TraumaBurn ClinicalGuidelines Final PDF

D
I
Trauma/Burn Clinical Guidelines
S
A Quick Guide for the

Management of Trauma/Burn Disasters for S
Emergency Department Personnel
Rev. August 2013
www.ynhhs.org/cepdr
R
Emergency Information for Trauma/Burn Emergencies
ORGANIZATION PHONE NUMBER
Local Police
State Police
Federal Bureau of Investigation (FBI)
Department of Homeland Security
Local Burn Center
Local Hyperbaric Chamber
Organization-Specific Contacts [see below]
Emergency Trauma/Burn Management Websites

ORGANIZATION WEBSITE
American Burn Association www.ameriburn.org/
http://emergency.cdc.gov/masscasualties/
CDC: Explosions and Blast Injuries
explosions.asp
http://emergency.cdc.gov/masscasualties/
CDC: Mass Casualties: Burns
burns.asp
US Health & Human Services: Burn Triage and
http://chemm.nlm.nih.gov/burns.htm
Treatment - Thermal Injuries
© Yale New Haven Health System Center for Emergency Preparedness and Disaster Response. None of this publication may be reproduced or trans-
mitted in any form without permission from Yale New Haven Health System Center for Emergency Preparedness and Disaster Response.
Page 1
Trauma/Burn Guidelines
Introduction:
This guide is a quick reference for the hospital’s initial response to Trauma/Burn emergencies. Based on the
word DISASTER*, it facilitates the ongoing qualitative and quantitative assessment of the incident.
D Detection
I ICS
S Safety/Security
A Assessment
S Support
T Triage and Treatment
E Evacuate
R Recovery
This guide includes components of the Hospital Incident Command System (HICS) version IV and utilizes
components of MASS, START and Jump START triage systems. This reference guide provides a framework
for a coordinated, effective hospital response to a trauma/burn incident.
Upon initial notification of a mass casualty event, hospital staff needs to be aware that the first casualties of the
event may arrive at the hospital without transport by EMS. If a larger number of casualties are expected, the
staff may need to utilize mass casualty triage methods.
Also note there may be additional hazards. If the explosion was caused by a chemical event, casualties may
need to be decontaminated or a risk that a bomb was a radiological dispersion device (RDD), also known as a
“dirty bomb”, See the appropriate guidelines for appropriate interventions.
* The mnemonic, D-I-S-A-S-T-E-R, is taken from the National Disaster Life Support program and is used with the gracious
permission of the American Medical Association and the National Disaster Life Support Educational Foundation.
Page 2
DETECTION
Based upon information received, the hospital may need to prepare to D – Detection
receive numerous multi system trauma patients. Events have shown that
a high percentage of casualties from any mass casualty event are not
seriously injured (See Appendix 1). However, those that have sustained life-
threatening injuries require significant resources. It should also be noted that
I – Incident
Command
there is a limited number of specialty centers e.g., critical care burn beds,
System
pediatric ICU beds. If transport to a higher level of care is anticipated, those
facilities should be notified as soon as possible.
Announced event (from EMS, FD, etc): S – Safety and

ED Nurse or Physician:
Security
• Determines:
– Type, time, and scope of the event
– Type of exposure (shrapnel, collapse, etc.)
– Estimated number of casualties being sent to your ED A – Assessment
– Types and severity of injuries
– Whether casualties may have been exposed to chemical or
radiological contamination
– Estimated time of arrival of the first victim
– Whether incident directly involves people with medical dependencies
S – Support
including, children and the estimated number of these types of

patients
– Contact information for the reporting person or agency
• Notifies the Administrator-on-Duty if a large number of casualties are
T – Triage and
Treatment
anticipated
• Directs EMS personnel to deliver casualties to designated triage area
Unannounced event (victim(s) appear at the Emergency Department)

ED Nurse or Physician:
E – Evacuate
• Begins triaging and treating the victim(s) as usual

• Begins to obtain as much pertinent information as possible from the
casualties and the agency or public service answering point (PSAP)
having jurisdiction where incident occurred (see above) R – Recovery
• Directs all “walking wounded,” as well as worried well and victim’s
families to designated area
• Notifies Regional EMS communication center of event status and status
of the hospital e.g., bed availability, or ED status to accept additional
Appendices
patients
Page 3
INCIDENT COMMAND SYSTEM
Upon notification or determination of a trauma/burn event affecting a D – Detection
large number of patients:
Incident Commander (Administrator-on-Duty) I – Incident

• Activates HICS positions as needed Command
• Activates Emergency Operations Plan (EOP) as appropriate System
Incident Commander
S – Safety and
Public
Security
Safety
Information
Officer
Officer
A
Medical /
Liaison
Technical
– Assessment
Officer
Specialist
Finance /
Operations Planning Logistics
Administration
Section Chief Section Chief Section Chief
Section Chief
S
Staging Time
Time
– Support
Resources Service
Manager Unit Leader Branch Director Unit Leader
Unit Leader
Medical Care Casualty Care

Branch Director Unit Leader Support
Situation Procurement
Procurement
Branch Unit Leader
Unit Leader
Unit Leader
Director
T
Triage
– Triage and
Unit Leader
Infrastructure Minor
Branch Director Treatment
Unit Leader Documentation
Compensation /
Compensation
Claims
Claims
Treatment
Unit Leader Unit Leader
Unit Leader
Immediate
Treatment
Unit Leader
HazMat Delayed
Branch Director Treatment
Unit Leader Demobilization Cost
Cost
E
Unit Leader Unit Leader
Unit Leader
Decedent/
Expectant
Unit Leader – Evacuate
Security
Branch Director
Legend
Activated
Business Position
Continuity
Branch Director
R – Recovery
Modified from CEMSA Hospital Incident Command System (HICS)

www.emsa.ca.gov/hics
Appendices
Page 4
SAFETY AND SECURITY
Security Branch Director: I – Incident

