Fluid resuscitation in electrical burn

[medicv83]

Well, you know, it is only an opinion. I dont mean to come across as belittling the nursing profession. My wife is a pediatric nurse, and a Captain in the Army. I fully support nursing and the job that they do. I will say that whether it be ER, ICU, or general floor nursing, that they are not in any means obligated to make life saving decisions for their patients. Now surely this is not an argument that needs to be had or should be had in any event, but..........For the sake of the conversation, the paramedic responsible for making decisions in the truck, granted they may be by ingrained protocols, is still responsible for his/her decisions. The nurse administering medications, or eliciting a history is truly only doing so for the doctors benifit. As we are, but on a different level. Im not necessarily saying that nurses shouldnt teach per se, but the order of echelon shouldnt be what it is. It should be (in general) Doctor, Medic, Nurse, considering that the nurse is simply taking the orders of the physician at hand, and not responsible to choose the order of care that is given to the patient.

[Just Plain Ruff]

Well, you know, it is only an opinion. I dont mean to come across as belittling the nursing profession. My wife is a pediatric nurse, and a Captain in the Army. I fully support nursing and the job that they do. I will say that whether it be ER, ICU, or general floor nursing, that they are not in any means obligated to make life saving decisions for their patients. Now surely this is not an argument that needs to be had or should be had in any event, but..........For the sake of the conversation, the paramedic responsible for making decisions in the truck, granted they may be by ingrained protocols, is still responsible for his/her decisions. The nurse administering medications, or eliciting a history is truly only doing so for the doctors benifit. As we are, but on a different level. Im not necessarily saying that nurses shouldnt teach per se, but the order of echelon shouldnt be what it is. It should be (in general) Doctor, Medic, Nurse, considering that the nurse is simply taking the orders of the physician at hand, and not responsible to choose the order of care that is given to the patient.

you are kidding right? You believe what you type?

you are saying that the nurse is only giving medications and following orders for the doctors sake.

Just what the heck do you think we out in the field are doing? We are following protocols, written and approved by physicians. That we have a choice in what order we do to treat the patient? We do to some degree but in the end the protocols we have are there for a reason.

And your statement that the nurses are getting a history and information is only for the doctors benefit, the same holds true for EMS. Who eventually takes care of the patient? the physician and they rely on our documentation to treat the patient but your line of reason would be that since we aren't doing it for the benefit of the doctor then why should we even care about why we do it?

I'm sorry but that last post of yours is absurd and you might want to review why we are there for the patient, it's certainly not for our egos, it's so the continuum of care can be met. We are the first set of eyes an ears for the physician and the nurses in the ER and if we don't do it for them then who the heck are we doing it for?

I'll let others chime in on this and see if my thoughts hold true. I'll bet they do.

[AZCEP]

Effective thread hijacking Ruff, way to go.

A patient with an electrical burn needs significant amounts of fluid to effectively manage the problem. As Ruff mentioned with his first response, the entire body is being effected and you don't have any way to gauge the severity of the burned tissue. Aggressively manage the airway, initiate cardiac monitoring and replace fluids. One liter of saline, and one liter of LR in unison wide open and repeat until patient care is turned over.

The issue with NRP is not that you are specifically a paramedic, but more that you don't work exclusively in a neonate heavy environment enough to have good clinical experience with them. The sanctioning board is very tight with this requirement, and it is reasonable for them to be.

[triemal04]

Nice. Take what could have been an interesting topic and throw it way the hell of track. Before it get's that far, I'm curious why you say that most services that carry LR don't carry enough to provide fluid rescucitation. Taking burns in particular, unless an extremely small amount is carried (think less than 250ml) a couple of liters should be good. While the Parkland formula is 4 x %BSA burned x wt in kg, that is the total amount to be given in 24 hours. Half of that should be given in the first 8 hours. So, take the worst case scenario: 100% burns to a 100kg pt. 4x100x100=40000. 40000/2=20000cc over 8 hours, 20000/8=2500cc/hr for the first 8 hours. 2.5 liters per hour...that's not a whole lot, unless you are dealing with a very long transport (which may be the case). Now, that doesn't mean that the pt might not require a whole lot more fluids to begin with, but, when using the Parkland formula, the amount of fluid that's given actually ends up being really small. And as far as fluid rescucitation goes...just remember that dumping more than 2-3 liters of fluids into someone who's bled out won't fix or help the problem.

As a side note, an easier way to remember the Parkland formula is (%BSA burned x wt in kg)/4=ml/hr for the first 8 hours. Much simpler. Either way, if the pt needs fluids, don't withhold them just because a formula says they don't need it.

With that out of the way...hush up on nurses sally. If you haven't figured it out by now, a nurse and a paramedic are not interchangeable, and while both are in the medical field, that's about as far as it goes. All your comments are doing is showing your own ignorance of BOTH professions. Just stop now while you're still ahead.

