# Burn victim treatment from an ALS/BLS standpoint



## Amycus (May 22, 2011)

Background info: I wasn't at this call. Propane tank explosion, 2nd and 3rd degree burns over 60%+ of the body, it was bad. Patient is alert and oriented, screaming in pain. ALS already en route, arrived quickly. Medflight en route.

I like to think about calls other crews go on, just to see if my treatment train of thought works differently. From a BLS standpoint, I was assuming high flow O2 (no OPA due to the alert factor, no NPA since well, likely unnecessary. The airway is patent for the moment), cut off all non-burned on clothing, and cover the patient's body with sterile burn dressings and blankets to preserve body heat.

However, the BLS crew on scene, and forewarning, I don't know if this was at the direction of ALS or independent action, said they began soaking trauma dressings in sterile water and began covering the burns.

Please, and I'd love to know if I'm wrong, I was taught that in cases of severe, high percentage burns, NOT to soak the burn areas and instead focus on preserving body heat, as with burns that severe, the body will have issues in some fashion. Soaking dressings and covering the burns I was taught for minor, sub 10% body area burns. I would think soaking dressings on someone with over half their body burnt would maybe, MAYBE, help comfort the patient, but ultimately would be bad due to the body heat loss.

Opinions? Please, I'm very curious on this. I love to learn and have yet to see a scenario like this. Thank you.


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## daj72 (May 22, 2011)

In Denmark we cool (spray on) the burns with NaCl 9%. We dont juse dressings.

If the burn is over 10% there is a pause for every 15 min. so the patient dont get hypothermia.

And off course O2 and analgesic IV.


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## Bosco836 (May 22, 2011)

Amycus said:


> Background info: I wasn't at this call. Propane tank explosion, 2nd and 3rd degree burns over 60%+ of the body, it was bad. Patient is alert and oriented, screaming in pain. ALS already en route, arrived quickly. Medflight en route.
> 
> I like to think about calls other crews go on, just to see if my treatment train of thought works differently. From a BLS standpoint, I was assuming high flow O2 (no OPA due to the alert factor, no NPA since well, likely unnecessary. The airway is patent for the moment), cut off all non-burned on clothing, and cover the patient's body with sterile burn dressings and blankets to preserve body heat.
> 
> ...




Our BLS Protocol is to cover any burn larger than 9% of the body with a dry, sterile dressing and transport ASAP (w/ALS is possible).


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## MSDeltaFlt (May 22, 2011)

Amycus said:


> Background info: I wasn't at this call. Propane tank explosion, 2nd and 3rd degree burns over 60%+ of the body, it was bad. Patient is alert and oriented, screaming in pain. ALS already en route, arrived quickly. Medflight en route.
> 
> I like to think about calls other crews go on, just to see if my treatment train of thought works differently. From a BLS standpoint, I was assuming high flow O2 (no OPA due to the alert factor, no NPA since well, likely unnecessary. The airway is patent for the moment), cut off all non-burned on clothing, and cover the patient's body with sterile burn dressings and blankets to preserve body heat.
> 
> ...



For Burns greater than 10% BSA, cover with dry sterile dressing.  Soaking the pt WILL enduce hypothermia.  It will do nothing for the pain.  You might, I repeat MIGHT, have enough morphine and fentanyl.  But I doubt it.  The only Burns you can treat that hurt are 2nd degree.  3rd and 4th won't hurt because dead tissue doesn't hurt at all.  Nerve endings are dead.

Remember on burn pts  the largest organ on the human body is traumatized: integumentary system (skin).  That regulates your body temp, maintains normal temp (euthermia).  In Burns it can nolonger do that job so your pt can and will drop their core temp like a bad habit.  Keep 'em dry.


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## Cawolf86 (May 23, 2011)

I would say the main addition in an ALS workup would be the availability of pain management and fluid (if poor perfusion).


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## medicRob (May 23, 2011)

MSDeltaFlt said:


> 3rd and 4th won't hurt because dead tissue doesn't hurt at all.  Nerve endings are dead.



This is actually a myth that a lot of burn unit surgeons would like to try to dispel. While it is true that some 3rd and 4th have COMPLETE damage to the nociceptors, a good number of these patients can still feel pain. I have seen several myself in the burn unit, personally. 

"The myth that "third degree burns don't hurt" unfortunately still serves as a basis for widespread institutional denial of pain assessment and treatment for burned patients. Pain control is essentially absent from current reviews of burn management, scientific programs of national burn associations, or funding agendas of the Federal government or major private burn treatment organizations, much as pediatric pain and cancer pain were a decade ago.

The AHCPR recommended a combination of opioids and sedatives, with cognitive-behavioral strategies used as adjunctive therapy."

Agency for Health Care Policy and Research. Other patients with special needs. In: Acute pain management: operative or medical procedures and trauma. Rockville, MD: U.S. Department of Health and Human Services; 1992. Clinical practice guideline;



References: 

1. Stoddard FJ, et al. Treatment of pain in acutely burned children. J Burn Care Rehabil 2002;23(2):135-56

 2. Summer GJ. Mechanisms of pain following thermal injury [unpublished doctoral dissertation]. San Francisco: University of California; 2005.

3. Malenfant A, et al. Tactile, thermal and pain sensibility in burned patients with and without chronic pain and paresthesia problems. Pain 1998;77(3):241-51.

4. Understanding and Managing Burn Pain: Part 1
Patricia A. Connor-Ballard PhD, ACNS-BC 

AJN, American Journal of Nursing
April 2009  
Volume 109 Number 4 
Pages 48 - 56


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## EMS49393 (May 23, 2011)

BLS - dry sterile dressings, infection will soon become this patients worst enemy; protect from hypothermia which is likely now this patients worst enemy; monitor airway and oxygen saturation, treat as appropriate with oxygen but be careful messing with the airway if there is any chance for inhalation injury, a patient with this type of injury pattern will likely require RSI yesterday.

ALS - fluids, preferably warmed; protect airway, if there is *any* chance for inhalation injury, that patient needs to be put down and tubed before it's too late; morphine/fentanyl (whatever you have) and lots of it; versed very very slowly if you have that as well.  Of course monitor, blah, blah, als toys blah, blah.  