• Assesses security needs and capabilities Command
• Follows guidance from Operations Section Chief regarding possible System
screening and visitor restriction
• Establishes and secure access and egress for vehicles delivering all
patients during the time of the event S – Safety and
Security
Safety Officer:
• Assigns a safety officer to the emergency department as necessary
• Monitors staff use of appropriate safety and infection control
procedures A – Assessment
• Monitors the transportation routes to provide safe and efficient ingress
and egress for vehicles bringing casualties and other personnel
wishing to gain access to the ED
S – Support
Note:
• Secondary hazards should be suspected, if the event appears to be an
act of terrorism T – Triage and
• Secondary hazards may include: Treatment
– Secondary explosive devices being placed at the hospital
– Chemical contamination of the victims
• Refer to Chemical Clinical Guidelines if suspected
– Radiological contamination of the victims E – Evacuate
• Refer to Radiation Clinical Guidelines if suspected
R – Recovery
Appendices
Page 5
ASSESSMENT
Medical/Technical Specialist (Trauma Chief or Critical Care Chief):

• Provides guidance to the Incident Commander and Operations Section I – Incident
Chief regarding:
Command
System
– Appropriate methods of treating casualties based on their severity
– Assesses and ensures necessary resources
• Number of casualties needing immediate surgery or other
treatments S – Safety and
• Number of casualties that could have delayed surgery or other Security
treatments
• Number of pediatric casualties (See Appendix 2)
• Determines the need to cancel elective surgeries; early transfer
of critical care patients, and/or early patient discharge to increase A – Assessment
bed availability for trauma/burn casualties
• Determines criteria for transferring casualties to other facilities
(trauma centers, burn centers, pediatric centers, etc.)
Other Medical/Technical Specialists may be required if additional

S – Support
hazards are suspected.
• Toxicologist if chemical contamination is suspected
• Radiation Safety Officer if radiation exposure or contamination is
suspected
T – Triage and
Treatment
Operations Section Chief:

• Shares information and plans with Branch and Unit Leaders to assure
emergency treatment plans and victim dispositions are properly
implemented
E – Evacuate
Casualty Care Unit Leader:

• Assesses ongoing patient needs and capacities and reports to Medical
Care Branch Director R – Recovery
• Assesses ongoing resource needs including trauma/burn specific
resources and reports to Operations Section Chief
• Assesses need for additional bed capacity due to patient surge and
reports to Operations Section Chief
Appendices
Page 6
SUPPORT
Incident Commander: I – Incident

• Considers need to activate Emergency Operations Plan Command
• Notifies senior hospital leadership of the situation System
• Activates HICS positions as indicated
• Establishes operational periods and the schedule for briefings
S – Safety and
Casualty Care Unit Leader: Security
• Maintains contact with the regional EMS communication centers
• Ensures appropriate control procedures are followed by all staff, patients
and visitors
• Establishes area(s) for the cohort of patients based on triage levels A – Assessment
Inpatient Unit Leader:

• Assures continued care for inpatients
• Manages the inpatient care areas S – Support
• Provides for early patient discharge, if indicated
• Facilitates rapid admission of casualties to appropriate care areas
Logistic Section Chief: T – Triage and

• Ensures an adequate supply of all resources necessary for patient care Treatment
activities
NOTES:
E – Evacuate
R – Recovery
Appendices
Page 7
TRIAGE AND TREATMENT
Operations Section Chief: I – Incident

• Shares information and plans with Branch and Unit Leaders to assure Command
emergency treatment plans and victim dispositions are properly and System
completely implemented
Casualty Care Unit Leader: S – Safety and

• Uses established triage guidelines (See Appendix 3 and 4) Security
• Prioritizes patients according to severity of injury
• Ensures that casualties with immediate life-threatening injuries receive
life-saving treatment to stabilize the casualties as needed according to
the principles of ABLS, ACLS, ADLS, AHLS, ATLS, PALS, and/or APLS A – Assessment
before decontamination, including:
– Maintains C-spine precautions, if appropriate
– Secures airway, provides ventilation with 100% oxygen
– IV fluid resuscitation
– Assesses and treats burn casualties according to the principles of
S – Support
Advanced Burn Life Support (See Appendix 5 and 6)

– Assesses and treats traumatic injuries including blast injuries
(See Appendix 7) and/or crush injury/compartment syndrome T – Triage and
(See Appendix 8) Treatment
• Establishes area(s) for the cohort of patients based on triage levels

• Assures continued care for inpatients E – Evacuate
– Burn injuries (See Appendix 5 and 6)
– Blast injuries (See Appendix 7)
– Crush injury/compartment syndrome (See Appendix 8)
• Manages the inpatient care areas
R – Recovery
• Provides for early patient discharge, if indicated
• Promotes rapid admission of casualties to appropriate care areas
Appendices
Page 8
EVACUATE
Casualty Care Unit Leader: I – Incident

• In consultation with the senior emergency department physican: Command
– Prepares the ED by making prompt disposition decisions: discharge System
to home, or admission to hospital
– Implements internal surge plans as necessary
– Transfers to a higher level of care or to another facility for continued S – Safety and
care (e.g., pediatric intensive care, burn center or rehabilitation Security
facility)

• In consultation with Medical Care Branch Director: A – Assessment
– Prepares the various inpatient units by making prompt disposition
decisions: early discharge, cancellation of elective procedures, in
accordance with internal surge plans
– Ensures secondary distribution to another facility for continued care S – Support
(e.g., pediatrics, burn casualties, long-term care patients
Potential For Emergency Evacuation Of The T – Triage and

