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8/13/2019 TraumaBurn ClinicalGuidelines Final
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Trauma/Burn Clinical Guidelines
A Quick Guide for the
Management of Trauma/Burn Disasters forEmergency Department Personnel
Rev. August 2013
www.ynhhs.org/cepdr
http://www.ynhhs.org/cepdrhttp://www.ynhhs.org/cepdr8/13/2019 TraumaBurn ClinicalGuidelines Final
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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.
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-Specic Contacts [see below]
Page 1
Trauma/Burn Guidelines
ORGANIZATION WEBSITE
American Burn Association www.ameriburn.org/
CDC: Explosions and Blast Injurieshttp://emergency.cdc.gov/masscasualties/
explosions.asp
CDC: Mass Casualties: Burnshttp://emergency.cdc.gov/masscasualties/
burns.asp
US Health & Human Services: Burn Triage and
Treatment - Thermal Injurieshttp://chemm.nlm.nih.gov/burns.htm
Emergency Trauma/Burn Management Websites
http://www.ameriburn.org/http://emergency.cdc.gov/masscasualties/explosions.asphttp://emergency.cdc.gov/masscasualties/explosions.asphttp://emergency.cdc.gov/masscasualties/explosions.asphttp://emergency.cdc.gov/masscasualties/explosions.asphttp://chemm.nlm.nih.gov/burns.htmhttp://www.ynhhs.org/cepdrhttp://chemm.nlm.nih.gov/burns.htmhttp://emergency.cdc.gov/masscasualties/explosions.asphttp://emergency.cdc.gov/masscasualties/explosions.asphttp://www.ameriburn.org/8/13/2019 TraumaBurn ClinicalGuidelines Final
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Introduction:
This guide is a quick reference for the hospitals initial response to Trauma/Burn emergencies. Based on the
word DISASTER*, it facilitates the ongoing qualitative and quantitative assessment of the incident.
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 notication of a mass casualty event, hospital staff needs to be aware that the rst 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.
D Detection
I ICS
S Safety/Security
A Assessment
S Support
T Triage and Treatment
E Evacuate
R Recovery
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Trauma/Burn Guidelines
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Page 3
Trauma/Burn Guidelines
DETECTIONBased upon information received, the hospital may need to prepare to
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 signicant resources. It should also be noted that
there is a limited number of specialty centers e.g., critical care burn beds,
pediatric ICU beds. If transport to a higher level of care is anticipated, those
facilities should be notied as soon as possible.
Announced event (from EMS, FD, etc):
ED Nurse or Physician:
Determines:
Type, time, and scope of the event
Type of exposure (shrapnel, collapse, etc.)
Estimated number of casualties being sent to your EDTypes and severity of injuries
Whether casualties may have been exposed to chemical or
radiological contamination
Estimated time of arrival of the rst victim
Whether incident directly involves people with medical dependencies
including, children and the estimated number of these types of
patients
Contact information for the reporting person or agency
Noties the Administrator-on-Duty if a large number of casualties are
anticipated
Directs EMS personnel to deliver casualties to designated triage area
Unannounced event (victim(s) appear at the Emergency Department)
ED Nurse or Physician:
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)
Directs all walking wounded, as well as worried well and victimsfamilies to designated area
Noties Regional EMS communication center of event status and status
