medicv83

Yeah, ultimately I think I was more or less looking at the Parkland formula more as a set in stone type of way to gain the appropriate fluid amount. Urinary output, ultimately will guide these burn patients course of fluid treatment then right? Adjust either by more or less depending on urine made, and address problems from there correct? As far as the field goes, has anyone actually started fluid resuscitation based on this formula. We dont, considering our transport times, all will be generally less than 20 minutes from anywhere in the county. Surely there are circumstances with say prolonged scene time and so forth.

Good post Logos. Your right with the rhabdo. I think, with at least these instructors, they were up in the air with as to initially treat aggressive with fluid in anticipation of myoglobinuria, or start low, and see how the urinary output was going to be. They also said that there should be consideration of the addition of 44 mEq of Bicarb to each liter of ringers to maintain an alkaline urine >6.0. Also they were neither for, nor against the administration of 12.5 grams of Mannitol to every liter of ringers until there was 75cc/hr of urine, once that occured they would discontinue the mannitol, and maintain bicarb with ringers hoping to clear the pigment. Originally though, I was curious as to how they come about obtaining the amount of fluid needed to maintain the urine output utilizing the parkland formula. I think most likely they are going to start low with the parkland formula, and wait out a few hours, measuring the urine, and let the urine output guide the resuscitation from that point on.

Triemal, what are you talking about? First off - My limited experience? Secondly, when is the time that I should be learning? You make it seem like im some student of sorts? Yes there is never a time when learning shouldnt be going on, its a constant thing in EMS as it should be in any profession. Thirdly, you are very wrong about estimating the Burned internal body surface. The ABA, nor many Burn surgeons recommend this. Now in the pre-hospital aspect, the theory of a liter of saline, and a liter of ringers wide open seems to be the best. But if we were to utilize the parkland formula, we absolutely would not want to just "estimate" the surface burned internally. Do you know exactly the course this electricity took in the body? Much like you wouldnt know the exact course of an entrance wound of a bullet. Please, if your going to condescend me on here, do so with an adequate post with some sort of knowledge. Once again, Sally is the name of a female, and I am not a female, so therefore, dont call me Sally to get my attention. With guesstimating the internal surface area burned and then applying that number to actual fluid resuscitation would either potentially over or under resuscitate the patient in the long run and further aggravate the edema that the patient is going to have, or place the pt in acute renal failure. As far as the field goes, sure we could estimate. But not for long term, total fluid resuscitation.

I sincerely apologize for the way my text read, it sounded immature and ignorant in and of itself. Should have maybe worded some things differently. Unfortunately I will continue to maintain an opinion about nurses vs paramedics, however I absolutely agree that the primary mission is the continuity of care. Nurses are invaluable, without question, and my objective was not to belittle, or degrade the profession at all. I just sometimes feel as though the nurses are, at least here at this hospital, are robots compared to the medics in the field serving the same hospital. They can't do a thing without getting ordered. Cant even put a pt on 02 without it! That is incredible! Triemal: First of all, please dont call me Sally, If im the one your referring to. Secondly - your absolutely right with the requirements for LR and I guess I didnt really think it through considering only a 15 - 20 minute trans time. But more importantly, the aim was to identify fluid needs overall for an electrical burn patient. Considering BSA. AZCEP is on track considering the best ya can do is to give em the best of both worlds with a liter of ringers and a liter of saline wide open together until transfer.

Well, you know, it is only an opinion. I dont mean to come across as belittling the nursing profession. My wife is a pediatric nurse, and a Captain in the Army. I fully support nursing and the job that they do. I will say that whether it be ER, ICU, or general floor nursing, that they are not in any means obligated to make life saving decisions for their patients. Now surely this is not an argument that needs to be had or should be had in any event, but..........For the sake of the conversation, the paramedic responsible for making decisions in the truck, granted they may be by ingrained protocols, is still responsible for his/her decisions. The nurse administering medications, or eliciting a history is truly only doing so for the doctors benifit. As we are, but on a different level. Im not necessarily saying that nurses shouldnt teach per se, but the order of echelon shouldnt be what it is. It should be (in general) Doctor, Medic, Nurse, considering that the nurse is simply taking the orders of the physician at hand, and not responsible to choose the order of care that is given to the patient.

