APPENDIX B BURN CRISIS STANDARDS OF CARE GUIDELINES · the scarcity of burn centers and complexity of initial care required. Despite the infrequency of significant burn disasters,

UTAH CRISIS STANDARDS OF CARE GUIDELINES

VERSION 2 | JUNE, 2018

PRODUCED IN COOPERATION WITH:

Support for this program is funded in part through Hospital Preparedness Program Grant CFDA #93.889

APPENDIX B

BURN CRISIS STANDARDS OF CARE GUIDELINES

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ABOUT THE GUIDELINES

These guidelines were developed by the Utah Hospital Association (UHA) Crisis Standards of Care Workgroup, as a result of a contract with the Utah Department of Health (UDOH) and the Hospital Preparedness Program Grant CFDA #93.889 U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Preparedness and Response (ASPR). This document Appendix B: Burn Crisis Standards of Care Guidelines supplements (with specific burn issues) elements not covered in the base Utah Crisis Standards of Care Guidelines. In 2010, the Utah Hospital Association, in cooperation with the Utah Department of Health, issued the Utah Pandemic Influenza Hospital and ICU Triage Guidelines. That document has been merged into the new Crisis Standards of Care document (Appendix C: Pandemic Guidelines). The original documents are included as an appendix purely as a reference. Finally, Appendix A: Pediatric Disaster Surge Planning provides specific elements regarding pediatric surge or MCI events. The 2018 Utah Crisis Standards of Care Guidelines (UCSCG) is to be considered as the guideline for both a pandemic or traumatic disaster situation.

The purpose of this document is to guide the allocation of patient care resources during an overwhelming public health emergency of any kind (pandemic or natural disaster) when demand for services dramatically exceeds the supply of the resources needed. These Guidelines represent a consensus view of the entire Crisis Standards of Care Stakeholder Workgroup. The document will be updated as needed and should be modified by facilities to meet the needs and abilities of each hospital. Application of these guidelines will require and depend on physician judgment at the point of patient care. The views expressed in the publication do not necessarily reflect the official policies of the U.S. Department of Health and Human Services or the Utah Department of Health.

SCOPE OF THIS DOCUMENT

When a situation is statewide: These triage guidelines apply to all healthcare professionals, clinics, and facilities in the state of Utah. The guidelines apply to all patients.

When the situation is limited (such as an earthquake) to a specific area of the state, these guidelines will only apply to the medical community affected and the immediate surrounding communities. However, if non-impacted community medical facilities are overwhelmed as a direct result of the event (population displacement, resource shortages, staffing shortages) consideration will be provided to extend the protections on a case-by-case basis.

When activated: Guidelines should be activated in the event of a public health emergency declared by the governor of the State of Utah. Individual healthcare facilities and organizations will manage their responses through their designated emergency operations plans and incident command structures. In turn, local hospitals will communicate with both local and state health department emergency operations centers as well as their regional healthcare coalitions to provide situational awareness and coordination regarding local response efforts and requests.

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ACTIVATION ALGORITHM

Communicate with HCC coordinator, state and local health departments regarding other facilities’ status, shortages, aid available.

Normal bed capacity, occasional limited resources, normal resupply, usual staffing.

CONVENTIONAL

Beyond typical bed capacity, emergency operations in effect. Elective procedures delayed, resources becoming scarce, conservation and substitution procedures in place. Patient/provider ratios expanded, extended scope of practice in place, higher than normal absenteeism.

CONTINGENCY

Still not able to meet demand for care, despite using

non-patient care areas.

Many critical resources unavailable (including beds,

ventilators, medications).

Critical staffing shortage. Staff operating outside normal scope of

practice, absenteeism > 30%.

BED STATUS RESOURCE LEVEL STAFF

All resource extenders have been utilized

Facility Incident Command determines necessity to move to Crisis Standards of Care

With UDOH permission, activate UCSCG

Communicate with HCC Coordinator, State and Local Health Departments regarding decision and status of surrounding facilities. Has the Governor declared a public health disaster?

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TABLE OF CONTENTS

About the Guidelines/Scope of this Document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Activation Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

American Burn Association Consultation Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Burn Estimate and Diagram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Initial Management Guidelines for the Adult Burn Patient

• Primary Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

• Secondary Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Fluid Infusion Rate > 30 kg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Adult Pain Medication Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

BTICU Fluid Calculation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Adult Fluid Resuscitation Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Initial Management Guidelines for the Pediatric Burn Patient

• Primary Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

• Secondary Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Fluid Infusion Rate < 30 kg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Pediatric Pain Medication Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

BTICU Fluid Calculation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Fluid Resuscitation of the Pediatric < 30 KG Acute Burn Patient . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Wound Care Supply Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Wound Management Treatment Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Outpatient Wound Care Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

Physical Therapy Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Crucial Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Radiation Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Burn Mass Casualty Incident Activation Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Western Region Burn Disaster Consortium 96-Hour Response Plan . . . . . . . . . . . . . . . . . . . . . . . . 41

Prolonged Care of the Burn Patient in a Non-Burn Facility Following a Burn Mass Casualty Incident (BMCI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

Module 1: Initial Assessment and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

Module 2: 0–48 Hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Module 3: 48–96 Hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

Module 4: Transfer and Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

BMCI Patient Medical Data Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

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INTRODUCTIONA burn mass casualty incident (BMCI) with a significant number of patients creates unique challenges due to the scarcity of burn centers and complexity of initial care required. Despite the infrequency of significant burn disasters, a BMCI can quickly overwhelm local resources and exceed the capacity of the closest local burn center to provide care. Patients will need to be cared for initially at non-burn facilities that may be called on to render immediate critical interventions and prolonged care until transfer to a burn center is possible.

Utah is home to only one burn specialty center (out of 53 total Utah Hospitals)which is located at University of Utah Health. With 15 beds the Burn Center frequently operates at or near capacity. In the mountain states (Utah, Idaho, Montana, Wyoming, Colorado), there are only six burn specialty centers, four of which are in Colorado. There are under 90 dedicated burn beds within this region and all centers have large geographical coverage areas.

The potential for any hospital in the state to receive significant numbers of burn patients in a disaster situation is very high. While all general hospitals in Utah see some burn patients in their facilities, seriously ill or injured burn survivors are generally transferred to the burn specialty hospital as soon as possible. Because of extreme weather conditions or other possible natural disasters, long transport distances, and a shortage of transport vehicles, it may not always be possible to get those patients to the Burn Center. In the case of a major earthquake in the Salt Lake Valley, there is a significant chance that the Burn Center may suffer such damage as to render it unusable.

Every hospital should be prepared for the possibility that they may need to care for seriously ill or injured burn patient(s) for an extended period of time (3 to 5 days). This document will provide resources to help facilities plan and care for a surge of these patients.

For our purposes, “Surge Capacity” may be best defined in terms of the 4 Ss: Staff, Space, Supplies, and System requirements. In general, burn beds, supplies and equipment are often kept at a minimum. It is critically important to predetermine your facility’s present capacity to care for burn patients and to develop a plan to increase your burn surge capacity.

BURN SURGE PLANNING

In order to plan for the possibilities of caring for critically ill and injured burn patients, it is recommended that each hospital strongly consider implementing the following:

• A staff burn champion should be identified to oversee burn planning and policies and serve as a regular member of the Hospital Disaster Committee.

• Identify hospital staff with burn experience.

• Burn specific education should be conducted for facility staff on a regular basis. Recommended training includes Advanced Burn Life Support (ABLS), Emergency Care of the Burn Patient and the Prolonged Care of the Burn Patient in a Non-Burn Facility Following a Burn Mass Casualty Incident (BMCI) e-learning modules. This e-learning curriculum can be found at the following website: http://crisisstandardsofcare.utah.edu

• Consider establishing telemedicine capability.

• Add special considerations for burn patients to your hospital decontamination plan.

• Develop and exercise a hospital-based burn disaster triage system.

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The American Burn Association identifies the following as injuries requiring a Burn Center consultation:

• 2nd degree burns > 10% TBSA

• Burns to face, hands, feet, genitalia, perineum, major joints

• 3rd degree burns

• Chemical burns

• Inhalation injuries

• Electrical injury (lightning included)

• Burns accompanied by pre-existing medical conditions

• Burns accompanied by trauma, where burn injury poses greatest risk of morbidity or mortality

• Burns to children in hospitals without pediatric services

• Patients with special social, emotional or rehabilitative needs.

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BURN ESTIMATE AND DIAGRAMBURN INJURY GUIDELINES FOR CARE

Area Birth–1 yr. 1–4 yr. 5–9 yr. 10–14 yr. 15 yr Adult 2nd 3rd TBSA% Total

Head 19 17 13 11 9 7

Neck 2 2 2 2 2 2

Ant. Trunk 13 13 13 13 13 13

Post. Trunk 13 13 13 13 13 13

R. Buttock 2.5 2.5 2.5 2.5 2.5 2.5

L. Buttock 2.5 2.5 2.5 2.5 2.5 2.5

Genitalia 1 1 1 1 1 1

R. U. Arm 4 4 4 4 4 4

L. U. Arm 4 4 4 4 4 4

R. L. Arm 3 3 3 3 3 3

L. L. Arm 3 3 3 3 3 3

R. Hand 2.5 2.5 2.5 2.5 2.5 2.5

L. Hand 2.5 2.5 2.5 2.5 2.5 2.5

R. Thigh 5.5 6.5 8 8.5 9 9.5

L. Thigh 5.5 6.5 8 8.5 9 9.5

R. Leg 5 5 5.5 6 6.5 7

L. Leg 5 5 5.5 6 6.5 7

R. Foot 3.5 3.5 3.5 3.5 3.5 3.5

L. Foot 3.5 3.5 3.5 3.5 3.5 3.5

TOTAL

Cause of burn

Additional injuries

Date of burn

Time of burn

Age

Sex

Weight Kg

Height cm

Date of assessment

Time of assessment

Assessed by

BURN DIAGRAM

COLOR CODE

X/red — 3°

=/blue — 2°

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INITIAL MANAGEMENT GUIDELINES FOR THE ADULT BURN PATIENTBURN INJURY GUIDELINES FOR CARE

Consider University of Utah Health Burn Center consultation at (801) 581-2700.

Prior to initiating care of the patient with wounds it is critical that healthcare providers take measures to reduce their own risk of exposure to potentially infectious substances and/or chemical contamination. In addition, patients with burns/wounds are at high risk for infection and potential cross contamination. Body substance precautions are the most effective way to do this. The level of protection utilized will be determined by patient presentation. Patients with burns > 20% TBSA are most at risk.

PRIMARY ASSESSMENT

Intervention/Care Key Points

Airway maintenance with C-Spine Protection Consider inhalation injury with:

• History of closed space fire• Hypoxia• Facial burns• Stridor• Carbonaceous sputum• Singed nasal hairs• Hoarseness

Treatment• High flow oxygen using a non-rebreather

mask, wean as appropriate.• Early intubation (Assess Glasgow prior to

intubation)• Secure the ETT with ties passed around the

head, do not use tape as it will not adhere to burned tissue.

• A nasogastric tube should be inserted on all patients who are intubated.

• Airway edema increases significantly after fluids are started.

• Stridor or noisy breath sounds are indicators of impending upper airway obstruction.

• Prophylactic intubation is often preferred because the ensuing edema obliterates the landmarks needed for successful intubation.

• An endotracheal tube that becomes dislodged may be impossible to replace due to obstruction of the upper airway by edema.

Breathing and Ventilation• Assess for appropriate rate and depth of

respirations in addition to breath sounds.• Monitor pulse oximetry and obtain ABGs.• Check CO level if indicated.• In circumferential torso burns monitor

chest expansion closely. Chest/abdominal escharotomy may be necessary; consider burn center consult.

An escharotomy is an incision performed longitudinally through burned tissue down to subcutaneous tissue over the entire involved area of full thickness circumferential (or nearly circumferential burn) that is causing constriction and loss of peripheral perfusion or airway constriction. Finger escharotomies are rarely indicated.

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Circulation with Hemorrhage Control• Heart Rate• Blood Pressure• Pulses and capillary refill• Skin color of unburned skin• Cardiac monitoring as appropriate and

available• Large bore IV or I/O line should be inserted as

necessary. Secure well.• IV/I/O Priority should be given to patients with

burns > 20% TBSA. Starting points for fluid resuscitation rates are as follows:

› 5 years or younger: 125 ml LR/NS/hr › 6-13 years of age: 250 ml LR/NS/hr › 14 years or older: 500 ml LR/NS/hr

• More definitive calculation is performed during the secondary survey when TBSA is known.

• Patients with burns usually do not develop shock within 60 minutes from time of injury if left untreated unless there are associated injuries or medical conditions in addition to the burn.

• Due to the increased circulating catecholamines and hypermetabolism associated with burn injuries, a normal heart rate for an adult is 100–120 bpm.

• Heart rates above this may indicate hypovolemia, inadequate oxygenation, unrelieved pain or anxiety.

• Heart rates below this level may be due to an underlying cardiac abnormality. Dysrhythmias may be the result of an electrical injury and are abnormal.

• The B/P in the early stages of burn resuscitation should be the individuals pre-injury B/P or higher.

• IVs may be placed through burned skin if necessary, suture to secure in place or use coban or kerlix roll.