of the hospital e.g., bed availability, or ED status to accept additional
patients
D Detection
I IncidentCommandSystem
S Safety andSecurity
A
Assessment
S Support
T Triage andTreatment
E Evacuate
R Recovery
Appendices
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INCIDENT COMMAND SYSTEM
Upon notication or determination of a trauma/burn event affecting a
large number of patients:
Incident Commander (Administrator-on-Duty)
Activates HICS positions as needed Activates Emergency Operations Plan (EOP) as appropriate
D Detection
I IncidentCommandSystem
S Safety andSecurity
A
Assessment
S Support
T Triage andTreatment
E Evacuate
R Recovery
Appendices
Planning
Section Chief
Operations
Section Chief
Finance/
Administration
Section Chief
Liaison
Officer
Medical/
Technical
Specialist
Safety
Officer
Public
Information
Officer
Procurement
Unit Leader
Compensation/
ClaimsUnit Leader
TimeUnit Leader
CostUnit Leader
ResourcesUnit Leader
SituationUnit Leader
DocumentationUnit Leader
DemobilizationUnit Leader
Staging
Manager
Medical Care
Branch Director
Infrastructure
Branch Director
HazMat
Branch Director
Security
Branch Director
Business
Continuity
Branch Director
Legend
ActivatedPosition
Logistics
Section Chief
Procurement
Unit Leader
Compensation/
ClaimsUnit Leader
TimeUnit Leader
Cost
Unit Leader
Service
Branch Director
Support
BranchDirector
Triage
Unit Leader
Decedent/
Expectant
Unit Leader
Delayed
TreatmentUnit Leader
Immediate
Treatment
Unit Leader
Minor
Treatment
Unit Leader
Casualty Care
Unit Leader
Incident Commander
Page 4
Trauma/Burn Guidelines
Modied from CEMSA Hospital Incident Command System (HICS)
www.emsa.ca.gov/hics
http://www.emsa.ca.gov/hicshttp://www.emsa.ca.gov/hics8/13/2019 TraumaBurn ClinicalGuidelines Final
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SAFETY AND SECURITY
Upon notication or determination of a trauma/burn event affecting a
large number of patients:
Security Branch Director:
Assesses security needs and capabilitiesFollows guidance from Operations Section Chief regarding possible
screening and visitor restriction
Establishes and secure access and egress for vehicles delivering all
patients during the time of the event
Safety Ofcer:
Assigns a safety ofcer to the emergency department as necessary
Monitors staff use of appropriate safety and infection control
proceduresMonitors the transportation routes to provide safe and efcient ingress
and egress for vehicles bringing casualties and other personnel
wishing to gain access to the ED
Note:
Secondary hazards should be suspected, if the event appears to be an
act of terrorism
Secondary hazards may include: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
Refer to Radiation Clinical Guidelines if suspected
D Detection
I IncidentCommandSystem
S Safety andSecurity
A
Assessment
S Support
T Triage andTreatment
E Evacuate
R Recovery
Appendices
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Trauma/Burn Guidelines
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ASSESSMENTUpon notication or determination of a trauma/burn event affecting a
large number of patients:
Medical/Technical Specialist (Trauma Chief or Critical Care Chief):
Provides guidance to the Incident Commander and Operations Section
Chief regarding:
Appropriate methods of treating casualties based on their severity
Assesses and ensures necessary resources
Number of casualties needing immediate surgery or other
treatments
Number of casualties that could have delayed surgery or other
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 increasebed 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
hazards are suspected.