Remember, nerves may be "dead" in a full-thickness burn, but the tissue around the full-thickness burn is likely 1st and 2nd degree burns which hurt a hell of a lot.  No lie, there is not enough opiate analgesic in the world for these patients and they can tolerate a HUGE frickin' amount of it as well.  A burn victim of this severity can get more then 60 mg of morphine an hour in a burn unit and still hurt so bad they wish they were dead.  I am a big fan of versed in conjunction with analgesic.  They will still hurt like hell, but you'll take away some of the memory of how badly they hurt and sedate them a little more.

I consider burns to be the absolute worst type of traumatic injury a patient can sustain.  God, they suck.

Anyway, you are correct; dry, sterile dressings. B)


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## Too Old To Work (May 23, 2011)

Dry dressings at the BLS level. Or just wrap in a clean sheet. These patients by definition are going to have infections, so I wouldn't worry about sterile sheets. 

At the ALS level, it's as  EMS49393 says. The last burn patient I had got 250mcg of Fentanyl during the ten minute ride to the ED and it just barely got the pain under control.


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## foxfire (May 23, 2011)

Never did quite understand the dry dressing thing until  going through the ALS burn section.  I have a better understanding. 
I have a thought though that I would like to throw out. 
When dry dressing is applies to a burn, it absorbs the serum seeping out. When that serum dries it will form a crust. Could that possibly do more damage removing the now crusty bandage than a moist bandage. I understand the reason for dry to avoid hypothermia,  but is there a way to keep the dressing moist but yet maintain body temperature?


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## usalsfyre (May 23, 2011)

Simple answer is not practically.

However, don't worry about damage done when the dressings are removed. If you've ever seen debriedment, you understand why.


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## DrParasite (May 24, 2011)

from the BLS level, flush the wounds with cool running water.  then apply dry sterile dressings.

from the ALS POV, fluid replenishment and pain control, and intubate if you have airway burns.


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## Sandog (May 24, 2011)

foxfire said:


> Never did quite understand the dry dressing thing until  going through the ALS burn section.  I have a better understanding.
> I have a thought though that I would like to throw out.
> When dry dressing is applies to a burn, it absorbs the serum seeping out. When that serum dries it will form a crust. Could that possibly do more damage removing the now crusty bandage than a moist bandage. I understand the reason for dry to avoid hypothermia,  but is there a way to keep the dressing moist but yet maintain body temperature?



Well, I can tell you this; some time ago while I was on board a Navy ship, I received serious burns to the anterior portions of my hands and shoulders. The first responders applied gauze around my hands. A few hours later I was flown to Cubi Pt. Philippines where I was treated. The nurses began to remove the dressing from my hands. Well, my body fluids managed to weld my flesh to the dressing and needless to say, the removal of the dressing was excruciating.

The follow on treatment was equally unpleasant as well. Mind you this was in the 70's so I hope the treatment has improved, but what they did was put me in a tub of hot water and get me nice and soggy. Once I soaked long enough, they would scour my burn wounds with some sort of scrubbing pad. The pain was the worst thing I have ever experienced, (and I had a compound fracture of the tibia). All the while they would not give me pain meds for fear of addiction I guess. The process lasted for about a week I think. After each treatment, they applied Silver sulfadiazine with a non stick pad over the wound then the dry dressing. I guess my point is that my burns were the most painful thing I have ever lived through and I would not wish such pain on my worst enemy.


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## Foxbat (May 24, 2011)

I recently had a con-ed class on burns. After the lecture I asked the doctor from the burn unit who was teaching the class about the whole cooling thing.
Her response was basically this: she gets this question asked all the time; she believes that cooling only helps if done immediately (like, minute or so) after receiving the burns, which rarely applies to EMS. Cooling can temporarily reduce pain but overall it's not a good idea (hypothermia, infection). Therefore, use dry dressings.
Although I did hear a recommendation from an emergency physician to laypeople that they should cool thermal burns with running water for a few minutes, because it supposedly helps to remove the heat that accumulated deeper in the tissues.


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## johnrsemt (May 26, 2011)

You can't give enough pain meds to addict the patients in a pre hospital setting.  Our old medical director used to teach us that 2-3 times the normal dose of pain meds for burn patients is not too much.    
   Burns hurt,  and about the only thing we can do pre hospital along with lots of fluid is pain relief.

  Also:  I didn't realize til last year,  but if you work with the Parkland formula for burns:  )BSA% X pt weight in kg/4 = mL/hr   to be given in first 8 hours).  If you are in rural setting and don't get the patient til 4 hours after burn:  the fluid for the first 8 hours is better to be given in the first 4 hours you and the ED has them.    Some of our response area can be 1-3 hours by ground,  after they hike/drive the same distance to get cell coverage to call for help.


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## medicRob (May 26, 2011)

When I get done at the lab, im gonna come home and do a write up in this thread, with citations from total burn care (one of the best burn textbooks there is) and talk about goal directed treatments for the first 24 hours, use of the formulas (Parkland, Muir), the major concerns with burn injury, post-burn receptor alterations (with citations), and the role of cellular signalling as well. I have neglected this particular thread temporarily because I have bee wrapped up in getting the next podcast episode ready. 

I will be home tonight around 6 pm CST. I will make sure to provide links to the burn center protocols for pain management, sedation, fluid rescuscitation, debridement, etc for those of you who are interested.


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## medicRob (May 26, 2011)

*This is unfinished, I will be updating it and writing more in increments.*

*Background: 
*
Burns are some of the most devastating injuries that one can encounter. In burns, the line between medical and trauma is blurred, and there are a whole series of considerations that a provider needs to take into account, whether they are ALS, ILS, or BLS.  Let’s for a moment stop thinking of things in the ALS, ILS, BLS sense, and instead look at burn management from a team approach. If you see something that is not within your scope of practice as an EMT-B, then you know that you can’t do that, you don’t need BLS/ALS lines to tell you that. By looking at this as a team effort, you will be better prepared to not only do your part in the initial management and transport, but will also get an idea why it is you are doing what you are doing, what is going to happen when the patient gets to us in the burn unit or ER (depending on severity), and will have a better understanding of burn management and shock states as a whole as well. 

