J R Army Med Corps 2005; 151: 192-198 J R Army Med Corps: first published as 10.1136/jramc-151-03-11 on 1 September 2005. Downloaded from

SELF ASSESSMENT

Self Assessment Exercises in Emergency Medicine

PAF Hunt, JE Smith

You are a medical officer attached to the two other officers. He is unconscious and Emergency Department of the British soaking wet. As you guide them to the Military Hospital in Southern Iraq. It is your area you try to obtain a history first day and you attend the department for from his companions.The two others tell you the beginning of your morning shift where that the group had been undertaking their there are already two patients waiting to be own endurance training by marching on a seen. 5km loop around the base carrying 35lb of weight. Around 50 minutes after starting 1. A 45-year-old ex-Gurkha soldier, now they had noticed their colleague staggering employed as a civilian contracted security and looking unwell. They had encouraged worker in Iraq, has noticed a painful swelling him to keep going but after a further 5 of his left ankle for the past three days. He minutes he had slowed to a stop and then does not recall any kind of trauma to his collapsed. They poured all of the water they ankle preceding the onset of symptoms. He had left over him, loosened his clothing and tells you that he was able to walk on the ankle flagged down a passing military vehicle to at first but now finds he cannot bear weight bring him to the hospital. at all on the affected side. On examination he is breathing On examination you note that he is in spontaneously but only responds to painful significant discomfort. He has a pulse rate of stimuli. He looks flushed and, despite much 115 per minute and a temperature of 37.8˚C of his clothing being soaking wet, his skin (tympanic).The ankle is red, warm, generally feels hot. His pulse rate is 120 per minute, swollen and tender with a marked restriction blood pressure 134/33mmHg and in both active and passive range of respiratory rate 32 per minute.The tympanic movement. X-ray investigation reveals thermometer shows a reading of 39.6˚C. features consistent with osteoarthritis but there is no sign of any acute bony problem. a. What is the likely diagnosis? b. What are your management priorities? http://militaryhealth.bmj.com/ a. What other features of the history may be c. What initial investigations are indicated? relevant? d. What methods of cooling can be employed b. What other clinical examination(s) would in hyperthermic patients such as this? you like to perform? c. What further investigations would you 4. A tall, thin 21-year-old lance corporal has Capt PAF Hunt MBBS, arrange? presented complaining of sudden right sided MFAEM, DipIMC RCSEd RAMC d. What is the likely diagnosis and what is chest pain that he describes as sharp in Army Emergency your management plan? nature, which started that morning at Medicine Trainee 0630hrs while he was out running with his

Academic Department 2. A 19-year-old female private soldier section. He is now feeling quite short of on September 30, 2021 by guest. Protected copyright. of Emergency presents requesting emergency cont- breath even at rest. He is usually fit and well Medicine, James Cook raception. She tells you that she had other than mild asthma for which he uses a University Hospital, protected sexual intercourse twelve hours salbutamol metered dose inhaler as required. Middlesbrough, TS4 ago but the condom had split. She is usually He tells you that the last time he needed 3BW. fit and well and does not take any hospital treatment for his asthma was when Email: [email protected] medications at all, having stopped the oral he was 14 years old. contraceptive pill 4 months before arriving in On examination he is breathless at rest theatre. with a respiratory rate of 28 breaths per minute but able to speak in full sentences. Surg Cdr JE Smith a. What important questions should be Pulse rate is 95 per minute and blood MBBS, MSc, asked when taking a history from this pressure 135/78mmHg. On examination of MRCP(UK), FFAEM, patient? his chest you note that expansion is slightly RN, Consultant in b. What examination(s) or investigation(s) reduced with a raised percussion note on the Emergency Medicine, Emergency should you carry out, and why? right side of his chest compared to the left. Department, Derriford c. What treatment would you offer her, and Auscultation reveals reduced respiratory Hospital, Plymouth, what further advice would you give? sounds on the right hand side compared to PL6 8DH. the left.The trachea is not deviated. His peak Email: 3. A 26-year-old officer is suddenly brought expiratory flow rate (PEFR) is 550 l/min. An [email protected] into the department being carried between ECG shows normal sinus rhythm and you PAF Hunt, JE Smith 193 J R Army Med Corps: first published as 10.1136/jramc-151-03-11 on 1 September 2005. Downloaded from

