DartmouthDave Posted June 25, 2012 Share Posted June 25, 2012 Hello, You are dispatched for an urgent transfer of a 47 year-old burn patient to the local university hospital (1 hour away). You are greeted by the ER RN and she tells you that the patient was welding when he had a seizure and set himself on fire at a local construction site. Workers quickly extinguished the flames with jackets and blankets. However, he has sustained burns to his hands, arms, and chest. He was intubated with difficultly by the ER Dr. A left femoral central line has been inserted after three failed attempts on the right side. He also has a #18IV in each AC and the patient is sedated with a Morphine (5mg/hr) and Versed (5mg/hr). You enter the trauma bay and hear a gurgling sound coming from the patient's mouth. He is shaking weakly. He has been in the department for 2 hours now. His VS are: HR 120 Sinus Tachycardia BP 90/40 SpO2 100% Temp 35.6 C Link to comment Share on other sites More sharing options...
island emt Posted June 25, 2012 Share Posted June 25, 2012 What percentage of body surface? What level of severity? Airway inhalation of flames? singed nose hair or swelling of tongue oral cavity? Any past cardiac hx? Is gurgling from him fighting tube? May need deeper sedation. What type of material was he welding? Possible toxic inhalation caused seizure? Link to comment Share on other sites More sharing options...
mobey Posted June 26, 2012 Share Posted June 26, 2012 Already I am saying shut off the morphine and start fentanyl bolus PRN. I'll wait till you get to some of the posted questions, but I would like to add; EtC02? Cuff pressure? Tube size? Link to comment Share on other sites More sharing options...
DartmouthDave Posted June 26, 2012 Author Share Posted June 26, 2012 (edited) Hello Island and Mobey, What percentage of body surface? ---> Front and back of each arm up the the albows (total 8%) and the front of his chest (18%) BSA= 36% What level of severity? ---> Hands are full thickness and arms and chest are partial thinkness Airway inhalation of flames? singed nose hair or swelling of tongue oral cavity? ---> Superfical burns to the face, no eye brows amd nurn hair Any past cardiac hx? --> No cardiac history Is gurgling from him fighting tube? May need deeper sedation. ----> He is moving some and shivering What type of material was he welding? Possible toxic inhalation caused seizure? ---> No sure what he was welding. No toxic exposure. He has had a generalized seizure disorder since childhood. Already I am saying shut off the morphine and start fentanyl bolus PRN. -----> He settles with Fentanly PRN I'll wait till you get to some of the posted questions, but I would like to add; EtC02? Cuff pressure? Tube size? ----> He has a #7.5 ETT at 22cm ATL and his EtCo2 is 28mmHg They are unable to measure the cuff pressure. Also, he has a foley in situ with 10cc of dark urine noted. Cheers Edited June 26, 2012 by DartmouthDave Link to comment Share on other sites More sharing options...
mobey Posted June 27, 2012 Share Posted June 27, 2012 Depth is good, size is OK. Lets pull all the air from the cuff, then reinflate till no leak - or 10ml of air. If it still leaks we may consider changing it for a bigger one. Do we have a ABG? Is he on a vent? or manual bag? Settings? How much fluid has he had? OKOK,,,, too many questions. Lets get him covered with a blanket, and sterile dressings on those burns. Can we get CBC as well? with Potassium level? Link to comment Share on other sites More sharing options...
eb1040 Posted June 27, 2012 Share Posted June 27, 2012 "He has a #7.5 ETT at 22cm ATL and his EtCo2 is 28mmHg They are unable to measure the cuff pressure." Unable as in not able to measure it due to lack of a manometer or the pressure is variable? Pilot balloon inflated? With more air did the leak cease or what it like going into nowhere? The cuff could be sitting on top of the cords. CXR? 22 cm ATL is also a little high for a man unless he has a short neck. Burn patients should also be measured at the teeth or gums for ET tube placement to account for swelling and fluid therapy. That lip could expand easily another 3 cm in a very quick time displacing the tube. How much fluid has been initiated? Parkland Forumula? LR? . Dry dressings in place? Any silvadene applied? Sulfa allergy checked? Link to comment Share on other sites More sharing options...
mobey Posted June 27, 2012 Share Posted June 27, 2012 22 cm ATL is also a little high for a man unless he has a short neck. Burn patients should also be measured at the teeth or gums for ET tube placement to account for swelling and fluid therapy. That lip could expand easily another 3 cm in a very quick time displacing the tube. Ahhhh, thank you for bringing a miscommunication to light. I read ATL as "At teeth level". welcome to the forum Please take a moment to introduce yourself! Link to comment Share on other sites More sharing options...
eb1040 Posted June 27, 2012 Share Posted June 27, 2012 (edited) Ahhhh, thank you for bringing a miscommunication to light. I read ATL as "At teeth level". I read it as At The Lip. In some places there is a joke about ATT or At the Tooth but you might have to be from there to see the humor. This is why it is good not to use abbreviations between different agencies. This little piece of information could be a headache in a pt like this where airway is important especially as the lip swells. Guess we'll have to see see how the author of this senario meant it. Is there a place for introductions? I don't want to sidetrack a good discussion. I think I am only allowed 2 posts and this is it for the night. Edited June 27, 2012 by eb1040 Link to comment Share on other sites More sharing options...
island emt Posted June 27, 2012 Share Posted June 27, 2012 Hello Island and Mobey, Also, he has a foley in situ with 10cc of dark urine noted. Cheers Thats a sign of him not getting enough fluids. How much has he had in the 2 hrs in ER? as noted above parkland formula for fluids. Do they have capability for labs at this little doc in the box? Did they get some base values done and see whats what? Other than that get the travel vent and spare battery checked out and get ready to head down the road to the real hospital. Link to comment Share on other sites More sharing options...
island emt Posted June 27, 2012 Share Posted June 27, 2012 Forgot to add: make sure your supply of pain meds and whatever you use for sedation are stoked up before leaving the ER for the road trip/ Link to comment Share on other sites More sharing options...
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