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Burn Pt Fachiotomy/escharotomy Protocol


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#1 Carpe Diem

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Posted 01 June 2012 - 12:25 PM

Do any of you guys have protocols set up for performing faschiotomy/ escharotomies for circumfrencial chest burn pts? This would be in the circumstances of increased chest wall excursion / high PIPs on vented pts leading to hypercarbia. etc.

We are a nurse/ paramedic team. I'm guessing to make it kosher enough to get medical direction approval I am steering clear of anything other than chest walls.

Any info as to what people are doing would be great.

Feel free to PM me or answer on the board.

Cheers.
carpe diem
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Kris


#2 scottyb

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Posted 01 June 2012 - 02:36 PM

Do any of you guys have protocols set up for performing faschiotomy/ escharotomies for circumfrencial chest burn pts? This would be in the circumstances of increased chest wall excursion / high PIPs on vented pts leading to hypercarbia. etc.

We are a nurse/ paramedic team. I'm guessing to make it kosher enough to get medical direction approval I am steering clear of anything other than chest walls.

Any info as to what people are doing would be great.

Feel free to PM me or answer on the board.

Cheers.
carpe diem

Carpe,

The one escharotomy that I know of that was performed at my agency was a gentleman who emptied a gas can on himself and lit a match in an attempt to harm himself (needless to say he obviously succeeded and then some). The pt. had 90% 2nd and 3rd degree burns (mostly third) and crews were unable to ventilate the pt. The flight nurse patched to the receiving hospital and the trauma doc literally talked the crew through performing the procedure.

If I were you I would try to set up some training with the burn center staff in your area regarding escharotomy, etc. Oncy you can show that the staff has been trained by persons versed in the procedure that is more ammo to bring to your medical control. At my agency this procedure is part of the RN skill set, but we have no "official" proficiency training/skills check off.

Good luck and keep us posted! -Scott
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Scott Bild RN, FP-C

#3 Carpe Diem

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Posted 01 June 2012 - 07:46 PM

Thanks for the reply Scotty.

With more of a follow up to my previous question-how common is it for programs to have this skill in their repertoire? I have the logistics and educational end worked out. Im tied into the burn network fairly well.

I just want to see if "everyone else is doing it, why can't we?!?" This would probably be more helpful.

Thanks again.

Cheers,
Carpe diem
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Kris


#4 Jwade

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Posted 01 June 2012 - 09:08 PM

Thanks for the reply Scotty.

With more of a follow up to my previous question-how common is it for programs to have this skill in their repertoire? I have the logistics and educational end worked out. Im tied into the burn network fairly well.

I just want to see if "everyone else is doing it, why can't we?!?" This would probably be more helpful.

Thanks again.

Cheers,
Carpe diem



The skill in and of itself is not difficult. It is nothing more than making a 2 inch incision through the fascia.

Just because " Everyone else is doing it" does not justify the need.

Seriously, from a pure statistical point of view, the justification for the initial and ongoing education time for a procedure that is considered an outlier, is probably difficult to justify if you are being objective.

HEMS programs have a horrid time getting enough intubations and OR time as it is, and that is a skill which is easily shown to be beneficial. LOL......

As ScottyB pointed out, on the <1% chance you would need to do this, any ER physician can walk you through it on the radio.

JW
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John Wade MBA, CCEMT-P, FP-C, RN

"Have the courage to follow your heart and intuition, they somehow already know what you truly want to become" Steve Jobs

#5 Carpe Diem

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Posted 01 June 2012 - 10:16 PM

Thanks for the response Jwade.<br />After rereading my posts I'm realizing that in my post night shift grogginess I'm not making myself as clear in my post as I do in my head.<br /><br />As an industry-how prevalent is the skill allowed? Whether it is standing order-medical control consult-nurse only-paramedic only-both-none?<br /><br />My desire for the skill set is not to emulate other programs but to see what the standard is and how prevalent the skill is listed in a team's repitoir. <br /><br />I am aware that statistically it is rare. However when it is needed life saving or perhaps life sustaining.<br /><br />I am well versed in the procedure and what it involves as I am an ABA faculty member.<br /><br />Thanks guys!<br />CD

Sending me a PM is fine rather than having people list who does what in a public forum
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Kris


#6 Carpe Diem

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Posted 01 June 2012 - 10:42 PM

Thanks for the response Jwade.

After rereading my posts I'm realizing that in my post night shift grogginess I'm not making myself as clear in my post as I do in my head.

As an industry-how prevalent is the skill allowed? Whether it is standing order,medical control consult, nurse only, paramedic only, both, none?

My desire for the skill set is not to emulate other programs but to see what the standard is and how prevalent the skill is listed in a team's repertoire.
I am aware that statistically it is rare. However when it is needed life saving or perhaps life sustaining. I am well versed in the procedure and what it involves as I am an ABA faculty member.

Sending me a PM is fine rather than having people list who does what in a public forum.

