traumaburn clinicalguidelines final

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/cepdr


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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/


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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

Page 2



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Page 3


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



A

Assessment

S Support


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

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Modied from CEMSA Hospital Incident Command System (HICS)

www.emsa.ca.gov/hics
http://www.emsa.ca.gov/hicshttp://www.emsa.ca.gov/hics


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SAFETY AND SECURITY



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



A

Assessment

S Support


E Evacuate

R Recovery

Appendices

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ASSESSMENTUpon notication or determination of a trauma/burn event affecting a


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



A

Assessment

S Support


E Evacuate

R Recovery

Appendices

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SUPPORT



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


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



A

Assessment

S Support


E Evacuate

R Recovery

Appendices


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TRIAGE AND TREATMENT



Operations Section Chief:

Shares information and plans with Branch and Unit Leaders to assureemergency treatment plans and victim dispositions are properly and

completely implemented


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


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



A

Assessment

S Support


E Evacuate

R Recovery

Appendices


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EVACUATE




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)


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



A

Assessment

S Support


E Evacuate

R Recovery

Appendices

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RECOVERY



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


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



A

Assessment

S Support


E Evacuate

R Recovery

Appendices


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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



A

Assessment

S Support


E Evacuate

R Recovery

Appendices


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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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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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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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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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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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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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Page 26



*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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Page 27


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.


- 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 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
http://emergency.cdc.gov/Blastinjurieshttp://emergency.cdc.gov/Blastinjurieshttp://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

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