• Oral resuscitation may be considered for awake alert adult patients with small burns using flavored sport drinks and/or an equal electrolyte maintenance solution. Monitor the quality and quantity of urinary output and watch for signs of dehydration.

Disability• Consider using the “AVPU” method:

› A – Alert › V – Responds to verbal stimuli › P – Responds to painful stimuli › U – Unresponsive

Typically the burn patient is alert and oriented

If altered neurological status, consider associated injury, CO poisoning, substance abuse, hypoxia, medications administered or pre-existing medical conditions.

Exposure• Check temperature• Remove all clothing and jewelry• Keep patient and environment warm and dry

Localized hypothermia causes vasoconstriction to the damaged area reducing blood flow and tissue oxygenation and may deepen the injury. Systemic hypothermia (core temp less than 95°F/35°C) induces peripheral vasoconstriction that may increase the depth of the burn and interfere with clotting mechanisms and respiration in addition to causing cardiac arrhythmias.

Adult

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INITIAL MANAGEMENT GUIDELINES FOR THE ADULT BURN PATIENTBURN INJURY GUIDELINES FOR CARE

Consider University of Utah Health Burn Center consultation at (801) 581-2700.

SECONDARY ASSESSMENT

History:• Consider the use of “Ample” to aid in obtaining information

› A – Allergies › M – Medications › P – Previous illness, past medical history › L – Last meal or fluid intake › E – Events/environment related to the injury

• Do not use silver sulfadiazine on a patient with a sulfa allergy; instead use another topical or wound coverage product.

INTERVENTION/CARE

Burn Specific Physical Examination:

Airway and Breathing

• Supportive therapy and O2; wean as appropriate.• Unless contraindicated by the patient’s medical condition or associated trauma, the head of bed should

be elevated 30 degrees to minimize facial and airway edema.• Use reverse trendelenburg for patients with C-spine precautions.• Chest X-ray if intubated, inhalation injury suspected or underlying pulmonary condition.• Chest X-ray will usually be clear on admit and then if inhalation injury is present will show infiltrates

around the second day correlating with a deteriorating oxygen status.• Frequent suctioning is necessary to prevent occlusion of the airway and endotracheal tube. Anyone

with an inhalation injury is subject to increased respiratory secretions and may have a large amount of carbonaceous debris in the respiratory tract.

Estimate Burn Size and depth

• Determine the extent of the burn using the Rule of Nines, Rule of the Palm or Lund-Browder chart. See Burn Estimate and Diagram.

Initiate Fluid Resuscitation

• 4ml (LR) x body weight (kg) x TBSA % burn = mL of Lactated Ringers solution (LR) to be given during the first 24 hours post burn (calculate from time of burn).

• Give half the fluid (LR) in the first 8 hours then the next half (LR) over the next 16 hours.• Remember this is just a starting point and fluids should be titrated according to urine output. See Fluid

Infusion Rate > 30 kg.

Adul

t

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Resuscitation Guidelines

• Insert a foley catheter as necessary depending on burn size.• Burns of the penis may require insertion of a foley catheter to maintain patency of the urethra.• Titrate IV rate to maintain a urine output: 0.5ml/kg for adults (30-50ml/hr).

Eyes

• Remove contacts prior to eyelid swelling if facial involvement.• Fluorescein should be used to identify corneal injury.• If eye involvement consider consulting an ophthalmologist.

Circulation

• Elevate burned extremities on pillows or blankets to improve circulation and minimize edema.• Monitor pulses with a Doppler, if necessary.• Circumferential chest injuries may become life threatening; an escharotomy may be necessary.• Verify that pulselessness is not due to profound hypotension.• Scrotal swelling, though often significant, does not require specific treatment.

Monitor for the following signs and symptoms in full thickness, circumferential burn injuries which may indicate circulatory compromise:

• Pallor or cyanosis of distal unburned skin on limb.• Capillary refill > 5 seconds.• Unrelenting deep tissue pain.• Progressive loss of sensation or motor function.• Inability to ventilate in patients with deep circumferential burns of the chest.

Body Temperature

• Keep patient normo-thermic, especially during wound care.• Keep patient covered. If supplies of blankets are depleted, patients can be wrapped in plastic wrap or

aluminum foil for insulation and warmth.• Warm the room.• Warm IV fluid if possible, especially if patient is very hypothermic.

Labs

• Labs on admission and as dictated by medical condition: › Arterial Blood Gases if inhalation injury is suspected › Serum Chemistries/Electrolytes › Complete Blood Count (CBC) › Glucose Levels, especially in children and diabetics › EKG for electrical injury or cardiac history › Type and Screen if additional trauma is suspected

• Tetanus prophylaxis unless given in last five years.

COMFORT:• Frequent pain/sedation assessment; minimum every four hours.• Assess patient pain score before and after pain/sedation medication given.• Emotional support and education is essential.• IV analgesia is the preferred route during the initial post injury period.• Administer opioids in frequent small to moderate bolus doses.• See Adult Pain Medication Guidelines.

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FLUID INFUSION RATE > 30KGBURN INJURY GUIDELINES FOR CARE

*Fluid of choice LR, DO NOT use dextrose containing fluids

Wt (lbs) Wt (kg) % TBSA ml/hr for 1st 8 hrs of care

66 30 10 7566 30 20 15066 30 30 22566 30 40 30066 30 50 37566 30 60 45088 40 10 10088 40 20 20088 40 30 30088 40 40 40088 40 50 50088 40 60 600110 50 10 125110 50 20 250110 50 30 375110 50 40 500110 50 50 625110 50 60 750132 60 10 150132 60 20 300132 60 30 450132 60 40 600132 60 50 750132 60 60 900154 70 10 175154 70 20 350154 70 30 525154 70 40 700154 70 50 875154 70 60 1050176 80 10 200176 80 20 400176 80 30 600176 80 40 800176 80 50 1000176 80 60 1200198 90 10 225198 90 20 450198 90 30 675198 90 40 900198 90 50 1125198 90 60 1350220 100 10 250220 100 20 500220 100 30 750220 100 40 1000220 100 50 1250220 100 60 1500242 110 10 275242 110 20 550242 110 30 825242 110 40 1100242 110 50 1375242 110 60 1650264 120 10 300264 120 20 600264 120 30 825264 120 40 1200264 120 50 1500264 120 60 1650

Wt (lbs) Wt (kg) % TBSA ml/hr for 1st 8 hrs of care

287 130 10 325287 130 20 650287 130 30 975287 130 40 1300287 130 50 1625287 130 60 1950309 140 10 350309 140 20 700309 140 30 1050309 140 40 1400309 140 50 1750309 140 60 2100331 150 10 375331 150 20 750331 150 30 1125331 150 40 1500331 150 50 1875331 150 60 2250353 160 10 400353 160 20 800353 160 30 1200353 160 40 1600353 160 50 2000353 160 60 2400375 170 10 425375 170 20 850375 170 30 1275375 170 40 1700375 170 50 2125375 170 60 2550397 180 10 450397 180 20 900397 180 30 1350397 180 40 1800397 180 50 2250397 180 60 2700419 190 10 475419 190 20 950419 190 30 1425419 190 40 1900419 190 50 2375419 190 60 2850441 200 10 500441 200 20 1000441 200 30 1500441 200 40 2000441 200 50 2500441 200 60 3000463 210 10 525463 210 20 1050463 210 30 1575463 210 40 2100463 210 50 2625463 210 60 3150485 220 10 550485 220 20 1100485 220 30 1650485 220 40 2200485 220 50 2750485 220 60 3300

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ADULT PAIN MEDICATION GUIDELINESBURN INJURY GUIDELINES FOR CARE

Burn Pain may be excruciating, and it is not unusual initially for the narcotic dose to exceed the standard weight-based recommendations. During IV fluid resuscitation all pain medications should be given intravenously. The IM or SQ routes should not be used.

After the resuscitation phase has been completed, patients may be given oral pain medications. Please consider renal function before initiating any pain regimen, especially NSAIDs. With IV medications, titrate to effect and patient vital signs. It is best to give smaller doses more frequently until the provider is comfortable with giving larger doses. Patients will never be pain free; educate them about the burn injury and ask them what pain level is tolerable for them.

Mild to Moderate Pain:

Oral IV

Acetaminophen 650-1000 mg Acetaminophen 1000 mg

Ibuprofen 600-800 mg Ketorolac 15-60 mg

Naproxen 250-500 mg Fentanyl 25-50 mcg

Tramadol 50-100 mg Morphine 0.5-2 mg

Acetaminophen with codeine 30/300 1-2 tablets

Hydrocodone with acetaminophen 5/500 1-2 tablets

Oxycodone with acetaminophen 5/325 1-2 tablets

Moderate to Severe Pain:

Oral IV

Hydrocodone with acetaminophen 7.5/500 1-2 tablets Fentanyl 25-100 mcg

Oxycodone with acetaminophen 10/325 1-2 tablets Morphine 2-4 mg

Oxycodone 5-15 mg Hydromorphone 0.5-2 mg

Morphine 15-45 mg Ketamine 0.3mg/kg /dose

Hydromorphone 2-6 mg Ketamine 0.05-0.1mg/kg/hr (use as an adjunct)

For Moderate to Severe pain with around-the-clock use of oral pain meds, consider adding extended release products:

Methadone 5-10 mg PO twice daily

Oxycontin 10 mg PO twice daily

MsContin 15 mg PO 3 times daily

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BTICU FLUID CALCULATIONWeight (kg): Height (cm):

Body Surface Area (BSA m2) (Mostellar Equation1): m2

Total Body Surface Area burn2 (TBSA): (as a whole number)

Fluids given prior to arrival: ml Urine output prior to arrival: ml

Burn Injury Time:

Time of Admission:

1 . RESUSCITATION CALCULATION

Resuscitation and Basal Requirement Formula:

(4 ml × kg × TBSA) + (1500 ml × BSA m2) = ml (total fluids in 24hr)

÷ 2 = ml

÷ 8 (begin fluid resuscitation rate3) = ml/hr

Give ½ of the total fluids in the first 8 hours.

2. MAINTENANCE CALCULATION

Basal requirement in 24 hours:

(1500 ml × BSA m2) ÷ 24 = ml/hr

Evaporative Water Loss per hour:

Adults: (25 + TBSA) × BSA m2 = ml/hr

Children: (35 + TBSA) × BSA m2 = ml/hr

Calculated Maintenance Rate4 = (basal requirement + evaporative loss) ml/hr

Attending Signature:

RN Co-Signature:

1. If manually calculating the BSA, BTICU uses the Mostellar Equation.

2. TBSA is calculated using the “Lund and Browder Chart”. Although spoken of as a percent, the value is used as a whole number when completing all calculations.

3. Per the Parkland Formula, ½ of the total fluids calculated for the first 24 hours should be given in the first 8 hours. However the BTICU only uses the rate calculated for the first 8 hours as a starting point for the first hour. This is your “begin fluid resuscitation rate” as noted on Step One of the BTICU Adult/Pediatric Fluid Resuscitation Order. The remaining hourly fluid requirement is titrated based on hourly urine output. See the BTICU Adult/Pediatric Fluid Resuscitation Order for more details.

4. Calculated maintenance rate is the total fluid goal once the patient has completed their fluid resuscitation.

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Call Attending

ADULT FLUID RESUSCITATION ORDER

ALBUMIN PROTOCOL

Patients Admit Wt: kg

Urine Output <15 cc

• Consider order for bladder scan

• Flush foley with 30 ml sterile H2O

(If < 15 cc/hr for 2 hrs see 3rd box below)

UOP < 15 cc/hr for two hours despite an increase in fluid

Calculated Maintenance Rate

is reached and held for two hours and the pt. is at least 24

hours post burn

Fluid resuscitation is COMPLETE

Switch to D5 0.45 NS with 20 mEq KCL/L at

Calculated Maintenance Rate

TOTAL FLUIDS SHOULD NOW EQUAL Calculated Maintenance

Rate (all fluids)

Call Attending and consider:

• Order for bladder pressure

• beginning ALBUMIN PROTOCOL

If patient again develops oliguria or hemodynamic instability CALL

ATTENDING and restart patient on LR increasing current rate by 10% or 100cc/hr (whichever is greater)

Increase IV rate by 20% or 200 cc/hr (whichever

is greater)

Urine output 15-29 cc

Increase IV rate by 10% or 100 cc/hr (whichever is greater)

Urine output > 50 cc

Decrease IV rate by 10% or 100 cc/hr (whichever is greater)

Urine output 30-50 cc

Leave IV at current rate

Urine output > 200 cc

Consider decreasing IV rate every 1/2 hr by 10%. Be sure to assess patient’s blood sugar, BP, HR, lactic

acid, hemoglobin, before decreasing IV rate. Consult with CN first, then Attending for any questions.

Vital Signs Stable: HR < 140, MAP > 60

REPEAT STEP ONE EVERY HOUR UNTIL:

Vitals unstable: HR > 140 or MAP < 60

Begin fluid resuscitation

LR @

Then measure urine output hourly

STEP ONE

Attending Signature: Date

RN Co-Sign: Date

If patient requires > calculated fluids or has complications related to edema, consider Albumin protocol.

Patient may need colloid resuscitation: Call attending to discuss starting 5% albumin at one-third current hourly

rate, LR at two-thirds current rate. Example (if current rate of LR is 900cc/hr, it should be changed to 600cc/hr LR,

and 300cc/hr 5% Albumin.

