Burn victim treatment from an ALS/BLS standpoint

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.
 
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.
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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.
 
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":-)
 
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.:ph34r:

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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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.
 
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.....
 
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.....
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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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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.....
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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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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.
 
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.
 
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.
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http://en.wikipedia.org/wiki/John_Snow_(physician)
 
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.
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Pardon my ignorance, what's "snowing"?
 
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.
 
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.
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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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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.
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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)
 
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)
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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.
 
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)
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Optimal or not, that is still pretty cool. Kind of like a venous cutdown that the injury did for you.
 
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