 hours
The IV fluid rate is LR at 200mL/h, with a cumulative total IV UOP is stable. At 60 hours post-burn, IV fluids were turned
fluid input of 17,992mL (~18 L) or 6,800mL over 24 hours. down to 100mL/h. Work of breathing and oxygenation im-
UOP is 100mL/h over the last 3 hours, yellow in color. Cumu- proved. The team is notified that MEDEVAC is available in
lative total UOP is 2,800mL (1,400mL over 24 hours). 12 hours.

Providers were unable to run more laboratory data because of The patient’s vital signs are as follows: HR, 92bpm; BP,
limited capabilities on DDG. 100/68mmHg; RR, 22–28 breaths/min; SpO 94% on 4L via
2
nasal cannula; temperature, 37.5°C.
The patient’s extremity pain is well controlled with scheduled
acetaminophen and as-needed IV morphine. Bilateral upper The IV fluid rate is LR at 100mL/h, for a cumulative total IV
extremity pulses are intact. Chest tube output is <250mL of fluid input of 20,992mL (~21L) or 3,000mL over 24 hours.
serosanguinous fluid. Crackles are heard in the posterior chest Cumulative total UOP is 4000mL (50mL/h over the last 12
bilaterally. hours, yellow).
Patient Assessment of Clinical Information: Chest tube output is <100mL. No bleeding is seen through
• Pulmonary edema from resuscitation versus lung injury dressings from escharotomy sites.
from thoracic trauma.
• Stable upper extremity burns with escharotomy. Unable to obtain additional laboratory data.

Recommended interventions include the following: The patient’s pain is well controlled with scheduled acetamin-
• Arranging telemedicine consultation. ophen and as-needed IV morphine and intermittent ketamine
• Decreasing IV fluid rate by 25%. New IV fluid rate: with position changes.
150mL/h.
• Titrating oxygen to >92% SpO ; consider a simple face Recommended interventions include the following:
2
mask if requiring >8L of oxygen. • Arrange telemedicine consultation. If diuretics are given for
• Encouraging deep breathing and positional changes as pulmonary edema, it should only be done in conjunction
tolerated. with a telemedicine burn unit consultation.

Burn Injury on a Destroyer During DMOs | 69