*The Types of burns: *

Whenever we think of burns fire enters our mind. However, this isn’t always the case. Burns can be Thermal, Mechanical, Chemical, Electrical, and from radiation (gamma, xray, uv). Examples of thermal burns can be house fires, explosions, and any process involving extreme heat or cold applied to the body. Mechanical burns can be from friction or abrasion, although you don’t usually hear about these in EMS all that much.  Chemical burns are from acidic or alkali substances (examples:  Sodium Hydroxide, Dry Lime, Hydrochloric Acid, Sulfuric Acid). Electrical burns are self-explanatory, and are the most fatal of burns. Radiation burns are particularly horrible in that one must not only worry about the burn, but a whole host of effects that can come later such as radiation poisoning, cancer, etc. (Examples can include: Sun burns (1st and 2nd degree) and gamma radiation. 

*Burn Classifications: *

Burns can be classified based on severity and feature into 4 classifications known as degrees.

1st degree   Partial thickness, painful, No Blisters, Pink and red and extend only to the epidermal strata. 

2nd degree – Deep partial thickness, painful with blister, (+) blanching and refill, extends to both the epidermis and the dermis. 

3rd degree -  Full Thickness , pain will be discussed below, leathery, extends to fascia and muscle. ** (see note)*

4th degree – Bones and visceral organs are affected. 

***While many EMS providers will tell you that individuals with 3rd degree burns feel no pain because the nerve endings are burnt, this is largely a myth. Sure there are some patients that we come across who might have so much damage that they no longer can feel. However, this isn’t always the case, because there are factors such as inflammation, toxins in the blood stream, and a whole host of other issues that can cause pain. [1, 2]

*Major Complications of Burn Patients: *

Airway compromise, Fluid Loss (Shock, Electrolytic imbalance, etc),  Hypothermia, and  Infection. 

*Pathophysiology of Burn Shock:*

Whenever the average person sees a burn, they are mainly focusing only on the damage they can observe. They do not think about the pathophysiology of the burn state and the subsequent alterations of physiology that occur in the molecular and cellular levels, resulting in a whole cascade of secondary injuries, just as we see happen in brain injury, where the secondary injury actually becomes more damaging than the initial insult in most cases. 
Those of you here at EMTLife that have taken PHTLS remember the analogy of the trauma square where you imagine your patient standing within a square that represents the limits of their health at any particular time. Whenever that square is large, such as 100’ x 100’, it takes a lot more to knock us out of that square than it does if it were  10” x 10”. Imagine, if you will a burn injury causing that square to get smaller. Then on top of that,  shock and cellular signaling causing that square to get even smaller until the point where the smallest thing can knock that person out of the square. This is most readily observed in ICU patients suffering from failure of multiple systems and multiple trauma etiologies, in which something as simple as about of flu can spell disaster, whereas before the trauma, they might’ve shaken it off in several days.  Whenever a significant enough amount of damage has occurred from a burn, there is set into state, a whole cascade of events at the cellular level which lead to further disruption of an already detrimented homeostasis. The text, Total burn care goes into great detail with regard to burn shock, and the overall pathophysiology of burn edema, explaining the various forces that come into play in the acute burn patient. Most of these modicums can be applied to shock in general (Remember what I said in the first part about the lines of trauma and medical being blurred?). 

_The following is a direct excerpt from Total Burn Care about the overall pathophysiological mechanisms of burn shock and edema. _



> “Cutaneous thermal injury greater than one-third of the total body surface area (TBSA) invariably results in the severe and unique derangements of cardiovascular function called burn shock. Shock is an abnormal physiologic state in which tissue perfusion is insuffi cient to maintain adequate delivery ofoxygen and nutrients and removal of cellular waste products. Before the 19th century, investigators demonstrated that, after a burn, fl uid is lost from the blood and blood becomes thicker; and in 1897, saline infusions for severe burns were fi rst advocated.  However, a more complete understanding of burn pathophysiology was not reached until the work of Frank Underhill. He demonstrated that unresuscitated burn shock correlates with increased hematocrit values in burned patients, which are secondary to fl uid and electrolyte loss after burn injury. Increased hematocrit values occurring shortly after severe burn were interpreted as a plasma volume defi cit. Cope and Moore showed that the hypovolemia of burn injury resulted from fl uid and protein translocation into both burned and non-burned tissues. Over the last 80 years an extensive record of both animal and clinical studies has established the importance of fluid resuscitation for burn shock. Investigations have focused on correcting the rapid and massive fl uid sequestration in the burn wound and the resultant hypovolemia. The peer-reviewed literature contains a large experimental and clinical database on the circulatory and microcirculatory alterations associated with burn shock and edema generation in both the burn wound  and non-burned tissues. During the last 40 years, research hasfocused on identifying and defi ning the release mechanisms and effects of the many inflammatory mediators  produced after burn injury. [What? Did you think that inflammatory mediators were only going to be present in IgE mediated type I hypersensitivities, aka Anaphylaxis? ] It is now recognized that burn shock is a complex process of cardiovascular dysfunction that is not easily or fully repaired by fluid resuscitation. Severe burn injury results in significant hypovolemic shock and substantial tissue trauma, both of which cause the formation and release of many local and systemic mediators.  Burn shock results from the interplay of hypovolemia and multiple mediators of inflammation with effects on both the microcirculation as well as the function of the heart, large vessels, and lungs. Subsequently, burn shock continues as a signifi cant pathophysiologic state, even if hypovolemia is corrected. Increases in pulmonary and systemic vascular resistance (SVR) and myocardial depression occur despite adequate preload and volume support. Such cardiovascular dysfunctions can further exacerbate the whole body inflammatory response into a vicious cycle of accelerating organ dysfunction.  Hemorrhagic  hypovolemia with
> severe mechanical trauma can provoke a similar form of shock.[3] ”



*Mechanisms of Burn Edema: *

Since I have probably already scared most of you with the above information on burn shock, I am going to spare you with regard to burn edema [and spare myself the typing], the landis starling equation, microcirculatory fluid exchange, and capillary filtration coefficients (If you want to read about this in great detail, see Total Burn Care[3]). Instead, I will move on to fluid rescuscitation and early management. 

