Burn victim treatment from an ALS/BLS standpoint

[Lifes Pleasures]

Wow

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.

 

[Shishkabob]

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.

 

[usalsfyre]

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.

 

[Veneficus]

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?

 

[mycrofft]

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.

 

[exodus]

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?

 

[Aidey]

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.

 

[almostmedic]

Also nebulized albuterol for suspected respiratory burns/ smoke inhalation.

 

[TheGodfather]

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.

 

[exodus]

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.

 

[TheGodfather]

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)..

 

[Shishkabob]

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.

 

[exodus]

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?

 

[abckidsmom]

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.

 

[exodus]

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.

 

[Doczilla]

Aww, man. Someone beat me to the ketamine .

 

[Melclin]

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?

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.

 

[TheGodfather]

Aww, man. Someone beat me to the ketamine .

 

[Veneficus]

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.

 

[mycrofft]

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?