Emergency Department Treatment
Secondary hazards should be suspected, if the event appears to be an

act of terrorism
E – Evacuate
Secondary hazards may include:
• Secondary explosive devices being placed in or around the hospital
• Chemical contamination of the victims
– Refer to chemical clinical guidelines if suspected R – Recovery
• Radiological contamination of the victims
– Refer to radiation clinical guidelines if suspected
Appendices
Page 9
RECOVERY
Behavioral Health Unit Leader: I – Incident

• Aids recovery by addressing the behavioral health needs of patients, Command
visitors and healthcare personnel System
• If needed, enlists the services of:
– Social Services Department
– Pastoral Care department S – Safety and
– Department of Psychiatry Security
– Child Life Specialists
– Employee Assistance Services
– Other, outside behavioral health services
A – Assessment
Casualty Care Unit Leader:
• Monitors staff for signs/symptoms of injury
• Relieves staff showing signs of excessive fatigue or stress
• Monitors triage and treatment area staffing patterns and adjust S – Support
according to anticipated needs
• Has all unneeded equipment cleaned and returned to the staging area,
or returned to its original location
• Returns all unused supplies to staging or to their original location T – Triage and
Treatment
NOTES:
E – Evacuate
R – Recovery
Appendices
Page 10
D – Detection
I – Incident
Command
System
S – Safety and
Appendices
Security
Appendix 1: Event Characteristics and Anticipated Impact on

Hospitals A – Assessment
Appendix 2: Principles of Care of Children from MCI Incident
Resulting in Traumatic/Burn Injuries
Appendix 3: Mass Casualty Triage Tags
Appendix 4: Mass Triage Systems S – Support
Appendix 5: General Burn Guidelines
Appendix 6: Burn Care and Treatment
Appendix 7: Blast Injuries Care and Treatment T – Triage and
Appendix 8: Crush Injury/Compartment Syndrome Care and Treatment
Treatment
Appendix 9: Abbreviations
E – Evacuate
R – Recovery
Appendices
Page 11
Appendix 1: Event Characteristics and Anticipated Impact on Hospitals
Anticipated impact
Event characteristic Implication Number of injured
survivors seeking Injury frequency Injury severity
emergency care
Event near hospital ↑ number of injured survivors will ↑ at nearby hospitals ↑ minor injuries Variable – more minor
arrive at ED without EMS transport ↑ “worried well” and more serious injuries
↓ EMS transport time to hospital

Vehicle delivery system in ↑ explosive magnitude, structural ↑ May produce 100s to Variable ↑ in severity
explosions collapse possible 1,000s of injured survivors
↑ immediate deaths close to

detonation point or inside collapse
Pre-explosion or ↑ distance between potential victims ↓ number of injured ↓ Primary blast injury, ↓ in severity
pre-collapse evacuation and detonation point survivors traumatic amputations,
flash burns
↓ number at risk
Open-air explosions Blast energy dissipated, but spread ↑ May produce up to ↑ Secondary blast injury ↓ in severity
over greater area, structural collapse 200 injured survivors, many
Page 12
unlikely with minor injuries
↓ number of immediate deaths
Confined space Blast energy potentiated, but ↓ Usually produces < 100 ↑ Primary blast injury, ↑ in severity
explosions contained in lesser area injured survivors amputations, burns
↑ number of immediate deaths inside
space
↑ number of injured exposed to blast

effects
↑ effects in smaller space (e.g., bus)
Appendix 1
Appendix 2: Principles of Care of Children from MCI Incident Resulting in Traumatic/Burn Injuries
General Principles • No widely utilized system for rapid triage of children in MCIs. Jump START is the most widely known
• Children and their parents should not be separated during triage. (Injured children should be reunited with responsible
parent or caregiver as soon as possible, since anxiety exacerbated by separation from parents or caregivers often
confounds their evaluation.)
• Children have incompletely developed motor skills and cognition. (Therefore, they may not be able to escape site of an
incident and may not be able to follow directions.)
• Injured children should be managed according to the general principles of PALS and ATLS.
Trauma/Burn • Injured children are at higher risk for hypothermia, with significantly greater thermo-regulatory problems in younger
children. With smaller circulating blood volume, (despite greater tolerance of volume loss per kilogram), decomposition
into shock may be more rapid and more difficult to reverse.
• Airway is smaller, increasing risk of airway edema.
• Children are at greater risk of head injury because of disproportionately larger head size.
• Head injury severity is the main determinant of a pediatric patient’s outcome.
• Cervical spine and spinal cord injuries are less common in children because of greater flexibility and mobility.
(Conversely, spinal cord injuries in the absence of radiographic abnormalities are more likely to be present.)
• Damage to internal organs is greater due to increased chest wall compliance and greater transfer of energy to internal
organs, while rib fractures and flail chest are relatively uncommon. (If rib fractures are present, there is a much greater
risk of intrathoracic injuries.)
Behavioral Health • Greater risk of psychological trauma.
Page 13
• Children’s’ reactions to situations vary, and depend on a child’s developmental level (cognitive, physical, educational
and social).
• Child’s behavior may depend on emotional state of caretakers.
• Behavior may appear oppositional, based on cognitive ability and fear.
• Behavioral healthcare should include age-appropriate interventions.
• Long-term psychological impacts and behavioral disturbances may occur.
Appendix 2
Mass Casualty Triage Tag A
FRONT BACK
Page 14
Mass Casualty Triage Tag B
FRONT BACK
Page 15
SMART Triage Tag System
Page 16
Appendix 4: Mass Triage Systems
START Adult Triage System
Adapted from http://www.start-triage.com/
Page 17
JumpSTART Pediatric Triage System
Adapted from http://www.jumpstarttriage.com/
Page 18
SALT Mass Casualty Triage System
Adapted from:
SALT mass casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma,
American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury
Prevention Directors Association. Disaster Med Public Health Prep. 2008 Dec;2(4):245-6. [PubMed Citation]
Page 19
Appendix 5: General Burn Guidelines
Burn Severity Percent of total body surface • Burns >20-25% TBSA require IV fluid resuscitation
area (TBSA) involvement • Burns >30-40% TBSA may be fatal without treatment.
- In adults: “Rule of Nines” is used as a rough
indicator of % TBSA (See chart)
- In children, adjust percents because they have
proportionally larger heads (up to 20%) and smaller
legs (13% in infants) than adults (See chart)
• Lund-Browder diagrams improve the accuracy of the
% TBSA for children.
• Palmar hand surface is approximately 1% TBSA
Depth of Burn Injury Superficial Burns First-degree burns
• Damage above basal layer of epidermis
• Dry, red, painful (“sunburn”)
Second-degree burns
• Damage into dermis
• Skin adnexa (hair follicles, oil glands, etc,) remain
• Heal by re-epithelialization from skin adnexa
• Moist, red, blanching, blisters, extremely painful
• Superficial burns heal by re-epithelialization and
usually do not scar if healed within 2 weeks
Deep Burns Deep second-degree burns (deep partial-thickness)
[Deep burns usually need skin • Damage to deeper dermis
grafts to optimize results and • Less moist, less blanching, less pain
lead to hypertrophic (raised) • Heal by scar deposition, contraction and limited re-
scars if not grafted] epithelialization
Third-degree burns (full-thickness)

