Fluid resuscitation in electrical burn

[medicv83]

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.

[Just Plain Ruff]

Well I think that the answer should take into account that an electrical burn affects not only the entrance wound area and the exit wound area but the entire body as a whole. The burn is not limited to just the hand and feet but it also extends to the internal organs, the brain, the kidneys, the lungs and basically every system taht the electricity went thru from hand to foot.

So you start at the hand and move up the arm, down the chest cavity, the abdomonal area the legs and then the feet. Don't forget that it also could have hit the brain and the head and neck.

Electrical burns are bad mojo and since the current was flowing thru the body instead of the burn staying on the surface of the skin and it's subsequent layers it makes the electrical burns the "Most Extreme" ha ha Hence the requirement for more fluid therapy

ps, the instructors you got sound like they had no clue in what they were teaching. I've read your other post on this too.

I would call the place you got your training from and let them know that you were not satisfied. Do you think you got your $249.99 worth? If not you owe it to your self, your training entity, your service and your Country to demand a recount.

[medicv83]

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?

[Just Plain Ruff]

absolutely but here's the overall point.

Remember that ABLS is meant to be geared towards in hospital treatment rather than pre-hospital treatment.

in the field are you really going to be able to document urine output? Are you really going to be concerned right then and there in the calculating of fluid rates which more than likely will be revised once they reach definitive treatment.

This course is really a good course to augment your treatment in the field but if you were expecting this course to be a pre-hospital course (which I'm not saying that is the case here) then you were expecting a little too much.

now if you are working in a burn unit or are working in the ER then this course is nice to have. but pre-hospital I think it's not a great class to have.

I used to be a ABLS instructor which is funny because when I sent in my paperwork for the class I was supposed to have a class and go thru it. I got the manual, the testing material and also a card saying I was a ABLS instructor. I never went to the instructor class nor did I go to a ABLS provider class - I just got the card, clerical error I think so. Did I ever teach the class, I could have but my schedule never allowed for it, would I have, NOPE as I did not feel I was instructor worthy.

[medicv83]

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?

[Eydawn]

In the burn patient though, the most important thing is that you're starting them on fluids right away... I don't think that a prehospital drip rate is going to change much, because as was said before, you can't calculate urine output...

Wendy

CO EMT-B

[Just Plain Ruff]

Don't get me wrong, I was not saying you were whining I just think you might have expected a little more than the course was going to give.

It's not unfair to expect some quality education from so-called experts. but to hear them read the slides and then not be able to answer your questions, is nuts.

Even I as a psuedo instructor would be able to offer more than what was on the slides.

I would be a little more than miffed if all I got was a reading of the slides, I can do that when I'm at home.

I do understand your pain.

[Just Plain Ruff]

One other thing, I think that this course ABLS like all the other advanced single subject courses really disappoint the class member if they do not provide information that can be used.

Take NRP for example, The only real difference I found when I took the class was that we were focused on neonates. We took what we got from PALS and focused it on neonates. Was it worth going to class for 2 full days? nOpe was it worth a 1 day class you betcha.

I was overall happy with that course but I would have liked to have seen a shorter class.

I also was a NRP instructor until they realized that I was a lowly paramedic and "paramedics" couldn't teach the class. They said only nurses could teach the class. I tried arguing the point that I was a Regional faculty member for ACLS and PALS, a BTLS instructor, a Paramedic course instructor, a ABLS instructor(ok that was a stretch) a CPR instructor and a overall really good guy. But they wouldn't budge. But they had no problem using me as their lead lab instructor but I just couldn't instruct any lectures. Damn elitists.

[medicv83]

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.

[Just Plain Ruff]

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. .

Be careful on that type of statement. I'm curious as to why you say that paramedics should be teaching the courses if there isn't a doctor teaching them. Why do you say that?

I'll bet that an ICU nurse has run more codes per year than many many medics do. I'd also say that ER nurses run/participate in more codes per year than the average paramedic.

What makes them less qualified to teach the class?

Statements like the above shows an elitist view that I'm not comfortable with? if you can back up your claims then maybe I'd reconsider. It's sort of like saying "that with 3 months more education any paramedic could do an RN's job"