Fluid resuscitation in electrical burn

[medicv83]

Triemal, what are you talking about? First off - My limited experience? Secondly, when is the time that I should be learning? You make it seem like im some student of sorts? Yes there is never a time when learning shouldnt be going on, its a constant thing in EMS as it should be in any profession. Thirdly, you are very wrong about estimating the Burned internal body surface. The ABA, nor many Burn surgeons recommend this. Now in the pre-hospital aspect, the theory of a liter of saline, and a liter of ringers wide open seems to be the best. But if we were to utilize the parkland formula, we absolutely would not want to just "estimate" the surface burned internally. Do you know exactly the course this electricity took in the body? Much like you wouldnt know the exact course of an entrance wound of a bullet. Please, if your going to condescend me on here, do so with an adequate post with some sort of knowledge. Once again, Sally is the name of a female, and I am not a female, so therefore, dont call me Sally to get my attention. With guesstimating the internal surface area burned and then applying that number to actual fluid resuscitation would either potentially over or under resuscitate the patient in the long run and further aggravate the edema that the patient is going to have, or place the pt in acute renal failure. As far as the field goes, sure we could estimate. But not for long term, total fluid resuscitation.

[medicv83]

Good post Logos. Your right with the rhabdo. I think, with at least these instructors, they were up in the air with as to initially treat aggressive with fluid in anticipation of myoglobinuria, or start low, and see how the urinary output was going to be. They also said that there should be consideration of the addition of 44 mEq of Bicarb to each liter of ringers to maintain an alkaline urine >6.0. Also they were neither for, nor against the administration of 12.5 grams of Mannitol to every liter of ringers until there was 75cc/hr of urine, once that occured they would discontinue the mannitol, and maintain bicarb with ringers hoping to clear the pigment. Originally though, I was curious as to how they come about obtaining the amount of fluid needed to maintain the urine output utilizing the parkland formula. I think most likely they are going to start low with the parkland formula, and wait out a few hours, measuring the urine, and let the urine output guide the resuscitation from that point on.

[chbare]

I attended ABLS this week, and I have an un-answered question. Per the American Burn Association, the " burn consensus formula " AKA the "parkland formula" for the adult is 2-4 cc x kg x bsa = _____ ml/24 hour. We all know this. This is guided by urine output ultimately. In electrical injury, with significant internal injury noted by hemochromagens in the urine (myoglobinuria) the ABA suggests maintaining an adult urine output of 75 - 100 cc/hr to aid in diluting and clearing pigment in the urine. This means MORE fluid than the thermal burn patient would recieve. Now, with that being said - the formula uses BSA as a determinant of fluid needed. My question is - If my patient has an electrical entrance surface burn say 4 or 5 cm to his/her Right hand, and a 4 or 5 exit surface burn to say his/her left shoulder, that is essentially only maybe 2 % BSA......Where are we getting the additional BSA to calculate the additional fluid needed for this electrical burn patient to maintain a UOP of 75 - 100 cc?????? I got completely avoided answers during the course. Wondering what yall's thoughts are on this.

First, let us better define a few concepts:

1) The Consensus Formula is not the same as the Parkland Formula. Two common burn formulas are the Parkland and Modified Brooke. The Consensus formula is a combination of both formulas.

2) I suspect you would have a very difficult time using any of the burn formulas to calculate for adequate fluid delivery in the electrical burn injury patient.

3) Many experts have all kinds of thoughts on proper fluid type and delivery for burn patients. Generally, I find most people are at least ok with using an isotonic crystalloid.

4) Urinary output is going to be a critical indicator of adequate resuscitation when considering the electrical burn patient.

5) Rhabdo is a concern. Rhabdo can lead to ATN and ATN can lead to ARF.

6) We must consider all other injuries and conditions in addition to the electrical burn injury.

With that, I understand that you were told to use a conventional burn formula to calculate how much fluid is required to resuscitate these patients? We already have a good indicator of adequate resuscitation; urinary output. We can use the recommendation of 75-100 ml/hr. These patients will need a Foley, and we will need to closely monitor I&O.

In the initial phases of resuscitation, the EMS considerations will include; safety, removal from the scene, supportive care and stabilization of the ABC's. Then, we can make fluid resuscitation decisions. We need to understand that this is a dynamic process. Initially, we will may not have a urine output, so we will have to use our judgment regarding how much fluid to give. In most cases, an adult who is otherwise healthy can tolerate a fair amount of fluid. Personally, I would not be afraid to initially be aggressive with fluid delivery provided the patient can tolerate the fluid.

The bottom line: You will have to use your own judgment and remain flexible. Even the burn formulas with a conventional burn patient should not be looked at as commandments set in stone. The patients overall condition and urine output should guide your therapy.

Take care,

chbare.

[Just Plain Ruff]

With that, I understand that you were told to use a conventional burn formula to calculate how much fluid is required to resuscitate these patients? We already have a good indicator of adequate resuscitation; urinary output. We can use the recommendation of 75-100 ml/hr. These patients will need a Foley, and we will need to closely monitor I&O.

And REMEMBER, when you put a foley in to start to monitor urine output, make sure you empty the bladder and start from there. I can't tell you how many times someone has said, his urine output is great he put out 800 cc's of urine when I put in the foley and they counted that as urine output.

[chbare]

Yes. Typically, I will place a Foley and note the immediate return. Then, I get rid of it and start monitoring hourly urine output from there.

In addition, do not get so wrapped up with obtaining the perfect number that you render yourself unable to see the forest through the trees. For example, I am not going to get all crazy and adjust the fluid rate if I notice my patients output is 110 ml/hr provided they are stable otherwise. I really think this whole concept requires clinical judgment and common sense.

Take care,

chbare.

[medic_texas]

Just to clarify something and excuse me if this has already been addressed.

Nurses work under ACLS protocol and RUN the code where I work. Paramedics also work under ACLS protocol. Where I work, nurses who are paramedics can intubate after we take a class (and you also have to do x amount of intubations every 6 months, which is 6 intubations). If they are not around, a RT will intubate, and finally if a doctor is availible, they will intubate. A cardiologist can come in and take over the code otherwise it is up to the nurses to run the code. I'm assuming that most hospitals are similar.

Also, a lot of ICU nurses work under standing orders, protocol, and are allowed some flexibility with their patient and how they are treated. I can only speak for ICU nurses because that's all I have ever worked.

I can say this because I have been on both sides of the fence.

The topic starter may not mean anything by his comments but they came across as ignorant and without warrant. Hope this helps!

[spenac]

http://www.emedicine.com/derm/topic859.htm#comp

[Just Plain Ruff]

Spenac, check your email. I just sent you a high priority email.

[spenac]

And REMEMBER, when you put a foley in to start to monitor urine output, make sure you empty the bladder and start from there. I can't tell you how many times someone has said, his urine output is great he put out 800 cc's of urine when I put in the foley and they counted that as urine output.

Surely you joke. That is first thing taught after respect sterile field about foleys. Please tell me people are not really that ignorant.

[Just Plain Ruff]

actually I have seen it a more than you know. It usually is the new paramedics in the ER who put them in. They don't get the empty the bladder before you count lecture unless it was from me.

Training was sort of hit or miss where I was at.