Burned

[streetsurgeon]

really az? fluid overload = bad airway, or did fluids take priority of airway... ? just curious to what happened?

[BushyFromOz]

When available, the Parkland formula is useful, but not really necessary.

Thanks az, i could not for the life of me remember the name of the formula

[AZCEP]

really az? fluid overload = bad airway, or did fluids take priority of airway... ? just curious to what happened?

The soft tissue swelling was made worse by aggressive fluid replacement. The inhalation issue was more subtle on presentation than we gave it credit for. A surgical airway later fluids continued.

[firedoc5]

I was very tempted to go for a carotid stick. But due to space in the rig and doing what dressings we could, I just didn't get the chance. I was lucky to get the antecubital in one stick. I always thought back that I should have used a 14g instead of the 16g. :roll: As far as starting an IV in a 3rd degree burned area is not acceptable. Plus I don't think you'd find any veins usable. An IV in the area of a 2nd degree burn should be avoided but can be done if necessary.

All burn patients are very prone to infection, even by their own skin. As human skin burns it gives off a poisonous toxin which is also absorbed into the skin. For the life of me I can't remember what it is called. :?

Keep all clothing and foot ware. The burn center will need to know what materials were used to make the clothing. Probably 80% of her rubber boots were melted onto her. She did lose both feet eventually.

AZCEP is right about the airway. Rapid fluid replacement can be detrimental if not monitored. Between that and possible inhalation burns, you can lose the airway very quickly. Airway needs to be watched at all times, especially if not intubated yet. If need be sedate and intubate.

Luckily this lady did not have any noticeable inhalation burns. Unfortunately, even after a total of 10mg. MS, she remained C & A X 3. At that time all we had was MS and Valium. I didn't want to use the Valium due to concern of knocking out her breathing and knew the difficulty of trying to intubate while en-route due to lack of moving space.

Once in the ER, found out that she was the aunt of one of the nurses on duty. So we had that going on too. Due to weather, ARCH helo. out of St. Louis was grounded. So I got to do the transport by ground. It was two nurses, an RT, and myself in back. I made sure we had our best driver go, who happened to be my partner. Later I asked Brad how fast he was going. He said that sometimes he didn't know, the speedometer only went to 85. But he made sure he only went that fast of the completely straight sections of the Interstate.

I was very impressed with the burn unit at Barnes Hosp. (Now Barnes/ Jewish). Luckily Brad and I went. The doc. at the burn unit wanted to know everything from the time we first saw her until she arrived in the burn unit. I would highly suggest that if you do tend to a burn patient and they are transferred by ground, if at all possible go on the transfer. You might be the best source of info.

[Just Plain Ruff]

Other than infection why do you say that an IV thru the burned area is not acceptable. Is that a blanket hard and fast statement or are you saying that if you have any other place pick that other place.

I agree with the IV in any other place than a burned area but the patient I had had 2nd degree on nearly all her body and 3rd degree on a lot of other places.

Each place I looked for an iv site was burned. neck, chest, arms, legs etc. This lady died eventually of DIC and numerous other things.

But if your rule is never put an iv in a burned area then what would you have suggested.

our transport time on this lady was 35 minutes. She was conscious and able to talk to me prior to my intubating her but where do you suggest I start the iv if every place I looked either had 2nd degree or 3rd. degree????? Tell me.

[firedoc5]

Other than infection why do you say that an IV thru the burned area is not acceptable. Is that a blanket hard and fast statement or are you saying that if you have any other place pick that other place.

I agree with the IV in any other place than a burned area but the patient I had had 2nd degree on nearly all her body and 3rd degree on a lot of other places.

Each place I looked for an iv site was burned. neck, chest, arms, legs etc. This lady died eventually of DIC and numerous other things.

But if your rule is never put an iv in a burned area then what would you have suggested.

our transport time on this lady was 35 minutes. She was conscious and able to talk to me prior to my intubating her but where do you suggest I start the iv if every place I looked either had 2nd degree or 3rd. degree????? Tell me.

I don't think you can say never start a line in the burned area. But I don't think you'll find a vein very easily. May have to "hunt & fish" for one. The 3rd degree burn, especially deep will damage whatever vein is there. But if there is even just one other place, go for it. It would be hard to say to with hold at least an attempt, but I don't think you'll have much luck.

It might have to wait until a doc could put in a central line or do a cut down in the ER. I know some of us have been trained to do a cut down, but it's not usually practiced pre-hosp., at least around here at that time.

Also, I would think that if you did get a line started it will more than likely infiltrate causing even more tissue damage, and like you said, Ruff, increase the risk of infection.

I hope this helps, Ruff.

[paramedicmike]

Seriously burned patients are going to get some pretty significant antibiotic treatments. The burn itself, if serious enough, is more an infection threat than the IV. Start the IV where you can and go with it. The fluids and analgesia you can give be a good short term intervention until you can get them to the burn center.

-be safe

[saboats]

The Parkland Formula mentioned earlier is ( fluids volume)= total body surface area of burn (%) x weight (kg) x 4

1/2 of dose admin. in 1st 8 hours, the rest in the following 16.

However I believe FireDoc (I think it was him) was right, start the fluid ressecutation, and that number of CCs will be subtracted from the total vml at the burn unit.

Some things to remember, we (EMS/ED) almost always under estimate the BSA, and burn centers re-estimate after 24 hours to get a true messurment of true BSA. The inital fluid administration is over 24 hours (what the parkland formula was for), and we shouldn't be fluid over loading our patient pre-hospitally. We can cause airway problems from too much fluid, eg. non-cardiogenic pulmonary edema, from baseline fluid overload, and these patients are sick enough, we don't need to stress their systems more. IMHO I would say analgesia is more important in the immediate short term.

[air.stump]

I remember during clinicals at a burn center that the reason for recalculation of BSA is that there is usually an increase in % because the size of the burn increases during the first couple of hours.

IV placement for IV access and fluids is important during the pre-hospital care but most significant burns received a central line during the initial workup.

[BurnNurse]

I remember during clinicals at a burn center that the reason for recalculation of BSA is that there is usually an increase in % because the size of the burn increases during the first couple of hours.

IV placement for IV access and fluids is important during the pre-hospital care but most significant burns received a central line during the initial workup.

Ok burns are an evolving injury, what you see in the field may not be the whole extent of the injury.

First is to stop the burning process. every one is good with that. Don't get yourself crazy over the sterility of your dressings and what the patient will be on in the field. nothing is sterile in the field and darn few things are in the ED. the thing that kills burn patients in the beginning is one of three things Hypothermia (skin regulates body temp) that leads to metabolic miscues (acidosis, hyperdynamic state) Fluid loss Parkland and other fluid replacement formulas are fine . IV access through anything you can get . Fluids started in the field get a head start on the damage done. if an ED nurse gives you trouble for this they are wrong (being an expericed Burn and ED nurse I can say it) Infection is not the immediate problem for prehospital providers. Be aware of it and do what you can to prevent it but don't get crazy.

Transport if possible to a burn center, that will give the patient the best chance of survival. Oh and the last thing that kills burn patients in the beginning is hidden injuries. be proactive and don't get distracted by the burn, do a good head to toe. To deal with burns better the american burn association has advanced burn lifesupport. if you get a chance take the course. get your local burn center to do some teaching, thats what they are there for.

Rob EMTP/RN ect..........................