*Fluid Resuscitation and early management of burns:*

In my initial post on this thread, I said I was going to explain muir, parkland, and the other fluid rescuscitation formulas in this post. However, I have decided to only show Parkland, as I really don’t want to confuse some members any more than necessary and it is the most common formula for fluid rescuscitation in burns that I see used in the field. 
Research conducted in the 1940s, cited hypovolemic or shock-induced renal failure as the leading cause of death after burn injury. Given the advances we have made in burn care, mortality due to volume loss in burns has decreased considerably, resulting in fewer deaths within the first 24-48 hours post-burn. 
According to Total Burn Care, approximately 50% of all deaths in acute burns result in the first 10 days following burn injury from a multitude of various causes, and one of the most significant is INADEQUATE FLUID RESCUSCITATION THERAPY [3]. This is where you come in. 

_Crystalloids vs Colloids & other fluids_

Crystalloid rescuscitation (particularly lactated Ringer’s solution with a sodium concentration of 130 mEq/L) is the most popular rescuscitation fluid being utilized in the field and in the literature, not to mention, the most feasible as it has not been shown to have any better outcomes in acute burns than the other solutions, specifically colloids, which are more expensive.  However, there is a scientific basis for the choice of crystalloids over colloids as the most common reason for not using colloids is that even large proteins leak from the capillary following thermal injury, even though capillaries in nonburned tissues do continue to sieve proteins, maintaining relatively normal protein permeability characteristics [Now do you see the bigger picture of why we use TBSA?] 

*The Parkland Formula: *

While there are many formulas for the estimation of fluid needs in the adult burn patient (Evans, Brooke, Slater, Parkland, modified Parkland, Brooke, Monafo, Warden, and Demling), we are only going to talk about Parkland. Again, if you want the others, Total Burn Care is the way to go.  (TBSA is calculated by the Browd & Lunder, aka Rule of 9’s chart) 

The Parkland formula calls for fluid replacement with Lactated Ringer’s at 4 cc/kg/% TBSA.  Therefore, in a patient weighing 100 lb (45 kg), with 30% full thickness burns, we would get out our calculator, and multiply



> *4 x 45 x 30 = 5400 mL*



*This is the volume of LR the patient needs over the next 24 hours. (5.4 L) HOLD, WE ARE NOT DONE. 

The Parkland formula calls for us to give half of that in the first 8 hours, so we divide 5.4 L by 2, to get a total of 2.7 L that we have to give over the FIRST 8 HOURS.*  Now, obviously, we are not going to be with the patient for 8 hours, but it is critical that we start this process in the field, and keep up with our calculations, although for our purposes, we will just be running it wide open. 

However, don’t just think, Oh I’ll run LR wide open to the hospital with no regard for what amounts were given or doing any calculations. YOU ARE THE EMS 2.0 Provider,  YOU ARE BETER THAN THAT. 

So, having used the Parkland formula to estimate the fluid requirements for this patient over the next 24 hours, I know that the patient needs: 
5.4 Liters  over the next 24 hours, with 2.7 of those liters administered over the first 8 hours. 

_All information below will be specifically focused on the acute full-thickness thermal burn patient with > 20% TBSA as per the Browd & Lunder calculations chart (Rule of 9s). (I might do a write up on electrical burns, myoglobinurea, output considerations, etc at some point, but I have too much on my plate right now.)_

*Emergency Management of the Acute Burn Patient:*

The emergency management of burns (depending on who you ask) can be divided into 3 phases The first phase being the prehospital phase,  the second phase being the in-hospital phase, and the third being rehabilitation (There can be more phases depending on if the patient is sent to an initial care facility first rather than a specialty center, but for our purposes, we will assume you are transporting the patient by whatever means, be it air or surface to a specialty center with a burn unit and trauma surgeons available).


*Phase I:  Pre-hospital Assessment, Interventions, & Transport for severe burns*

•	Remove patient from the source of the injury (i.e. stove, etc)
•	ensure that you don’t get burnt by items on them such as clothing, jewelry especially, and other items. 
•	AIRWAY MANAGEMENT (Just because you have an airway now, doesn’t mean you will in 5 minutes, burn patients are notorious for difficult intubations due to swelling and inhalation from smoke injury, actual burn damage,  edema, etc. )
•	Pain Management (Fentanyl & Versed combination works well , refer to your protocols. As others have said, you don’t have enough narcotics on your unit to even begin to comfort this patient) 
•	Fluid Rescuscitation (See Parkland Above) 
•	Minimize heat loss (This is a BIG CONCERN) 
•	Protect against infection, the skin is your first line of defense against micro-organisms. 

*Phase II:  In-hospital assessment, stabilization, and stepdown *

COMING SHORTLY, I AM TIRED OF TYPING RIGHT NOW. 


*Note: 
This is largely unfinished because I am about to have to move on to another project momentarily. However, I decided to post this anyways for the benefit of those reading. Not to mention, given all the content that there is to absorb, it is probably best that I deliver this in increments. *

*References*

1.	GJ., S., Mechanisms of pain following thermal injury [doctoral dissertation]. San Francisco: University of California, 2005.
2.	Malenfant A, e.a., Tactile, thermal, and pain sensibility in burned patients with and without chronic pain and paresthesia problems. . Pain, 1998. 77(3): p. 241-51.
3.	Herndon, D.N., Total Burn Care. 3rd ed. 2007.


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## Aprz (May 27, 2011)

Thanks for the preview of the article medicRob. Reading it, I am little confused about crystalloid v. colloid. I may be mixing them up, but I thought crystalloids would increase the hydostatic pressure and colloids would increase the colloid osmotic pressure. I didn't completely finish reading Chapter 8 of Total Burn Care (was planning on reading all of that and a linked your shared in chat once that might be useful to this thread which is http://www.medbc.com/annals/review/vol_16/num_1/text/vol16n1p3.asp), but I was under the imperssion that increasing the colloid osmotic pressure of the capillaries was a good thing because it would reduce swelling and diluting the RBC wouldn't be a bad thing since I believe the viscosity of the blood increased (hematocrit increased, higher percent of RBC than plasma, right?), which I speculate would contribute to increased SVR also.

Note: I'm tire too so I hope y'all had a good laugh if I embarrassed myself.  G'night.