Repeat step one until patient maintains total maintenance fluid rate with UOP greater than 30cc/hr.

When combined LR and Albumin rates reach the total maintenance fluid rate change to LR for two hours.

If patient maintained UOP for two hours on LR and is 24 hrs post burn, FLUID RESUSCITATION IS COMPLETE

Change to D5 0.45 NS with 20 mEq KCL/L at Calculated Maintenance Rate.

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17

INITIAL MANAGEMENT GUIDELINES FOR THE PEDIATRIC BURN PATIENTBURN INJURY GUIDELINES FOR CARE

Consider Burn Center Consultation at (801) 581-2700.

Using the Broselow tape for equipment and medication dosages is recommended. Prior to initiating care of the patient with wounds, it is critical that healthcare providers take measures to reduce their own risk of exposure to potentially infectious substances and/or chemical contamination. In addition, patients with burns/wounds are at high risk for infection and potential cross contamination. Body substance precautions are the most effective way to do this. The level of protection utilized will be determined by patient presentation. Patients with burns > 20% TBSA are most at risk.

PRIMARY ASSESSMENT


Airway maintenance with C-Spine Protection

Consider inhalation injury with:• History of closed space fire• Hypoxia• Facial Burns• Stridor• Carbonaceous sputum• Nasal Singe• Hoarseness

Treatment• High flow oxygen using a non-rebreather

mask, wean as appropriate.• Early intubation (Assess Glasgow prior to

intubation)• Secure the ETT with ties passed around the

head; do not use tape as it will not adhere to burned tissue.


• Airway edema increases significantly after fluids are started.


• Younger children and those with larger burns are more likely to require intubation due to the smaller diameter of the child’s airway and the need for significant fluid volumes during resuscitation.

• Prophylactic intubation is preferred because the ensuing edema obliterates the landmarks needed for successful intubation.


• It is critical that the ETT is secured well.

Breathing and Ventilation• Assess for appropriate rate and depth of

respirations in addition to breath sounds.• Monitor pulse oximetry and obtain ABGs.• Check CO level if indicated.• In circumferential torso burns, monitor

chest expansion closely. Chest/abdominal escharotomy may be necessary; consider burn center consult.

An escharotomy is an incision performed longitudinally through burned tissue down to subcutaneous tissue over the entire involved area of full thickness circumferential (or nearly circumferential burn) that is causing constriction and loss of peripheral perfusion or airway constriction. Finger escharotomies are rarely indicated.

Pediatric

18


Circulation with Hemorrhage Control• Heart Rate• Blood Pressure• Pulses and capillary refill• Skin color of unburned skin• Cardiac monitoring as appropriate and

available• Large-bore Intraosseous or IV line should be

inserted as necessary. Secure well.• IV/I/O Priority should be given to pediatric

patients with burns >10% TBSA.• Starting points for fluid resuscitation rates are

as follows: › 5 years or younger: 125ml LR/NS/hr › 6-13 years of age: 250ml LR/NS/hr › 14 years or older: 500ml LR/NS/hr

• More definitive calculation is performed during the secondary survey when TBSA is known.

• Due to the increased circulating catecholamines and hypermetabolism associated with burn injuries, the HR will be increased. Sustained high heart rates may indicate hypovolemia, inadequate oxygenation, unrelieved pain or anxiety.

• Dysrhythmias may be the result of an electrical injury and are abnormal.

• Patients with burns usually do not develop shock within 60 minutes from time of injury if left untreated unless there are associated injuries. The B/P should be close to the individuals pre-injury pressure or higher.

• IVs may be placed through burned skin if necessary; suture to secure in place.

• Oral resuscitation may be considered for awake alert pediatric patients with small burns using flavored sport drinks and/or an equal electrolyte maintenance solution. Monitor the quality and quantity of urinary output and watch for signs of dehydration.

• A maintenance dextrose fluid may be required for very young children. See Fluid Resuscitation of the Pediatric < 30kg Acute Burn Patient.

Age of Patient HR RR Systolic BP Temp

0 days – <1 mo < 80 > 205 < 30 > 60 < 60 < 36 > 38

≥ 1 mo – < 3 mos < 80 > 205 < 30 > 60 < 70 < 36 > 38

≥ 3 mos – < 1 yr < 75 > 190 < 30 > 60 < 70 < 36 > 38.5

≥ 1 yr – < 2 yrs < 75 > 190 < 24 > 40 < 70 + (age x 2) < 36 > 38.5

≥ 2 yrs – < 4 yrs < 75 > 190 < 24 > 40 < 70 + (age x 2) < 36 > 38.5

≥ 4 yrs – 6 yrs < 60 > 140 < 22 > 34 < 70 + (age x 2) < 36 > 38.5

≥ 6 yrs – < 10 yrs < 60 > 140 < 18 > 30 < 70 + (age x 2) < 36 > 38.5

≥ 10 yrs – < 13 yrs < 60 > 100 < 18 > 30 < 90 < 36 > 38.5

≥ 13 yrs – < 18 yrs < 60 > 100 < 12 > 16 < 90 < 36 > 38.5

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Disability• Consider using the “AVPU” method:

› A – Alert › V – Responds to verbal stimuli › P – Responds to painful stimuli › U – Unresponsive

Typically the burn patient is alert and oriented.

If altered neurological status, consider associated injury, CO poisoning, hypoxia, medications administered or pre-existing medical conditions. In infants, hypoglycemia may develop due to limited glycogen reserves; therefore, blood glucose levels should be closely monitored. Hypoglycemia and hypoxia often present as agitation and confusion.

Exposure• Check temperature• Remove all clothing and jewelry• Keep patient and environment warm and dry

Localized hypothermia causes vasoconstriction to the damaged area reducing blood flow and tissue oxygenation and may deepen the injury. Systemic hypothermia (core temp less than 95°F/35°C) induces peripheral vasoconstriction that may increase the depth of the burn and interfere with clotting mechanisms and respiration, in addition to causing cardiac arrhythmias.

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INITIAL MANAGEMENT GUIDELINES FOR THE PEDIATRIC BURN PATIENTBURN INJURY GUIDELINES FOR CARE

Consider Burn Center consultation (801) 581-2700.

SECONDARY ASSESSMENT

History:• Consider the use of “Ample” to aid in obtaining information

› A – Allergies › M – Medications › P – Previous illness, past medical history › L – Last meal or fluid intake › E – Events/environment related to the injury

• Do not use silver sulfadiazine on a patient with a sulfa allergy; instead use another topical or wound coverage product.

INTERVENTION/CARE

Burn Specific Physical Examination:

Airway and breathing• Supportive therapy and O2; wean as appropriate.• Unless contraindicated by the patient’s medical condition or associated trauma, the head of bed should

be elevated 30° to minimize facial and airway edema, maintain sniffing position.• Use reverse trendelenburg for patients with C-spine precautions.• Chest X-ray if intubated, inhalation injury suspected or underlying pulmonary condition.• Chest X-ray will usually be clear on admit and then if inhalation injury is present will show infiltrates

around the second day, correlating with a deteriorating oxygen status.• Frequent suctioning is necessary to prevent occlusion of the airway and endotracheal tube. Anyone

with an inhalation injury is subject to increased respiratory secretions and may have a large amount of carbonaceous debris in the respiratory tract.

Estimate burn size and depth• Determine the extent of the burn using the Rule of Nines, Rule of the Palm or Lund-Browder chart. See

Burn Estimate and Diagram.

Initiate fluid resuscitation• 4ml (LR) x body weight (kg) x TBSA % burn = Lactated Ringers solution (LR) fluid in first 24 hours post

burn (calculate from time of burn).• Give half the fluid (LR) in the first 8 hours then the next half (LR) over the next 16 hours. See Fluid Infusion

Rate < 30 kg.

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Resuscitation guidelines• Insert a foley as necessary depending on burn size.• Burns of the penis may require insertion of a foley catheter to maintain patency of the urethra.• Titrate IV rate to maintain a urine output of 1ml/kg/hr.• If there is evidence of hemochromogens the IV rate and urine output will need to be increased.

Eyes• Fluorescein should be used to identify corneal injury.• If eye involvement consider consulting an ophthalmologist.

Circulation• Elevate burned extremities on pillows or blankets to improve circulation and minimize edema.• Monitor pulses with a Doppler if necessary.• Circumferential chest injuries may become life threatening; an escharotomy may be necessary.• Verify that pulselessness is not due to profound hypotension.• Scrotal swelling, though often significant, does not require specific treatment.

Monitor for the following signs and symptoms in full thickness, circumferential burn injuries which may indicate circulatory compromise:

• Pallor or cyanosis of distal unburned skin on limb.• Capillary refill > 5 seconds.• Unrelenting deep tissue pain.• Progressive loss of sensation or motor function.• Inability to ventilate in patients with deep circumferential burns of the chest.

Body Temperature• Keep patient normo-thermic, especially during wound care.• Keep patient covered. When supplies of blankets are depleted, patients can be wrapped in plastic wrap

or aluminum foil for insulation and warmth.• Warm the room.• Warm IV fluid if possible, especially if the patient is very hypothermic.

Labs• Labs on admission and as dictated by medical condition:• Arterial Blood Gases if inhalation injury is suspected• Serum Chemistries/Electrolytes• Complete Blood Count (CBC)• Blood Glucose• EKG for electrical injury• Type and Screen if additional trauma is suspected• Tetanus prophylaxis unless given in last five years.

Comfort• Frequent pain/sedation assessment; minimum every four hours.• Assess patient pain score before and after pain/sedation medication given.• Emotional support and education is essential.• IV analgesia is the preferred route during the initial post injury period.• Administer opioids in frequent small to moderate bolus doses.

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FLUID INFUSION RATE < 30KGBURN INJURY GUIDELINES FOR CARE

* Fluid of choice LR, DO NOT use dextrose containing fluids for titration. D5LR may be used at a constant rate in small children as a glucose source. See Fluid Resuscitation of the Pediatric < 30kg Acute Burn Patient.

Wt (lbs) Wt (kg) % TBSAml/Hr for 1st 8

Hrs of care

11 5 10 12.5

11 5 20 25

11 5 30 37.5

11 5 40 50

11 5 50 62.5

11 5 60 75

22 10 10 25

22 10 20 50

22 10 30 75

22 10 40 100

22 10 50 125

22 10 60 150

27.5 12.5 10 31.3

27.5 12.5 20 62.5

27.5 12.5 30 93.8

27.5 12.5 40 125

27.5 12.5 50 156.2

27.5 12.5 60 187.4

33 15 10 37.5

33 15 20 75

33 15 30 112.5

33 15 40 150

33 15 50 187.5

33 15 60 225

38.5 17.5 10 43.8

38.5 17.5 20 87.5

38.5 17.5 30 131.3

38.5 17.5 40 175

38.5 17.5 50 218.7

38.5 17.5 60 262.4

Wt (lbs) Wt (kg) % TBSAml/Hr for 1st 8

Hrs of care

44 20 10 50

44 20 20 100

44 20 30 150

44 20 40 200

44 20 50 250

44 20 60 300

49.6 22.5 10 56.3

49.6 22.5 20 112.5

49.6 22.5 30 168.8

49.6 22.5 40 225

49.6 22.5 50 281.2

49.6 22.5 60 337.4

55.1 25 10 62.5

55.1 25 20 125

55.1 25 30 187.5

55.1 25 40 250

55.1 25 50 312.5

55.1 25 60 375

60.6 27.5 10 68.8

60.6 27.5 20 137.5

60.6 27.5 30 206.2

60.6 27.5 40 274.9

60.6 27.5 50 343.6

60.6 27.5 60 412.4

66 30 10 75

66 30 20 150

66 30 30 225

66 30 40 300

66 30 50 375

66 30 60 450

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PEDIATRIC PAIN MEDICATION GUIDELINESBURN INJURY GUIDELINES FOR CARE

*When possible try to give patient oral pain medications and start with the smallest dose possible. Please consider renal function before initiating any pain regimen, especially NSAIDs. With IV medications titrate to effect and patient vital signs. It is best to give smaller doses more frequently until the provider is more comfortable with giving bigger doses. Patients will never be pain free, educate them about the burn injury and ask them what pain level is tolerable for them.

Mild to Moderate Pain:

Oral

Acetaminophen 10-15 mg/kg per dose not to exceed 75 mg/kg/day

Ibuprofen 10 mg/kg per dose

Codeine with acetaminophen 0.5-1 mg/kg dose of codeine component

Moderate to Severe Pain:

Oral IV

Hydrocodone with acetaminophen 0.2 mg/kg/dose of hydrocodone component

Morphine 0.05-0.1 mg/kg/dose

Oxycodone with acetaminophen 0.05-0.15 mg/kg/dose of oxycodone component

Fentanyl 1-2 mcg/kg/dose

Oxycodone 0.05-0.15 mg/kg/dose Ketamine 0.3mg/kg/dose

Ketamine 0.05-1mg/kg/hr (use as an adjunct)

Nasal Fentanyl with atomizer 1-2mcg/kg/dose

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BTICU FLUID CALCULATIONWeight (kg): Height (cm):

Body Surface Area (BSA m2) (Mostellar Equation1): m2

Total Body Surface Area burn2 (TBSA): (as a whole number)

Fluids given prior to arrival: ml Urine output prior to arrival: ml

Burn Injury Time:

Time of Admission:

1 . RESUSCITATION CALCULATION

Resuscitation and Basal Requirement Formula:

(4 ml × kg × TBSA) + (1500 ml × BSA m2) = ml (total fluids in 24hr)

÷ 2 = ml

÷ 8 (begin fluid resuscitation rate3) = ml/hr

Give ½ of the total fluids in the first 8 hours.

