GROUP 1

MANAGEMENT OF BURNS OF
MASS CASUALTY INCIDENT

Recent Burn Mass

Casualty Events (cont.)
Bali nightclub bombing in 2002
190 killed at the scene
12 additional deaths after hospital
admission
> 500 injured, most with severe
burns
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

Station Nightclub fire in

Warwick, Rhode Island, February
20, 2003
96 killed at the scene
196 patients seen at 16
regional hospitals
50 % treated and released, 25
% admitted, 25 % transferred
to other hospitals
Only 4 subsequent deaths
17 % (35) required

Recent Burn Mass

Casualty Events (cont.)
Madrid, Spain train bombing, March 11, 2004
10 bombs exploded
181 dead at scene
10 died later in hospital
2051 wounded
82 in critical condition
Transported by 291 ambulances, 200
firemen and police vehicles, to 5 hospitals
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
Burn patients comprise 1 to over 40 % of
casualties depending on the event (usually
about 25 % from bombings)
Usually 50 % of patients who present to
emergency departments can be discharged
after initial evaluation and treatment
Mortality of injured patients after hospital
admission is 1 to 5 %
Victims may have smoke inhalation in addition
to other injuries

Minor Burns
Second degree < 15 % in adults
Second degree < 10 % in
children
Third degree < 2 %
No involvement of face, hands,
feet, genitalia (technically
difficult areas to graft)
No smoke inhalation
No complicating factors
No possible child abuse

Moderate Burns
Second degree of 15 to 25 % TBSA in adults
Second degree of 10 to 20 % TBSA in children
Third degree of 2 to 10 % (not involving hands,
feet, face, genitalia)
Circumferencial limb burns
Household current (110 or 220 volt) electrical
injuries
Smoke inhalation with minor (< 2 % TBSA)
burns
Possible child abuse
Patient not intelligent enough to care for burns
as outpatient

Severe Burns

Second degree > 25 % in adults

Second degree > 25 % in children
Third degree > 10 %
High voltage electrical burns
Deep second or third degree burns of face,
hands, feet, genitalia
Smoke inhalation with > 2 % burn
Burns with major trunk, head or orthopedic
injury
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

Ouraim

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.

Burn Injuries Guidelines :

Facility
Classification (Burns 2006;
32:933-939)

Type A : facilities that provide resuscitation

treatment only
Type B : facilities that provide both
resuscitation and post-resuscitation treatment
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
Healthcare facilities need to be designated
Type A, B, or C
Ambulance transport arrangements between
facilities are needed
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
Other surgeons at non-burn unit Type B
facilities need to be also trained in skin