Guidelines for Burn Care Under Austere Conditions

All disasters are local, and a burn mass casualty incident (BMCI) is no different. During the past 150 years, burn disasters have typically been associated with three factors: a fire/explosion in a mass gathering, natural disaster, or act of war/terrorism. Although the incidence of fire/explosion disasters has decreased during the past 50 years, recent natural disasters and acts of war/terrorism highlight the need for ongoing preparedness.1 The goal of this missive is to provide a background for disaster preparedness and a framework for initial assessment in a burn mass casualty. The Cocoanut Grove Night Club Fire (1942) in Boston, MA, resulting in 492 deaths, is perhaps the seminal BMCI.2 This entertainment-based mass gathering burn disaster highlighted the need for building code legislation to ensure public safety. Equally important, the study of the events surrounding the Cocoanut Grove disaster provided the foundation for many basic tenants of modern burn treatment, including fluid resuscitation, inhalation injury, posttraumatic stress disorder, and topical burn treatment. These concepts have saved far more lives than were lost in the event. Despite improved technology and building codes, fires involving entertainment-based mass gatherings continue to occur, including the Volendam Café Fire in the Netherlands (2001) the Rhode Island Station Night Club Fire (2003), and the Kiss Night Club Fire (2013) in Santa Maria, Brazil.3,–5 Each of these disasters left >100 dead and burned. Burn disasters are not limited to fires in structures, however. Natural disasters (Haiti Earthquake-2010, Great East Japan Earthquake-2011) and war/terrorism (9/11 attacks-2001, Madrid Train Bombing-2004, and London Subway/Bus Bombings-2005) emphasize the need for broad-based disaster preparedness.6,–13 Each type of disaster poses particular challenges. Incidents resulting in trauma, burn, or a combination of burn and trauma patients generate competition for scarce resources.14 Health system infrastructure can be catastrophically destroyed and limit the ability to provide the accepted injury standard of care.15 The use of thermonuclear explosive devices to intentionally destroy or injure poses the greatest threat to both infrastructure and resources.16 More than 65 years have passed since thermonuclear weapons injured thousands in Hiroshima and Nagasaki.17 Today a suitcase-sized highly enriched 5 to 20 kiloton nuclear weapon can produce the same result as the nuclear warhead in 1945. A tactical rocket-based nuclear warhead today has a 475 kiloton to 9 megaton yield; the resulting explosion would dwarf the number of injuries in Nagasaki.18,19 Efforts and planning associated with disaster preparedness must thus match advances in destructive capability. A BMCI occurs when the number of burn injuries exceeds available burn resources and exceeds the capacity of the local burn center to provide optimal care.15,20,21 Nondisaster medical care criteria are not applicable in such situations. Patient volume and injury burden dictate a different approach. Surge capacity (in a disaster) is the balance of staff, space, and supplies (to include equipment and pharmaceuticals) available to meet the needs of a sudden influx of a large number of patients.22 Surges of patients result in insufficient resources to serve all; hence, the concept of triage, in which resources are allocated to benefit the greatest number of injured individuals. Triaging patients requires a rapid, stream-lined approach and the willingness to limit care for one to benefit the many. Triage criteria must be easy to implement, especially for personnel unfamiliar with burn care management. For burn disasters, the aim is to reach a surge equilibrium by efficiently distributing patients (based on need) to available appropriate resources (staff, space, supplies, and transportation) in the region.22 Although current medical standard of care for nondisaster burn management includes treatment at centers designed, staffed, and equipped for burn care within 24 hours of an incident, this is unlikely in a mass casualty situation.20,21,23 To appropriately triage patients, centers must be able to assess both capacity and capability. Capacity is typically discussed in terms of available designated burn beds and does not consider burn center capability. Capability encompasses the need for specialized personnel and support staff, operating rooms, supplies, equipment, and other related resources necessary for recovery and rehabilitation. Although sometimes used interchangeably, capacity and capability are not synonymous in terms of disaster operations. Acceptable practice is to consider diverting or providing secondary triage to another burn center once capacity is greater than 50% above traditional occupancy.15,20,24,25 An organized process for transporting multiple patients in a BMCI is critical to survivability.26,–29 Protocols and procedures must be in place before an event so that all EMS and health care personnel understand their respective roles and responsibilities. Many local jurisdictions and state EMS agencies already employ some form of a structured methodology based on immediate needs for sorting patients. Typically this is a color-coded system. Two of the more common systems include smart or simple triage and rapid treatment systems.30,31 While specific parameters may vary slightly, it is universally accepted that the four principle groups with respective color codes denoting patient conditions are red/ immediate, yellow/delayed, green/minor, and black/expectant.30,31 This type of triage identifies an order in which care is to be administered, either on scene or on arrival at a surge