2. MAINTENANCE CALCULATION

Basal requirement in 24 hours:

(1500 ml × BSA m2) ÷ 24 = ml/hr

Evaporative Water Loss per hour:

Adults: (25 + TBSA) × BSA m2 = ml/hr

Children: (35 + TBSA) × BSA m2 = ml/hr

Calculated Maintenance Rate4 = (basal requirement + evaporative loss) ml/hr

Attending Signature:

RN Co-Signature:

1. If manually calculating the BSA, BTICU uses the Mostellar Equation.

2. TBSA is calculated using the “Lund and Browder Chart”. Although spoken of as a percent, the value is used as a whole number when completing all calculations.

3. Per the Parkland Formula, ½ of the total fluids calculated for the first 24 hours should be given in the first 8 hours. However the BTICU only uses the rate calculated for the first 8 hours as a starting point for the first hour. This is your “begin fluid resuscitation rate” as noted on Step One of the BTICU Adult/Pediatric Fluid Resuscitation Order. The remaining hourly fluid requirement is titrated based on hourly urine output. See the BTICU Adult/Pediatric Fluid Resuscitation Order for more details.

4. Calculated maintenance rate is the total fluid goal once the patient has completed their fluid resuscitation.

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Call Attending

FLUID RESUSCITATION OF THE PEDIATRIC < 30kg ACUTE BURN PATIENT:

ALBUMIN PROTOCOL

UOP <0.9ml/kg/hr

• Consider order for bladder scan

• Flush foley with 10ml sterile H2O

UOP <0.5ml/kg/hr

ml/hr

for two hours despite an increase in fluid

Total maintenance fluid rate

of LR/D5LR

reached and held for two hours and the pt. is at least 24 hours

Fluid resuscitation is COMPLETE

Switch to D5 0.45 NS with 20 mEq KCL at Run IV @ calculated

Total maintenance fluid rate

@

STOP LR/D5LR NOW GOAL RATE= ALL FLUIDS

Call Attending and consider:

• Order for bladder pressure

• beginning ALBUMIN PROTOCOL

If patient again develops oliguria or hemodynamic

instability CALL ATTENDING and restart patient on LR/D5LR

Increase IV rate by 10% Leave IV at current rate Decrease IV rate by 10%

UOP 1–1.9ml/kg/hr

ml/hr

UOP > 2ml/kg/hr

ml/hr

UOP > 4ml/kg/hr

ml/hr

Consider decreasing IV rate every 1/2 hr by 10%. Be sure to assess patient’s blood sugar, BP, HR, lactic

acid, hemoglobin, before decreasing IV rate. Consult with CN first, then Attending for any questions.

Vital Signs Stable: HR < 180, Systolic BP > 80

REPEAT STEP ONE EVERY HOUR UNTIL:

Vitals unstable: HR > 180 or Systolic BP < 80

Pt. Wt kg on admission

Begin fluid resuscitation

LR @ , & D5LR @ 25ml/hr

Then measure urine output hourly

STEP ONE

Attending Signature: Date

RN Co-Sign: Date

If patient requires > calculated fluids or has complications related to edema, consider Albumin protocol.

Patient may need colloid resuscitation: Call attending to discuss starting 5% albumin at one-third current hourly rate, LR/D5LR at two-thirds current rate. Example (if

current rate of LR/D5LR is 90 ml/hr, it should be changed to 60 ml/hr LR/D5LR, and 30 ml/hr 5% albumin.

Repeat step one until patient maintains total maintenance fluid rate with UOP greater than 1ml/kg/hr for two hours.

When combined LR and Albumin rates reach the total maintenance fluid rate change to LR for two hours.

If patient maintained UOP for two hours on LR/D5LR and is 24 hours post burn

FLUID RESUSCITATION IS COMPLETE. Change to D5 0.45 NS with 20 mEq KCL/L at goal rate.

26

WOUND CARE SUPPLY GUIDELINEBURN DISASTER CRISIS STANDARDS OF CARE

*Suggested wound care supplies for the treatment of ten patients with 50% TBSA burns for three dressing changes

Description Quantity Notes

Wound Veil (24in x 36in)

30 packets

Recommend adding an additional 5 packets when possible

Two sheets per pack.

If Wound Veil is unavailable, Adaptic can be substituted. There are approximately six 9x16 Adaptics to one package of veil, equaling 180 packages.

Mesh Gauze (18 in x 18 in)

30 boxes

Recommend adding an additional 5 packets when possible

6 gauze per pack

Fluff roll or Kerlix (4.5 x 4.1 yd)

150 rolls

Recommend adding an additional 5 rolls when possible

Estimated at 5 rolls per dressing

Kerlix sponges (4 in x 4 in)

30 boxes

Recommend adding an additional 5 boxes if possible

10 sponges per box

Tubular elastic dressing retainer # 1 (otherwise known as netting )

2 boxes 50 yds per box

Netting # 3 2 boxes 50 yds per box




Betasept 4 % (960 ml) or a mild, non-perfumed soap. Baby shampoo could also be used.

15 bottles of Betasept.

30 bars of soap, 1 per patient per day.

30 1 fluid oz bottles of baby shampoo, 1 bottle per dressing change.

Can use 5 bottles of Betasept per day for the 10 patients and pour at a central location; NOT in the patient’s room due to crosscontamination risk.

Basin (large) 15This number includes 5 extra in case additional are needed.

Scissors sharp/blunt 30 pairs Could decrease this number to 20

Tape (1 in x 10 yds) 30 rolls

Elastic bandage 4 in x 4.5 yds (Ace wrap ) 4 bundles (total of 40 Aces ) 10 bandages per bundle

This is a simplified list containing only burn-specific supplies. Other items that could be required would include personal protective equipment, IV tubing, LR (suggest 100 liter bags), topical ointments or silver-impregnated products, warming blankets, heater unit (3 units with 10 blankets), IV/blood warmers with tubing (3 units and 30 sets of tubing). Optimally, supply carts are locked and burn wound care fast reference cards are laminated and tied to the cart. In the event that dressing supplies are exhausted, burn wounds can be placed in a topical ointment/wound product and dressed with clean cotton t-shirts, socks, gloves, biker shorts, onesies, maxi pads or diapers.

27

WOUND MANAGEMENT TREATMENT GUIDELINESBURN INJURY GUIDELINES FOR CARE

It is not always possible to know burn depth for several days as burn appearance may be deceiving or burn injury may deepen.

Depth of injuryWound characteristics

Course Intervention/Care

First degree

Limited damage to epidermis, skin intact

• Painful

• No immediate blister formation

• Red

Heals completely in 3–5 days, without scarring

*Give pain medications as necessary. Open to air. Wash with mild soap, water and wash cloth twice per day.

Superficial/partial thickness (second degree)

Epidermis destroyed, minimal damage to superficial layers of dermis

• Pink or red

• Moist

• Weepy

• Blanching

• Blisters

• Painful

Usually heals completely within 5–21 days with little or no scarring. Grafting not usually required.

*Give pain medications. Wash with mild soap, water and wash cloth. Dress wound with topical ointment; change every 12–24 hours. If silver-impregnated dressing is used, follow manufacturer’s guidelines.

Deeper (second-degree)

Epidermis and dermis involved

• May be red or pearly white

• Drier in appearance than superficial injury

• Painful

May take 3–8 weeks to heal, sometimes with heavy scarring. May require a skin graft.


Full thickness (third degree)

All epidermis and dermis destroyed

• White, cherry red, brown or black in color

• Hard and leathery

• Insensitive to pinprick

Prolonged healing; will require a skin graft.


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OUTPATIENT WOUND CARE INSTRUCTIONSBURN INJURY GUIDELINES FOR CARE

If you have questions, please call University of Utah Health Burn Center at (801) 581-2700.

Silver Sulfadiazine Dressing (Thermazene or Silvadene)

Your burn has been dressed in Silver Sulfadiazine. This is to be changed twice a day. This is very important to promote healing and prevent infection.

Follow these guidelines as your care provider has instructed you:

a. Wash the burn with mild soap, water, and a washcloth, removing all old ointment and any loose skin.

b. Blot dry.

c. Apply a thick coat of Silver Sulfadiazine (like icing on a cake) and cover with a minimal amount of gauze netting. Silver Sulfadiazine tends to work better when some air can get through the dressings.

Bacitracin/Neosporin/Polysporin and Non-Stick Gauze

Your burn has been dressed in a topical ointment with non-stick gauze. This dressing is changed once a day. This is very important to promote healing and prevent infection.


a. Wash the burn with mild soap, water, and a washcloth, removing all old ointment and any loose skin.

b. Blot dry.

c. Apply a thin layer of ointment, only to the injured areas.

d. Place non-stick dressing over the ointment. Do not overlap excessively.

e. Cover with a minimal amount of gauze followed by netting.

Silver Impregnated Dressing

Your burn has been dressed in a Silver Impregnated Dressing. This dressing is NOT to be changed until your next clinic visit.


a. Keep dressing clean, dry and intact. If your dressing becomes wet, please contact your care provider. You may change the outer gauze wrap and netting if there is excessive drainage or it becomes dirty. Do NOT remove silver-impregnated dressing.

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GENERAL WOUND CARE GUIDELINES

Moisturizer and Sun Block

Oil glands, which provide natural oils to keep the skin moisturized, become damaged as a result of the burn injury. Frequent application of moisturizer to healed areas can help skin stay hydrated and therefore less dry. Healed skin is pink and shiny with no drainage.

As the skin heals it relearns its natural pigmentation, although it may never completely return to its original color. During this time it is important to protect your skin from the sun. If the skin is sunburned or tanned while healing, pigmentation can change long term. During the first year, or as long as your skin is pink, red or purple, you should use sunscreen and protect your skin with clothing or compression garments.

Face and Neck Burn

Face and neck burns should be washed at least twice a day, removing old ointment and any loose skin. Apply topical ointment to all open areas. If this ointment is rubbed off during the course of the day, reapply topical ointment as often as needed to keep wounds moist.

Infection

A low-grade fever associated with burn injuries is normal. Cellulitis, however, is a localized infection of the burn wound and would benefit from simple treatment. If there is redness spreading out from the burn wound and the surrounding skin is warm and swollen, you should contact the care provider immediately.

Bathing

*DO NOT BATHE IF IN SILVER IMPREGNATED DRESSINGS. A sponge bath to other areas is fine as long as the wounds dressed in the silver product remain dry.* A daily bath is helpful in wound management. Shampoo and other chemicals involved in bathing will not contaminate your burn injury. Before getting out of the tub/shower, wash your wounds as described above.

Diet

Fluid intake is very important. Increasing your normal fluid intake with juices and drinks high in protein and calories will help speed healing. If available, flavored sports drinks are a great option. Be sure to eat well-balanced, nutritious meals.

Activity

Maintaining function of a burned extremity decreases pain and swelling as well as promotes healing. Therefore, we encourage normal activity except when otherwise instructed by your care provider.

Pain Control

Dressing changes are often very painful and medication cannot take all the pain away. It may be helpful for you to take pain medication 30 minutes before doing the dressing change. Please talk with your care provider about appropriate pain medication and any required refills.

Itching

Your dry skin, combined with sensory nerves growing back, causes itching. Although uncomfortable at times it will lessen over the next few months. Talk to your care provider about medications that might ease itching.

Tight Tough Skin

Continued physical therapy and stretching will soften the skin over time. It will not feel that way forever.

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31

PHYSICAL THERAPY GUIDELINESBURN INJURY GUIDELINES FOR CARE

POSITIONINGBurn-injured extremities should be elevated with pillows. Upper extremities should be positioned with the shoulders abducted to 90°, elbows extended, palms up. If the hands are involved, the patient should have a resting hand splint. This can be fabricated out of gauze wraps, casting material, splinting material or purchased (see illustrations). The lower extremities should be positioned with the knees in extension and the feet supported in neutral. If the burn is partial thickness, the feet can be supported with pillows. If the burn is deep, the feet should be in a foot splint, if possible. It is important to keep the heels protected with gel pads and limit weight bearing on the heels while the patient is on bed rest. In addition, patients with neck and ear burns should not be allowed to use pillows with the exception of a donut head pillow. Gel pads can be used on the back of the head to help prevent pressure sores.

ACTIVITY/ROMThe patient should not be encouraged to increase activity during the first 24-48 hours of fluid resuscitation. Once the patient is stable and they do not have any additional injuries such as fractures or exposed tendons, they should be able to move all areas that are burned. They should flex and extend the knees, elbows and wrists. They should raise their arms over their heads. They should make circles with their ankles. They should touch each fingertip to their thumb and then straighten the fingers. If the back of the hand has a deep burn they should not try and make a fist. Standing and ambulating are fine, even if the bottoms of the feet are burned. Sitting and trying to feed themselves should be encouraged. The patient should continue to elevate extremities during periods of rest, which will prevent swelling.