• Entire thickness of skin destroyed (into fat)
• Any color (white, black, red, brown), dry, less painful
(dermal plexus of nerves destroyed)
• Heal by contraction and scar deposition (no epithelium
left in middle of wound)
Fourth-degree burns
• Burn into muscle, tendon, bone
• Need specialized care (grafts will not work)
Factors Increasing Age • Mortality for any given burn size increases with age
Morbidity and Mortality • Children/young adults can survive massive burns
• Children require more fluid per TBSA burns
• Elderly may die from small (<15% TBSA) burns
Smoke Inhalation Injury • Smoke inhalation injury doubles the mortality relative
to burn size
Associated Injuries • Other trauma increases severity of injury
Delay in Resuscitation • Delay increases fluid requirements
Other factors increasing • Need for escharotomies and fasciotomies
morbidity and mortality • Excessive use of alcohol or drugs
Page 20
Appendix 5: Rule of Nines
Head and neck - 9%
Trunk
Anterior 18%
Arm - 9% (each)
Posterior 18%
a a
1 1
13 2 13 2
2 2
1½ 1½ 1½
1½
1½ 1½
Genitalia and
1½ 1½ 2½ 2½
Perineum - 1% 1
Leg - 18% (each) b b

b b
c c c c
1¾ 1¾
Anterior Posterior
A B
Relative percentage of body surface area (%BSA) affected by growth
Age
Body Part 0 yr 1 yr 5yr 10yr 15 yr
a= 1/2 of head 9½ 8½ 6½ 5½ 4½
b = 1/2 of 1 thigh 2¾ 3¼ 4 4¼ 4½
c = 1/2 of 1 lower leg 2½ 2½ 2¾ 3 3¼
Provided by:
http://www.merckmanuals.com/professional/injuries_poisoning/burns/burns.html?qt=rule%20of%20nines&alt=sh
(Redrawn from Artz CP, JA Moncrief: The Treatment of Burns, ed. 2. Philadelphia, WB Saunders Company, 1969)
Page 21
Appendix 6: Burn Care and Treatment
Primary Burn Care and Treatment

Airway • Extensive burns may lead to massive edema
• Obstruction may result from upper airway swelling
• Signs of airway obstruction
- Hoarseness or change in voice
- Use of accessory respiratory muscles
- High anxiety
• Risk of upper airway obstruction increases with
- Massive burns
- All patients with deep burns (>35-40% TBSA should be endotracheally intubated )
- Burns to the head
- Burns inside the mouth
• Intubate early if massive burn or signs of obstruction
- Intubate if patients require prolonged transport and/or any concern with potential for
obstruction
- If any concerns about the airway, it is safer to intubate earlier than when the patient begins to
decompensate
• Tracheotomies not needed during resuscitation period
Breathing Carbon Monoxide (CO)
• Pathophysiology
- Byproduct of incomplete combustion
- Binds hemoglobin with 200 times the affinity of oxygen
- Leads to inadequate oxygenation
• Diagnosis
- PaO2 (partial pressure of O2 dissolved in serum)
- Oximeter (difference in oxy- and deoxyhemoglobin)
- Carboxyhemoglobin levels
• <10% is normal
• >40% is severe intoxication
• Treatment
- Remove source
- 100% oxygen until CO levels are <10%
- Consider hyperbaric therapy
Smoke Inhalation Injury

• Pathophysiology
- Smoke particles settle in distal bronchioles
- Sloughing
- Distal atelectasis
- Increase risk for pneumonia
• Diagnosis
- History of being in a smoke-filled enclosed space
- Early chest x-ray
- Early blood gases
- Bronchoscopy
• Soot in sputum or saliva
• Singed facial hair
• Soot beneath the glottis
• Airway edema, erythema, ulceration
• Treatment
- Supportive pulmonary management (including intubation)
- Aggressive respiratory therapy
- IV Steroids
Page 22
Appendix 6: Burn Care and Treatment (continued)
Primary Burn Care and Treatment

Circulation • Obtain IV access anywhere possible
- Unburned areas preferred
- Burned areas acceptable
- Central access more reliable
• Fluid Resuscitation (first 24 hours) (see Parkland Formula below)

