5.5 Burns, Fractures, Environmental Injuries & Casualty Movement

5.5 Burns, Fractures, Environmental Injuries & Casualty Movement

Core Principle: Industrial shipboard operations expose seafarers to extreme thermal environments, mechanical trauma, and hazardous chemicals far from shoreside trauma centers. Mastering burn stabilization, fracture immobilization, environmental exposure management, and specialized shipboard extrication ensures casualty survivability during prolonged transit.

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1. Burn Assessment & Emergency Treatment

Shipboard burns commonly result from boiler flashbacks, steam pipe ruptures, electrical arc flashes, galley grease fires, and hazardous chemical spills. Burn severity depends on depth, total surface area, anatomical location (face, airway, hands, perineum), and casualty age.

                        BURN DEPTH CLASSIFICATION

     1ST DEGREE (Superficial)    ──► Epidermis only; red, dry, painful, no blisters
     2ND DEGREE (Partial Thick.) ──► Dermis involved; blisters, mottled red, intense pain
     3RD DEGREE (Full Thickness) ──► Subcutaneous destroyed; leathery/charred, painless center
     4TH DEGREE (Deep Tissue)    ──► Involves fascia, muscle, tendon, and underlying bone

Comprehensive Burn Depth Matrix

Estimating Burn Surface Area: The Rule of Nines (Adults)

The Rule of Nines divides the adult body surface area into sections representing 9% (or multiples of 9%) of the Total Body Surface Area (TBSA).

                     ADULT RULE OF NINES ANATOMICAL MAP

             HEAD & NECK (Entire):  9% (4.5% Front / 4.5% Back)
             ANTERIOR TRUNK:       18% (Chest: 9% / Abdomen: 9%)
             POSTERIOR TRUNK:      18% (Upper Back: 9% / Lower Back: 9%)
             EACH ARM (Entire):     9% (4.5% Front / 4.5% Back) x 2 = 18%
             EACH LEG (Entire):    18% (9% Front / 9% Back) x 2 = 36%
             PERINEUM / GENITALIA:  1%
             ─────────────────────────────────────────────────────────────
             TOTAL BODY SURFACE AREA: 100%

• Palmar Method: For scattered, irregular burns, the palm of the casualty's hand (including closed fingers) represents approximately 1% of their TBSA.

Emergency Management of Burns

                     BURN EMERGENCY MANAGEMENT PROTOCOL

  1. STOP BURNING PROCESS ──► Extinguish flames; smother with blanket; remove hot clothes
  2. ACTIVE COOLING       ──► Flush with clean cold running water (15–25°C) for ≥20 MIN
  3. REMOVE CONSTRICTION  ──► Remove rings, watches, belts, jewelry before edema develops
  4. DRESSING APPLICATION ──► Cover loosely with sterile dressing or clean plastic wrap
  5. AVOID PROHIBITIONS   ──► NO ICE, NO BUTTER/OILS, NO BURSTING BLISTERS

• Cooling Protocols: Irrigate thermal burns immediately with clean, cold potable running water for at least 20 minutes (effective if initiated within 3 hours of injury). This halts thermal progression into deeper tissue beds, reduces pain, and blunts inflammatory edema.
• Dressings: Apply clean, sterile non-adherent dressings or clean plastic food wrap (cling film) placed loosely in flat sheets over the burn. Never wrap cling film tightly around a limb, as post-burn swelling will create a tourniquet effect.
• Chemical Burns:
  • Dry Chemical Powders (e.g., lime, caustic soda): Brush off all dry powder completely with a cloth before applying water (adding water to dry powder creates an exothermic chemical reaction).
  • Liquid Acids & Alkalis: Flush continuously under an emergency deluge shower or eyewash with copious flowing water for at least 20 to 30 minutes.
• Electrical Burns: Always de-energize the circuit before touching the casualty. Search for entrance and exit wounds. Monitor continuously for lethal cardiac dysrhythmias (VF) and internal deep muscle compartment syndrome.

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2. Fractures & Musculoskeletal Trauma

Fractures are classified into Closed (Simple) fractures, where the overlying skin remains intact, and Open (Compound) fractures, where fractured bone ends have pierced through the skin, creating a severe open wound and extreme risk of bacterial osteomyelitis.

                      FRACTURE SIGNS & SYMPTOMS

     • Deformity / unnatural angulation       • Rapid localized swelling & ecchymosis
     • Point tenderness over bony landmark    • Crepitus (grating sound of bone ends)
     • Loss of distal motor / sensory function • Shortening or rotation of injured limb

Golden Rules of Emergency Splinting

1. Immobilize Joint Above & Below: A splint must immobilize the joint immediately proximal (above) and the joint immediately distal (below) the fracture site (e.g., a mid-shaft tibia fracture requires splinting from the foot/ankle up past the knee joint).
2. CMS Neurovascular Assessment: Check Circulation, Motor, and Sensory (CMS) status distal to the fracture BEFORE and AFTER applying any splint.
   • C — Circulation: Palpate distal pulse (radial or dorsalis pedis/posterior tibial) and check capillary refill time (<2 sec).
   • M — Motor: Ask casualty to wiggle fingers or toes.
   • S — Sensory: Lightly touch the distal extremity and confirm the casualty feels sensation without numbness or tingling.
3. Open Fracture Care: Irrigate surface debris gently with sterile saline, cover bone ends and wound with sterile moist dressings, and splint in place. NEVER attempt to push exposed bone fragments back into the tissue.
4. Splint Types: SAM splints (malleable aluminum-foam), rigid wooden/metal padded splints, air splints, anatomical splinting (buddy taping toes/fingers; securing injured leg to uninjured leg), and slings/swathes for upper extremity fractures.