request a chest X-ray, which is shown in Answers to self assessment Figure 1. exercises Fig 1. Chest X-ray Question 1

a. Obtain a thorough history regarding the possible presence of sexually transmitted diseases, a history of previous penetrating or (including iatrogenic) to the affected joint, a history of underlying joint disease (especially rheumatoid arthritis) or features suggestive of immunocompromise. A history of recent systemic illness, such as gastroenteritis or a respiratory tract infection may suggest a reactive arthritis. Symptoms of urethritis and conjunctivitis associated with arthropathy may suggest Reiter’s syndrome. b. A careful examination of the whole lower limb is required to assess the peripheral neurology and circulation as well as to ascertain any lymphadenopathy. The unaffected side should also be examined a. Describe the appearances on the chest X- for comparison. Evidence of bilateral ray and comment on the likely diagnosis. oedema may indicate an alternative cause b. How would you manage this patient? for tissue swelling such as right ventricular c. What advice must you give the soldier failure. Examination should be made of the before he leaves the department? whole body to explore for other joint swelling or tenderness and for other 5. A 26-year-old senior aircrewman is abnormalities such as psoriasis. evacuated by helicopter from Basra airport to c. Samples for full blood count, urea and the hospital by the Immediate Response electrolytes, liver function tests, glucose, C- Team (IRT). He has been involved in a fire 2 reactive protein (and/or erythrocyte hours previously which occurred while he was sedimentation rate) and blood cultures filling a generator with fuel. A spark had should be taken. ignited the fuel which exploded and splashed d. Septic arthritis of the ankle. The http://militaryhealth.bmj.com/ burning fuel onto his hands and arms, then differential diagnoses may have included set light to his clothing.The flames enveloped reactive arthritis, osteomyelitis, gout or his head and neck.The fire was put out within pseudogout. seconds by bystanders. The IRT have administered high flow oxygen by mask and Discussion placed a large bore intravenous cannula into his right antecubital fossa. 1000ml of Hartmann’s solution is running. He has been Infective arthritis may represent a direct given 10mg of morphine and 10mg of invasion of joint space by a variety of micro- metoclopromide IV. The have organisms, with bacterial pathogens being the been cooled and appropriately dressed. most rapidly destructive. Failure to recognize on September 30, 2021 by guest. Protected copyright. On examination he is alert and orientated, and appropriately treat bacterial septic able to speak clearly in full sentences with no arthritis may lead to significant rates of signs of respiratory distress.You note that he morbidity and mortality. The incidence is has singed nostril hairs and eyebrows with approximately 8 cases per 100,000 person- partial thickness over the entire surface years with males being slightly more of his head and neck, distal half of the left arm commonly affected than females. In adults and hand, with erythema over the entire Staphylococcus aureus is the most common anterior aspect of his right arm. He weighs causative organism, followed by Neisseria 75kg. gonorrhoeae. In children the most common infecting organism is Haemophilus influenzae a. What are the priorities of assessment and followed by Staphylococcus aureus.The most immediate management of this patient? commonly involved joint is the knee (50% of b. Estimate the total body surface area of skin cases), followed by the hip (20%), shoulder affected (%TBSA) for this patient and (8%), ankle and wrists (7% each). In infants calculate his fluid requirement in the first the most common joint affected is the hip. 24 hours. 10% of patients have multiple joint c. What are the management priorities for involvement (1, 2). this patient following his initial The principal sequel to infective arthritis is resuscitation and stabilisation? significant dysfunction of the joint, even if 194 Self Assessment Exercises J R Army Med Corps: first published as 10.1136/jramc-151-03-11 on 1 September 2005. Downloaded from