Thanks guys,
CD
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Kris


#7 Jwade

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Posted 01 June 2012 - 11:24 PM

Thanks for the response Jwade.

After rereading my posts I'm realizing that in my post night shift grogginess I'm not making myself as clear in my post as I do in my head.

As an industry-how prevalent is the skill allowed? Whether it is standing order,medical control consult, nurse only, paramedic only, both, none?

My desire for the skill set is not to emulate other programs but to see what the standard is and how prevalent the skill is listed in a team's repertoire.
I am aware that statistically it is rare. However when it is needed life saving or perhaps life sustaining. I am well versed in the procedure and what it involves as I am an ABA faculty member.

Sending me a PM is fine rather than having people list who does what in a public forum.

Thanks guys,
CD


CD,

Thanks for the clarification.

Why don't you just make up a 5 question survey using survey-monkey which will provide you with the answers you are looking for.

Regardless of qualifications, when deciding wether or not to add this type of procedure, it should be based on metrics which, clearly show an evidence based practice need. This "skill" is an outlier no matter which way you try to look at it......You can make the same argument for Pericardiocentesis as well......Again, another outlier procedure that takes ongoing practice for something that has such a narrow window of time to affect a positive outcome........Once the blood starts to clot, it's a worthless procedure. So, the chances for a HEMS crew to show up during this 3-5 minute window is clearly not statistically feasible.

I have 8+ years of working in surgery with many HOT A$$ hours spent in the burn OR first assisting, and, I would consider myself an expert on this procedure, but, given all that, I would be very hesitant to feel the need to add this to my programs repertoire without showing an evidenced based statistical need.......

I apologize if I am still missing your main point here, but, just doesn't make much sense. What I am hearing you say in your posts are if the " Standard" and " Prevalence in scope of practice" is greater than 51% it would justify you approaching the medical director to add this skill?

Respectfully,
JW
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John Wade MBA, CCEMT-P, FP-C, RN

"Have the courage to follow your heart and intuition, they somehow already know what you truly want to become" Steve Jobs

#8 insen...

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Posted 02 June 2012 - 09:41 PM

Thanks for the response Jwade.

After rereading my posts I'm realizing that in my post night shift grogginess I'm not making myself as clear in my post as I do in my head.

As an industry-how prevalent is the skill allowed? Whether it is standing order,medical control consult, nurse only, paramedic only, both, none?

My desire for the skill set is not to emulate other programs but to see what the standard is and how prevalent the skill is listed in a team's repertoire.


Completing just over 2,000 patient missions in about 7.5 years of flying (traditional adult program), I only encountered the need once. I don't remember if it was a standing order, but it was easy to accomplish, and it made a substantial difference in my ability to ventilate the patient...better stated, I was completely unable to ventilate the patient until I carved him.

My partner dry-heaved throughout the procedure until turning (his/her) head and looking out the window. Then she/he resigned shortly after.
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"Miserere stultus qui dicit latin." Contemporary French Linguist Insenescence

#9 old school

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Posted 06 June 2012 - 03:11 AM

Completing just over 2,000 patient missions in about 7.5 years of flying (traditional adult program), I only encountered the need once. I don't remember if it was a standing order, but it was easy to accomplish, and it made a substantial difference in my ability to ventilate the patient...better stated, I was completely unable to ventilate the patient until I carved him.


Exactly. It's just as much about the risk:benefit of a procedure as it is the frequency with which it's performed.

I'm a big advocate of developing evidenced-based protocols. But even the best ideas and approaches have their limitations, and EBM becomes less relevant, less useful when talking about rare, unusual situations. The less common a given clinical scenario is, the less likely it is to have been examined in an objective, scientific way.

For example, I'm aware (or I should say, I've always been told) that that there is research that shows that prehospital pericardiocentesis confers little benefit. But in order to get a reasonable sample size, studies such as this are usually done in systems where protocols call for pericardiocentesis on all traumatic arrests, or some other similarly broad criteria. With acute pericardial tamponade being the primary cause of very few deaths, its not surprising that such a study would show that it rarely helps.

However, such a trial really ends up looking more at the protocol (that calls for the procedure to be performed when its not indicated), than it does the procedure itself. It is impossible based on such a study to make the claim that there is no subset of patients that can't potentially benefit. Given that there is virtually no risk in tapping the pericardium of a patient who shows signs of tamponade and is in extremis, and given the fact that it's not a technically difficult procedure, it may be feasible for a HEMS program that transports lots of sick trauma patients and has the resources the practice the skill, to include it in their protocols.

The same exact reasoning can be used with escharotomy. The fact that these procedures are rarely needed doesn't mean that they don't have a place in your skills repertoire.


All by itself, the fact that a given intervention is rarely performed is not a reason to keep it out of your bag of tricks. For example, what percentage of HEMS patients benefit from defibrillation during flight? How often is that even done in flight? But is anyone suggesting that we don't need the expense and weight of defibrillators onboard HEMS aircraft?
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