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## medicRob (May 27, 2011)

Aprz said:


> Thanks for the preview of the article medicRob. Reading it, I am little confused about crystalloid v. colloid. I may be mixing them up, but I thought crystalloids would increase the hydostatic pressure and colloids would increase the colloid osmotic pressure. I didn't completely finish reading Chapter 8 of Total Burn Care (was planning on reading all of that and a linked your shared in chat once that might be useful to this thread which is http://www.medbc.com/annals/review/vol_16/num_1/text/vol16n1p3.asp), but I was under the imperssion that increasing the colloid osmotic pressure of the capillaries was a good thing because it would reduce swelling and diluting the RBC wouldn't be a bad thing since I believe the viscosity of the blood increased (hematocrit increased, higher percent of RBC than plasma, right?), which I speculate would contribute to increased SVR also.
> 
> Note: I'm tire too so I hope y'all had a good laugh if I embarrassed myself.  G'night.



This is not an article, it is a forum post by me that is just neatly organized.

Colloids are no better than crystalloids when used alone for rescuscitation following thermal injury. The main reason is because even large proteins leak from the capillaries following thermal injury, even though capillaries in non-burned tissues continue to sieve proteins, maintaining normal permeability characteristics.[1] It is not that colloids cannot be used, it is just that they are 

A. More Expensive
B. Not Proven any better or worse than Crystalloids for this particular injury. 


References:

1. Pruitt BA Jr, Mason AD Jr, Moncrief JA. Hemodynamic changes
in the early post burn patients: the infl uence of fl uid administration
and of a vasodilator (hydralazine). J Trauma 1971; 11:36–46.

2. Carvajal HF, Brouhard BH, Linares HA. Effect of antihistamineantiserotonin
and ganglionic blocking agents upon increased capillary
permeability following burn trauma. J Trauma 1975;
15:969–975.


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## Deltachange (May 27, 2011)

So as an EMTB IV in Colorado, it is within my protocols to start fluid resuscitation on patients. However, crystalloids only.(which really doesn't matter as you have pointed out crystalloid vs. colloid shows no difference in patient outcome in  this particular scenario.) However has there been any studies done, or in your experience is there a difference in outcome between NS and LR? Obviously LR is your best choice due to electrolytes and such, but if the company doesn't have LR, (yes some companies in my area are moving away from them, I don't know why.) Would there be a difference in patient outcome from using only NS, as the point is fluid restoration from plasma and serum loss, not to keep the BP up as in blood loss?
   Basically, you are replacing fluid that is lost from the burn, that normally doesn't carry oxygen, as opposed to trying to replace blood with NS?


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## medicRob (May 27, 2011)

Deltachange said:


> So as an EMTB IV in Colorado, it is within my protocols to start fluid resuscitation on patients. However, crystalloids only.(which really doesn't matter as you have pointed out crystalloid vs. colloid shows no difference in patient outcome in  this particular scenario.) However has there been any studies done, or in your experience is there a difference in outcome between NS and LR? Obviously LR is your best choice due to electrolytes and such, but if the company doesn't have LR, (yes some companies in my area are moving away from them, I don't know why.) Would there be a difference in patient outcome from using only NS, as the point is fluid restoration from plasma and serum loss, not to keep the BP up as in blood loss?
> Basically, you are replacing fluid that is lost from the burn, that normally doesn't carry oxygen, as opposed to trying to replace blood with NS?



Not sure, I'll do some research. However, one consideration is that blood and LR are incompatible, so I like to start a line of NS along with the line of LR.


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## Lifes Pleasures (Jun 10, 2012)

*Wow*



Too Old To Work said:


> Dry dressings at the BLS level. Or just wrap in a clean sheet. These patients by definition are going to have infections, so I wouldn't worry about sterile sheets.
> 
> At the ALS level, it's as  EMS49393 says. The last burn patient I had got 250mcg of Fentanyl during the ten minute ride to the ED and it just barely got the pain under control.



Would you really increase the chance of infection just because they have a high chance of infection? You should not wrap them in a sheet, especially after since most EMS personell get there sheets from out of the ER. I've personally watch sheets fall on the floor and get picked up by ER staff. For that matter I've seen a nurse drop a glove on the floor, pick it up and then proceed to swap the patients mouth for strep. So lets play it safe sterile is in the best interest of the patient.


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## Shishkabob (Jun 10, 2012)

Lifes Pleasures said:


> Would you really increase the chance of infection just because they have a high chance of infection? You should not wrap them in a sheet, especially after since most EMS personell get there sheets from out of the ER. I've personally watch sheets fall on the floor and get picked up by ER staff. For that matter I've seen a nurse drop a glove on the floor, pick it up and then proceed to swap the patients mouth for strep. So lets play it safe sterile is in the best interest of the patient.



Parkland.  You may have heard of them.  They know a thing or two about burns and burn care.  Once had a physician from there come talk during a PEPP class.  They say sterile vs clean is of no matter, they're most likely going to be bombarded by anti-biotics for the forseeable future anyhow.

Infact, ABLS (Advanced Burn Life Support) says clean is fine as well, as long as the wound gets covered.   

Sterile is nice, but not necessary.  And I don't know about your ambulances, but mine don't carry a crap load of sterile dressings.


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## usalsfyre (Jun 10, 2012)

Lifes Pleasures said:


> Would you really increase the chance of infection just because they have a high chance of infection? You should not wrap them in a sheet, especially after since most EMS personell get there sheets from out of the ER. I've personally watch sheets fall on the floor and get picked up by ER staff. For that matter I've seen a nurse drop a glove on the floor, pick it up and then proceed to swap the patients mouth for strep. So lets play it safe sterile is in the best interest of the patient.



Another fact. The hospital your gonna take them to? It's full of sick people....

These patients are infected. The last major burn I had was rolling around in the grass of a highway median on arrival. The time to worry about sterile is post-debriedment.


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## Veneficus (Jun 10, 2012)

Lifes Pleasures said:


> Would you really increase the chance of infection just because they have a high chance of infection? You should not wrap them in a sheet, especially after since most EMS personell get there sheets from out of the ER. I've personally watch sheets fall on the floor and get picked up by ER staff. For that matter I've seen a nurse drop a glove on the floor, pick it up and then proceed to swap the patients mouth for strep. So lets play it safe sterile is in the best interest of the patient.