Exercise stimulates circulation, reduces swelling, maintains strength and functional movement and prevents scar contracture. Exercise and mobility also prevent serious medical conditions such as blood clots, pneumonia and bone loss. A burn wound will heal in the position it is held most often. For this reason it is important to maintain proper positioning during rest to prevent contractures.

Physical Therapy

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Phys

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CRUCIAL POINTSBURN INJURY GUIDELINES FOR CARE

*Items in bold are action items

AIRWAY MANAGEMENT• Those with Inhalation injury will do worse than those without inhalation injury.

• Tracheobronchitis with severe spasm and wheezing may occur in the first minutes to hours post-injury.

• The onset of symptoms is so unpredictable that the patient with possible inhalation should be observed for 24 hours.



• Secure the ETT with ties passed around the head; do not use tape, as it will not adhere to burned tissue.


• In unresuscitated patients, supraglottic edema may be delayed in onset until fluid resuscitation is well underway. Prophylactic intubation is preferred because the ensuing edema obliterates the landmarks needed for successful intubation.

• Supraglottic edema may occur without direct thermal injury to the airway but secondary to the fluid shifts associated with the burn injury and fluid resuscitation.

• Noxious chemicals are adherent to smoke particles and cause damage to the epithelium of the large airways. Smaller airways and terminal bronchi are usually affected by prolonged smoke exposure.

• Pathophysiology changes associated with injury below the glottis include:

› Sloughing of the epithelial lining of the airway, mucus hyper secretion, impaired ciliary activity, inflammation, surfactant inactivation, pulmonary edema, ventilation/perfusion mismatch, increased blood flow, spasm of bronchi and bronchioles and impaired immune defenses.

• Chest X-rays are often normal upon admission of patients with inhalation injuries.

• The presence of inhalation injury markedly worsens prognosis of cutaneous burns, especially if the burn is large and the onset of respiratory distress occurs in the first few hours post-injury.

• Mucosal sloughing may occur as late as 4-5 days following an inhalation injury.

• Anyone with an inhalation injury is subject to increased respiratory secretions and may have a large amount of carbonaceous debris in the respiratory tract. Frequent and adequate suctioning is necessary to prevent occlusion of the airway and endotracheal tube.

Crucial Points

34

FLUID MANAGEMENT• Unless blood loss has occurred or the patient is extremely anemic, packed red blood cells should not be

given.

• Fluid loss associated with burn injuries is slow and progressive. Patients with burns usually do not develop shock within 60 minutes from time of injury if left untreated unless there are associated injuries or medical conditions in addition to the burn.

• Initially burns do not bleed; if there is bleeding there may be associated trauma. For more detailed fluid management instructions refer to the Fluid Infusion Rate chart.

EATING AND DRINKING• During IV fluid resuscitation, patients are not given anything to drink or eat because the stress on the

body as a result of the burn affects the stomach’s ability to digest. If food or fluids are given before normal stomach activity returns, the patient may become sick and vomit.

• After two to three days the body begins to use energy at a very rapid rate. This increased use of energy is characterized by an increase in heart rate, respiratory rate and body temperature. Due to these changes, the body requires a large amount of calories and protein to heal.

• In large burns, an IV alone provides inadequate nutrition, so it may be necessary to place a feeding tube. This tube can be removed when patients are able to eat enough on their own.

• Patients should be encouraged to drink fluids containing calories and protein instead of water.

• There are many drinks available to add calories and protein; milk is the easiest and least expensive. Other options include supplements such as Carnation Instant Breakfast, Ensure, etc.

WOUND MANAGEMENT• Prior to initiating care of the patient with wounds, it is critical that healthcare providers take measures

to reduce their own risk of exposure to potentially infectious substances and/or chemical contamination. In addition, patients with burns/wounds are at high risk for infection and potential cross contamination. Body substance precautions are the most effective way to do this. The level of protection utilized will be determined by patient presentation. Patients with burns > 20% TBSA are most at risk.

• Any clean, non-sterile dressings may be used on a burn patient.

• Burned scalps and faces should be shaved daily if possible.

• Genitalia and perineal burns may require a foley to maintain patency.

• Wrap fingers and toes separately if possible when burned.

• Be sure to check for sulfa allergy prior to applying silver sulfadiazine cream to a patient.

• Elevate burned extremities above the level of the heart on pillows or blankets.

• The layer of silver sulfadiazine should be thick enough to prevent the wound from drying out prior to the next dressing change.

• Other appropriate dressing coverage includes silver-impregnated or any broad spectrum antimicrobial.

Cru

cial

Poi

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35

• The purpose of a dressing is to keep the cream from rubbing off before the next dressing change.

• Do not use silver sulfadiazine cream on the face and keep all topical creams out of the eyes.

• If silver sulfadiazine or silver products are not available, consider using another antibiotic ointment such as Bacitracin/Neomycin/Polysporin.

• For more detailed dressing instruction refer to the Outpatient Wound Care Instruction Sheet.

PAIN CONTROL• Burn pain is excruciating because of the exposed nerve endings and patients will require large doses of

narcotics.

• Education to the patient regarding why the burn hurts is important; this will alleviate some of their anxiety and make them feel better.

• For more detailed pain control instructions refer to the Adult and Pediatric Pain Medication Guidelines.

TEMPERATURE CONTROL• Because burn patients are unable to regulate their own body temperature, blankets need to be used in

order to keep the patient warm.

• If supplies of blankets are depleted, patients can be wrapped in plastic wrap or aluminum foil for insulation and warmth.

• Hypothermia causes vasoconstriction of the blood vessels and will decrease blood flow to already compromised areas of burn injury.

COMFORT CARE

Aggressive treatment may need to be denied to those patients with severe burn injuries in the event of a disaster where resources are depleted and there are large numbers of patients. This will ensure the greatest number of people benefit from the limited care and resources available.

Patients placed in the comfort care category should not be intubated but oxygen should be administered to aid comfort and prevent air hunger. IVs should be started for administration of medication to manage pain and anxiety. Do not administer large volumes of fluid. Excessive fluid will result in decreased circulation and increased pain due to edema and constriction of circumferential burns of the torso or neck and changes in sensorium due to cerebral edema. Psychological support should be provided to the patient and to their families.

Comfort care patients may need to wait for provider and resource availability. These patients may also need to wait for transfer until all other patients have been moved.

For more detailed information please refer to the “Prolonged Care of the Burn Patient in a Non-Burn Facility following a Burn Mass Casualty Incident (BMCI)” modules at the end of this toolkit.

36

RADIATION INJURY—EDBURN DISASTER CRISIS STANDARDS OF CARE

See Radiation Patient Treatment Algorithm on next page.For 24/7 assistance, contact Radiation Emergency Assistance Center (REAC/TS): 865-576-1005.

IF RADIATION IS SUSPECTED OR IF AN EXPLOSIVE EVENT TRIGGER IS UNKNOWN:

• Use appropriate PPE (Tyvek suit, if available—gown, gloves, and mask suffice).• Don’t let patients die whilst waiting for decontamination. If life saving care needs to be performed

prior to entering the facility a medical team wearing appropriate PPE should provide care until decontamination occurs.

• Trauma trumps decontamination. Decontaminate as able, but decontamination should NOT supersede critical intervention. Minimize exposure of personnel and equipment by properly containing potential contaminants. (Cover contaminated wounds, cocoon-wrap patient, etc.)

• Exposure and/or contamination alone are NOT medical emergencies. Begin with head-to-toe assessment and triage.

• The psychological well-being of the patient should be constantly addressed.

If radiation contamination is suspected, a contamination survey can be conducted with a Geiger meter (“pancake probe”). Contact your HAZMAT team and/or local RITN Center for support and notify your assigned regional coalition coordinator in addition to the DOH at 866 364-8824.

FOLLOW STANDARD ATLS GUIDELINES• Maintain airway, breathing, circulation.• Monitor for disability and deficit.

› If deficits exist consider lethal radiation dose.

CONSIDERATIONS:• Establish a secure perimeter to prevent unnecessary exposure/contamination of personnel, equipment,

and facility. Direct patient traffic to appropriate areas.• Universal precautions (Tyvek suit, if available—Bunny suit, surgical gloves under disposable gloves, mask/

hood suffice) to avoid unnecessary contamination of personnel and equipment.• Maintain “clean” and “dirty” zones to avoid cross-contamination: Cover unnecessary items with

plastic/sheets as available. Place tape on floor and cordon off areas for “contaminated” and “clean” zones. Conduct radiological survey of all persons/equipment leaving the “contaminated” zone to prevent contamination of clean areas. If transport of contaminated patients is necessary prior to decontamination place a hair net and cocoon wrap the contaminated patient/wound and clean equipment prior to movement. Use the shortest possible route.

• Removal of contaminated clothing and shoes and rapid washing of exposed skin and hair removes 90% contamination.

• As soon as reasonably feasible, decontaminate open wounds, orifices, and known contaminated sites on patient. Ask the patient to blow their nose.

› Decontamination of a wound—Using one cleansing wipe at a time, clean from OUTSIDE IN, with a single swipe per cleansing cloth. Dispose of cleansing wipe after single swipe and start fresh, continuing from OUTSIDE to INSIDE.

• Considering possibility of internal contamination (inhalation or ingestion of radionuclides or open wound contamination), it is important to swab nares and/or wound for radiological survey. Collect expelled bodily fluids for safe disposal per hospital-specific guidelines.

• VENTILATION—As reasonably feasible, perform triage, treatment, and decontamination in Negative Pressure spaces to avoid recirculation of potentially contaminated air throughout the department or facility. Consult Emergency Management or Engineering teams to discuss need for further ventilation precautions.

37

Radiation Injury

38

RADIATION INJURY—DEFINITIVE CAREBURN DISASTER CRISIS STANDARDS OF CARE

Hematopoietic Syndrome• Seen in absorbed doses of 1 Gy or greater and require 7 days or more to manifest, depending upon dose.• Filgrastim/Pegfilgrastim for neutropenia.• Packed Red Blood Cells and Platelets should be irradiated, if possible, per AABB guidelines.• Platelet transfusion parameters in the non-hemorrhagic patient for platelet counts of <15,000.• In the presence of open wounds or bleeding, a higher parameter may need to be considered.

Gastrointestinal Syndrome• Nausea and vomiting are the earliest indicators of gastrointestinal syndrome.• Time-To-Vomiting is an indicator of absorbed dose. (See Table 2 in Reference Tables)• Aggressive management of fluid loss.• Antiemetic regimen—5HT3 antagonists, benzodiazepine, and phenothiazines.• Patients will not be amenable to enteral feeding and may require parenteral nutrition.• Expect development of anorexia, abdominal pain, and diarrhea.

Neurovascular Syndrome• Seen in very high dose exposures (20-30 Gy).• Cognitive and neurological deficits, ataxia, seizures, and hypotension may all present from cerebral edema.• Symptoms present hours to days from exposure and are generally fatal.

Cutaneous Radiation Syndrome• Epilation 3 Gy ~ 17 days• Erythema/blistering 6 Gy May be early (days) to weeks• Dry Desquamation 10–15 Gy 2–3 weeks• Wet Desquamation 20–50 Gy 2–3 weeks• Deep Ulceration > 30 Gy > 3weeks

Infection Risk• Absolute Neutrophil Count (ANC) <500 puts patient at high risk for opportunistic infection.• As possible, patients should be maintained in Positive Pressure environment:

› Strict hand washing; all personnel need to follow facility protocol for isolation. › Patient should wear protective face mask (N-95 standard) when outside isolation.

• Prophylactic standard of care is a flouroquinolone, acyclovir, and an antifungal.• In febrile patient, antibiotic coverage must be expanded to include gram positive and gram negative bacteria.• Infection risk is directly related to neutropenia and varies by patient.

Considerations for Acute Radiation Syndrome and Radiation Burns• Incident history• History of Signs and Symptoms• Physical Examination—document skin changes. (See Cutaneous Radiation Syndrome above.)

› If skin changes occur over time and are indicative of radiation burns, treat the affected area in accordance with thermal burn treatment guidelines and consider consultation with local Burn Center.

• Labs to consider in addition to routine labs: › CBC/diff every 6 hours › Absolute Lymphocyte Count (ALC) › Serum amylase › Urinalysis and urine for bioassay in addition to a 24 hour fecal.

NOTE: Transfer of radiation patients to an RITN facility should occur as soon as conditions allow. For guidance call: 865-576-1005 (24/7 Ask for REAC/TS).

Radi

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39

REFERENCE TABLES

Table 1. Phases of Radation InjuryDose Range, Gy Prodrome Manifestation of Illness Prognosis (without Therapy)

0.5–1.0 Mild Slight decrease in blood cell counts Almost certain survival

1.0–2.0 Mild to moderate Early signs of bone marrow disease Highly probable survival (>90% of victims)

2.0–3.5 Moderate Moderate to severe bone marrow disease Probably survival

3.5–5.5 Severe Severe bone marrow damage; slight GI damage Death within 3.5–6 wk (50% of victims)

5.5–7.5 Severe Pancytopenia and moderate GI damage Death probable within 2–3 wk

7.5–10.0 Severe Marked GI and bone marrow damage, hypotension Death probable within 1–2.5 wk

10.0–20.0 SevereSevere GI damage, pneumonitis, altered mental status, cognitive disfunction

Death certain within 5–12 d

20.0–30.0 Severe Cerebrovascular collapse, fever, shock Death certain within 2–5 d

*Modified from Walker RI, Cerveny RJ, eds. (21). GI = gastrointestinal.