treated appropriately. The mortality rate Discussion primarily depends on the causative organism. Neisseria gonorrhoeae has an extremely low A history of the event is important, including mortality rate, while that of Staphylococcus the time delay in seeking treatment. Contra- aureus can approach 50%. Complications of indications to the use of emergency septic arthritis include avascular necrosis contraceptives should be specifically sought (AVN) of the epiphysis, joint subluxation / prior to administration. It is important to dislocation, growth disturbances in children, exclude the possibility that she has been the secondary osteoarthritis and persistent or victim of a sexual assault as she may require recurrent infection (2). counselling and further support as well as the This patient requires admission and urgent provision of emergency contraception (4). orthopaedic review. With these clinical The current recommendations are to use symptoms and signs, septic arthritis must be progesterone-only emergency contraception ruled out. Intravenous access is required for (POEC). Single dose simplifies the use of antibiotic treatment as well as for analgesia. A levonorgestrel in this situation without an diagnostic joint aspirate is vital and this increase in side-effects (5, 6). Current procedure must be performed under the most pregnancy, a history of porphyria or a known sterile conditions possible to prevent the allergy to the drug are the only stated absolute introduction of infection. This sample should contraindications to use of levonorgestrel. be sent for urgent gram stain, microscopy for However, caution should be exercised with a organisms, crystals and cells, and culture. past history of ectopic pregnancy, with breast- Empirical antibiotic therapy may be feeding mothers or the concurrent use of commenced based on likely organisms and enzyme inducing drugs (e.g. many then adjusted later depending on antibiotic antiepileptics, rifampicin, barbiturates etc). sensitivities. Surgical management may be When taking enzyme inducing drugs the dose required and involves joint drainage and of levonorgestrel should be increased (usually lavage which may be performed double the dose to 3mg in total). If there are arthroscopically. Early joint mobilisation concerns about sexually transmitted diseases should be encouraged post-operatively (1-3). follow up should be arranged with the GUM clinic. Question 2 A routine pelvic examination is not indicated for the provision of hormonal a. You should to take a quick though emergency contraception (5). The patient comprehensive sexual and gynaecological should be advised that her next period may be history including details of previous early or late and that a barrier method of contraception needs to be used until then. pregnancies, births, miscarriages or She should be evaluated for pregnancy if http://militaryhealth.bmj.com/ terminations, previous genito-urinary menses have not begun within 21 days medicine (GUM) treatment and, most following emergency contraception. importantly, ask when her last menstrual However, she should be reassured that some period was. Enquire into any relevant vaginal spotting and other changes in medical history such as porphyria, bleeding patterns following use of the POEC hypertension or migraines and any regular are not unusual (7). medications (especially antiepileptics, or Post-coital contraception has an other enzyme inducing drugs). Also ask approximate 0.5% - 1% failure rate (in the her if she thinks she may already be first 24 hours) but there is still a good chance pregnant and if she will consent to having of preventing pregnancy if taken up to 72 a pregnancy test performed in the hours after unprotected sex. It is possible that on September 30, 2021 by guest. Protected copyright. department. she may still require further treatment at a b. A pregnancy test (urinary bHCG) should later stage, including insertion of an be carried out if hormonal emergency intrauterine device up to 7 days or a contraception is to be offered as current termination of pregnancy. If she vomits pregnancy is a direct contraindication to its within 3 hours of taking levonorgestrel then a use. Ask if she has successfully retrieved replacement dose can be given (if necessary, the condom herself - if she has ‘lost’ the domperidone is an effective anti-emetic). condom this will need to be retrieved Finally, all clinicians should be alert to the manually or by speculum examination. possibility of an ectopic