Sterile in the prehospital environment? 
:rofl:

Maybe before the package is open.

I would also like to point out that the most common cause of surgical infection is the patient's own body flora. 

One of the 4 most common infective agents found in burns, 3 are normal flora in the human population and the 4th is normal in 20% of the human population.

You really think because you got a temporary dressing out of a package or a sheet off the floor that will make a difference in a patient who will get a burn scrubbed at the hospital?


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## mycrofft (Jun 10, 2012)

THis is a blaring example of how the field of burn care needs to get together and reorganize the prehospital treatment and teaching paradigm vertically (that is, so that every step from first aid to ALS transport works within the same scientific framework towards the same goal), and it needs to be pragmatic. 
This will, however, require students who can think more, especially as they get past the first responder stage ("better than nothing").

For example, since infection is a given, would not an IV antibiotic blast in the field help to stem the crisis for a while, before the bugs they are getting exposed to are the iatrogenic (resistant) types.


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## exodus (Jun 10, 2012)

Random question. If your protocol allows for sedation and RSI of patients. Would it be appropriate to do that to a severely burned patient simply because if they're asleep, they wont feel pain?


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## Aidey (Jun 10, 2012)

exodus said:


> Random question. If your protocol allows for sedation and RSI of patients. Would it be appropriate to do that to a severely burned patient simply because if they're asleep, they wont feel pain?



Yes, but only if you can include a massive dose of analgesics in the course of the RSI.


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## almostmedic (Jun 10, 2012)

Also nebulized albuterol for suspected respiratory burns/ smoke inhalation.


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## TheGodfather (Jun 10, 2012)

Aidey said:


> Yes, but only if you can include a massive dose of analgesics in the course of the RSI.



Very good point! Ketamine would usually be a great option in this situation.


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## exodus (Jun 10, 2012)

Aidey said:


> Yes, but only if you can include a massive dose of analgesics in the course of the RSI.



I would assume since you're taking control of their respiratory drive you could load them up with as much analgesia as you want.


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## TheGodfather (Jun 11, 2012)

exodus said:


> I would assume since you're taking control of their respiratory drive you could load them up with as much analgesia as you want.



you should still maintain a level of accuracy when dosing for analgesia.. besides respiratory depression, there is a handful of other complications from opioid toxicity secondary to CNS depression (seizures, cardiac arrhythmias, etc)..


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## Shishkabob (Jun 11, 2012)

exodus said:


> Random question. If your protocol allows for sedation and RSI of patients. Would it be appropriate to do that to a severely burned patient simply because if they're asleep, they wont feel pain?



Even unconscious patients still feel pain and react to it, with their body doing catecholamine dumps.  This is why burn patients are on constant narcotic infusions (in HUGE amounts) and even the 'average' intubated patient is on some type of analgesic for the irritation caused by the tube itself.


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## exodus (Jun 11, 2012)

Linuss said:


> Even unconscious patients still feel pain and react to it, with their body doing catecholamine dumps.  This is why burn patients are on constant narcotic infusions (in HUGE amounts) and even the 'average' intubated patient is on some type of analgesic for the irritation caused by the tube itself.



That makes sense, but do they remember the pain though?


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## abckidsmom (Jun 11, 2012)

exodus said:


> That makes sense, but do they remember the pain though?



No, but the stress is high enough from the energy, we should do what we can to calm the body's response to it. 

I had some debriding once of some majorly nasty road rash. They gave me versed, and though the nurse was scrubbin my wounds with a scrub brush and I was screaming and swinging, I remember scratching, and feeling afraid. That's all. I was 15.


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## exodus (Jun 11, 2012)

I just want to clarify, I'm not saying don't give them a ton of analgesics, but if you have the option, knock them out as well. It will make it easier on them IMO. It will happen a lot faster for them too.


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## Doczilla (Jun 11, 2012)

Aww, man. Someone beat me to the ketamine .


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## Melclin (Jun 11, 2012)

What an interesting thread. I'm glad we carry buckets of analgesia. I feared the major BSA burns pt before moving to where I currently work. Now I carry 80mg morphine, 400mcg IV fent, 1200mcg IN fent, 6mls of volatile anaesthetic/analgesic. Special-K shouldn't be far away. Should be able cover most things pretty well with that. 

I would have said that you'd have to cool the burn a little. 

I still think some cooling should be attempted and I think that would still be the practice here. The amount of cooling you did would be dependant on the individual pt, extent of the burn, ease of simultaneously warming and cooling etc. 

Surely you can crank the heat in the truck, hang a bag or two of the warm stuff, wrap them up and still do a few mins of cooling in the process, then dress them, taking regular temps like with a trauma pt to make sure you avoid the badness.  

Burns have never really been an area of interest for me so I'm embarrassed to admit I'm shockingly ignorant of much of the burns literature. 

What do you, the experts, think of this idea? I'd be perfectly happy to hear its rubbish if it is. Also, titrating analgesia in a major burns pt must be difficult initially. What kinds of initial doses and titration strategies should we be looking at? I'd be thinking 200mcg IN fent + methoxyflurane during the canulation process, the first 10mg amp of morph given neat as soon as I get a line. After that though I'm not sure what the best way to go about it would be. Any thoughts?



abckidsmom said:


> No, but the stress is high enough from the energy, we should do what we can to calm the body's response to it.
> 
> I had some debriding once of some majorly nasty road rash. They gave me versed, and though the nurse was scrubbin my wounds with a scrub brush and I was screaming and swinging, I remember scratching, and feeling afraid. That's all. I was 15.



I remember doing roughly the same thing when some nurses tried to put me on a CPAP mask. I remember the distinct sensation of feeling like I was drowning, throwing punches indiscriminantly..then ....nothing. Presumably I was sedated.


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## TheGodfather (Jun 11, 2012)

Doczilla said:


> Aww, man. Someone beat me to the ketamine .


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## Veneficus (Jun 11, 2012)

*analgesia vs anesthesia*

When you are talking about about massive opioid doses, with or without paralytic, and patients sleeping and not remembering, you have crossed the line from analgesia to anesthesia. 

The abbreviated goals of anesthesia are:

Pt. doesn't feel
Pt. doesn't react
Pt. doesn't remember

In the prehospital setting, RSI will likely be the best option to reduce pain and awareness.

