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Doc Dutch
07-01-2008, 04:10
You are out in the desert at a first aid station at a recreation center when a 22 year old male stumbles up to you and nearly collapses as he gets to the shade of your tent. He has been in the desert on a hiking trail and got lost. He denies alcohol or drug ingestion. He denies a trauma history on his hike. He did not take enough water with him and he lay down for a minute behind a rock because he got tired and tried to escape the heat. He lost track of time and now on the left side and posterior side of his body, legs and arms he is burned.

On initial examination he has about 4.5 percent burns on his left upper extremity (forearm and brachium), 7 percent on his left thigh plus his legs added together. These burn wounds are pink and shiny and moist with obvious skin sloughing. The rest of his exposed skin of his upper and lower extremities are sunburned. His shirt is "stuck" to his left torso (what I am suggesting is that if you remove the shirt, so will you remove skin and he cries out in pain as you try to remove it). His oral mucosa is dry and sticky. His face is starting to develop fine blisters. He complains of being "dizzy" and he feels hot to the touch. There is some minimal sweat on his skin. He tries to cry but cannot form tears. He cannot urinate any fluid.

Now what? I will tell you at this first aid station you have everything a paramedic/EMT needs but you are definitely "out in the field" and not a level one trauma or burn center. The nearest medical center is an hour and thrirty minutes by ambulance. You can call for air but by the time you call and the med-evac bird fires up and makes it to you, you may as well have placed him in the ambulance and sent him once you decide he needs to be transferred. It is about 120 degrees out there today and no good shade unless you are in-doors or under a tent and even still, sunblock is an imperative as is frequent hydration.

Thoughts?

Dutch Matthews, MD

FMF DOC
07-01-2008, 06:26
2 IV's
If a plastic kiddy pool is available filled with water have him lay in it.
If not improvise to make such a pool.
Constantly monitoring level on consciousness and ready to intibate at anytime.
Monitor core temp via rectal themometer and other VS
Sips of water as long as it's not causing N/V
I would not try removing any sticky clothing at this time.
Keep him calm and comfortable and talking while waiting
Possibly fanning him with sheets or towels.

FMF DOC
07-01-2008, 06:27
sorry about my typing, just finishing up a 24hr shift

Doc Dutch
07-01-2008, 11:12
FMF Doc,

That is pretty darn near perfect. We soaked the shirt off of him but moved him to the rec center where it was air-conditioned to get out of the ambient heat that was een killing us under a tent. We poured water on the shirt and it peeled away to show a 4.5 percent second degree. Once the water hitthe shirt it "wanted" to fall off under its own weight with him sitting up. We had RL for IVF's and started two IV's. We "spritzed" him with water from a spray bottle and had two fans we brought in from outside blowing on him. His temp was 104 degrees F. His HR was 125. After 4 liters his heart rate started to come down. His pulse ox was 99% to 100% on 2 liters. Still had not urinated with us before he left.

For his burns, we did not have silvadene but we had a ton of sunblock. So, after his temp hit 100 degrees we covered him in sunblock and wrapped only the second degree burns in kerlix since the skin was open and defenseless at those points. The first degree burns were just covered in sunblock without the bandages. We called fro air transport because of concerns for the holiday traffic. By the time he left he looked like a burn patient in our center.

By the way, I really like the kiddy pool idea and agree with oral resuscitation as long as there is no nausea or vomiting. His GCS never wavered but we worried about it so we had him on O2 by NC. Slipped him some Ibuprofen PO. When you are out of your comfort zone, everything beomes a tool to be used.

Oh, we gave him a telephone to call his parents so they could come and get his car.

Dutch Matthews

FMF DOC
07-01-2008, 21:28
Outstanding,

The kiddy pool idea was a trick I learned from Quantico. Every summer infact about this time a year they run around 1200 + aspiring officers through a six week course. The non-typical O course through the woods in the heat and humidty would knock them down sometimes a dozen at a time so we had about 15 kiddy pools on standby underneath cammo netting outside the Aid Station to help with blocking the sun and large fans blowing. Manmade IV poles put right in the ground beside the kiddy pools. Our litter bearers would also help fan these kids and of course the more serious ones would be taking inside. The most we ever had go down at one time while I was there was 26. Of course 911 was called and several outside organizations responded to help transport. As you stated when your pucker factor rises everything becomes a tool.

Thanks for posting these, I've been out of the game for awhile and enjoying diagnosing them.

Rumblyguts
07-02-2008, 09:33
Coming at this from a wilderness first responder POV.

I haven't heard of the sunblock idea, but it seems like something that should really be useful in a wilderness context. Sunscreen is always around via participants, but burn ointments are limited to kit space. Are you're reasons for using it along the lines of a cooling agent, UV protectant, both, other?

Thanks.

swatsurgeon
07-02-2008, 12:43
be careful with some sunblockers....they can trap heat, forming a barrier to evaporation. Water based are usually okay but some of the oil based and ones containing a pertoleum product may not allow any /minimal cooling. We lose heat via convection, conduction and evaporation...use all 3 if possible to the patients advantage. When ambient temp is greater than body temp, your options become limited.

ss

Doc Dutch
07-03-2008, 16:50
Yes.

Just to block any further burning to areas not wrapped up (first degree burns) as the sunlight will get through windows or windshieds of vehicles while driving and flying. Sunburns can even be extended or deepen if you wear thin clothing like white thin t-shirts. Learned that many years ago as an intern from our venerable burn attending.

Only used the sunblock to the second degrees to keep dressings from sticking to the open wounds. If you wrap the patient's wounds in sterile gauze (Kerlix) do not apply them dry on the second degree wound beds. The result will be the sticking of the soft bandage to the wound and then you are repeating the pealing off of the bandage at the burn center like the shirt described earlier. This will then act like a wet to dry dressing and inadvertantly see debridement of the open second degree at a time of acute injury where it is not necessary at this phase or potentially never. If we had a barrier like adaptic or xeroform/xeroflo you could have used that as a barrier. Typically Silvadene (AgSD) is used. As second degree burns represent a loss of the natural barrier to the environment they should be wrapped up if possible. The sunblock was our temporary fix for a barrier and it worked. It is either that or wrap the wounds in a sterile blue sheet is available. Keep it lose so it does not stick to the open burns prior to us seeing it in the burn center.

Thanks,

Ducth Matthews

Doc Dutch
07-03-2008, 16:58
SS,

Agreed. Tomato paste burns deeper much like oil as it gets hotter than water. Therefore, you must stop the burning process first. Decrease the patient's temperature but do not overshoot. Once you are at 38.5 degrees C, consider the patient cool enough. Trapping heat is bad and usually getting them into the air-conditioning (if possible) and spritzing them in front of fans helps off load the heat. Once cooled, move them quickly from the air conditioned department to the ambulance or helicopter so as not to be exposed to the ambient temperatures again.

D-