pregnancy in women c. Progesterone-only emergency contra- who become pregnant or complain of lower ception (POEC) is indicated when there is abdominal pain after taking levonorgestrel non-compliance or accidents with the use (8). of regular methods of contraception, or when women have had voluntary or Question 3 imposed unprotected intercourse. Levonorgestrel 1.5 mg (two split doses or a a. Exertional heat illness. Differential single dose) and low or mid-doses (25-50 diagnoses may include other causes of mg) of mifepristone offer high efficacy with sudden collapse such as syncope, cardiac an acceptable side-effect profile. arrhythmias or hypoglycaemia. PAF Hunt, JE Smith 195 J R Army Med Corps: first published as 10.1136/jramc-151-03-11 on 1 September 2005. Downloaded from

b. Assessment and resuscitation of Airway, monitoring, regular blood sampling and Breathing and Circulation. Initiate assessment of the filling state. Urinary external cooling. catheterisation is indicated in all but mild c. Clinical assessment should include a cases in order to enable more accurate rectal temperature. A bedside glucose monitoring of fluid resuscitation. (BM stix) should be performed early to Rapid cooling is essential to reduce exclude hypoglycaemia. Blood samples neurological morbidity. The ‘strip-spray-fan’ should be taken for a full blood count, method is highly effective at facilitating heat serum urea and electrolytes, liver function loss by evaporation and convection in both tests, glucose, creatine kinase and clotting pre-hospital and hospital settings and is studies. Arterial blood gases should be recommended (11). Other methods include performed. whole-body immersion, immersion of the d. The first and most practical form of wrists and hands, the use of ice packs, and cooling available is the ‘strip-spray-fan’ invasive methods such as naso-gastric or approach. The patient should be stripped bladder lavage with cold water. Practically, a to underwear, sprayed (or splashed) with combination of evaporative cooling and lukewarm/tepid water and then fanned. immersion of the wrists and hands in cold water is probably the most likely to be Discussion effective in the resuscitation room (12). In the event of violent shivering the use of Exertional heat illness is a medical chlorpromazine or benzodiazepines may be emergency. The heat produced by the body considered. However, there are arguments during exercise exceeds heat loss against the use of chlorpromazine due to the mechanisms, resulting in an unchecked rise in additional risk of hepatic toxicity and core temperature. The exact pathophysiology decreased threshold for seizures (13). is not clear, but several theories have been Investigations may reveal raised serum proposed (9,10). Predisposing factors among creatine kinase, transaminases, and LDH military personnel may include inadequate levels (from ). In severe cases acclimatisation, sleep deprivation and fatigue, evidence of organ failure will be evident, with obesity, lack of physical fitness and abnormal renal function, hepatic function dehydration as well as use of some drugs such and coagulation abnormalities. In most cases, as anticholinergics and alcohol (10, 11). blood gas measurements initially reveal a Typically, the patient collapses during respiratory alkalosis, secondary to exercise or work in a hot environment. By hyperventilation, though a severe metabolic definition they will have a raised core acidosis usually develops later due to glycosis temperature at the time of collapse, but if and hyperlactaemia. Following successful cooling measures cooling has been initiated before arrival at http://militaryhealth.bmj.com/ hospital the temperature may have returned patients will require supportive care with towards normal. close monitoring. Despite normalisation of Definitions such as ‘heat cramps’, ‘heat body temperature the inflammatory response exhaustion’ and ‘heat stroke’ are poorly and multi-organ dysfunction is not always reproducible terms and reflect a continuous prevented. The goals of further care are to spectrum of heat-related illness. Heat stroke control seizures, restore organ perfusion and implies raised core temperature in association tissue oxygenation, prevent myoglobin- with neurological compromise, most induced renal and prevent cardiac commonly a reduced conscious level. dysrrhythmias. Hypotension usually responds This patient has a reduced level of to volume expansion though vasopressor or consciousness (responding only to pain) and, inotropic agents may be required in on