I am not sure paramedics are ready or even willing to start managing anesthetized patients.

With the treatments available prehospital, as well as lack of resources to safely deal with anesthesia and resuscitation, and within predefined protocol parameters, I do not think a "winging it" approach is the best answer. 

You are talking about a burn patient, who is or will be hypovolemic, that is losing blood components, administering more medication that will decrease cardiovascular capability, and managing ventilation and respiratory function together, in a truck, without optimal treatment options. 

While it may be easy to armchair QB this with "I would not want to feel, be awake, etc" Do you want to wake up with anasthesia induced brain damage? renal failure? The list goes on.

While there may be a few medics who can do such care with some acceptable level of risk, I am sure nobody is going to sign off on it for them. 

This is not ready for prime time.


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## mycrofft (Jun 11, 2012)

Wouldn't such anesthesia also be tricky because you are hopefully trying to titrate meds to pt effect/affect? A little too much anesthetic, give him a little Narcan...oops, coming out own it now, push a little more meds...get into a positive feedback cycle like trying to titrate NPH insulin to finely onctrol diabetic sugars inn a five minute basis.h34r:

Wouldn't cooling locally, if possible, be of help in forestalling or preventing one localized third-spacing, or will the insulted vascular bed  just leak it anyway?


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## jjesusfreak01 (Jun 17, 2012)

The correct answer is that you should dress burns according to local protocols which hopefully coordinates with your local burn center's guidelines. The goal is that your patient's burns are dressed as the burn center would want them, so that they don't have to focus on immediately fixing your work when the patient gets to the hospital.


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## Veneficus (Jun 17, 2012)

jjesusfreak01 said:


> The correct answer is that you should dress burns according to local protocols which hopefully coordinates with your local burn center's guidelines. The goal is that your patient's burns are dressed as the burn center would want them, so that they don't have to focus on immediately fixing your work when the patient gets to the hospital.



The dressing is going to come off at the hospital anyway.

I think that hypovolemia and pain management is more of a concern than the temporary covering used.


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## ah2388 (Jun 17, 2012)

Vene,
I think you make a good point on p4.  Keeping in mind limited resources, and also that some (or all) of the available resources have no business managing a critically ill pt requiring a multi pronged approach to effective management.

I think we need to be careful here.

Hopefully one day, through the "empowering" of prehospital providers in the US, we may come closer to safely crossing the line.

As others have said, analgesia and volume support "ftw"


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## RocketMedic (Jun 17, 2012)

mycrofft said:


> Wouldn't such anesthesia also be tricky because you are hopefully trying to titrate meds to pt effect/affect? A little too much anesthetic, give him a little Narcan...oops, coming out own it now, push a little more meds...get into a positive feedback cycle like trying to titrate NPH insulin to finely onctrol diabetic sugars inn a five minute basis.h34r:
> 
> Wouldn't cooling locally, if possible, be of help in forestalling or preventing one localized third-spacing, or will the insulted vascular bed  just leak it anyway?



I'd reckon it would leak in a massive burn, but it would probably provide some very temporary pain relief in 1st and 2* burns.


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## lightsandsirens5 (Jun 18, 2012)

Something I might be unclear on.....

Once the burn pt ends up in shock (or any pt for that matter) haven't opiods been shown to have extremely increased effects? Like a small 25 mcg bolus of fent totally snowing them? I remember my instructors talking something about that, but now I can't remember. I would think that in a patient with severe burns should be monitored incredibly closly for shock, one reason being not wanting to schnocker them with meds inadvertently?

Or am I totally off.....


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## the_negro_puppy (Jun 18, 2012)

We dress our burns with Sarin / cling wrap


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## Handsome Robb (Jun 18, 2012)

lightsandsirens5 said:


> Something I might be unclear on.....
> 
> Once the burn pt ends up in shock (or any pt for that matter) haven't opiods been shown to have extremely increased effects? Like a small 25 mcg bolus of fent totally snowing them? I remember my instructors talking something about that, but now I can't remember. I would think that in a patient with severe burns should be monitored incredibly closly for shock, one reason being not wanting to schnocker them with meds inadvertently?
> 
> Or am I totally off.....



Everything I have been taught about burns is that we don't carry enough narcotics on the truck to make these people comfortable. 

They are in exorbitant amounts of pain with a sympathetic response to match. As long as you have adequate/appropriate fluid resuscitation started I see no reason to withhold meds for fear of snowing them. Personally, if I can snow them I absolutely will after getting what I need as far as assessment out of them. 

Fentanyl is pretty hemodynamically stable when compared to morphine and it's quick onset is definitely something I'd prefer at the point that I am caring for that person. Unfortunately I can't stack fent/MS I have to pick one then call for orders to use the other or go past my max of 300 mcg on the fentanyl, so I'll lean towards the faster acting one and let the hospital get the longer term heavier duty stuff on board. I also generally have <10-15 minute transports routine and <10 code 3 and can bypass our hospitals with a flight crew if the patient meets burn center criteria as well as geographical criteria to request a scene flight from our HEMS service. The flight crews can stack fent and MS so that solves that problem.

As far as dressing burns we have burn sheets on all our units as well as the foil emergency blankets and follow the 10% guidelines.

The other thing I will say is I've never seen anything more than a minor burn victim. The rest of it is all from class and being grilled on protocols, scenarios and studies by my preceptor.


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## ah2388 (Jun 18, 2012)

lightsandsirens5 said:


> Something I might be unclear on.....
> 
> Once the burn pt ends up in shock (or any pt for that matter) haven't opiods been shown to have extremely increased effects? Like a small 25 mcg bolus of fent totally snowing them? I remember my instructors talking something about that, but now I can't remember. I would think that in a patient with severe burns should be monitored incredibly closly for shock, one reason being not wanting to schnocker them with meds inadvertently?
> 
> Or am I totally off.....



I think generally, we can say that the pt with clinically significant burns will:
a. require volume replacement of some kind
b. require analgesia to help control pain

I'm not sure I've ever heard of shock making pt's "more sensitive" to analgesia.  

I would absolutely suggest liberal pain management, keeping in mind that volume support will likely be necessary(outside of the opiates the pt is receiving.)

