MANAGEMENT OF BURNS OF MASS CASUALTY INCIDENT

GROUP 1

Recent Burn Mass Casualty Events (cont.)

ƒ Bali nightclub bombing in 2002ƒ 190 killed at the sceneƒ 12 additional deaths after hospital admission

ƒ > 500 injured, most with severe burns

ƒ 62 burn patients were transferred to Australia and all its burn beds were filled (Australia has 12 burn centers with 146 beds)

Aftermath of the Bali bombing

Recent Burn Mass Casualty Events

ƒ Station Nightclub fire in Warwick, Rhode Island, February 20, 2003ƒ 96 killed at the sceneƒ 196 patients seen at 16

regional hospitalsƒ 50 % treated and released, 25

% admitted, 25 % transferred to other hospitalsƒ Only 4 subsequent deathsƒ 17 % (35) required

intensive care and ventilatory support

Recent Burn Mass Casualty Events (cont.)

ƒ Madrid, Spain train bombing, March 11, 2004ƒ 10 bombs exploded ƒ 181 dead at scene

ƒ 10 died later in hospitalƒ 2051 wounded

ƒ 82 in critical conditionƒ Transported by 291 ambulances, 200 firemen and police vehicles, to 5 hospitals

ƒ City-wide disaster plan activated by the health authority

Security camera view of one of the first Madrid train bomb explosions

Security camera view of second bomb explosion in the Madrid train station

After the initial explosion, smoke then becomes a severe and dangerous problem

One of the Madrid trains bombed in 2004

General Aspects Common to Most Burn Mass Casualty

Events

ƒ Burn patients comprise 1 to over 40 % of casualties depending on the event (usually about 25 % from bombings)

ƒ Usually 50 % of patients who present to emergency departments can be discharged after initial evaluation and treatment

ƒ Mortality of injured patients after hospital admission is 1 to 5 %

ƒ Victims may have smoke inhalation in addition to other injuries

Minor Burns

ƒ Second degree < 15 % in adultsƒ Second degree < 10 % in

childrenƒ Third degree < 2 %ƒ No involvement of face, hands,

feet, genitalia (technically difficult areas to graft)

ƒ No smoke inhalationƒ No complicating factorsƒ No possible child abuse

Moderate Burnsƒ Second degree of 15 to 25 % TBSA in adultsƒ Second degree of 10 to 20 % TBSA in childrenƒ Third degree of 2 to 10 % (not involving hands,

feet, face, genitalia)ƒ Circumferencial limb burnsƒ Household current (110 or 220 volt) electrical

injuriesƒ Smoke inhalation with minor (< 2 % TBSA)

burnsƒ Possible child abuseƒ Patient not intelligent enough to care for burns

as outpatient

Severe Burnsƒ Second degree > 25 % in adultsƒ Second degree > 25 % in childrenƒ Third degree > 10 % ƒ High voltage electrical burnsƒ Deep second or third degree burns of face,

hands, feet, genitaliaƒ Smoke inhalation with > 2 % burnƒ Burns with major trunk, head or orthopedic

injuryƒ Burns in poor risk patients (elderly, diabetic,

chronic lung or heart disease, obese, etc.)

Causes of burns in mass casualties

Civilian causes: Fire in meeting places, especially confined ones: Theatres, lecture rooms, circuses and cinemas.

War Injuries: Flame throwers and napalm: direct injury with these agents is fatal or causes charring of the injured parts.

Thermonuclear weapons: these are accompanied by the release of an enormous amount of kinetic energy, 80% of which is in the form of ordinary heat. Tens of thousands of burn casualties would result from a major thermonuclear blast.

Scheme for Management

Our aim should be to provide the maximum care for the maximum number of patients and to avoid any procedure that might reduce a patient's ability to care for himself.The most experienced person should be responsible for deciding and outlining necessary compromises in therapy. The medical sorting of the casualties depends on the number of injured, the available facilities and the personnel.

Sorting

Sorting The percentage of surface area burnt and depth of

bum is the accepted rule:

1. Patients with second- and third-degree bums involving more than 40% and patients with combined mechanical and radiation injury of less than 40% will not survive. They will need expectant treatment and are made as comfortable as possible with adequate doses of morphine. They should not receive definitive treatment until all patients in higher priority groups are cared for.2. Patients with 15-40% will need careful therapy.

3. Patients with less than 15% superficial burns may be discharged to self-care if the location of the burn does not interfere with ambulation, after being supplied with food, electrolytes and antibiotics. Patients in this group atTected in the face and legs could be referred to general local hospitals where untrained personnel could care for their daily needs.

Patients with minor injuries can care for those more severely injured.

Steps in Therapy

1. Relief of pain: full-thickness burns are painless; patients with partial -thickness injuries are given morphine intravenously. The bums become painless after a few hours, with the formation of a dry crust.

2. Supportive therapy: if facilities allow, intravenous therapy is given with the use of a formula. If this is not available, the requirements are given orally: 3 gin salt and 1.5 gin sodium bicarbonate in a litre of water. This can be supplied in a package together with some type of water purification tablets. It may also be used for burns of less than 30%; blood may be given to correct anaemia several days later.

3. The bum wound: in ideal circumstances, clean the surface with mild soap or detergent. Exposure is the mode of choice, reserving dressings for mechanical injuries. Blankets and other types of coverage should be used in cold weather. If time permits and dressings are available, they are utilized for individuals who will most benefit from their use.4. Antibiotics: oral antibiotics should be used to prevent infection by haemolytic streptococci.

Burn Centres

Certain hospitals are designated as Burn Centres, where trained staff and proper equipment are available. Compromise therapy and sorting should also be performed in these centres. Casualties needing one grafting procedure should be taken to the operating theatre first. Mesh grafting is the preferable procedure for extensive bums. Cadaver homografting is used as a dressing in cases who have to wait for their turn in autografting and for cases whose general condition necessitates it.

International Society for Burn Injuries Guidelines :

Facility Classification (Burns 2006;

32:933-939)

ƒ Type A : facilities that provide resuscitation treatment only

ƒ Type B : facilities that provide both resuscitation and post-resuscitation treatment

ƒ Type C : facilities that provide rehabilitative and reconstructive treatment only

Note that if a Burn Center suffers structural or functional damage from the disaster (such as an earthquake) it might only be able to function as a Type A ; a distant Burn Center could function as a Type B if helicopter evacuation is available.

Regional and National Planning for Burn Mass

Casualty Events

ƒ Healthcare facilities need to be designated Type A, B, or C

ƒ Ambulance transport arrangements between facilities are needed

ƒ Burn unit staff (from Type B and C facilities) need to train emergency physicians, family and general practice physicians, surgeons and nurses at the Type A facilities in burn resuscitation (including escharotomy) and referral

ƒ Other surgeons at non-burn unit Type B facilities need to be also trained in skin grafting and other definitive burn care