- Massive capillary leak occurs after major burns
- Fluids shift from intravascular space to interstitial space
- IV fluid rate dependent on physiologic response
• Place Foley catheter to monitor urine output
• Goal for adults: urine output of 0.5 ml/kg/hour
• Goal for children: urine output of 1 ml/kg/hour
• If urine output below these levels, increase fluid rate
• Preferred fluid: Lactated Ringer’s Solution

- Isotonic
- Inexpensive
- Easily stored
Parkland Formula
IV fluid
• Lactated Ringer’s Solution
Fluid calculation:
• 4 x weight in kg x %TBSA burn
• Give 1/2 of that volume in the first 8 hours
• Give other 1/2 over next 16 hours
Warning: Despite the formula suggesting cutting the fluid rate in half at 8 hours, the fluid rate should
be gradually reduced throughout the resuscitation to maintain the targeted urine output,( e.g., do not
follow the second part of the formula that says to reduce the rate at 8 hours, adjust the rate based on
the urine output).
Example of Fluid Calculation

• 100-kg man with 80% TBSA burn
• Parkland formula:
• 4 x 100 x 80 = 32,000 ml
• Give 1/2 in first 8 hours = 16,000 ml in first 8 hours
• Starting rate = 2,000 ml/hour
• Resuscitation formulas are just a guide for initiating resuscitation
- Adjust fluid rate to maintain urine output of 50 ml/hr for adults
• Albumin may be added toward end of 24 hours if not adequate response

• When maintenance rate is reached (approximately 24 hours), change fluids to D5/.5 NS with 20
mEq KCl at maintenance fluid rate (see below)
- Maintenance fluid rate
• Adult maintenance fluid rate: 1500cc x total body surface area (TBSA) (for 24 hrs)
• Pediatric maintenance fluid rate: May use 100 ml/kg for 1st 10 kg; 50 ml/kg for
2nd 10 kg; 20 ml/kg for remaining kg for 24 hrs
Page 23
Complications of Over-Resuscitation
Compartment • Limb Compartment Syndrome
Syndrome - Symptoms of severe pain (worse with movement), numbness, cool extremity, tight feeling
(Transfer to compartments
Verified Burn - Distal pulses will be lost when the compartment pressure exceeds the systolic blood pressure
Center*, if - Compartment pressure >30 mmHg may compromise muscle/nerves
possible) - Measure compartment pressures with arterial line monitor (place needle into compartment)
- Escharotomies may save limbs
• Performed laterally and medially throughout entire limb
• Performed with arms supinated
• Hemostasis is required
- Fasciotomies may be needed if pressure does not drop to <30 mmHg
• Requires surgical expertise
• Hemostasis is required
• Chest Compartment Syndrome
- Increased peak inspiratory pressure (PIP) due to circumferential trunk burns
- Escharotomies through mid-axillary line, horizontally across chest/abdominal junction
• Abdominal Compartment Syndrome
- Pressure in peritoneal cavity > 30 mmHg
• Measure through Foley catheter
- Signs: increased peak inspiratory pressure (PIP), decreased urine output despite massive
fluids, hemodynamic instability, tight abdomen
- Treatment
• Abdominal escharotomy
• NG tube
• Possible placement of peritoneal catheter to drain fluid
• Laparotomy as last resort
Acute • Increased risk if fluid resuscitation to aggressive
Respiratory • Supportive treatment
Distress
Syndrome
(ARDS)
Page 24
Secondary Burn Care and Treatment

Wound Care • During initial or emergent care, wound care is of secondary importance
Acute • Advanced Burn Life Support recommendations
Respiratory - Cover wound with clean, dry sheet or dressing. NO MOIST DRESSINGS if TBSA> 10%, pt will
Distress become hypothermic
Syndrome • Sterile dressings are preferred but not necessary
(ARDS) • Covering wounds decreases pain
• Elevate burned extremities
- Maintain patient’s body temperature (keep patient warm)
• While cooling may make a small wound more comfortable, cooling any wound >10%
TBSA may cause hypothermia
• If providing prolonged care
- Wash wounds with soap and water (sterility is not necessary)
- Maintain body temperature
- Topical antimicrobials help prevent infection but do not eliminate bacteria
• Silver sulfadiazine for deep burns
• Bacitracin and nonstick dressings for more superficial burns
• Skin grafting
- Deep burns require skin grafting
- Grafting may not be necessary for days
- Preferable to refer patients with need for grafting to Verified Burn Center* or, if not available,
others trained in surgical techniques
• Grafting of extensive areas may require significant amounts of blood
• Patient’s temperature must be watched
• Anesthesia requires extra attention
• Medications
- All pain medication should be given IV
- Tetanus prophylaxis should be given as appropriate
- Prophylactic antibiotics are contraindicated
• Systemic antibiotics are only given to treat infections
Special Burn • Electrical injuries
Considerations - Extent of injury may not be apparent
(often require • Damage occurs deep within tissues
specialized • Damage frequently progresses
care, transfer • Electricity contracts muscles, so watch for associated fractures and tissue injury
to Verified - Cardiac arrhythmias may occur
Burn Center* if • All patients with electrical burns need cardiac monitoring
possible) - Myoglobinuria may be present
• Color best indicator of severity
• If urine is dark (black, red), myoglobinuria needs to be treated
- Increase fluids to induce urine output of 75-100 ml/hr in adults
- In children, target urine output of 2 ml/kg/hour
- Alkalinize urine (give NaHCO3)
- Mannitol as last resort
- Compartment syndromes are common
- Long-term neuro-psychiatric problems may result
• Chemical Burns
- Decontamination as advised (per hazard risk assessment)
- Prolonged irrigation may be required
- Do not seek antidote
• Delays treatment
• May result in heat production
- Special chemical burns require contacting a Poison Control Center and/or Verified Burn
Center*, for example: Hydrofluoric acid burn
Page 25
*American Burn Association Burn Unit Referral Criteria
1. Second- and third-degree burns greater than 10% TBSA in patients under 10 or over 50 years of age
2. Second- and third-degree burns greater than 20% TBSA in other age groups
3. Second- and third-degree burns that involve the face, hands, feet, genitalia, perineum and major joints
4. Third-degree burns greater than 5% TBSA in any age group
5. Electrical burns, including lightning injury
6. Chemical burns
7. Inhalation injury
8. Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery or
affect mortality (e.g., significant radiation exposure)
9. Any patients with burns and concomitant trauma (e.g., fractures, blast injury) where burn injury poses the greatest
risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be
treated initially in a trauma center until stable before being transferred to a burn center. Physician judgment will be
necessary in such situations and should be in concert with the regional medical control plan and triage protocols
appropriate for the incident
10. Hospitals without qualified personnel or equipment for the care of children should transfer children with burns to a
Burn Center with these capabilities
11. Burn injury in children who will require special social/emotional and/or long-term rehabilitative support, including
cases involving suspected child or substance abuse
Note: Criteria not established for very large mass casualty incidents (MCI)
Page 26
Appendix 7: Blast Injuries Care and Treatment
Pearls for Clinical Practice