That crap really lights a fire under me. Since when, honestly, is a nurse more qualified to teach, or to perform the skills needed in say NRP, or ACLS/PALS? Paramedics should honestly teach those courses, if it isnt a Doctor teaching them. The second question with burn resuscitation is fluid choice. Standard is Lactated Ringers. Great choice of course, but not alot of ambulances here carry LR in a quantity sufficient to initiate fluid therapy, if they carry it at all. So the question was brought up with the use of Normal Saline in the pre-hospital environment. Which per the ABA is ok. However, with the NS used, they are going to recalculate the formula anyways at that point. I guess the underlying thing is just to hang a liter with a large bore IV and open her wide open until transfer, let the staff at the facility take her from there.

Im very sure they did know their stuff. Considering the qualifications in the room. Im just whining. Hey, it was free. haha.

hahhaha. Doesnt take much to be an instructor of the course I gather, all ya have to do is read directly from the slides hahah. Just messing. Your right, Im doing a little whining I guess. I understand it isnt geared towards pre-hospital care. All the scenarios are based as a medic/nurse in hospital. Just nice to get solid info. I just would like to see the ABA put out definitive guidelines, like the AHA and so forth, thats all. That good solid core of knowledge that all their research is for, ya know?

Yeah really! It was a UNC Burn team that came down, including 3 nurses and a Burn Surgeon who taught it. In any case, I see the relevance of your point about the fluid, however, I've thought about that, amongst other people, but with that, you might as well take into account 100% BSA then, know what I mean? My point is, there is no guideline to really go off of. I just feel as though if the ABA wants to go out of facility and "public" if you will, then they need to start setting a standard in content/science based treatment. The Brady books, ITLS/BTLS, ABA' ABLS manual and so on all have different "rule's of nines". See my point?

I attended ABLS this week, and I have an un-answered question. Per the American Burn Association, the " burn consensus formula " AKA the "parkland formula" for the adult is 2-4 cc x kg x bsa = _____ ml/24 hour. We all know this. This is guided by urine output ultimately. In electrical injury, with significant internal injury noted by hemochromagens in the urine (myoglobinuria) the ABA suggests maintaining an adult urine output of 75 - 100 cc/hr to aid in diluting and clearing pigment in the urine. This means MORE fluid than the thermal burn patient would recieve. Now, with that being said - the formula uses BSA as a determinant of fluid needed. My question is - If my patient has an electrical entrance surface burn say 4 or 5 cm to his/her Right hand, and a 4 or 5 exit surface burn to say his/her left shoulder, that is essentially only maybe 2 % BSA......Where are we getting the additional BSA to calculate the additional fluid needed for this electrical burn patient to maintain a UOP of 75 - 100 cc?????? I got completely avoided answers during the course. Wondering what yall's thoughts are on this.

Im a paramedic down in fayetteville. They came down yesterday and taught it. The quality and content of the material was just poor. Very rudementary and disorganized. Every instructor except one, this tall black guy, been burn nursing for 28 yrs. He seemed like he was squared away, but he also seemed held back by the content that he was teaching. A burn surgeon, who also taught seemed like he had no idea what he was talking about. I was astonished. This other nurse, really really really pretty, didnt know the first thing about a burn it seemed. It was amazing. Everyone there, the 30 of us or so all commented on how poor the quality of instruction and the material was. We all had high hopes of really learning new things and we would have been better off reading a magazine article written by a boy scout about burn care.

I took Advanced Burn Life Support today, offered by UNC Burn Center. They came down here to where I'm at and offered it. It was absolutely horrible. Outside of fluid resuscitation, there was nothing of value to nurses, paramedics, or 3rd graders for that matter. The instructors read ver batim from the slides. Now of course, like the typical ancillary courses, one should know the material prior to taking the course, and of course I did, but I was hoping for some stability with "the rule of nines" or the " Burn Consensus Formula" as they call it. They contradicting eachother constantly on fluid resuscitation, and the material was as basic as could be. Just was wondering if anyone else who has taken this course has had the same experience?!?!?!