Table 2. Triage Categories Based on Time-to-Emesis

Physical injury without irradiation

Expected changes in triage categories after whole-body irradiation

< 2 Gy Vomit > 4 h

2–6 Gy Vomit 1–4 h

> 6 Gy Vomit < 1 h, early erythema

Uninjured Ambulatory monitoringAmbulatory monitoring,

administer cytokines and delay hospitalization

Minimal Minimal Delayed

Delayed DelayedVariable

Immediate Immediate

Expectant

*From Uniformed Services University of the Health Sciences (USUHS)

Table 3. Triage Category Affected by Radiation Dose and Resource AvailabilityRadiation Dose* (Gy) RADIATION ONLY

> 10* Likely fatal (in higher range)

Expectant3

Expectant3 Expectant3 Expectant3

Immediate2

6–10* Severe

Immediate2 Immediate2 Delayed2 Expectant3

> 2–6* Moderate

Immediate1 Immediate1 Immediate1 Immediate1

> 0.5 – < 2* Minimal

Minimal B3 Minimal B3 Minimal B3 Minimal B3

< 0.5* Minimal

Minimal A3 Minimal A3 Minimal A3 Minimal A3

Resource availability Normal Good Fair Poor

Standard of care Conventional Contingency Crisis Crisis

Legend: Radiation Only

* Radiation dose received by the whole body or a significant portion of the whole body.

** Institute of Medicine. Guidance for establishing crisis standards of care for use in disaster situations: A letter report. Washington, DC: Institute of Medicine, National Academies of Science; 2009.

Expectant

40

BURN MASS CASUALTY INCIDENTACTIVATION ALGORITHM

BURN INCIDENT

w/ 10+ persons involved *

866-364-8824

24/7 On-Call Line

Western Region Burn Coordinating Center Activation

Western Region Burn Disaster Consortium Bed Census (UNIS)

Coordination of Patient Triage & Transfer if needed*Or as defined by state/ individual healthcare facility/EMS Agency

41

WESTERN REGION BURN DISASTER CONSORTIUMMASS BURN EVENT

96-HOUR RESPONSE PLAN

Agency/Entity Primary Roles Secondary Roles

EMSLocal Healthcare CoalitionPublic Health (PH) Emergency Management (EM)

• Rescue, transport, and distribute casualties to appropriate local facilities in accordance with established burn center MCI protocols.

• Request/mobilize any coalition/regional caches of burn supplies.

• Activate coalition coordination mechanisms and any burn-specific plans.

• Coordinate local lists of casualties and clinical information.

• Triage/prioritize patients for forward movement to specialty centers in accordance with established BMCI protocols and /or expert input.

• Coordinate with burn experts to determine appropriate destinations for patients that cannot be accommodated in the local healthcare system with assistance from state and American Burn Association (ABA).

• Assure that appropriate clinical information is relayed between the referring and receiving facilities during the transfer process.

• Coordinate information with state/federal/ABA partners.

Closest ABA Burn Center

• Provide patient care.• Activate facility and regional surge

capacity plans to accommodate multiple patients.

• Liaison between local response and regional ABA coordinating center.

• Assist with patient triage for forward movement.

• Support facilities providing care for burn patients in the area via telephone or telemedicine and/or request support from WRBDC coordination center.

• Ensure burn surge facilities use existing resources (Prolonged Care of the Burn Patient in a Non-Burn Facility following a Burn Mass Casualty Incident [BMCI]).

Burn Mass Casualty

Incident (BMCI)

42

Agency/Entity Primary Roles Secondary Roles

Western Region Burn Coordination Center (WRBDCC)

• Serve as the point of contact (POC) for the ABA system.

• Conduct bed polling initially and as needed within ABA region (and request assistance from adjacent regions as required).

• Assist the affected local burn center and state PH in determining appropriate patient destinations and transportations.

• Assist with the tracking of patient movement including arrival to destination centers. Provide updates as requested.

• Facilitate requests for tissue bank products, as well as graft equipment and other specialized supplies.

• In collaboration with state and regional partners, establish when the BMCI has concluded.

• Establish any post-incident system needs and initiate after action report (AAR) process.

• Assist with bed matching (right patient to right bed/facility, while being mindful of family units).

• Facilitate exchange of patient transfer information between referring and receiving facilities once patients are matched to destinations.

• Assist the affected local burn center and/or burn surge facility by providing expert advice or telemedicine as requested. Engagement of other WRBDC facilities will be imperative.

• Circulate/facilitate additional staff and supply needs as possible (e.g., notify regional facilities of specialized resource/staff requests that they may be able to assist with) in conjunction with affected community and Assistant Secretary for Preparedness and Response (ASPR) Regional Emergency Coordinator (REC).

• Provide situational awareness to all appropriate agencies

State PH/EM • Support local jurisdiction with state-level coordination and requests for assistance (e.g., federal declarations).

• Assure that patient triage, tracking, and transport needs are addressed.

• Make request for burn care assets, including dressings and other materials from the Strategic National Stockpile (SNS).

• Engage Emergency Management Assistance Compact (EMAC) assets to provide inter-state support for transportation, staff, or other logistics.

• Liaison between local and federal resources.

• Support bed polling and matching functions as required in coordination with ABA regional center.

ABA National Headquarters

• Provide expertise and advice on request from a member center.

• Provide expertise and advice to inform the federal response.

Health and Human Services (HHS)/ASPR

• Provide federal support to local and state activities as requested/ authorized under the National Response Framework including supplies, staff, and transportation assistance through the Federal Coordinating Officer (FCO) appointed to the State for the incident.

• Coordinate approved use of National Disaster Medical System (NDMS) personnel or transportation assets.

• Coordinate information and access to burn expertise during BMCI.

• Support/assist states and ABA information and system needs (e.g., bed polling/data management).

*Plan adopted from the Mass Burn Event Brief accessible at: https://asprtracie.hhs.gov/documents/aspr-aba-oem-mass-burn-event-overview.pdf

Burn

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The following four modules are taken from the “Prolonged Care of the Burn Patient in a Non-Burn Facility following a Burn Mass Casualty Incident (BMCI)” E-Learning curriculum.

They are practice guidelines identifying definitive medical management in the event of a BMCI for 96 hours when resources and personnel are severely limited. The essential, better and best care recommendations build on each other so that movement from one to the other is simple as additional resources became available in a fluctuating resource environment.

Additional E-Learning curriculum can be found at the following website:

http://crisisstandardsofcare.utah.edu

44

45© Western Region Burn Disaster Consortium | Prolonged Care of the Burn Patient in a Non-Burn Facility following a Burn Mass Casualty Incident (BMCI)

MODULE 1INITIAL ASSESSMENT AND MANAGEMENT

Use these Quick Reference Sheets to identify, prepare and package patients for transfer.

The following Crisis Standards of Care recommendations are to be implemented only when numbers of seriously ill patients greatly surpass the capability of available care and normal standards of care can no longer be maintained.

Essential Care This is the minimum care given to patients based on your available resources.

No Access to Advanced Airway/Respiratory Supplies

Primary Survey— Airway & Breathing

� Assess for early signs of upper airway burns

� Monitor for changes in mental status, hypoxia, hoarse voice or stridor

� Open airway using manual maneuvers or airway adjuncts (nasopharyngeal (NPA)/ oropharyngeal airway (OPA)

� Administer high flow oxygen using a non-rebreather mask or via nasal cannula or mask

� Maintain patient in sitting or head elevated position to minimize upper airway edema

› Consider spinal precautions

� Use walking wounded to Bag Valve Mask (BVM) ventilate if necessary

Circulation

� Monitor for signs of shock

Deficits

� Monitor for changing level of consciousness

Exposure

� Remove all clothing

› Decontaminate patient if chemical exposure

Secondary Survey

� Perform head-to-toe assessment

� Obtain patient history

� Document essential information

� Resuscitate with salt-containing fluids

� Priority should be given to:

› Adults with burns >20% TBSA injury

› Pediatric patients with burns >10%

› Associated trauma with blood loss

46 © Western Region Burn Disaster Consortium | Prolonged Care of the Burn Patient in a Non-Burn Facility following a Burn Mass Casualty Incident (BMCI)

� Use Oral Resuscitation Therapy (ORT) if IV access is unavailable

› Up to 20% TBSA

› Consider in up to 40% TBSA

› Sips every five minutes, at least four cups/hr. (1 liter)

› Wait 10 minutes after vomiting

� Use rectal infusion therapy if ORT restricted/no IV

� Tap water or saline up to 400 ml/hr.

� Adjust fluids based on heart rate, capillary refill and mental status

� Minimize patient exposure time

� Warm the room

� Avoid cold surfaces

� Keep patient warm and dry, do not use wet dressings or wet blankets

� Wrap in a space blanket/plastic wrap/large plastic bag/aluminum foil if clean dry blankets are not available

� Measure patient temperature every four hours

� If temperature is <37° C (98.6° F)

› Consider having patient lie close to family member to gain heat

� Evaluate the patient for pain and anxiety

� Assess with a standardized metric

› Under austere conditions a pain level goal of 6-8/10 may be considered

� Non-pharmacologic interventions:

› Elevate burned extremities

› Decrease external stimuli

› Do not use excessive pressure when handling wounds

› Use hypnosis and/or virtual reality if available

› Use family/friends for support

� Use all your resources so patients do not die from a correctable cause (e.g., use laymen to bag ventilate)

� Focus efforts on the moderate (30-60%) burns rather than the minor or severe

� Consider treating some severe as expectant if appropriate

� Call for resources (transportation, supplies, disaster plan activation, or just advice) early

� Do not forget the basics in the first hours—airway, fluids, analgesia

� Transfer patients as soon as possible to make room for more


Better Care Better care builds on essential care and is based on available resources.

Some Access to Advanced Airway/Respiratory Supplies

Primary Survey—Airway and Breathing

� Apply cooled humidified oxygen to minimize upper airway edema

� Maintain airway and provide ventilation using

› Laryngeal Mask Airway (LMA)/High Flow Nasal Cannula/CPAP

� Bag Mask Valve (BVM) ventilation performed by providers

� Begin IV fluid resuscitation

� Primary Survey initial start rates:

› 0-5 years: 125 cc/hr.

› 6-13 years: 250 cc/hr.

› 14 years and older: 500 cc/hr.

Secondary Survey

� Document history and physical on patient record

� Calculate TBSA and adjust fluid rate:

› Body weight in kg x % TBSA burns x 2-4 ml of Lactated Ringers or other isotonic crystalloid over 24 hrs.

› Administer 50% during the first eight hours following the burn

› May use a pre-calculated Parkland Formula fluid infusion chart to begin resuscitation

� Use two clean dry blankets to cover the patient

� Measure patient temperature every two hours

� If temperature is <37° C (98.6° F):

› Use warm IV fluid if possible

› Use forced air warming blanket if available

� Consider oral routes of medication delivery in small (<20% TBSA injury)

� Consider NSAIDs, acetaminophen, gabapentin and benzodiazepines

� Use weight-based, incremental dosing with appropriate frequency to obtain adequate relief

� Use standardized pain scale metrics to quantify pain and anxiety level

� Be prepared to use any medication available for pain treatment

› Think outside the box

� Consider how resources can be conserved

› Adapt strategies or substitute medications to make what you have go further

� Do not withhold more resources than you have to (proportionality)

� Re-evaluate as the situation evolves


Best Care Best care builds on better and essential care and is based on available resources.

