Israeli Paramedics Association
7
The Israeli Emergency Medical Journal
Chief Editor - Paramedic Neomi Zvi
TRAUMA -->Case Report
Combined Burns Trauma
By
Paramedic Neomi Zvi
Very busy Saturday night , 10:30pm , Israel.
We (MICU/ALS team: EMT-B , Paramedic , Paramedic Trainee) were called by
the BLS ambulance (2 EMTs) - to a severe burns victim.
We arrived to the scene ; Outside the building there were so many people
(neighbors) - dispite the stormy wheahter and the heavy rain.
One of the EMTs met us outside - reporting while we are climbing the 1st floor
narrow winding stairs.
"Her little brother was trying to kill a cockroach by spilling Acetone & Carbamates
and put it on fire. The 17 y/o girl's clothes were all in flames. Burning like a torch ,
she run downstairs from the 4th floor to the first, she is severely burned"
"Is she the only victim" ? I asked. "I don't know" said the EMT.
I sent him to check.
We entered the living room. There were at least 20 people in the house , the floor
was flooded , and the poor girl was laying on the wet , cold floor , prone , naked ,
only remnant of burned clothes and hair.. 2nd & 3rd degree burns of the neck ,
hands , back , bottom , and upper third of the back thighs.- the same on her front ,
include her face. - about 70-75 % life threatening burns..
She was fully alert , already getting 90% Oxygen by face mask.
I asked the crowd to leave the house.
I set down behind her , supporting her head (she was cold to touch) , ordered my
Trainee to access C , and the EMT- to prepare BVM and intubation with 7mm ETT -
while am doing quick accessment of A & B.
It was obvious she is going to be intubated -
We rolled her over , straight on the Spinal Board that was covered
already with the "Burnshild" blanket.
"What's your name ?" - "Orna" she answered .
Her voice was weak but clear at the moment. I couldn't disregard the Acetone smell
of her breath and the efforts she made to talk.
Aescultation to breath sounds - mild Pulmonary Edema and a lot of secritions in upper
airways.Her Carotid pulse was about 90/min , irragular and thready.
She was relatively Hypothermic.
I ordered to move here on the wide living room table - out of the water.
The EMT I sent to check for other casualties was back from upstairs. "Her 6 years
old brother have small local burn on his palm - nothing else. His father is taking
care of it" . "OK , then , prepare for IV, please"
The trainee said - "I 'm not sure if there was a Radial pulse or not -
her extremities are frozen"....
"I'm willing to "spend" about 1 minute to establish an IV line " I said to my trainee
"You'll try on one foot , and I'm on the other"
While trying to obtain IV line , I asked the owner of the house to boild some water
and asked Orna:"Have any Allergies to drugs"? "No" said Orna......"I don't take any"
Cold , collapsed empty viens........We both failed to obtain an IV line.
Non of the Jugular Veins are available due to severe burns in the neck.....
"14 G cathether, Please" . "And pray that she is thin enough for the 14 g to reach
her Femoralis and stay there" I said. It was in. Fixating the precious IV line , put the
3-tops-pipe and administered Kethamine + Lidocaine.
She was awake , with Trismus ... I added Kethamin and Midazolam.....and bagged her
with 95% of oxygen....A lot of thick mucose......wet cough...
She was still half awake......, well , sorry ...I performed laryngoscopy - Orna
raised her hand..I could easily see her Vocal Cords - But There is no way that
7mm ETT will go through...6.5 passed the vocal cords but not the sub-glottis.
Laryngeal and Tracheal Edema.....I tubed her with 6mm ETT.
BV-ETT , O2 , connecting PEEP device (5 cmH2O) .
In the mean time , she was put on monitor (one sticker on the forhead and two
others - one on each leg). Sinus Tachycardia with VPBs of 105/min. , getting
warmed fluids , and Radial pulse , thready - but can be pulpated
Re-access of the A + B , short deep suction for the thick mucose / checking for
the breath sounds to estimate again the progressing of the Pulmonary Edema......
and it was progressing alright...