I appreciate yall's input on this. Tough time making decisions. I've never utilized reciprocity though. Kinda oblivious to the process. I mean sure I've read how to do it on NY states website thing, but can I apply for, say, Rural Metro now? While I still have an NC card, and like work it so that I dont start until I get up there and get my reciprocity switched over? My biggest thing is avoiding having a drastic gap between employment.

Wow! Sounds horrid lol. Im heading back up that way because my wife wants to be closer to her family, who lives in hamburg. Im generally not that ecstatic about it, but, she wants it. So is it better to go with Twin City, or Rural Metro? Twin Cities pay looked HORRIBLE....And by any chance, can anyone let me know where to find a copy of ALS/BLS NYS protocols? Cant find em anywhere

Need some help trying to find a really good service in Buffalo, with relation to a great hospital up there. Me and my family are moving there here in a few months, and im about to start the process of reciprocity from NC to NY. Im a medic

You da man. Thanks

Purrciate it buddy, thanks

Ok yall, This is not a fun question, but I need some help figuring something out. What is the action of Glucagon in a Beta Blocker overdose. Please help me yall.

Sorry I didnt post a reply sooner, but was out and about all day. First, absolutely you can admin IV glucagon. This actually happened at the hospital, per the doctors orders to a pt we brought in. We initially gave, D50, OJ afterwords with some peanut butter cracker things she had for the kiddos. Then enroute, her sugar dropped again, and we gave a second amp of D50. At the hospital, doc admined another amp of D50 after her sugar dropped from out second dose, and he also ordered IV Glucagon...His rationale was that it blocked the liver from storing glycogen, or in any case, the conversion from glucose to glycogen, to keep max amount of dextrose in the blood available for metabolism.

We have this patient in which we have all seen. The hypoglycemic, in which you've raised their sugar and it spikes ---- 156 from say 34.......Then Bammmm - back down to 32 (you've raised it with D50 yada yada yada....) So, now you admin another amp of Dextrose. Spikes again, and drops again to 36. Question is, if you could, IF your med director would allow you to do it, would you admin IV glucagon, and then, please, state why you would give it. I have my theory, which is of course, of the most miniscule of thinking, but would love to hear others approach WITH IV glucagon.

Makes perfect sense! Thanks again for everyones input!

I think I was totally off, well, was to vague with my impression of Atropine's effects on the parasympathetic nervous system.........So the impression here is that, with Neurgenic shock, administration of Atropine in the Cardiac arrest setting will not adversly effect resuscitation? Shall I even ask the question of the alive Neuroshock patient and the use of atropine?

Rest assured, I am in no position to validate anything. The medical world is much much bigger than me and my little mind. Initially, it was a question simply about the basic effects of atropine use in the neuro shock, arrest patient. Would it, or would it not be beneficial. With that, I have totally learned alot just reading everyones input here, and I appreciate everyone responding. So far I have gathered that I will have to delve into the deeper aspect of the pharmacodynamics of Atropine. My thought was that, Atropine, being the parasympatholytic that it is, would cut off the only source of autonomic tone to the body, and with that, would not be beneficial. Thats all. No validation, no nothing, simply trying to discern the actions.

DwayneEMP.............Thank you by the way. Should have said that earlier. Rest assured, I will continually post complex, intriguing questions, that I myself am in search of answers to. I support the same notion that one must think before looking to the books for answers. Us Medics, basics, and intermediates on here know the answers to most, but are just to lazy to think sometimes.

All well thinking of course. I truly understand that in any case, neurogenic shock would not be an initial train of though, however a diagnosis of rule - out. BUT..........We are saying the the neuro shock pt who codes yada yada yada..........The issue is not the ability to produce catecholamines, but the ability to conduct the transmission via the nervous tracts. Yet, of course the tissues ( end organs ) once able to recieve the neurotransmitter, will be able to act, will perform the expected action. That is why initially I said I support the administration of pressor agents, as well as possibly a dopamine drip. Your input is very logical....Just trying to counter it for the sake of countering it. lol