Burn dressings vs. Defibrillation

[marienm, RN, CCRN]

Hi, burn unit friends and problem-solvers! This question has come up a few times at work recently: How can we get the defibrillator pads on a patient with extensive chest/torso dressings? The dressings are usually thick gauze over xeroform and secured with bandnet. They are *hard* to cut through even in a non-emergency situation. What is your emergency procedure for this?

Part 2: Once you get the dressing off, do you prefer the pads or the paddles? Lets assume the skin underneath is a sloppy mess of grafts and drainage (now that we've been doing chest comprssions on it, at least).

To be clear, I'm not worried about salvaging the grafts during a code! I'm just wondering what you've found to be the fastest and safest way to defib if needed.

[Rose_Queen, BSN, MSN, RN]

Not a burn nurse, but there are alternative pad placement options beyond the standard placement of right upper chest and left side. I work cardiac surgery, so having a pad on the chest isn't an option due to sterility needs. Instead, we place ours on the right shoulder, just lateral to the scapula. If it's a patient where you can access areas where the electricity will cross the heart, creative pad placement can work.

[WestCoastSunRN, MSN, CNS]

Hey there, Marienm,

I was wondering about this, too, so I asked some coworkers what typical practice is. The dressings get cut down (yes, they can be hard to cut through!!) and pads go on. We do not use paddles -- pads only. Obviously it isn't ideal when you have to code a patient who has no skin (or healing grafts), but if we are shocking them it's because they're dead. Now if you can't get the pads to stick --- well we can get the paddles if we need them, but we don't keep them on the cart. I do also wonder about alternative placement....

[marienm, RN, CCRN]

We use the Zoll ONEStep pads (which are actually pretty cool) but we've gotten numerous warnings about needing good, dry skin to apply them and have them analyze properly. Our carts do have the paddles on them so we always have them as an option--but with certain patients we've debated whether to go right to paddles or at least attempt the pads first. The ideal placement for them is anterior/posterior, with right-anterior/left-lateral being the only optional placement we've been given. I haven't been present for our last couple of burn codes (not that they happen *all* that often!) so I haven't gotten to see how it all happened in real time.

[offlabel]

I'd cut the dressings and use gel pads with the paddles. Better chance of saving grafts than the stick on pads I would think, and you can put the paddles where they're supposed to go for optimizing the chance of converting to a perfusing rhythm.

[phoenixrn]

Gosh.... this is a great question. And what if you cut the dressings down but the torso is covered in goopy silvadene and eschar? Burn patients are often slimy and slippery. And we get plenty of patients that are burned almost entirely on their back and chest.