Toxicologist if chemical contamination is suspected
Radiation Safety Ofcer if radiation exposure or contamination is
suspected
Operations Section Chief:
Shares information and plans with Branch and Unit Leaders to assure
emergency treatment plans and victim dispositions are properly
implemented
Casualty Care Unit Leader:
Assesses ongoing patient needs and capacities and reports to Medical
Care Branch Director
Assesses ongoing resource needs including trauma/burn specicresources and reports to Operations Section Chief
Assesses need for additional bed capacity due to patient surge and
reports to Operations Section Chief
D Detection
I IncidentCommandSystem
S Safety andSecurity
A
Assessment
S Support
T Triage andTreatment
E Evacuate
R Recovery
Appendices
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Trauma/Burn Guidelines
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Trauma/Burn Guidelines
SUPPORT
Upon notication or determination of a trauma/burn event affecting a
large number of patients:
Incident Commander:
Considers need to activate Emergency Operations Plan Noties senior hospital leadership of the situation
Activates HICS positions as indicated
Establishes operational periods and the schedule for briengs
Casualty Care Unit Leader:
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
Inpatient Unit Leader:
Assures continued care for inpatients
Manages the inpatient care areas
Provides for early patient discharge, if indicated
Facilitates rapid admission of casualties to appropriate care areas
Logistic Section Chief:
Ensures an adequate supply of all resources necessary for patient careactivities
NOTES:
D Detection
I IncidentCommandSystem
S Safety andSecurity
A
Assessment
S Support
T Triage andTreatment
E Evacuate
R Recovery
Appendices
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Trauma/Burn Guidelines
TRIAGE AND TREATMENT
Upon notication or determination of a trauma/burn event affecting a
large number of patients:
Operations Section Chief:
Shares information and plans with Branch and Unit Leaders to assureemergency treatment plans and victim dispositions are properly and
completely implemented
Casualty Care Unit Leader:
Uses established triage guidelines (See Appendix 3 and 4)
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 APLSbefore 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
Advanced Burn Life Support (See Appendix 5and 6)
Assesses and treats traumatic injuries including blast injuries
(See Appendix 7)and/or crush injury/compartment syndrome
(See Appendix 8)
Establishes area(s) for the cohort of patients based on triage levels
Inpatient Unit Leader:
Assures continued care for inpatients
Burn injuries(See Appendix 5and 6)
Blast injuries(See Appendix 7)
Crush injury/compartment syndrome(See Appendix 8)
Manages the inpatient care areas
Provides for early patient discharge, if indicated
Promotes rapid admission of casualties to appropriate care areas
D Detection
I IncidentCommandSystem
S Safety andSecurity
A
Assessment
S Support
T Triage andTreatment
E Evacuate
R Recovery
Appendices
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EVACUATE
Upon notication or determination of a trauma/burn event affecting a
large number of patients:
Casualty Care Unit Leader:
In consultation with the senior emergency department physican: Prepares the ED by making prompt disposition decisions: discharge
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
care (e.g., pediatric intensive care, burn center or rehabilitation
facility)
Inpatient Unit Leader:
In consultation with Medical Care Branch Director: 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
(e.g., pediatrics, burn casualties, long-term care patients
POTENTIAL FOR EMERGENCY EVACUATION OF THE
EMERGENCY DEPARTMENT
Secondary hazards should be suspected, if the event appears to be an
act of terrorism
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
Radiological contamination of the victims Refer to radiation clinical guidelines if suspected
D Detection
I IncidentCommandSystem
S Safety andSecurity
A
Assessment
S Support
T Triage andTreatment
E Evacuate
R Recovery
Appendices
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Trauma/Burn Guidelines
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Page 10
Trauma/Burn Guidelines
RECOVERY
Upon notication or determination of a trauma/burn event affecting a
large number of patients:
Behavioral Health Unit Leader:
Aids recovery by addressing the behavioral health needs of patients,visitors and healthcare personnel