Pain + Fear=release of endogenous catecholamines (gets a bit foggy from here, someone elaborate, its bad)  In someone who is "pretty sick", you may see a drop in blood pressure, even with Fentanyl, which is why its a good idea to be providing volume support as well!

-Adam


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## Akulahawk (Jun 18, 2012)

From my understanding of field burn treatment, basically just keep the burned area clean. Dress it so that no extra crud can get to the burned area as that just brings another potential source of infection... that will inevitably set in... but why make it any more difficult that need be?  Also, I figure that the insulted capillary bed will leak regardless of cooling applied to the burned area, though some cooling will help with initial pain control, but with large burned areas, hypothermia will be a huge problem. 

Pain control will be the biggest thing. One of the last burn patients I transported had been given around 350 mcg of Fentanyl - and that _just_ began to make the patient comfortable and it hadn't affected his respiratory rate one iota. He probably could have been given quite a bit more without too much of an issue. Personally, I don't think we carry enough pain relief meds for burn patients. Nowhere enough... but carrying that much would also make ambulances a bigger target for those that seek such drugs because there'd be a LOT onboard.


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## DPM (Jun 18, 2012)

With regards to the pain management, one of my instructors (former Life Flight nurse) has a good way of putting it. "People in lots of pain will tolerate lots of pain meds".

And I agree with the comments on snowing. Once you've got your assessment out the way, does it really matter if they're snowed? The poor b*stards will probably be thankful for it.


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## Veneficus (Jun 18, 2012)

*just interesting trivia on snowing people*



DPM said:


> With regards to the pain management, one of my instructors (former Life Flight nurse) has a good way of putting it. "People in lots of pain will tolerate lots of pain meds".
> 
> And I agree with the comments on snowing. Once you've got your assessment out the way, does it really matter if they're snowed? The poor b*stards will probably be thankful for it.



http://en.wikipedia.org/wiki/John_Snow_(physician)


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## Hunter (Jun 18, 2012)

DPM said:


> With regards to the pain management, one of my instructors (former Life Flight nurse) has a good way of putting it. "People in lots of pain will tolerate lots of pain meds".
> 
> And I agree with the comments on snowing. Once you've got your assessment out the way, does it really matter if they're snowed? The poor b*stards will probably be thankful for it.



Pardon my ignorance, what's "snowing"?


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## DPM (Jun 18, 2012)

Hunter said:


> Pardon my ignorance, what's "snowing"?



Sorry mate, that's slang for when your PT get's KO'd by their meds. I think it's short for 'snowed under'.


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## johnrsemt (Jun 19, 2012)

Why wait til you get your assessment out of the way to starting "snowing" the patient with pain meds?   What do you need a critical burn patient to be awake for?
   Only thing I would do first is check allergies:  then give them 100mcg of Fentanyl.   you can find out what happened from people around patient;  or look at the patient:  he is Burned.
   One dose of Fentanyl or Morphine is NOT going to take a patient out that is in severe pain from burns/trauma;  you can still get their medical history and meds, what happened etc.

    Patient like that my goal is 1st dose of pain meds within 3 minutes of arriving at the patient;  check quick BP and find out what they are allergic to.  give them IN pain relief.


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## Handsome Robb (Jun 19, 2012)

johnrsemt said:


> Why wait til you get your assessment out of the way to starting "snowing" the patient with pain meds?   What do you need a critical burn patient to be awake for?
> Only thing I would do first is check allergies:  then give them 100mcg of Fentanyl.   you can find out what happened from people around patient;  or look at the patient:  he is Burned.
> One dose of Fentanyl or Morphine is NOT going to take a patient out that is in severe pain from burns/trauma;  you can still get their medical history and meds, what happened etc.
> 
> Patient like that my goal is 1st dose of pain meds within 3 minutes of arriving at the patient;  check quick BP and find out what they are allergic to.  give them IN pain relief.



I never said I'd withhold rapid pain management. But I'm going to get a lot more aggressive and start using versed concurrently to try and get some sedation as well once I have everything I need. The hospital is going to need to know demographics and allergies at minimum so they can find out more about the patient and possible comorbidities they are going to be dealing with during the resuscitation and healing process and if I snow the guy before I get any of that info out of him it's going to make things a bit more difficult, no?

I personally have no faith in IN fentanyl in adults. I'll take the extra 30 seconds it takes to get a line started plus I want the lines before he starts third-spacing fluid and finding vascular access becomes much more difficult if not impossible in the field. While pain management is important these patients are going to die without adequate fluid resuscitation among other things that require IV access.


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## Veneficus (Jun 19, 2012)

NVRob said:


> I personally have no faith in IN fentanyl in adults. I'll take the extra 30 seconds it takes to get a line started plus I want the lines before he starts third-spacing fluid and finding vascular access becomes much more difficult if not impossible in the field. While pain management is important these patients are going to die without adequate fluid resuscitation among other things that require IV access.



I agree with your thinking on this, but would just like to ask, have you ever tried to get vascular access on a patient with a large body surface burn? (like 90% or greater?) 

The little that the IN fent helps may be the best you can do for some minutes. 

Unless you wind up with an experience like mine where you actually deglove the skin and put the line directly into the exposed vein. (no it was not optimal, it was unexpected and there was no other option anyway)


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## Handsome Robb (Jun 19, 2012)

Veneficus said:


> I agree with your thinking on this, but would just like to ask, have you ever tried to get vascular access on a patient with a large body surface burn? (like 90% or greater?)
> 
> The little that the IN fent helps may be the best you can do for some minutes.
> 
> Unless you wind up with an experience like mine where you actually deglove the skin and put the line directly into the exposed vein. (no it was not optimal, it was unexpected and there was no other option anyway)



I've never dealt with a burn patient with anything more than minor burns. I'm not claiming to be an expert but burns have always interested me. All of this comes from class, self study and scenarios.


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## NYMedic828 (Jun 19, 2012)

Veneficus said:


> Unless you wind up with an experience like mine where you actually deglove the skin and put the line directly into the exposed vein. (no it was not optimal, it was unexpected and there was no other option anyway)



Optimal or not, that is still pretty cool. Kind of like a venous cutdown that the injury did for you.


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