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PreHospital Burn Management Part 2: Burn Care

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Consider Etomidate and/or Succs for initial induction, with valium/Versed and MS as adjuncts. ... as Valium, Ativan, or versed. Opioids such as Morphine , ... – PowerPoint PPT presentation

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Title: PreHospital Burn Management Part 2: Burn Care


1
Pre-Hospital Burn Management Part 2 Burn Care
  • Robert S. Cole
  • Paramedic, CCEMTP

2
Are You Ready???
3

4
Objectives
  • Obtain a basic understanding of infection
    mediation, Airway management and destination
    priorities in the burn pt.
  • Gain a basic understanding of escharotomy, Fluid
    resuscitation, Pain Management and other aspects
    of advanced burn care

5
Basic Burn Care
6
Basic Burn Care Save yourself before you save
others
  • Dont be a blue canary
  • There are many many potential hazards besides the
    fire,
  • Toxic gasses (Especially in industrial sites and
    Meth Labs)
  • Gas mains
  • Secondary explosives
  • Electricity
  • Chemical Exposure

7
Basic Burn Care Save yourself before you save
others
  • BEWARE OF CONFINED SPACES
  • 60 of fatalities in rescue situations are would
    be rescuers!
  • Dont be a statistic

8
Basic Burn Care Stop The Burning Process
  • Remove the pt (And You) from the proximity of the
    Burn and other hazards
  • If Trauma is associated, Follow BTLS rapid
    extrication Guidelines
  • If Chemical, let the experts handle it. Attempt
    dry decon if possible before flushing.
  • If Electrical, Let the experts remove him

9
Basic Burn CareThe First 10 minutes
  • BSI Infection Mediation from the Start!
  • C-Spine Secure if indicated.
  • LOC Obtunded or lethargic- Think CO, Toxic
    Gasses, Drugs, or Head Trauma
  • A Stridor? Intubate! Sooty airways, Be prepared,
    Give O2
  • B Severe refractory distress, Intubate. Hacking
    cough, Hoarse Voice, Soot flecked sputum,
    Strongly consider intubation, Give O2

10
Basic Burn Care The First 10 minutes
  • C Pulse should be elevated, pt should be
    normotensive or Hypertensive. If pulse is weak
    thready or absent at radius, look for other cause
    of shock. Also look for circumferential burns w/
    swelling
  • Dysfunction Mini Neuro
  • E Expose and examine, Look for other Injuries,
    Leave Stuck clothing in place, remove Jewelry,
    Clothing may be considered evidence.

11
Basic Burn Care The First 10 minutes
  • F Fluid Therapy- Get your line started, If burns
    are moderate or major, do in transit.
  • If you are not already enroute, Ask yourself why?
  • Stay and Play or Load and Go?
  • Sometimes Tincture of transport is the best
    medicine, especially if you can get Tx done
    enroute.

12
Basic Burn Care The second 10 minutes and beyond
  • Delegate early notification to the hospital
  • Reassess the Complete primary survey, do a head
    to toe evaluation and assessment.
  • Estimate BSA, severity.
  • If Intubated, Recheck Tube, consider NG, ETCO2,
    Etc. Include other ALS assessments.
  • Pain Relief Opiates, Benzos MANDATORY for
    moderate/major burns.
  • Less than 10 BSA, may flush with sterile
    saline/H2O

13
Basic Burn Care The second 10 minutes and beyond
  • Prevent Hypothermia.
  • Other Specific injury/burn location related care.
  • Reassess Frequently, assume nothing
  • Fluid Resuscitation Begin calculations (covered
    later)
  • Give full report to receiving hospital
  • Consider NG, Foley, etc as soon as feasible

14
Basic Burn Care Dressing the area
  • A Major cause of death after the first 48 hours
    is Infection. In everything you do, consider
    burns to be large open highways for infection to
    travel.
  • Use aseptic/sterile tech.

15
Basic Burn Care Dressing the area
  • lt 10 BSA , cool saline/Sterile H20 is OK , on
    moist dressings, followed by dry outer layers
    (Moisture is a route of infection)
  • gt 10 BSA, Dry Dressings,
  • consider silvadine ointment or topical anesthetic
    for mild burns.
  • Remember, dont promote infection.

16
Basic Burn Care Dressing the area
  • Facial Burns (protect the airway), raise head 30
    Degrees to minimize swelling.
  • Burns to eyes consider continuous saline flush,
    consider Tetricaine ointment after consult, do
    not use steroid containing solutions.
  • Hands remove all jewelry, cut free if required,
    no exceptions. Dry dressings if required, elevate
    above heart, active ROM q hour for 5 minutes if
    possible. If wrapped, wrap in position of
    function.

17
Basic Burn Care Dressing the area
  • Feet Same as Hands, keep elevated.
  • Genital Prompt insertion of a Foley is
    essential.
  • Tar Burns Focused at cooling down the Tar ASAP,
    it is otherwise non toxic.

18
Basic Burn Care Psychological Considerations
  • Fear of disfigurement, amputation, death are
    common.
  • Be hopeful but honest
  • Most burn patients will be alert, keep them
    informed. This will lessen anxiety, O2 demand,
    and cardiac stress
  • If no apparent clear mechanism of burn is known,
    consider the possibility of a suicide attempt and
    safeguard appropriately.
  • Consider sedation if severely anxious or anxiety
    is having an adverse effect on patient status

19
Advanced Burn Care
20
Advanced Burn Care
  • For the purposes of this lecture Advanced Burn
    care is considered measures or procedures
    normally in the scope of practice of Medics,
    EMT-Is, or advanced practice nurses.
  • Follow local guidelines, some of the procedures
    may be out of your scope of practice or may
    require medical control authorization
  • All Practitioners should have passing familiarity
    with these procedures.