If needed, enlists the services of:
Social Services Department
Pastoral Care department
Department of Psychiatry
Child Life Specialists
Employee Assistance Services
Other, outside behavioral health services
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 stafng patterns and adjust
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
NOTES:
D Detection
I IncidentCommandSystem
S Safety andSecurity
A
Assessment
S Support
T Triage andTreatment
E Evacuate
R Recovery
Appendices
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Trauma/Burn Guidelines
Appendices
Appendix 1: Event Characteristics and Anticipated Impact on
HospitalsAppendix 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
Appendix 5: General Burn Guidelines
Appendix 6: Burn Care and Treatment
Appendix 7: Blast Injuries Care and Treatment
Appendix 8: Crush Injury/Compartment Syndrome Care and
Treatment
Appendix 9: Abbreviations
D Detection
I IncidentCommandSystem
S Safety andSecurity
A
Assessment
S Support
T Triage andTreatment
E Evacuate
R Recovery
Appendices
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Trauma/Burn Guidelines
Appen
dix1:
Even
tCha
rac
teris
ticsan
dAn
tic
ipa
tedImpac
ton
Hosp
ita
ls
Even
tc
harac
teris
tic
Imp
lica
tion
An
tic
ipa
tedimpac
t
Num
bero
finjure
d
surv
ivorssee
king
emergencycare
Injury
frequency
In
juryseveri
ty
Even
tnear
hosp
ita
l
n
umberofinjuredsurvivorswill
arriveatEDwithoutEMStransp
ort
E
MStransporttimetohospital
a
tnearbyhospitals
m
inorinjuries
worriedwell
Variablemoreminor
andmoreseriousinjuries
Ve
hiclede
liverysys
tem
in
exp
los
ions
e
xplosivemagnitude,structural
collapsepossible
i
mmediatedeathscloseto
detonationpointorinsidecollap
se
M
ayproduce100sto
1,0
00sofinjuredsurvivors
Variable
i
nseverity
Pre-exp
los
ionor
pre-co
llapseevacua
tion
d
istancebetweenpotentialvic
tims
anddetonationpoint
n
umberatrisk
n
umberofinjured
survivors
P
rimaryblastinjury,
traumaticamputations,
ashburns
i
nseverity
Open-a
irexp
los
ions
Blastenergydissipated,
butspread
overgreaterarea,structuralcollapse
unlikely
n
umberofimmediatedeaths
M
ayproduceupto
200injuredsurvivors,many
withminorinjuries
S
econdaryblastinjury
i
nseverity
Confned
space
exp
los
ions
Blastenergypotentiated,
but
containedinlesserarea
n
umberofimmediatedeathsinside
space
n
umberofinjuredexposedto
blast
effects
e
ffectsinsmallerspace(e.g.,
bus)
U
suallyproduces20-25% TBSA require IV uid resuscitation
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 smallerlegs (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 Supercial 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 painfulSupercial burns heal by re-epithelialization and
usually do not scar if healed within 2 weeks
Deep Burns
[Deep burns usually need skin
grafts to optimize results and
lead to hypertrophic (raised)
scars if not grafted]
Deep second-degree burns(deep partial-thickness)
Damage to deeper dermis
Less moist, less blanching, less pain
Heal by scar deposition, contraction and limited re-
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
Morbidity and Mortality
Age Mortality for any given burn size increases with age
Children/young adults can survive massive burns
Children require more uid per TBSA burns
Elderly may die from small (
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Trauma/Burn Guidelines
Appendix 5: Rule of Nines
Head and neck - 9%
Trunk
Anterior 18% Posterior 18%
Genitalia and
Perineum - 1%
Arm - 9% (each)
Leg - 18% (each)
A
a
1
2 213
2 2
b b
c c
1
1
1
1
1
b b
c c
1
1
13
1
1
2 2
a
1
1
1
Anterior Posterior B
Relative percentage of body surface area (%BSA) affected by growth
AgeBody Part 0 yr 1 yr 5yr 10yr 15 yr
a= 1/2 of head 9 8 6 5 4
b = 1/2 of 1 thigh 2 3 4 4 4
c = 1/2 of 1 lower leg 2 2 2 3 3
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)
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Trauma/Burn Guidelines
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 anxietyRisk 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 afnity of oxygen
- Leads to inadequate oxygenation
Diagnosis
- PaO2(partial pressure of O
2dissolved in serum)
- Oximeter (difference in oxy- and deoxyhemoglobin)
- Carboxyhemoglobin levels
40% is severe intoxication
Treatment
- Remove source
- 100% oxygen until CO levels are
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Trauma/Burn Guidelines
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 (rst 24 hours) (see Parkland Formula below) - Massive capillary leak occurs after major burns
- Fluids shift from intravascular space to interstitial space