Warming Metal blanket, Headvice and down stairs while ventilating, difficult
extrication. We have about 38 minutes drive to the Trauma Center
(and 25 minutes to the nearest hospital but not a trauma center).
Outside , it was raining like hell - and yet - the whole neighborhood (religous) stood
outside , praying for Orna's sake .
The BLS team just left when a pale lady , supported by two other women approached
us . I saw Orna's mother - for the first time.- "Are you coming with us" ? I asked
while ventilating her daughter and moving towards the MICU
"...I can't....." she answered with shaky voice. "My friend will ...."
"That's OK , Mam" I said......."write down my cell phone number and call me in
10 minutes " She thanked with her eyes.....
We loaded Orna , the equipment and ourselfs. I checked again the location of the
ETT. The friend joined us on our way to Shiva Medical Center.
On our way to the hospital :
I asked the dispach center to get the Burn's ICU on the phone .
Reevaluation: ETT- where it should be. The cuff was a little over inflated (I don't
recall if I did it un-purposely or - the tracheal edema advanced) so I lowered its
pressure. Mild Pulmonary Edema (little less then it was in first place). ,
SaPO2 = 97% (finally can be readable - BUT - it is not necessarily indicate of good
oxygenation. because it 'count' the CarboxyHemoglobin as well) ,
Capnometer is not available in our MICU.
HR = 122/min irregular , Sinus Tachycardia + VPBs , BP (on the leg) =
100 / 60 mmHg , Replacing the empty infusion bag- and with no other way to
warm it - I used the "old method" and put the infusion beg in the 'pressure sleeve'
and put it....under my shirt..:-) . Continuing Manual Ventilation with BV
Orna started to woke up again , and I added another 50mg Ketalar + 50mg
Lidocaine. We have now 2 IV lines - due to successful trial of my trainee.
Orna's mother called . I wish I could promise her what we all hoped for ...
The Burn's ICU doc was on the phone - He got an update but denied
my request to bring Orna directly to the burn's Unit. He said , he will wait for
us in the Trauma Unit.
Outcome: Orna stayed few months in ICU . Went through many skin's transplants
operations ... long time of rehabilitation care......an back home.
Summary:
Orna suffered from Combined Trauma:
1. Mechanism of Trauma:
Direct fire , Thermal & Chemical burnes , Duration of Burning (it takes time to
reach from 4th floor to the 1st),Running makes the fire inflaming , Running
DOWN stairs increasing the chances for Smoke Inhalation. In that case ,
the neighbors turned off the fire by Water (it takes more time)....
2. Life threatening burns:
2nd & 3rd degree burns / Large areas / Involved Vital organs / Combined with
associate trauma
3. Chemical Inhalation:
Acetone , Carbamate (acting like Organo-Phosphate) / CO / Smoke.....
In this case - the Acetone Fume caused the Non Cardiogenic Pulmonary Edema.
The main treatment to that is Intubation +Ventilation. The Non-Cardiogenic
Pulmonary Edema , can be also caused by smoke inhalation.
The Carbamate inhalation (insignificant in this case) makes difficult dilemma
of drugs intervention in trauma. (and hope that your pt is not G6PD deficiency)
Most likely that the Laryngeal & Tracheal Edema were due to the Chemicals
and not the High tempratue of the inhaled gases.
4. Relative Hypothermia:
makes the evaluation of shock very limited and inaccurate , can fail the
compensatory reactions , make technical difficulties like access to peripheral
veins , arrhithmias due to invasive treatment ,Impact Drug's effect , decreased
the survival rate....ect.....
5. Distance:
Distanced from Trauma Center - is the distance from definitive care.
The Golden Hour is turn to dust.
Paramedic Neomi Zvi - June 2000
Urgent- The Israeli Emergency Medicine Journal , Volume No 8