21
Airway Management
  • Pre-Hospital Personnel should have a Low
    Intubation Threshold when presented with
    possible inhalation/airway issues.
  • Nasal ETT or RSI and Oral ETT is indicated.
    Adequate sedation AND analgesia is indicated in
    addition to any paralytics needed.

22
Airway Management
  • Consider Etomidate and/or Succs for initial
    induction, with valium/Versed and MS as adjuncts.
  • Etomidate 0.3 mg/kg IVP (common dose 20-30 mg)
  • Succinylcholine 1 mg/kg, contraindicated after
    first 36 hours

23
Airway Management
  • Tubes may be Coughed out of place, secure well,
    consider a long acting paralytic like vecuronium
    (0.1 mg/kg every 20-45 minutes) during transport.
  • Alternative airways and skills are a must!
  • Retrograde
  • Surgical
  • Blind airways are not likely to be much use in
    inhalation injuries.

24
Respiratory Support
  • High flow humidified O2
  • If intubated, a Transport grade ventilator is
    better than bagging (Only applies to transport
    grade)
  • ETCO2 w/ wave form is a valuable tool for
    assessing sedation, gas exchange, use of PEEP,
    effectiveness of ventilation, etc.

25
Emergent Escharotomy
  • Are you ready for this?
  • Often Taboo but potentially Lifesaving.

26
Emergent Escharotomy
  • Circumferential burns to the chest and neck of
    full thickness or deep partial thickness results
    in swelling.
  • This in turn results in respiratory compromise.
  • While rare, rapid eval and TX can be lifesaving.
  • Rare in the first 3-6 hours.

27
Emergent Escharotomy
  • While Escharotomies are also done to extremities,
    these are not commonly done in the field.
  • While this procedure is uncommon, there are
    paramedic level (non critical care) services who
    do this in the field. Ex King County Medic 1.
  • This should be mandatory training for rural
    services, Tactical and back country teams.
  • Sterility/aseptic tech. Should be maintained.

28
Emergent Escharotomy
  • Examples of potential locations for incisions
  • Before You get to this, r/o airway obstruction
    and D.O.P.E.
  • Most of these patients should be Intubated
    already, If not , you may have your priorities
    out of whack.

29
Vascular Access
  • Ideally IV access should be 2 large bore IVs (16
    or larger)
  • Idealy through non burned tissue
  • This is not always an option
  • Central lines, if appropriately trained , are an
    alternative if unable to get peripheral access.
  • IOs in the burned child are also an alternative
  • Sternal IOs in the adult may have value as well.

30
Sternal IOs

31
Fluid Resuscitation
  • Fluid resuscitation is vital to improved outcomes
  • Increased Vascular permeability (3rd spacing)
    results in 10-15 reduction of Cardiac Output for
    first 12 hours post burns (this is in proportion
    to severity of burn)
  • This combined with cellular destruction means
    fluid administration is vital to prevent organ
    death.

32
Fluid Resuscitation
  • The goal of (Fluid) resuscitation is to maintain
    vital organ function while avoiding the
    complications of inadequate or excessive (Fluid)
    therapy.- ABLS Text P. 21
  • To do this accurate assessment of BSA is
    essential
  • Also significantly large bore IVs (14 or 16)

33
Fluid Resuscitation
  • 2 types of fluids Crystalloids and Colloids
  • Crystalloids ( Saline and Ringers Lactate)
  • Colloids (Albumin, Plasmanate, Dextran) Colloid
    pulling pressure makes little difference in first
    24 hours, therefore crystalloids are initial
    fluid of choice.
  • Outside the military, Crystalloids are all that
    is available to most pre-hospital agencies.

34
Fluid Resuscitation
  • Formulas for administration
  • Many out there, the ABA Consensus is
  • Adults 2-4 ml x Kg x BSA a
  • Children 3-4 ml x Kg x BSA a
  • ½ of a is given over first 8 hours, remainder
    given over following 16 hours.
  • Use a Volutrol in children.

35
Fluid Resuscitation
  • If done promptly, this formula will allow only a
    minimal drop in circulating volume in the first
    24 hours post burn and will allow return of
    normal circulating volume by the time the patient
    enters his second 24 hours. At this time a burn
    center should be consulted.
  • If s/s of Cardiogenic shock develop-r/o MI
  • If pt is Hypotensive, look for other causes.
  • After the first day, colloids are used to keep
    vascular volume intact w/o fluid overload.

36
Fluid Resuscitation
  • The most reliable indicator of adequate fluid
    resuscitation remains urine output
  • Adult 30-50 ml/hour
  • Children 1 ml/kg an hour
  • (increase or decrease rate by 1/3 if urine output
    is exceeds or does not meet above standards for 3
    consecutive hours)

37
Fluid Resuscitation
  • Other v/s are not as reliable in gauging fluid
    therapy.
  • B/P will maintain normal until the Pre-Code
    downward cycle (CTD)
  • HR should be expected to be elevated 100-120 (as
    high as 140 in peds) for other reasons.
    Therefore it is not a good indicator.

38
Drugs in brief
  • Aggressive well thought out use of multiple
    pharmacological therapies is mandatory
  • Sedatives such as Valium, Ativan, or versed.
  • Opioids such as Morphine , Fentanyl
  • Steroids Not recommended for respiratory nor
    optic injuries.
  • Tetanus and Antibiotics.
  • IV route is preferred for appropriate drugs.

39
Questions?
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