Wound Care • Expect an “upside-down” triage - the most severely injured arrive after the less injured, who by-
Acute pass EMS triage and go directly to the closest hospitals
Respiratory • If structural collapse occurs, expect increased severity and delayed arrival of casualties
Distress • Clinical signs of blast-related abdominal injuries can be initially silent until signs of acute
Syndrome abdomen or sepsis are advanced.
(ARDS) • Standard penetrating and blunt trauma to any body surface is the most common injury seen
among survivors. Primary blast lung and blast abdomen are associated with a high mortality
rate. “Blast Lung” is the most common fatal injury among initial survivors
• Isolated tympanic membrane rupture is not a marker of morbidity; however, traumatic amputation
of any limb is a marker for multi-system injuries.
• Air embolism is common, and can present as stroke, MI, acute abdomen, blindness, deafness,
spinal cord injury, or claudication. Hyperbaric oxygen therapy may be effective in some cases
• Determinants of Injury from Blasts
- Size of the explosion – larger blasts create a larger pressure differential which cause injury
and structural damage
- The initial pressure wave from a high energy explosive is a sharp overpressure, followed by a
slight negative pressure before returning to baseline
- Distance from the blast – the further the victim from the center of the blast, the less injury they
might experience
- Protection – solid walls can provide protection from the pressure wave, shrapnel, and heat
• If the victim is in front of the wall, the pressure wave will hit them in the front, bounce off
the wall and hit them again in the back
• If in a corner of two walls, the pressure wave may hit the victim three times
- Casualties may have increased chances of survival if they are in an open field, rather than
being in a confined room
- Body armor may increase the amount of trauma to lungs
Category Characteristics Body Parts Affected Types of Injuries

Primary Results from the impact of the Gas filled structures are most • Blast lung (pulmonary
over-pressurization wave with susceptible barotrauma)
body surfaces. • Lungs • TM rupture and middle ear
• GI tract damage
• Middle ear • Abdominal hemorrhage and
perforation
• Globe (eye) rupture
• Concussion (TBI without
physical signs of head
injury)
Secondary Results from flying debris and Any body part may be affected. • Penetrating ballistic
bomb fragments. (fragmentation)
• Blunt injuries
• Eye penetration (may be
occult)
Tertiary Results from individuals being Any body part may be affected. • Fracture
thrown by the blast wind. • Traumatic amputation
• Closed and open brain
injury
Page 27
Appendix 7: Blast Injuries Care and Treatment (continued)
Category Characteristics Body Parts Affected Types of Injuries

Quaternary • All explosion-related Any body part may be affected. • Burns (flash, partial and full
injuries, illnesses, or thickness)
diseases not due to • Crush injuries
primary, secondary or • Closed and open brain
tertiary mechanisms. injury
• Includes exacerbation or • Asthma, COPD, or other
complications of existing breathing problems from
conditions. dust, smoke or toxic fumes
• Angina
• Hyperglycemia
• Hypertension
Note: Up to 10% of blast survivors have significant eye injuries.
Selected Blast Injuries

Lung Injury
“Blast lung” is a direct consequence of the over-pressurization wave. It is the most common fatal primary blast injury
among initial survivors. Signs of blast lung are usually present at the time of initial evaluation, but they have been
reported as late as 48 hours after the explosion. Blast lung is characterized by the clinical triad of apnea, bradycardia,
and hypotension. Pulmonary injuries vary from scattered petechiae to confluent hemorrhages. Blast lung should be
suspected for anyone with dyspnea, cough, hemoptysis or chest pain following blast exposure. Blast lung produces
a characteristic “butterfly” pattern on chest X-ray. A chest X-ray is recommended for all exposed persons and a
prophylactic chest tube (thoracostomy) is recommended before general anesthesia or air transport is indicated if blast
lung is suspected.
• Clinical Presentation
- Symptoms may include dyspnea, hemoptysis, cough, and chest pain
- Signs may include tachypnea, hypoxia, cyanosis, apnea, wheezing, decreased breath sounds and hemodynamic
instability
- Associated pathology may include bronchopleural fistula, air emboli, and hemothoraces or pneumothoraces
- Other injuries may be present
• Diagnostic Evaluation
- Chest radiography is necessary for anyone who is exposed to a blast. A characteristic “butterfly” pattern may be
revealed upon X-ray
- Arterial blood gases, computerized tomography, and Doppler technology may be used
- Most laboratory and diagnostic testing can be conducted per resuscitation protocols and further directed based
upon the nature of the explosion (e.g., confined space, fire, prolonged entrapment or extrication, suspected
chemical or biologic event, etc.)
• Management
- Initial triage, trauma resuscitation, treatment, and transfer should follow standard protocols; however some
diagnostic or therapeutic options may be limited in a disaster or mass casualty situation
- In general, managing blast lung injury is similar to caring for pulmonary contusion, which requires judicious fluid
use and administration ensuring tissue perfusion without volume overload
Page 28
Appendix 7: Blast Injuries Care and Treatment (continued)
Selected Blast Injuries

