7-26
Primary: NPO. Maintenance IV fluid at 125 ml/hr. Cefoxitin 1 gm q 8 hrs or ceftriaxone 2 gm q
day IV or IM. Evacuate PRIORITY for surgical care within 4 hours. Monitor for peritonitis and sepsis.
Prochlorperazine 25 mg or promethazine 25 mg up to qid IV or IM, if needed to prevent recurrent
vomiting.
Alternative: Maintenance po water, if no IV and evacuation time > 4 hours. Ciprofloxacin 500 mg q
12 hrs and metronidazole 500 mg q 8 hrs po, if parenteral cephalosporins not carried or casualty is
allergic to them. Virtually any broad-spectrum antibiotic coverage is better than nothing when time to
definitive care is prolonged.
- TM rupture: Patient may not dive, swim or shower until TM heals. Risk of otitis progressing to
encephalitis, permanent hearing loss, vertigo, tinnitus and other complications.
Primary: Do not attempt removal of foreign debris. Prevent water and other non-sterile material from
entering ear canal.
Empiric: Prophylactic antibiotics not indicated. If infection of TM (myringitis) develops, instill ophthalmo
logical (eye) gentamicin 2 drops (not ointment) q 6 hrs for 10 days. Otological (ear) suspensions for otitis
externa contraindicated when TM ruptured.
Alternative: Amoxicillin/clavulanate 875 mg q 12 hrs (500 mg q 8 hrs) or ciprofloxacin 500 mg q 12
hrs po, if ophthalmological antibiotic drops not available.
Return Evaluation: Inspect area surrounding ear, external ear, ear canal, and TM daily for redness,
swelling, or purulent drainage. Pain when gently pulling up and back on pinna or pressing on cartilage just
in front of canal also indicates otitis externa.
Consultation Criteria: ENT consult within 3 days; sooner if significant debris in canal; up to 2 weeks
acceptable, if no infection. - Head trauma from blast: See Trauma on CD-ROM. Transient amnesia is common after loss of
consciousness caused by explosions. Vertigo is usually due to head injury, not blast effects on the ear.
Meclizine 25 mg q 8 hrs as needed po can improve symptoms but can also sedate, thus impairing ability
to function and making assessment of mental status more difficult
Evacuation: Pneumothorax, AGE, and bowel-wall stretching injuries are more likely to be initiated or
exacerbated by decreased ambient external pressure (associated with ascent from dive, travel to altitude
in ground vehicle or aircraft, or combination) on the casualty. Reassess frequently! Monitor cardiac (EKG
monitor if available) and pulmonary status (including pulse oximetry) throughout trip. If there is a possibility
the patient has a pneumothorax, place a chest tube before any ascent to altitude. Tension pneumoperitoneum
affecting respiration is rare, but may require 14-gauge needle paracentesis in midline just above umbilicus
for decompression. Remove air from cuffs on Foley catheters and endotracheal tubes and replace with
liquid. Notify receiving facility of urgent need for appropriate special services: neurosurgeon, general surgeon,
hyperbaric chamber, intensive care, etc.
Electrical and Lightning Injuries
Maj Michael Curriston, USAF, MC, LTC Lee Cancio, MC, USA & 1LT Harold Becker, SP, PA, USARIntroduction: Electrical and lightning injuries span a wide spectrum of potential injuries. Low voltage AC tends
to result in tetanic muscle contractions “freezing” the victim to the source. High voltage DC exposures tend
to be brief and explosive in nature, often throwing the victim from the source. Lightning strikes rarely cause
the injuries associated with “man-made” forms of electrocution due to the extremely brief duration. In mass
casualty triage following lightning strike, employ a form of “reverse triage”: Give immediate care first to those
victims in cardiopulmonary arrest. The heart often resumes spontaneous rhythmic contractions and patients
may only require airway control and ventilatory assistance. Conscious victims of a lightning strike are unlikely
to develop imminent demise. NOTE: Victims of electrocution or lightning are not electrically “charged” and
may be touched immediately after injury provided they are no longer in contact with the “live” electrical source.
Subjective: Symptoms
Cardiopulmonary arrest, loss of consciousness, entry/exit burns and wounds, delirium, pain, numbness and
tingling.