Burns associated with wars and disasters

care as a burn center in the U. S., however. Lack of experience on the part of many providers, absence of multidisciplinary burn team members, limitations with respect to supplies, equipment, and physical plant, and patient-related factors such as delays in presentation heightened the challenge.

Because burn patient care is very costly with respect to supplies, manpower, and length of stay, and because bed space is limited at Role III facilities, it was necessary to expedite such treatment. Several techniques evolved over time to accomplish this. Patients with burns of up to 50–60% TBSA received definitive care at Role III hospitals. It became apparent that surgical care of patients with larger burns was futile; these patients were therefore triaged to comfort care. Excision and grafting of burns was performed at Role III hospitals within a day or two of admission (Fig. 3). Negative-pressure wound therapy (Vacuum-Assisted Closure) was frequently used to speed up engraftment or to help prepare wound beds for grafting. Topical wound therapies, such as artificial skin (Biobrane), silver-impregnated dressings (Silverlon; others), and gamma-irradiated homograft (Gammagraft) were used as appropriate. A small number of burned children were flown out of theater on commercial airlines by civilian charities for care at Shriners Institutes for Burned Children in the U. S. (Fig. 4) [25]. From these events, we can conclude that burn care, to include definitive care of civilians of all ages with major thermal injuries, is part of the usual workload of Role III hospitals on the modern battlefield; that these hospitals should have the supplies and equipment needed to provide definitive care to these patients; and that personnel should obtain experience with definitive burn care before deploying.

Fig. 3. Excision to fascia of infected lower extremity burns in an Iraqi male at the Combat Support Hospital (CSH) in Baghdad. Patient was transferred from a local facility 10 days after injury by an improvised explosive device (IED), and was successfully excised and grafted on day of admission to CSH

decades is the emergence of terrorism as a cause of mass casualty burns. Burn disasters are challenging because (1) burn victims are extremely resourceand time-intensive in their care needs and (2) burn expertise is normally concentrated in specialized centers, but local hospitals with no experience in the care of burns may be required to provide care of casualties for hours or days following a disaster.

Burn mass casualty incidents have provided unique opportunities for health care providers to

Disaster-related burns

Mass casualties as a result of fire have occurred with some regularity in the US since the country was founded. The first large-scale fire occurred at Jamestown, Virginia in May 1607, decimating the colony [26, 27]. Worldwide, catastrophic fires have punctuated history due to their social and political implications. A recent development in the latter half of the twentieth century and specifically in the last two

Fig. 4. Iraqi child selected for transfer to Shriners Institute in Boston, MA. Despite extensive full-thickness burns, patient was extubated and transitioned to oral medications before commercial flight

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review the treatment of these patients and to develop improvements in care. An excellent example of this is the Cocoanut Grove nightclub fire that occurred in Boston, MA in 1942. As a result of the attack on Pearl Harbor in 1941 (where half of the casualties were burned), the Massachusetts General Hospital and Boston City Hospital were conducting research in burn care and had already developed guidelines for disaster preparedness which included the development of a blood bank, publication of a disaster manual, and accumulation of sterile supplies for multiple simultaneous operations [28]. The physicians that cared for victims of the Cocoanut Grove fire paved the way for the future management of burn victims [28]. More recently, since the terrorist attacks on the World Trade Center on 11 September 2001 in New York City and the bombing in Bali on 12 October 2002, awareness has increased regarding the importance of disaster preparedness. The purpose of this section is to outline the epidemiology of burns suffered by victims of mass casualty events, review techniques for triage, prehospital care, acute management and resuscitation, and other principles of care of multiple burn victims by burn centers.

Epidemiology

Barillo performed a thorough review of historic US fire catastrophes during the twentieth century [9]. The largest number of significant fires were classified as “residential” and included fires in hotels, nursing homes, jails, and hospitals [9]. Fatally injured casualties from burn disasters typically die at the scene, during transport to a local hospital, or shortly after arrival to the hospital [30–39]. For example, the Iroquois Theater fire of 1903 in Chicago resulted in 602 deaths with a list of 571 fatalities published in the Chicago Tribune by the morning after the fire [30]. The Cocoanut Grove fire death toll was 492. Three hours after the fire occurred, the city mortuary had accounted for over 400 bodies in morgues around the city [31]. More recently, the 1990 Happy Land Social Club fire in Bronx, New York resulted in 87 deaths all identified at the scene, and the 1991 Imperial Foods plant disaster in Hamlet, North Carolina resulted in 25 deaths with 24 pronounced at the scene [32, 33]. The Station Nightclub fire in Warwick, Rhode

Island in 2003 occurred in a 1950s-era building that was not equipped with sprinklers when it ignited as a result of pyrotechnics during a concert [38]. Of the 439 people inside at the time of the fire, 96 people died at the scene and only an additional 4 died in surrounding area hospitals in the weeks following the incident. The Rhode Island hospital evaluated a total of 64 patients in their emergency department, admitting 47 to a converted trauma ward. A total of 28 of the 47 admitted had inhalation injury. 33 had less than 20% TBSA burns, 12 patients had burns of between 21 and 40%, and two had burns of 40% TBSA. The predominance of early deaths in indoor fire disasters points to the importance of asphyxia (hypoxia and inhalation of toxic gases) and upper airway injury.

By contrast, the Ringling Brothers Circus in 1944 at Hartford, Connecticut led to a predominance of fatalities due to severe burns from the heavy canvas that was engulfed by flames and fell onto the crowd [36]. The canvas had been coated with paraffin dissolved in gasoline to make it waterproof. The open air tent resulted in only a few patients suffering inhalation injury [37]. In Arturson’s review, fires due to indoor disasters tend to cause smaller TBSA burns in survivors than casualties burned in outdoor catastrophic fires [40]. Experts suggest that in disasterrelated fires, 80% of survivors will sustain burns of 20% or less of the TBSA [41].