Lung Injury
• Clinical Interventions
- All patients with suspected or confirmed BLI should receive supplemental high flow oxygen sufficient to prevent
hypoxemia (delivery may include non-rebreather masks, continuous positive airway pressure or endotracheal
intubation)
- Impending airway compromise, secondary edema, injury, or massive hemoptysis requires immediate intervention
to secure the airway. Patients with massive hemoptysis or significant air leaks may benefit from selective
bronchus intubation
- Clinical evidence of or suspicion for a hemothorax or pneumothorax warrants prompt decompression.
- If ventilatory failure is imminent or occurs, patients should be intubated; however, caution should be used in
the decision to intubate patients, as mechanical ventilation and positive end pressure may increase the risk of
alveolar rupture and air embolism
- High flow oxygen should be administered if air embolism is suspected, and the patient should be placed in prone,
semi-left lateral or left lateral positions. Patients treated for air emboli should be transferred to a hyperbaric
chamber
Ear Injury
Primary blast injuries of the auditory system cause significant morbidity, but are easily overlooked. Injury is dependent
on the orientation of the ear to the blast. TM perforation is the most common injury to the middle ear.
- Signs of ear injury are usually present at time of initial evaluation and should be suspected for anyone presenting
with:
• Hearing loss
• Tinnitus
• Otalgia
• Vertigo
• Bleeding from the external canal
• Tympanic membrane rupture
• Mucopurulent otorhea
• Clinical Interventions
- All patients exposed to blast should have an otologic assessment and audiometry
Abdominal Injury
Gas-containing sections of the GI tract are most vulnerable to primary blast effect. This can cause immediate bowel
perforation, hemorrhage (ranging from small petechiae to large hematomas), mesenteric shear injuries, solid organ
lacerations, and testicular rupture.
- Blast abdominal injury should be suspected in anyone exposed to an explosion with:
• Abdominal pain
• Nausea, vomiting
• Hematemesis
• Rectal pain
• Testicular pain
• Unexplained hypovolemia
• Any findings suggestive of an acute abdomen
• Clinical findings may be absent until the onset of complications
Brain Injury
Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) without a direct blow to the head.
Consider the proximity of the victim to the blast particularly when given complaints of headache, fatigue, poor
concentration, lethargy, depression, anxiety or insomnia. The symptoms of concussion and post traumatic stress
disorder can be similar.
Modified from: CDC, Blast and bombing injuries: Fact sheet for professionals booklet,
http://emergency.cdc.gov/BlastInjuries
Page 29
Appendix 8: Crush Injury/Compartment Syndrome Care and Treatment
Background
Crush injury and crush syndrome may result from structural collapse after a bombing or explosion. Crush injury is
defined as compression of extremities or other parts of the body that causes muscle swelling and/or neurological
disturbances in the affected areas of the body. Typically affected areas of the body include lower extremities (74%),
upper extremities (10%), and trunk (9%). Crush syndrome is localized crush injury with systemic manifestations. These
systemic effects are caused by a traumatic rhabdomyolysis (muscle breakdown) and the release of potentially toxic
muscle cell components and electrolytes into the circulatory system. Crush syndrome can cause local tissue injury,
organ dysfunction, and metabolic abnormalities, including acidosis, hyperkalemia and hypocalcemia.
Previous experience with earthquakes that caused major structural damage has demonstrated that the incidence of
crush syndrome is 2-15% with approximately 50% of those with crush syndrome developing acute renal failure and over
50% needing fasciotomy. Of those with renal failure, 50% need dialysis.
Clinical Presentation
Sudden release of a crushed extremity may result in reperfusion syndrome—acute hypovolemia and metabolic
abnormalities. This condition may cause lethal cardiac arrhythmias. Further, the sudden release of toxins from necrotic
muscle into the circulatory system leads to myoglobinuria, which causes renal failure if untreated.
• Hypotension
- Massive third spacing occurs, requiring considerable fluid replacement in the first 24 hours; Patients may
sequester (third space) more than 12 L of fluid in the crushed area over a 48-hour period
- Third spacing may lead to secondary complications such as compartment syndrome, which is swelling within a
closed anatomical space; compartment syndrome often requires fasciotomy
- Hypotension may also contribute to renal failure
• Renal Failure
- Rhabdomyolysis releases myoglobin, potassium, phosphorous, and creatinine into the circulation
- Myoglobinuria may result in renal tubular necrosis if untreated
- Release of electrolytes from ischemic muscles causes metabolic abnormalities
• Metabolic Abnormalities
- Calcium flows into muscle cells through leaky membranes, causing systemic hypocalcemia
- Potassium is released from ischemic muscle into systemic circulation, causing hyperkalemia
- Lactic acid is released from ischemic muscle into systemic circulation, causing metabolic acidosis
- Imbalance of potassium and calcium may cause life-threatening cardiac arrhythmias, including cardiac arrest;
metabolic acidosis may exacerbate this situation
• Secondary Complications
- Compartment syndrome may occur, which will further worsen vascular compromise (however, crush syndrome
can occur in crush scenarios of less than 1 hour)
Page 30
Appendix 8: Crush Injury/Compartment Syndrome Care and Treatment (continued)
Initial Management
Sudden release of a crushed extremity may result in reperfusion syndrome—acute hypovolemia and metabolic
abnormalities. This condition may cause lethal cardiac arrhythmias. Further, the sudden release of toxins from necrotic
muscle into the circulatory system leads to myoglobinuria, which causes renal failure if untreated.
• Hypotension
- Massive third spacing occurs, requiring considerable fluid replacement in the first 24 hours; Patients may
sequester (third space) more than 12 L of fluid in the crushed area over a 48-hour period
- Third spacing may lead to secondary complications such as compartment syndrome, which is swelling within a
closed anatomical space; compartment syndrome often requires fasciotomy
- Hypotension may also contribute to renal failure
• Hypotension
- Initiate (or continue) IV hydration—up to 1.5 L/hour
• Renal Failure
- Prevent renal failure with appropriate hydration, using IV fluids and mannitol to maintain diuresis of at least
300 cc/hr
- Triage to hemodialysis as needed
• Metabolic Abnormalities
- Acidosis: Alkalinization of urine is critical; administer IV sodium bicarbonate until urine pH reaches 6.5 to prevent
myoglobin and uric acid deposition in kidneys
- Hyperkalemia/Hypocalcemia: Consider administering the following (adult doses): calcium gluconate 10% 10cc or
calcium chloride 10% 5cc IV over 2 minutes; sodium bicarbonate 1 meq/kg IV slow push; regular insulin 5-10 U
and D5O 1-2 ampules IV bolus; kayexalate 25-50g with sorbitol 20% 100mL PO or PR
• Cardiac Arrhythmias
- Monitor for cardiac arrhythmias and cardiac arrest, and treat accordingly
Secondary Complications
• Monitor casualties for compartment syndrome; monitor compartmental pressure if equipment is available; consider
emergency fasciotomy for compartment syndrome
• Treat open wounds with antibiotics, tetanus toxoid, and debridement of necrotic tissue
• Apply ice to injured areas and monitor for the 5 P’s: pain, pallor, parasthesias, pain with passive movement and
pulselessness
• Observe all crush casualties, even those who look well
• Delays in hydration of greater than 12 hours may increase the incidence of renal failure; delayed manifestations of
renal failure can occur
Disposition
• Patients with acute renal failure may require up to 60 days of dialysis treatment; unless sepsis is present, patients
are likely to regain normal kidney function
Page 31
Appendix 9: Abbreviations
ABLS Advance Burn Life Support