- IV uid 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 uid rate
Preferred uid: Lactated Ringers Solution
- Isotonic
- Inexpensive
- Easily stored
Parkland Formula
IV uid
Lactated Ringers Solution
Fluid calculation:
4 x weight in kg x %TBSA burn
Give 1/2 of that volume in the rst 8 hours
Give other 1/2 over next 16 hours
Warning:Despite the formula suggesting cutting the uid rate in half at 8 hours, the uid 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 onthe 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 rst 8 hours = 16,000 ml in rst 8 hours
Starting rate = 2,000 ml/hour
Resuscitation formulas are just a guide for initiating resuscitation
- Adjust uid rate to maintain urine output of 50 ml/hr for adults
Albumin may be added toward end of 24 hours if not adequate responseWhen maintenance rate is reached (approximately 24 hours), change uids to D5/.5 NS with 20
mEq KCl at maintenance uid rate (see below)
- Maintenance uid rate
Adult maintenance uid rate: 1500cc x total body surface area (TBSA) (for 24 hrs)
Pediatric maintenance uid 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
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Trauma/Burn Guidelines
Appendix 6: Burn Care and Treatment (continued)
Complications of Over-Resuscitation
Compartment
Syndrome
(Transfer to
Veried Burn
Center*, if
possible)
Limb Compartment Syndrome
- Symptoms of severe pain (worse with movement), numbness, cool extremity, tight feeling
compartments
- Distal pulses will be lost when the compartment pressure exceeds the systolic blood pressure
- Compartment pressure >30 mmHg may compromise muscle/nerves
- 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
Measure through Foley catheter- Signs: increased peak inspiratory pressure (PIP), decreased urine output despite massive
uids, hemodynamic instability, tight abdomen
- Treatment
Abdominal escharotomy
NG tube
Possible placement of peritoneal catheter to drain uid
Laparotomy as last resort
Acute
Respiratory
Distress
Syndrome
(ARDS)
Increased risk if uid resuscitation to aggressive
Supportive treatment
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Trauma/Burn Guidelines
Appendix 6: Burn Care and Treatment (continued)
Secondary Burn Care and Treatment
Wound Care
Acute
Respiratory
Distress
Syndrome
(ARDS)
During initial or emergent care, wound care is of secondary importance
Advanced Burn Life Support recommendations
- Cover wound with clean, dry sheet or dressing. NO MOIST DRESSINGS if TBSA> 10%, pt wil
become hypothermic
Sterile dressings are preferred but not necessary
Covering wounds decreases pain Elevate burned extremities
- Maintain patients 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 supercial burns
Skin grafting
- Deep burns require skin grafting
- Grafting may not be necessary for days- Preferable to refer patients with need for grafting to Veried Burn Center* or, if not available,
others trained in surgical techniques
Grafting of extensive areas may require signicant amounts of blood
Patients 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
Considerations(often require
specialized
care, transfer
to Veried
Burn Center* if
possible)
Electrical injuries
- Extent of injury may not be apparentDamage occurs deep within tissues
Damage frequently progresses
Electricity contracts muscles, so watch for associated fractures and tissue injury
- Cardiac arrhythmias may occur
All patients with electrical burns need cardiac monitoring
- Myoglobinuria may be present
Color best indicator of severity
If urine is dark (black, red), myoglobinuria needs to be treated
- Increase uids 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 Veried Burn
Center*, for example: Hydrouoric acid burn
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Trauma/Burn Guidelines
Appendix 6: Burn Care and Treatment (continued)
*American Burn Association Burn Unit Referral Criteria
Second- and third-degree burns greater than 10% TBSA in patients under 10 or over 50 years of age1.
Second- and third-degree burns greater than 20% TBSA in other age groups2.
Second- and third-degree burns that involve the face, hands, feet, genitalia, perineum and major joints3.
Third-degree burns greater than 5% TBSA in any age group4.
Electrical burns, including lightning injury5.
Chemical burns6.
Inhalation injury7.
Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery or8.
affect mortality (e.g., signicant radiation exposure)
Any patients with burns and concomitant trauma (e.g., fractures, blast injury) where burn injury poses the greatest9.