Access to Advanced Airway/Respiratory Supplies

Primary Survey – Airway & Breathing

� Intubate at the first signs of airway edema: hoarseness, stridor, or progressive voice change

� If insufficient ventilators

› Use walking wounded to bag patient

› Assess whether T-piece blow-by oxygen directly attached to the ETT may be sufficient

› Use transport ventilators in those with minimal airway needs

› Consider ventilator sharing in those with similar injuries

� Consider nasopharyngeal endoscopy or video-assisted laryngoscopy in airway assessment

� Consider bougie-assisted endotracheal intubation/intubating bronchoscope in edema obscuring landmarks

� Perform cricothyrotomy in patients with edema who cannot be intubated

Secondary Survey

� Burn Center consult via telemedicine or other available method

� Use Lactated Ringers

› If unavailable another isotonic crystalloid can be used

� Dextrose containing fluids should NOT be used for burn resuscitation

› Exception in the very young who require a glucose source in addition to resuscitation fluid

� Perform ongoing patient temperature evaluation

� If temperature is <37° C (98.6° F) treat according to Evidence Based Warming Strategies in Trauma

› Radiant warmer

› Humidified ventilation

› Circulating water garment

› Consider body cavity lavage, continuous arteriovenous warming, extracorporeal membrane oxygenation/bypass

� Intravenous opioids are the appropriate initial treatment for acute burn pain

› Unless the injury is minor

� Consider the Intraosseous route

� Consider use of IV benzodiazepines to alleviate anxiety and augment pain control

� Use standardized metrics to quantify pain and anxiety level

› Lower pain levels of 2-4/10 are desired

� Consult with a burn center and distribute patients to burn/burn surge facilities

� Follow local and regional burn coordination mechanisms for movement of patients and supplies

� Use transfer vehicles/aircraft to bring supplies and personnel when appropriate


MODULE 1 INITIAL ASSESSMENT AND MANAGEMENT

Prolonged Care of the Burn Patient in a Non-Burn Facility Following a Burn Mass Casualty Incident (BMCI)

ADDITIONAL GUIDELINES

Rule of Nines Rule of Palms

Examples of Oral Rehydration Solutions• One Liter of clean water/one teaspoon

of table salt (3 g)/three tablespoons of sugar (36 g or nine sugar cubes)

• Sports drinks such as Gatorade® or PowerAde®


Burn Size Group, %TBSA All

Age 0–9.9 10–19.9 20–29.9 30–39.9 40–49.9 50–59.9 60–69.9 70–79.9 80–89.9 ≥ 90

0–1.99 Very High Very High High High High Medium Medium Medium Low Low

2–4.99 Outpatient Very High High High High Medium Medium Medium Low Low

5–19.99 Outpatient Very High High High High High Medium Medium Low Low


30–39.99 Outpatient Very High High High Medium Medium Medium Low Low Expectant

40–49.99 Outpatient Very High High Medium Medium Medium Medium Low Low Expectant

50–59.99 Outpatient Very High High Medium Medium Low Low Expectant Expectant Expectant

60–69.99 Outpatient High Medium Medium Low Low Low Expectant Expectant Expectant

≥ 70 Very High Medium Low Low Low Expectant Expectant Expectant Expectant Expectant

Burn Size Group, %TBSA NO Inhalation Injury

Age 0–9.9 10–19.9 20–29.9 30–39.9 40–49.9 50–59.9 60–69.9 70–79.9 80–89.9 ≥ 90

0–1.99 Very High Very High High High High High Medium Medium Medium Medium

2–4.99 Outpatient Very High High High High High High Medium Medium Medium

5–19.99 Outpatient Very High High High High High High Medium Medium Low

20–29.99 Outpatient Very High High High High Medium Medium Medium Medium Low




60–69.99 Very High High Medium Medium Low Low Expectant Expectant Expectant Expectant

≥ 70 High Medium Medium Low Low Expectant Expectant Expectant Expectant Expectant

Burn Size Group, %TBSA WITH Inhalation Injury

Age 0–9.9 10–19.9 20–29.9 30–39.9 40–49.9 50–59.9 60–69.9 70–79.9 80–89.9 ≥ 90

0–1.99 High Medium Medium Medium Medium Medium Low Low Medium Medium

2–4.99 High High High High High Medium Medium Medium Low Low

5–19.99 High High High High Medium Medium Medium Medium Low Low

20–29.99 Very High High High Medium Medium Medium Medium Low Low Expectant


40–49.99 Very High High Medium Medium Medium Low Low Low Low Expectant

50–59.99 High Medium Medium Medium Medium Low Low Expectant Expectant Expectant

60–69.99 Medium Medium Medium Low Low Low Expectant Expectant Expectant Expectant

≥ 70 Medium Medium Low Low Expectant Expectant Expectant Expectant Expectant Expectant

OUTPATIENT: Survival and good outcome expected without requiring initial admission.

VERY HIGH: Mortality ≤10%, anticipated length of stay ≤ 4-21 days, 1-2 surgical procedures.

HIGH: Mortality ≤10%, anticipated length of stay ≥14-21 days, multiple surgical procedures.

MEDIUM: Mortality 10-50%, with provision of aggressive treatment which may require prolonged hospitalization and multiple surgical procedures.

LOW: Mortality 50-90%, even with provision of prolonged, intensive resources.

EXPECTANT: Mortality ≥90%, even with prolonged aggressive care.


MODULE 20 TO 48 HOURS




No Access to Advanced Airway/Respiratory Supplies

� Frequent respiratory assessment and communication with provider � Provide oxygen via nasal cannula or mask

› Oxygen saturation of 90-92% is acceptable � Open airway using airway adjuncts (nasopharyngeal (NPA)/oropharyngeal airway (OPA)) � Suction secretions as needed � Maintain patient in sitting or head elevated position

› Consider spinal precautions � Estimate each patient’s burn size (TBSA %)

› Do not include first degree burns in the TBSA % estimate › Use “Rule of Nines” for large burns › For smaller burns, patient’s palm (including fingers) is approximately 1% TBSA

� Resuscitate with salt-containing fluids › Adults with burns >20% TBSA injury › Pediatric patients with burns >10%

� Use Oral Resuscitation Therapy (ORT) if IV access is unavailable › Up to 20% TBSA › Consider in up to 40% TBSA

� Use rectal infusion therapy if ORT restricted/no IV › Tap water or saline up to 400 ml/hr.

� Adjust fluids based upon heart rate, capillary refill and mental status � Elevate burned extremities � Monitor pulses hourly

› Cut hole in dressings if wounds are wrapped � Educate about why burns are painful � Differentiate between pain and anxiety � Assess with a standardized metric:

› Every four hours › Pre- and post-intervention assessment › Under austere conditions a pain level goal of 6-8/10 may be considered


� Use non-pharmacologic interventions › Elevate burned extremities › Cover the injured areas › Minimize mechanical handling and cleaning › Hypnosis › Virtual reality

� Emphasis on acute and severe pain if resource-limited � Provide adequate pain control and anxiolysis if possible � Avoid scrubbing motions when cleaning � Use only enough pressure to remove loose debris

› Do not try to scrub off intact eschar � Have patients with small burns (<10% TBSA injury) wound care performed by self/friend/ family � If lack of supplies or personnel leave wounds open (open technique)

› Still requires careful and ongoing wound evaluation � Perform dressing changes in a clean environment

› Use clean water › Perform hand hygiene

� Select most appropriate, available topical or solution � Reassess wounds with each dressing change � Use oral intake of meals and supplements to support burn injuries <20% TBSA

› Supplements may include any local option with calories and protein


Some Access to Advanced Airway/Respiratory Supplies

� Maintain airway and provide ventilation using › Laryngeal Mask Airway (LMA)/High Flow Nasal Cannula/CPAP

� Bag Mask Valve (BVM) ventilation performed by providers � Debride the wound � Have a second practitioner confirm the TBSA % calculations � Oral Resuscitation Therapy (ORT) drinking “schedule” to meet targets

› Sips every five minutes › Wait 10 minutes after vomiting › At least four cups/hr. (1 liter)

� Collect urine output in a graduated container � Use IV or IO access for larger or more complicated burns

› Large bore IV › Avoid circumferentially burned extremity

� Use Doppler flow meter for hourly pulse checks � Perform escharotomy

› If unable to palpate distal pulses › Evacuation is delayed

� Use frequent small to moderate doses of analgesics and anxiolytics if available

ORT examples• One Liter of clean

water/one teaspoon of table salt (3g)/three tablespoons of sugar (36g or nine sugar cubes)



� Preferential use of oral agents in small (<20% TBSA injury) burns � Use non-opioid medications as adjuncts � Use of wound dressings in deep partial and full thickness burns (closed technique) � Identify and train a wound care team � Use nutritional supplementation for patients with burns

› >20% TBSA › Facial burns › Those requiring mechanical ventilation

� Consider a feeding tube if resources allow › Gastric or enteral

� Use clean local resources when no commercial products are available


Access to Advanced Airway/Respiratory Supplies

� Secure Endotracheal Tube (ETT): › ETT securement device › Tape (non-burned face only, if no other options) › Twill tie (burned face) › Hold ETT when moving patient and verify depth unchanged

� Perform chest x-ray � Place nasogastric tube � Ensure continuous sedation � Complete the Lund and Browder chart � Burn Center consult via telemedicine or other available method � Use LR or other isotonic crystalloid � Calculate using Parkland formula � Titrate based on urine output or other available monitoring techniques � Do not use dextrose containing solutions for resuscitation

› Exception would be very young patients requiring a glucose source � Perform escharotomy if circumferential 3rd degree burn � Burn Center consult via telemedicine or other available method � Use IV agents for pain management

› Titrated based upon effect and patient vital signs � Standardized metrics for pain scale

› Lower pain levels of 2-4/10 are desired � Multimodal plan to control

› Background pain › Breakthrough and procedural pain

� Use of durable silver dressings › Decreases need for pain control and clean environment for wound care › Preserves personnel time and effort

� Provide 50-60% of caloric goal in the first week after injury






Head 19 17 13 11 9 7

Neck 2 2 2 2 2 2

Ant. Trunk 13 13 13 13 13 13

Post. Trunk 13 13 13 13 13 13

R. Buttock 2.5 2.5 2.5 2.5 2.5 2.5

L. Buttock 2.5 2.5 2.5 2.5 2.5 2.5


R. U. Arm 4 4 4 4 4 4

L. U. Arm 4 4 4 4 4 4

R. L. Arm 3 3 3 3 3 3

L. L. Arm 3 3 3 3 3 3

R. Hand 2.5 2.5 2.5 2.5 2.5 2.5

L. Hand 2.5 2.5 2.5 2.5 2.5 2.5

R. Thigh 5.5 6.5 8 8.5 9 9.5

L. Thigh 5.5 6.5 8 8.5 9 9.5

R. Leg 5 5 5.5 6 6.5 7

L. Leg 5 5 5.5 6 6.5 7

R. Foot 3.5 3.5 3.5 3.5 3.5 3.5

L. Foot 3.5 3.5 3.5 3.5 3.5 3.5

TOTAL

Cause of burn

Additional injuries

Date of burn

Time of burn

Age

Sex

Weight Kg

Height cm

Date of assessment

Time of assessment

Assessed by

BURN DIAGRAM

COLOR CODE

X/red — 3°

=/blue — 2°






� Practice basic infection control concepts

� Do not give prophylactic antibiotics

� Meeting >3 of the following should trigger concern for infection:

› Temp >39°C (102.2° F) or <36 °C (96.8° F)

› Progressive tachycardia >110 bpm

› Tachypnea >25 breaths per minute not ventilated or >12 L/minute ventilated

› Thrombocytopenia <100,000 three days after initiation of resuscitation

› Hyperglycemia >200 mg/dl, >7 units of insulin/hour or >25% increase in insulin requirements over 24 hours

› Feeding intolerance >24 hours

� Reinforce burn pain education

� Continue to differentiate between pain and anxiety and provide psychological support

� Continue to assess with a standardized metric:

› Every four hours

› Pre-and post-intervention assessment

› Under austere conditions a pain level goal of 6-8/10 may be considered

� Continue to use non-pharmacologic interventions

› Elevate burned extremities

› Cover the injured areas

› Minimize mechanical handling and cleaning

› Hypnosis or Virtual reality if available

› Use family/friend for psychological support

� Emphasis on patients with acute and severe pain if resource-limited

� Determine overall health status of each patient

� Identify patients who are in shock or developing organ failure

� Repeat burn wound mapping to estimate true %TBSA

� Repeat triage


� Arrange priority transfer of critical patients to a higher level of care

› With burn surgery capability

� Continue to maintain organ perfusion with maintenance fluids for others

� Watch for and treat infectious complications.

� Continue to provide basic wound care with topical antimicrobials/silver dressings, etc.

� Reassess clinical status of remaining patients

� Use the burn triage table to guide decisions

› Patients re-triaged as expectant should be those who will most benefit from palliative care

› Promoting comfort should be the highest priority

� Assess immediately available resources

� Discuss future expected resources

� Ensure decisions are made equitably using evidence-based data

� Involve the family and patient in discussions


� If infection criteria is met:

› Culture patient

› Evaluate wounds/all sources of potential infection

› Initiate broad-spectrum antibiotics

� Follow up of cultures, antibiotic stewardship and de-escalating antibiotics as able is paramount

� Discontinue antibiotic use:

› If cultures are negative

› If no source is identified

� Use frequent small to moderate doses of analgesics and anxiolytics if available

� Preferential use of oral agents in small (<20% TBSA injury) burns

� Use non-opioid medications as adjuncts

� Consider using non-typical medical adjuncts such as cannabis

› If resources are limited

› Benefits must outweigh the risks

� Arrange priority transfer of the following:

› All burns who will require extensive burn surgery (>10% TBSA)

› Burns to anatomically important areas (face, genitals, hands, etc.)

� Ensure family, patients and staff have access to psychological specialists

� Provide access to spiritual support

� Provide patient and family privacy

� Use a hospital palliative care team if available



� If infectious source is identified:

› Obtain source control

› Treat per infectious guidelines

� Use IV agents for pain management

› Titrated based upon effect and patient vital signs

� Standardized metrics for pain scale

› Lower pain levels of 2-4/ 10 are desired.