ACA Ambulatory Care Area
ADLS Advance Disaster Life Support
AHLS Advanced Hazard Life Support
AOC Administrator-on-Call
APLS Advanced Pediatric Life Support
APR Air Purifying Respirator
ATLS Advance Trauma Life Support
CCLU Casualty Care Unit Leader
CDC Centers for Disease Control and Prevention
CTUT Contaminated Triage Unit Team
DHHS Department of Health and Human Services
DPH Department of Public Health
ED Emergency Department
EMP Emergency Management Plan
EMS Emergency Medical Services
EOC Emergency Operations Center
EOP Emergency Operations Plan
FDA Food and Drug Administration
HICS Hospital Incident Command System
ICS Incident Command System
PALS Pediatric Advanced Life Support
PAPR Powered-Air Purifying Respirators
PPE Personal Protective Equipment
SBD Security Branch Director
TUT Treatment Unit Team
WHO World Health Organization
Page 32
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D

A Quick Guide for the

Emergency Trauma/Burn Management Websites

Announced event (from EMS, FD, etc): S – Safety and

including, children and the estimated number of these types of

Unannounced event (victim(s) appear at the Emergency Department)

• Begins triaging and treating the victim(s) as usual

Incident Commander (Administrator-on-Duty) I – Incident

Medical Care Casualty Care

Modified from CEMSA Hospital Incident Command System (HICS)

Security Branch Director: I – Incident

Medical/Technical Specialist (Trauma Chief or Critical Care Chief):

Other Medical/Technical Specialists may be required if additional

Operations Section Chief:

Casualty Care Unit Leader:

Incident Commander: I – Incident

Inpatient Unit Leader:

Logistic Section Chief: T – Triage and

Operations Section Chief: I – Incident

Casualty Care Unit Leader: S – Safety and

Advanced Burn Life Support (See Appendix 5 and 6)

Inpatient Unit Leader:

Casualty Care Unit Leader: I – Incident

Inpatient Unit Leader:

Potential For Emergency Evacuation Of The T – Triage and

Secondary hazards should be suspected, if the event appears to be an

Behavioral Health Unit Leader: I – Incident

Appendix 1: Event Characteristics and Anticipated Impact on

↓ EMS transport time to hospital

↑ immediate deaths close to

↑ number of injured exposed to blast

↑ effects in smaller space (e.g., bus)

Mass Casualty Triage Tag A

Mass Casualty Triage Tag B

SMART Triage Tag System

START Adult Triage System

Adapted from http://www.start-triage.com/

JumpSTART Pediatric Triage System

Adapted from http://www.jumpstarttriage.com/

SALT Mass Casualty Triage System

Third-degree burns (full-thickness)

Head and neck - 9%

Leg - 18% (each) b b

Primary Burn Care and Treatment

Smoke Inhalation Injury

Primary Burn Care and Treatment

• Fluid Resuscitation (first 24 hours) (see Parkland Formula below)

• Preferred fluid: Lactated Ringer’s Solution

Example of Fluid Calculation

• Albumin may be added toward end of 24 hours if not adequate response

Secondary Burn Care and Treatment

*American Burn Association Burn Unit Referral Criteria

Pearls for Clinical Practice

Category Characteristics Body Parts Affected Types of Injuries

Category Characteristics Body Parts Affected Types of Injuries

Selected Blast Injuries

Selected Blast Injuries

ABLS Advance Burn Life Support

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