September 30, 2021 by guest. Protected copyright. therefore, may need rapid sequence induction individual cases. and endotracheal intubation to secure his airway. High flow oxygen should be Question 4 administered. Intravenous access should be obtained and an infusion of cold normal a. The only abnormality of note is a large saline commenced. The cellular damage of the right side of more inflicted by heat-related illnesses is than 50% volume. determined by the duration of hyperthermia, b. The patient is symptomatic and has therefore cooling should be initiated radiological evidence of a large immediately and run in parallel with other pneumothorax (>2cm rim) and, therefore, resuscitative measures. simple aspiration is recommended as first This patient had a tympanic temperature line treatment (see discussion). reading on arrival. A rectal temperature is still c. Travel, diving and what to do if symptoms considered to be the standard for core worsen should all be discussed with the temperature assessment, and crucially patient prior to discharge. continuous readings can be monitored using an indwelling probe (hence rate of cooling Discussion assessed). Central venous access will be necessary in some patients to enable closer The diagnosis in this case is most likely a 196 Self Assessment Exercises J R Army Med Corps: first published as 10.1136/jramc-151-03-11 on 1 September 2005. Downloaded from

spontaneous pneumothorax secondary to a for diving deal with this in greater detail (16). rupture of subpleural bleb (note the history All patients discharged after active treatment of asthma and the classic body habitus). or otherwise should be given verbal and Spontaneous pneumothoraces often occur in written advice to return to the Emergency young healthy adult men (male to female Department immediately should they ratio of 6:1). 85% of patients are less than 40 develop further breathlessness. years old and the pneumothorax is bilateral in 10% of cases. It may occur as result of Question 5 rupture of an acquired subpleural bleb. The frequency of spontaneous pneumothorax a. Priorities are management of airway, increases after each episode and most breathing and circulation. Early recurrences will occur within 2 years of the endotracheal intubation should be initial episode (14). considered in this patient. High flow The volume of a pneumothorax may be oxygen should be administered, and estimated from a plain chest radiograph by intravenous access achieved. assessing the largest distance from the chest b. For this patient the rule of nines suggests wall to the pleural line. If this is below 2 cm at least 9%TBSA for head and neck + then the pneumothorax may be defined as around 5%TBSA for the distal half of his less than 50% and, if above 2 cm, more than left arm and his left hand.The right arm is 50% (15). The British Thoracic Society not included in the calculation as the skin (BTS) guidelines for management of on that side showed erythema only. spontaneous pneumothorax (15) recom- Therefore the %TBSA in this case is mend that observation alone is safe for small, estimated to be 14%. closed, mildly symptomatic spontaneous Fluid requirement over first 24 hours is, pneumothoraces. Repeated aspiration is therefore, 6700mls Hartmann’s solution. reasonable for primary pneumothorax when c. Primary and secondary surveys. Analg- the first aspiration has been unsuccessful (i.e. esia. Cover burns. Arrange definitive burn patient still symptomatic) and a volume of care. <2.5 litres has been aspirated on the first attempt. If simple aspiration or catheter Discussion aspiration drainage of any pneumothorax is unsuccessful in controlling symptoms, then The presence of head and neck burns with an intercostal drain should be inserted. evidence of airway involvement represents a Primary pneumothorax patients treated significant risk of airway compromise. Burns successfully by simple aspiration should be to the inside of the mouth or of the pharynx observed to ensure clinical stability before along with expectoration of soot and signs of discharge. Patients treated with simple respiratory distress would warn of an http://militaryhealth.bmj.com/ aspiration are less likely to be hospitalised, impending airway emergency and consid- less likely to suffer a recurrence of the eration should be given to early endotracheal pneumothorax over the next 12 months, have intubation (17). Smoke inhalation with a reduction in total pain scores during poisoning due to carbon monoxide (CO) hospitalisation and overall a shorter hospital and