[Just Plain Ruff]

sorry for putting this off track, I don't think I did that though. The discussion went it's own way. My original reply about the fluid stands but... I in no way will apologize for taking this thread the way it went, We all know that threads have a mind of their own and I am not going to be chastised for following the thread the way it has gone so far.

But in the end, my reponse regarding the fluid replacement was semi affirmed by the doctor I worked with today. He said that a lot of the fluid replacement in electrical burns is done on a trial and error basis and it's not unusual to see someone getting 3 - 4 times the amount of fluid called for in the formulas.

[Eydawn]

Actually, the crux of the issue is that while nurses are to some degree less independent in the hospital setting due to the innate structure of the hospital, they still have a far broader education base and therefore, theoretically would make better educators. Many RN's have Bachelor's degrees, or at least Associate's... many paramedics do not even have an Associate's. But the education discussion is a different one entirely...

Also, I don't know if it's different for your wife in the military setting, but in the civilian setting nurses are every bit as responsible for their patient care decisions and actions as any paramedic in the prehospital setting. Sure, you might have a doctor to order the medication... but you're still responsible for ensuring that the medication and the dosage are appropriate. Blindly follow a bad order, and you go down along with the doctor. Also, who do you think provides care and interventions until a doctor gets there in the hospital? A nurse... many nurses intubate, etc...

I think I see what you were TRYING to convey, medic... and I think it got lost in translation. For a class offered to prehospital providers, it would be beneficial to have those with prehospital experience teaching the course in order to make it more applicable to the attendees... right? So... a flight nurse, for example, would be preferable to an ICU nurse if the course was full of paramedics.

Yes? No? Maybe? I can see what you're saying if that was it. If you were saying that in general, courses of this type need to be taught by paramedics because they're more independent... well... I kinda agree with Mr. James. (Ruff... train hijacking...)

Wendy

CO EMT-B

Edited 1x for misreading a name and attributing a post to the wrong fellow. Sowwy!

[medicv83]

I sincerely apologize for the way my text read, it sounded immature and ignorant in and of itself. Should have maybe worded some things differently. Unfortunately I will continue to maintain an opinion about nurses vs paramedics, however I absolutely agree that the primary mission is the continuity of care. Nurses are invaluable, without question, and my objective was not to belittle, or degrade the profession at all. I just sometimes feel as though the nurses are, at least here at this hospital, are robots compared to the medics in the field serving the same hospital. They can't do a thing without getting ordered. Cant even put a pt on 02 without it! That is incredible!

Triemal: First of all, please dont call me Sally, If im the one your referring to. Secondly - your absolutely right with the requirements for LR and I guess I didnt really think it through considering only a 15 - 20 minute trans time. But more importantly, the aim was to identify fluid needs overall for an electrical burn patient. Considering BSA. AZCEP is on track considering the best ya can do is to give em the best of both worlds with a liter of ringers and a liter of saline wide open together until transfer.

[Just Plain Ruff]

I took it the way you wrote it but hey unfortunately a lot can be lost in translation via the internet.

[triemal04]

medicv83- I called you sally to get you to take notice and hopefully pay attention to what was written, both by you and everyone else. If it had that effect then don't expect an apology. Now isn't the time to be making judgements on an entire profession based on your own very limited personal experiences, now is when you should be open to learning EVERYTHING POSSIBLE about the medical field in it's entirety and not making snap judgements.

Far as electrical burns go...Parkland is a good way to start, but in judging BSA you need to take into account at MINIMUM the amount of tissue between the entrance and exit, and that very well may not be enough. This would be one of those times to treat your pt, how they are presenting and what you know is going on physiologically with them and ignore the formula.

Edit: Didn't mean you hijacked the thread Ruff.

[logos]

While I haven't taken the course in question, I think the answer to the original question is this: The rate of hydration mentioned is intended to treat the myoglobinuria. That is, because myoglobinuria leads to renal failure. Thus aggressive hydration is protective of renal function without regard to the cause of the myoglobinuria. One would expect electrical burns to cause more severe rhabdomyolysis than thermal burns in a general sense because electrical burns are not insulated from the muscle by subq fat in the same way thermal burns are.

http://www.emedicine.com/ped/topic1535.htm

All patients with suspected myoglobinuria or rhabdomyolysis should be admitted for IV hydration and management of complications. Initial treatment focuses on preventing myoglobin precipitation in the urine by inducing and maintaining a brisk diuresis. Immediately administer saline to patients with suspected myoglobinuria or rhabdomyolysis because early hydration is the key to ameliorate acute renal failure. Achievement of a minimum urine output goal of 2 mL/kg/h is recommended.