� Multimodal plan to control

› Background pain

› Breakthrough and procedural pain

� Prioritize patients

� Transfer those requiring definitive burn wound coverage. (i.e., skin grafting)

� Burn Center consult via telemedicine or other available method

� Initiate “airway rounds” by select providers

� Employ a deliberate system of ventilator allocation by a ventilator triage team

� Consider ventilator sharing with like patients

� Transfer to an alternative care site (e.g. Hospice or long term care site)




ADDITIONAL GUIDELINESBurn Size Group, %TBSA All

Age 0–9.9 10–19.9 20–29.9 30–39.9 40–49.9 50–59.9 60–69.9 70–79.9 80–89.9 ≥ 90











Age 0–9.9 10–19.9 20–29.9 30–39.9 40–49.9 50–59.9 60–69.9 70–79.9 80–89.9 ≥ 90











Age 0–9.9 10–19.9 20–29.9 30–39.9 40–49.9 50–59.9 60–69.9 70–79.9 80–89.9 ≥ 90

















BURN ESTIMATE AND DIAGRAMBURN INJURY GUIDELINES FOR CARE


Head 19 17 13 11 9 7

Neck 2 2 2 2 2 2

Ant. Trunk 13 13 13 13 13 13

Post. Trunk 13 13 13 13 13 13

R. Buttock 2.5 2.5 2.5 2.5 2.5 2.5

L. Buttock 2.5 2.5 2.5 2.5 2.5 2.5


R. U. Arm 4 4 4 4 4 4

L. U. Arm 4 4 4 4 4 4

R. L. Arm 3 3 3 3 3 3

L. L. Arm 3 3 3 3 3 3

R. Hand 2.5 2.5 2.5 2.5 2.5 2.5

L. Hand 2.5 2.5 2.5 2.5 2.5 2.5

R. Thigh 5.5 6.5 8 8.5 9 9.5

L. Thigh 5.5 6.5 8 8.5 9 9.5

R. Leg 5 5 5.5 6 6.5 7

L. Leg 5 5 5.5 6 6.5 7

R. Foot 3.5 3.5 3.5 3.5 3.5 3.5

L. Foot 3.5 3.5 3.5 3.5 3.5 3.5

TOTAL

Cause of burn

Additional injuries

Date of burn

Time of burn

Age

Sex

Weight Kg

Height cm

Date of assessment

Time of assessment

Assessed by

BURN DIAGRAM

COLOR CODE

X/red — 3°

=/blue — 2°


MODULE 4TRANSFER AND TRANSPORT




� Obtain/Estimate each patient’s age

� Estimate each patient’s burn size (TBSA %)

› Do not include first degree burns in the TBSA % estimate

› Use “Rule of Nines” or Palmar method

� Using the All Burn Triage Table, determine triage category of all patients

� Consider transfer of patients in the following priority order:

› Medium, High and Very High are most likely to benefit from specialized care

› Low category patients have a mortality rate of 50-90% even with prolonged, intensive resources

› Expectant category patients have > 90% mortality

� Arrange transport based on priority ordering and other factors

› Determinations regarding which specific patients should be transported and in which order, will ultimately rest with the practitioner’s judgement

� Variables, in addition to the All Burn Triage Table category, should be considered including:

› Degree of injury

› Comorbid factors

› Facility capabilities

› Time, distance and transportation methods

� Classify as dead all patients who are pulseless and apneic

› Terminate resuscitative measures

› Relocate decedent away from treatment areas to preserve family privacy and protect belongings

If the number of critical patients, outnumbers available personnel or resources � Withhold or terminate care in apneic patients after repositioning airway -

� Provide palliative or comfort care to all patients who have a pulse and spontaneous respirations and who are classified as expectant using the “All Patients – Burn Triage Table”


No Access to Advanced Airway/Respiratory Supplies � Maintain patient in sitting or head elevated position

› Consider spinal precautions

� Provide oxygen via nasal cannula or mask

› Oxygen saturation of 90-92% is acceptable

� Maintain open airway using airway adjuncts (nasopharyngeal (NPA)/oropharyngeal airway (OPA)

� Frequent respiratory assessment and communication with provider

No Access to Intravenous (IV) Supplies � Use Oral Resuscitation Therapy (ORT) if IV access is unavailable and less than 20% TBSA

› Consider in burns up to 40% TBSA

Non-pharmacologic Interventions � Elevate burned extremities

� Decrease external stimuli

� Do not use excessive pressure when handling wounds

› Support burned extremities from underneath rather than gripping

› Use flat surface of hands/forearms rather than fingertips

� Measure patient temperature in preparation for transport

� If <360 C (96.80 F)

› Minimize patient exposure time

› Warm the room

› Avoid cold surfaces

� Keep the patient warm and dry

› If clean, dry blankets are not available wrap patient in a space blanket/plastic wrap/large plastic bag/aluminum foil for insulation and warmth

� Do not use wet dressings or wet blankets

� If <360 C (96.80 F) consider risk vs benefit of delaying transport until patient temperature rises

� If >400 C (1040 F) administer antipyretic medication and consider delaying transport until temperature is below 400 C (1040 F). Consider adding external cooling if no response to antipyretics.

� If between 360 C (96.80 F) - 400 C (1040 F) continue preparations for transport

� If between 390 C (102.20 F) - 400 C (1040 F) consider administering antipyretic medication for patient comfort

� Protect patient from cold/wet weather when moving to transport vehicle

� Cover with two blankets or improvised cover such as plastic wrap/aluminum foil/plastic bag If unable to measure temperature during transport

� Ensure all patient(s) receive a medical screening exam, appropriate triage and stabilization

› Within the capability and capacity of the facility)

› Primary goal is to minimize the risk of patient(s) deterioration during transport

� Ensure receiving facility agrees to accept the patient

› In the event of a national emergency or crisis, a community-wide written protocol designating specific entities (i.e. trauma destination policy) may be relied on for pre-established referrals


� Ensure patient(s) handoff communication tool has a unique identifier, pre-burn estimate of weight, estimation of % TBSA and the name of accepting hospital and physician

› This may be provided via triage tag, hospital cover sheet, and summary sheet or provider notes

� Ensure verbal report is given to the transport team consisting of:

› A summary of patient’s initial condition

› Medical treatments and therapies administered

› Patients’ response to the medical care provided

� Package all medical records, lab results and x-rays available at the time of transport, and send with patient(s) to receiving hospital


� Have second practitioner confirm the TBSA % calculations

� Identify patients who have inhalation injuries and comorbidities

� Comorbidities with significant impact are:

› Renal disease, obesity, liver disease, HIV/AIDS, pulmonary disorders, alcohol abuse, CHF, metastatic cancer and peripheral vascular disorders

� Use the Inhalation Injury and Non-Inhalation Injury Burn Triage Tables to determine triage category of all patients

� Wounds are cleaned and TBSA% re-evaluated by second practitioner

If the number of critical patients outnumbers available personnel or resources � Deliver palliative or comfort care to patients who:

› Have a pulse and spontaneous respirations and are classified as expectant using the “Inhalation Injury and Non-Inhalation Injury Burn Triage Tables”

Some Access to Advanced Airway/Respiratory Supplies � Maintain airway using:

› Laryngeal Mask Airway (LMA)

� Provide oxygenation/ventilation using

› High Flow Nasal Cannula/CPAP

› Bag Mask Valve (BVM) ventilation

Some Access to Intravenous (IV) Supplies � Initiate peripheral IV access

› Large bore IV

› Avoid circumferentially burned extremity

› Avoid infusion distal to burned tissue


Pharmacological Interventions � Oral medications may be considered when oral intake is not contraindicated, however, assess for possible adverse effects including, but not limited to, airway compromise

� We recommend that ketamine be preferred over morphine for Intramuscular (IM) analgesia

� Measure temperature during transport every 4 hours

� If < 36.00 C (96.80 F) use available active warming means to achieve normothermia

› Warm transport vehicle/warm blankets/heating blankets/warm IV fluids

� If >390 C (102.20F) remove blanket, consider administering antipyretic medications for patient comfort

� If >400C (1040F) and unresponsive to medications consider adding cold air-conditioning and wetting sheets with saline

� If between 360 C (96.80 F) and 390 C (102.20F) cover patient with a blanket

� Send a copy of patient’s initial medical record & face sheet

� Ensure verbal report is given from referring physician to receiving physician

� Ensure essential elements of patient care are recorded on a standardized, pre-printed handoff communication tool (such as the BMCI Patient Medical Data Form)


� Burn Center Consult via telemedicine or other available method

If the number of critical patients outnumbers available personnel or resources � Transfer expectant patients to identified alternative care sites

› Hospices, long term care facilities

Access to Advanced Airway/Respiratory Supplies � Secure Endotracheal Tube (ETT)

› ETT Securement device

› Tape (non-burned face only, if no other options)

› Twill Tie (burned face)

› Hold ETT when moving patient

› Note depth of tube and verify unchanged after movement

� Provide continuous sedation during transport

Access to Intravenous (IV) Supplies � Central Line Access if requirements exceed safe capacity of peripheral IV

� Intravenous or intraosseous pain medication administration

› Consider possible adverse effects

� Measure temperature during transport every 2 hours

� Ensure a BMCI Patient Medical Data Form is completed for each burn patient transferred

� Ensure any medical equipment accompanying the patient (IV Pumps, ventilators, monitors, etc.) are notated on patient chart by item, brand, BMET service tag number and serial number


MODULE 4TRANSFER AND TRANSPORT



Rule of Nines Rule of Palms

Examples of Oral Rehydration Solutions• One Liter of clean water/one teaspoon

of table salt (3 g)/three tablespoons of sugar (36 g or nine sugar cubes)



Burn Size Group, %TBSA All

Age 0–9.9 10–19.9 20–29.9 30–39.9 40–49.9 50–59.9 60–69.9 70–79.9 80–89.9 ≥ 90











Age 0–9.9 10–19.9 20–29.9 30–39.9 40–49.9 50–59.9 60–69.9 70–79.9 80–89.9 ≥ 90











Age 0–9.9 10–19.9 20–29.9 30–39.9 40–49.9 50–59.9 60–69.9 70–79.9 80–89.9 ≥ 90
















66

BMCI PATIENT MEDICAL DATA FORMMRN:

Date & time: Mode of transport & ETA:

Patie

ntId

entif

icat

ion Name: DOB: Age: SEX: M / F Weight: kg/lb

Burn date: Burn type: TBSA:

Mechanism of injury: Inhalation injury: Y / N Intubated: Y / N

Fluid resuscitated: Y / N Peripheral IV: � Central Line � A-Line Escharotomy: � Fasciotomy: �

Con

tact

Info

rmat

ion

Referring Hospital: Referring Physician:

Contact Number:

Accepting Hospital: Accepting Physician:

Contact Number: Telemedicine Completed: Y / N

Notification: � Spouse/S.O. � Parent � Other: Name:

Contact Number:

Patie

ntIn

form

atio

n

Code Status: full code / no code: � DNR � DNI � Advanced directives: is document present: Y / N

Traumatic injuries: Y / N Type:

Last vital signs: HR: RR: B/P: Temp: O2 sat:

Diabetic: Y / N Last meal: Insulin drip: Y / N Last blood sugar (date, time and value):

Tetanus booster: Y / N (Last date of tetanus):

Critical meds—MAR attached: Y / N (if not attached: include medication, dose, route and time given):

Critical labs:

Pertinent DX exams:

Org

anSy

stem

s

Neuro: Dx: GCS: PERRLA:

Pulmonary: Dx: ETT Size: Depth: FiO2:

Vent settings: Chest tube: ABG:

Cardiovascular: Dx: Rhythm/ectopy:

Vasoactive drips:

Renal: Dx: Foley: Y / N Volume last hour ml Dialysis: Y / N

Last dialysis (date/time):

GI: Dx: NPO: Y / N Reason: Feeding Tube: Y / N

Send

ing

Faci

lity

Time & date departed:

Equipment sent with patient: � IV pumps: � Monitor: � Pulse oximeter:

Ventilator/CPAP/BIPAP: Other:

Items sent with the patient:

Rece

ivin

g Fa

cilit

y

Time & date arrived: Received by:

Receiving Facility MR#:

Equipment received with patient:

Items received with patient:

67

Interpreter: Y / N Language: Sign language: Y / N

Past medical history:

Allergies:

Medications (include dose, route, time given):

All continuous IV infusions including rate & dose:

Feeding tube: formula type and rate:

Labs:

Narrative summary of care:BURN DIAGRAM

COLOR CODE

X/red — 3°

=/blue — 2°

BUN

WBC

Hgb

Hct

Plt

Na

K

Cl

CO2

BUN

Gluc

Creat

Mag

Phos

68

69

Resources

ADDITIONAL RESOURCES

Kevin M. McCulleyPublic Health, Medical, and Special Pathogens Preparedness ManagerBureau of EMS and PreparednessUtah Department of Health

Office: 801-273-6669

Cell: 801-641-1295

Email: [email protected]

24/7 Disaster Line: 866-DOH-UTAH (866-364-8824)

Annette Newman MS, RN CCRNCommunity Outreach/Burn Disaster Coordinator University of Utah Health Burn Center

Office: 801-585-2076

Cell: 435-901-1425

Email: [email protected]

All Western Region Burn Disaster Consortia plans, the “Prolonged Care of the Burn Patient in a Non-Burn Facility Following a Burn Mass Casualty Incident (BMCI) E-Learning modules, and Crisis Triage Officer Training are located on the following website:

http://crisisstandardsofcare.utah.edu

70

Reso

urce

s

Documents

APPENDIX B BURN CRISIS STANDARDS OF CARE GUIDELINES · the scarcity of burn centers and complexity of initial care required. Despite the infrequency of significant burn disasters,