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
Hospitals without qualied personnel or equipment for the care of children should transfer children with burns to a10.
Burn Center with these capabilities
Burn injury in children who will require special social/emotional and/or long-term rehabilitative support, including11. cases involving suspected child or substance abuse
Note: Criteria not established for very large mass casualty incidents (MCI)
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Trauma/Burn Guidelines
Appendix 7: Blast Injuries Care and Treatment
Pearls for Clinical Practice
Wound Care
Acute
Respiratory
Distress
Syndrome
(ARDS)
Expect an upside-down triage - the most severely injured arrive after the less injured, who by-
pass EMS triage and go directly to the closest hospitals
If structural collapse occurs, expect increased severity and delayed arrival of casualties
Clinical signs of blast-related abdominal injuries can be initially silent until signs of acute
abdomen or sepsis are advanced.
Standard penetrating and blunt trauma to any body surface is the most common injury seenamong 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 eld, rather than
being in a conned 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
over-pressurization wave with
body surfaces.
Gas lled structures are most
susceptible
LungsGI tract
Middle ear
Blast lung (pulmonary
barotrauma)
TM rupture and middle eardamage
Abdominal hemorrhage and
perforation
Globe (eye) rupture
Concussion (TBI without
physical signs of head
injury)
Secondary Results from ying debris and
bomb fragments.
Any body part may be affected. Penetrating ballistic
(fragmentation)
Blunt injuries
Eye penetration (may be
occult)Tertiary Results from individuals being
thrown by the blast wind.
Any body part may be affected. Fracture
Traumatic amputation
Closed and open brain
injury
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Appendix 7: Blast Injuries Care and Treatment (continued)
Category Characteristics Body Parts Affected Types of Injuries
Quaternary All explosion-related
injuries, illnesses, or
diseases not due to
primary, secondary or
tertiary mechanisms.
Includes exacerbation orcomplications of existing
conditions.
Any body part may be affected. Burns (ash, partial and full
thickness)
Crush injuries
Closed and open brain
injury
Asthma, COPD, or otherbreathing problems from
dust, smoke or toxic fumes
Angina
Hyperglycemia
Hypertension
Note: Up to 10% of blast survivors have signicant 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 conuent hemorrhages. Blast lung should be
suspected for anyone with dyspnea, cough, hemoptysis or chest pain following blast exposure. Blast lung produces
a characteristic buttery 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 stula, 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 buttery 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., conned space, re, 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 uiduse and administration ensuring tissue perfusion without volume overload
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Appendix 7: Blast Injuries Care and Treatment (continued)
Selected Blast Injuries
Lung Injury
Clinical Interventions
- All patients with suspected or conrmed BLI should receive supplemental high ow oxygen sufcient 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 signicant air leaks may benet 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 ow 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 signicant 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.
Clinical Presentation
- 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.
Clinical Presentation
- Blast abdominal injury should be suspected in anyone exposed to an explosion with:
Abdominal pain
Nausea, vomiting
Hematemesis
Rectal pain
Testicular pain
Unexplained hypovolemiaAny ndings suggestive of an acute abdomen
Clinical ndings 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.
Modied from: CDC, Blast and bombing injuries: Fact sheet for professionals booklet,
http://emergency.cdc.gov/BlastInjuries
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Appendix 8: Crush Injury/Compartment Syndrome Care and Treatment (continued)
Initial Management
Sudden release of a crushed extremity may result in reperfusion syndromeacute 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 uid replacement in the rst 24 hours; Patients maysequester (third space) more than 12 L of uid 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 hydrationup to 1.5 L/hour
Renal Failure
- Prevent renal failure with appropriate hydration, using IV uids 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; consideremergency 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 Ps: 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
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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
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www.ynhhs.org/cepdr
http://www.ynhhs.org/cepdrhttp://www.ynhhs.org/cepdr