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3. Environmental Thermal Emergencies: Heat & Cold

Shipboard personnel encounter extreme thermal gradients, from radiant heat in enclosed engine spaces (temperatures exceeding 50°C/122°F) to sub-zero polar operations and cold water immersion.

                         HEAT ILLNESS SPECTRUM

    HEAT CRAMPS         ──► Painful muscle spasms; normal core temp; electrolyte loss
         │
    HEAT EXHAUSTION     ──► Core temp 37.5–40°C; heavy sweating; pale/clammy; dizziness;
         │                  normal mental status ──► Rest in cool space + fluids
         │
    HEAT STROKE         ──► Core temp > 40°C (104°F); hot/flushed/dry skin; confusion;
    [MEDICAL EMERGENCY]     seizures; coma ──► IMMEDIATE RAPID AGGRESSIVE COOLING

Heat Exhaustion vs. Heat Stroke Comparison

Accidental Hypothermia & Cold Water Immersion

Hypothermia occurs when the body's core temperature drops below 35°C (95°F). In cold water, thermal conductivity is 25 times greater than in air of the same temperature.

• Mild Hypothermia (32°C–35°C): Vigorous shivering, lethargy, ataxia, cold/pale skin.
• Moderate to Severe Hypothermia (<32°C): Shivering ceases, muscle rigidity, severe bradycardia, profound hypotension, fixed dilated pupils, loss of consciousness.
• Critical Handling Rule: Handle hypothermic casualties with extreme gentleness. Rough physical movement or aggressive chest compressions can instantly trigger refractory Ventricular Fibrillation (VF) in a cold, irritable myocardium.
• Rewarming Protocol: Move to warm compartment (22–24°C); gently remove wet clothing; wrap in dry blankets/survival bags. Allow passive external rewarming. Administer warm sweet non-alcoholic drinks ONLY if the casualty is fully conscious and swallowing normally.

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4. Shipboard Casualty Extrication & Movement

Extricating an injured mariner through watertight doors, steep companionways, vertical ladders, and narrow engine room escape trunks requires specialized equipment and rigid spinal precautions.

                      SHIPBOARD STRETCHER SELECTION MATRIX

  NEIL ROBERTSON STRETCHER   STOKES BASKET LITTER        SCOOP ORTHOPEDIC STRETCHER
  • Semi-rigid wood/canvas   • Rigid wire / plastic frame • Splits longitudinally
  • Encloses body cylinder   • Horizontal & boat transfer • Slides under patient
  • VERTICAL HOISTING        • HELICOPTER WINCHING       • Minimized movement for
  • Narrow hatches & trunks  • Flotation collars           pelvic/spinal trauma

Specialized Stretcher Capabilities

• Neil Robertson Stretcher: Constructed of flexible wooden slats encased in heavy canvas. It wraps snugly around the casualty, securing the head, torso, and legs into a rigid cylinder. It is specifically engineered for vertical hoisting through narrow shipboard access hatches, vertical ladders, and watertight doors.
• Stokes Basket Stretcher: Heavy-duty rigid frame (steel or high-density plastic) with internal cushioning and multiple restraint straps. Standard equipment for helicopter winching operations and boat-to-boat transfers at sea.
• Scoop Stretcher: Splits into two longitudinal halves that slide under the casualty from both sides, eliminating the need to log-roll patients with suspected pelvic or spinal fractures.
• Shipboard Transport Rule: Casualties should be carried feet-first when traveling down companionways/passageways (allowing the casualty to see forward and preventing blood pooling in the head) and head-first when ascending vertical/inclined ladders.

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5. Telemedical Maritime Assistance Services (TMAS)

Under international maritime conventions and SOLAS, ships at sea without a physician on board have 24/7 access to free professional medical advice through Telemedical Maritime Assistance Services (TMAS) (provided by national Coast Guards or CIRM - Centro Internazionale Radio Medico).

                      STRUCTURED ISBAR TMAS TRANSMISSION

    [I] IDENTIFICATION ──► Vessel name, call sign, position, mariner age/sex/rank
    [S] SITUATION      ──► Immediate chief complaint and nature of emergency
    [B] BACKGROUND     ──► Mechanism of injury, medical history, medications, allergies
    [A] ASSESSMENT     ──► Full vitals (BP, HR, RR, SpO2, Temp, AVPU/GCS), physical exam
    [R] RECOMMENDATION ──► Specific treatment advice, medicine chest release, MEDEVAC

Clinical Vitals Transmission Standards

Before establishing TMAS communication, the ship's medical officer must obtain a complete set of baseline vital signs:

• Blood Pressure (BP) and Heart Rate (HR)
• Respiratory Rate (RR) and Oxygen Saturation (SpO₂)
• Core Body Temperature
• Level of Consciousness (AVPU / Glasgow Coma Scale)
• Pupillary Reaction and Pain Assessment