cyanide (CN) must also be suspected stay (15). where relevant (unlikely in this case as the Patients discharged without intervention incident occurred outside in the open air). should avoid air travel until a chest High concentration oxygen is mandatory for radiograph has confirmed resolution of the all significant cases of burn . pneumothorax. Commercial airlines There are two common conventions for currently arbitrarily advise that there should the quick estimation of %TBSA, namely the on September 30, 2021 by guest. Protected copyright. be a 6 week interval between having a Wallace ‘rule of nines’, and using the pneumothorax and travelling by air. There is patient’s own palmar surface area (minus no evidence that air travel precipitates recur- fingers) to equal 1%. To obtain a more rence of a pneumothorax, but recurrence accurate calculation the Lund & Browder during a flight may have serious reper- chart should be used and it should be noted cussions. The BTS Air Travel Working Party that the rule of nines is only for use in stress that patients may travel safely 6 weeks patients aged 14 or over. after a definitive surgical procedure or To calculate the fluid requirement in the resolution of the pneumothorax on the chest first 24 hours from the burn injury, the radiograph (15). Parkland formula should be used (4 mls per Strong emphasis should be placed on the kg body weight per %TBSA burn).This uses relationship between the recurrence of Hartmann’s solution (or Ringers Lactate), pneumothorax and smoking in an effort to and should be in addition to normal daily encourage patients to stop smoking. After a fluid requirements. The first half of this fluid pneumothorax, diving should be discouraged should be given in 8 hours and the second permanently unless a very secure definitive half over 16 hours. Adding to this the normal prevention strategy such as surgical maintenance fluid requirements of approx- pleurectomy has been performed. The BTS imately 2.5 litres per day suggests a total in guidelines on respiratory aspects of fitness 24 hours for this patient to be = 2500mls + PAF Hunt, JE Smith 197 J R Army Med Corps: first published as 10.1136/jramc-151-03-11 on 1 September 2005. Downloaded from

(4 x 14 x 75) mls = 6700mls. The best mild smoke inhalation are at significant risk method of ensuring correct fluid of respiratory failure and the need for resuscitation is to pay attention to clinical ventilatory support. Age, burn size, parameters, for example maintaining an inhalation injury, and co-morbid diseases are adequate urine output (0.5 - 1.0ml / kg / important factors in predicting survival of hour in adults, 1.0 - 2.0ml / kg / hour in patients with burn injuries and important children) (18). With an inhalation injury the when attempting to objectively define the Parkland formula may overestimate fluid point when burn care may be futile (22). resuscitation requirements (19). Prophylactic antibiotics are not routinely Once the airway is secure, breathing is indicated in any age group (23). However, being managed appropriately the correct extreme vigilance is required and with the fluid replacement strategy has been initiated, development of signs of true infection, the next priorities follow normal ATLS cultures should be taken and the principals. The patient should be fully inspected by senior clinician experienced exposed and a secondary survey carried out with burn management prior to starting searching for associated wounds or injuries antibiotic therapy. Lastly, tetanus vaccination not seen during initial treatment and imaging status should be checked and completion of requested as required. If respiratory thermal primary course or booster offered as injury is suspected a baseline chest X-ray will appropriate with the addition of human be useful to assist with monitoring. A series tetanus immunoglobulin for tetanus-prone of routine blood tests should be requested including full blood count, urea and wounds where the risk of infection is electrolytes, glucose and a group and save in especially high. the event that blood products are required for resuscitation or peri-operatively (17). References Considerable analgesia will be required in most cases of partial thickness burns and 1. Till SH, Snaith ML. Assessment, investigation, and management of acute monoarthritis. J Accid Emerg should include opiates if necessary. Patient Med 1999;16(5):355-61. controlled analgesia (PCA) is a promising 2. Brusch JL. Septic Arthritis. Emedicine 2004 [serial method but not always appropriate, and non- on