facility. A benefit-to-ration triage decision table was developed and revised to provide an objective framework for BMCI treatment decisions (Table 1).32,33 Patients are classified as 1) outpatient: <10% with no inhalation injury; 2) very high: mortality ≤10%, anticipated length of stay ≤14 to 21 days, 1 to 2 surgical procedures; high: mortality ≤10%, anticipated length of stay ≥14 to 21 days, multiple surgical procedures; medium: mortality 10 to 50%; low: predicted mortality 50 to 90%; and expectant: predicted mortality >90%. The revised triage decision table offers guidance in prioritizing burn patient transfer/treatment. Resource triage diagram for burn injury in a disaster Resource triage diagram for burn injury in a disaster The revised triage decision tables also allow for some modification. Depending on the size and scope of an incident, classifications may be adjusted accordingly. For example, individuals designated as “low” or “expectant” may still be transferred to a burn center if or when a center is able to accommodate such a transfer. Grids also follow a color-coded format similar to other standard triage tag systems, further reinforcing ease of use. Decision tables, however, only address burn risk factors; scoring for concomitant traumatic injury or comorbidities must be taken into account when conducting a full triage assessment.34 Initial assessment of a burn patient begins with primary stabilization; maintaining a patent airway, ensuring adequate breathing and circulation, providing analgesia to manage pain and anxiety, assessing level of consciousness, and minimizing the risk of hypothermia. Estimating extent and depth of a burn wound can be challenging, especially for personnel unfamiliar with this process. A common method to calculate extent of burn is “Rule of Nines”20 (Figure 1). Estimates in infants and small children using the “Rule of Nines” must be adjusted to account for differences in head-to-body surface ratio in these age groups. Extent may also be estimated by Palmar method20 (Figure 1). The size of the patient's palm, including fingers, represents approximately 1%. Palmar method is especially helpful when estimating scattered burns, is easy to remember, and may be particularly helpful in a disaster situation, where “Rule of Nine” charts may not be readily available. Regardless of which method is employed, only partial thickness or full thickness burns should be included in TBSA calculations. Depiction of the Rule of Nine's and Palmar Method of burn size estimation. For the Rule of Nines, each body region has a surface area in a multiple of nine. In the Palmar Method, the patient's palm represents approximately 1% of that patient's BSA. Reprinted with courtesy from The Burn Center at Saint Barnabas Medical Center, Livingston, New Jersey. Mechanism of injury may provide valuable insight into potential underlying complications, concomitant trauma, or chemical injury. Other factors to consider include allergies, medications, past medical history, last meal and events/environment related to the injury.20 If obtaining a tetanus history is unclear, or the most recent tetanus vaccination is more than 5 years and resources allow, consider revaccination.22 As there is no definitive evidence regarding prophylactic antibiotic use early on in the burn process, antibiotics should not be administered prophylactically in the austere environment.35,36 Baseline laboratory values such as hematocrit, chemistries, urinalysis, or chest x-ray may be beneficial for burns >15% TBSA.20 Circumstances will likely limit any ability to perform such testing initially and these too may have to be deferred. Depending on the size and scope of an incident, the number of injured or the available personnel, detailed histories and physical exams may not be possible early on. Once conditions permit a complete head-to-toe assessment should be conducted and recorded for each patient. Despite the circumstances of a disaster every effort should be made to ensure patients are stabilized, kept warm, and transported to (verified) burn centers. In situations where the number of injured exceeds capability of the local burn center, it may be necessary for patients to be referred to a regional burn center, not necessarily the nearest burn center. Transport arrangements should be coordinated in accordance with established local, regional, or national disaster plans. All available documentation should accompany the patient. Detailed information and extensive medical histories may not be readily available during the initial stages of a BMCI, thus triage tags should be completed as accurately as possible and remain with each patient to ensure continuity of care, as injured personnel are moved from one site to another. detailed information including disaster triage, treatment, and of the patient with burn injuries may also be on the from thousands of injuries as and nuclear or a natural disaster) to a at a mass All will the system. Each offers for the medical system will and will an standard of care into the of supplies and personnel as as the need for triage not typically Burn care are in a to to the disaster and thus should be with basic disaster of a burn disaster from nuclear to fires in a mass gathering and natural such as All medical should be with basic disaster and these in a triage criteria should be for patients resulting from a mass casualty should capacity and capability. Burn patients should be in terms of airway, circulation, and fluid and burn size estimated using Rule of or Palmar If patients to a (verified) burn center within 24 burn patients with and of burns, of by and and inhalation of resulting in and management. 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