the internet] [cited 18 July 2005]. Available steroidal anti-inflammatories (NSAIDs) are from: www.emedicine.com/med/topic3394.htm. also useful analgesics in burns. Appropriate 3. Ma DT, Carroll GJ. Monoarthropathy. Could this be infection? Aust Fam Physician 1998;27(1-2):28- and careful dressing of the wounds will 31. markedly reduce pain from burns as well as 4. Patel A, Simons R, Piotrowski ZH, et al. Under-use other non-pharmacological methods (17). of emergency contraception for victims of sexual Fully circumferential limb burns or thoracic assault. Int J Fertil Womens Med 2004;49(6):269-73. burns that limit respiratory excursion may 5. Dunn S, Guilbert E, Lefebvre G, et al. Emergency http://militaryhealth.bmj.com/ require eshcarotomy and/or fasciotomy. contraception. J Obstet Gynaecol Can 2003;25(8): 673-87. Guidelines for the treatment of burn 6. Cheng L, Gulmezoglu AM, Oel CJ, et al. injuries have been produced by the National Interventions for emergency contraception. Burn Care Review Committee (20) though Cochrane Database Syst Rev 2004;(3):CD001324. facilities may vary nationally and, therefore, 7. Webb A, Shochet T, Bigrigg A, et al. Effect of local guidelines should be consulted. hormonal emergency contraception on bleeding patterns. Contraception 2004:69(2):133-5. Immediate referral to local burn centre or 8. Sheffer-Mimouni G, Pauzner D, Maslovitch S, et al. burn unit is recommended for people with Ectopic pregnancies following emergency complex burn injuries such as burns with levonorgestrel contraception. Contraception 2003; dermal or full-thickness loss covering more 67(4):267-9. than 5% TBSA (children) or 10% TBSA 9. Smith JE. The pathophysiology of exertional on September 30, 2021 by guest. Protected copyright. (adults). Special attention should be paid to heatstroke. J R Nav Med Serv 2004;90(3):135-138. 10. Bouchama A, Knochel JP. Heat stroke. N Eng J Med burns to the face, hands, feet, perineum, or 2002;346(25):1978-88. any flexure (particularly the neck or axilla) 11. Joint Service Publication 539. Climatic Injuries in and circumferential dermal or full-thickness the Armed Forces: Prevention and Treatment. burns of the limbs, torso, or neck. Superficial January 2003. partial thickness burns less than 5%TBSA in 12. Smith JE. Cooling methods used in the treatment of exertional heat illness. Br J Sports Med, 2003;39; a fit and well patient aged between 5 and 60 503-507. years may be managed safely in primary care. 13. Khosla R, Guntupalli KK. Heat-related illnesses. Basic wound care consists of cleaning (and Critical Care Clinics 1999;15(2):251-63. keeping clean) the burn area with sterile 14. Baumann MH, Strange C. Treatment of water or saline and applying appropriate spontaneous pneumothorax. Chest 1997;112:789- dressings. Controversy remains over whether 804. 15. Henry M, Arnold T, Harvey J. BTS Guidelines for to drain or de-roof though, in the Management of Spontaneous Pneumothorax. practice, small or thick-walled blisters are Thorax 2003;58 (Suppl II):ii 39-52. often left intact, whereas large confluent or 16. British Thoracic Society Fitness to Dive Group. thin-walled blisters are usually drained. BTS guidelines on respiratory aspects of fitness for Smoke inhalation is the principal cause of diving. Thorax 2003;58:3-11. 17. Treharne LJ, Kay AR. The initial management of death in burn patients (21). Patients with as acute burns. J R Army Med Corps 2001;147:198- little as 15% total body surface burns with 205. 198 Self Assessment Exercises J R Army Med Corps: first published as 10.1136/jramc-151-03-11 on 1 September 2005. Downloaded from

18. Yowler CJ, Fratianne RB. Current status of burn accident and emergency department after smoke resuscitation. Clin Plast Surg 2000;27(1):1-10. inhalation: influence of clinical factors and 19. Scheulen JJ, Munster AM.The Parkland formula in emergency investigations. Eur J Emerg Med 2004; patients with burns and inhalation injury. J Trauma 11(3):141-4. 1982;22(10):869-71. 22. Fratianne RB, Brandt CP. Determining when care 20. National Burn Care Review Committee. National for burns is futile. J Burn Care Rehabil 1997;18(3): burn care review. British Association of Plastic 262-7. Surgeons. [cited 18 July 2005]. Available from: 23. Ergun O, Celik A, Ergun G, et al. Prophylactic www.baps.co.uk/uploadfiles/National%20Burn%20 antibiotic use in paediatric burn units. Eur J Pediatr Care%20Review.pdf Surg 2004;14(6):422-6. 21. Mushtaq F, Graham CA. Discharge from the http://militaryhealth.bmj.com/ on September 30, 2021 by guest. Protected copyright.