Medical response at the scene of the attack on the World Trade Center towers on 11 September 2001 was complicated by the fact that both towers collapsed, making evacuation and survival the primary mission of first responders [43–45]. Had the towers not collapsed, many more thermally injured casualties may have survived and needed treatment at burn centers [46 – 48]. A total of 39 casualties sustained burns that required treatment. The New YorkPresbyterian Weill Cornell Center, with a total burn bed capacity of 40, received 18 patients by the 27th hour after the disaster [48]. Nine were transferred directly from the scene and an additional nine were transferred from surrounding hospitals. The mean TBSA burned at that burn center was 52 +/– 7% (range 14 to 100%). Eight of the patients sustained burns involving more than 60% of the TBSA. Inhalation injury complicated the injuries of 14 patients admitted to the burn center.

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The terrorist attack on a nightclub in Bali, Indonesia on 12 October 2002 resulted in the single largest loss of civilian life in Australia’s history [49]. The disaster caused more than 200 fatalities at the scene. The burn center at the Repatriation General Hospital in Concord, Sydney received a total of 12 burn victims, 11 of them evacuated within 54 to 69 hours of the incident. The TBSA involvement ranged between 15 and 85%, mostly full thickness in depth.

Treatment of disaster-related burns

Prehospital

The scene of a burn catastrophe is best described as chaotic in the moments after the incident. In Arturson’s review of the San Juanico, Mexico liquid petroleum gas explosion in 1984, the author notes that no evacuation plan was in place to remove casualties from the scene [50]. Poor evacuation management affects outcomes, evidenced by the analysis of the petroleum gas tanker truck explosion in Los Alfaques, Spain in 1978 [51]. The incident caused a highway blockage, presenting two evacuation routes for patients needing further care. The group of 82 patients that was transported south had no en route medical care, traveled 150 km, and had a survival rate of 43%. The 58 patients taken via the north evacuation route were provided care en route and experienced a 93% survival rate. A lack of field triage after the 1970 Osaka, Japan gas line explosion resulted in misutilization of hospital-based physicians [52]. Central to most recent US burn disasters has been the establishment of an onsite triage center. This is accomplished by both insightful on-scene responders as well as local emergency medical responders. After the MGM Grand Hotel fire in Las Vegas, Nevada in 1980, over 3000 patients were triaged on the scene, allowing for evacuation of only 726 patients to hospitals and movement of 1700 minimally injured casualties to an off-site treatment center [52]. In order to prevent overwhelming of the regional burn center that will provide care for victims of a burn catastrophe, care should be provided on or close to the scene to both minimally injured victims as well as casualties suffering non-survivable injuries [54]. Some have suggested that on site presence of a burn surgeon

may facilitate triage of victims so that resources are optimized at receiving hospitals [39].

Guidance for initial triage of burned victims is different during a mass casualty situation. The lethality of a burn differs based on age and TBSA involved. The lethal area fifty percent (LA50) for a young adult is 80% [29]. This means that of young adults suffering 80% TBSA burns, half of the patients receiving care at a US burn center can be expected to survive. During a burn disaster, providers performing triage may be required to triage patients in this age group with burns over 80% TBSA into the expectant category. The presence of inhalation injury, concomitant traumatic injuries, and advanced age decrease the LA50. The ABA has published an age/TBSA survival grid that can be used to guide on-scene providers triaging burn victims (Fig. 5) [42]. This grid should only be used in the setting of a burn catastrophe, however. Ultimately, the burn center’s outpatient clinic will be responsible for the long-term wound care and rehabilitative needs of minimally burned victims not needing inpatient treatment.

A three-level method can be used for on-scene triage in catastrophic fires [29]. Level 1 includes sorting patients as acute or non-acute. Level 2 triage categorizes patients into immediate, delayed, minimal, and expectant. Level 3 triage sorts based on priority of evacuation. If a burn provider is not available on the scene of a fire, burn triage should occur before casualties enter the emergency department as to not overwhelm the facility with patients, most of whom will need outpatient care. Following catastrophic fires, “secondary triage” may be necessary in hospital to select patients for transfer to hospitals distant from the admitting burn facility [55].

International support is another way to enhance a region’s ability to care for mass casualty survivors. After the café fire in Volendam, Netherlands in 2001, 182 burn victims required hospital admission [58]. Due to the overwhelming number of acutely ill burn victims, some patients were transferred to burn centers in Belgium and Germany. The USAISR Burn Flight Team has assisted in several international burn disasters since its inception in 1951 [16]. Days after the Bashkirian gas pipeline explosion in 1989, 17 personnel from the USAISR arrived in Ufa, Russia and assisted with excision and autografting of burn wounds and rehabilitation [57].

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Fig. 5. American Burn Association age/survival grid for triage during burn disasters resulting in multiple casualtiest

Expansion of both hospital personnel and bed space is necessary. After the Station nightclub fire, physicians from the Rhode Island Hospital fortunately began receiving casualties during a shift change when two sets of staff were in house and available [38]. The trauma ward was cleared of inpatients, and burn bed capacity was increased by utilizing extra suction and oxygen mounts already present in the trauma ward rooms. This allowed rapid expansion and enabled admission of a large number of burn casualties. Bedside paper charting may be more efficient than complex computerbased charting, especially if outside providers are brought in to assist [22]. Delegation of care can be performed, such that a burn surgeon and senior burn nurse provide oversight and managerial support and non-burn providers carry out daily care to

include wound care, pain management, resuscitation, and rehabilitation [29]. The stress on the hospital staff must be alleviated by implementation of a rotation schedule, a meal service, and a counseling program [59]. Supply and equipment lists should be generated including standard and portable mechanical ventilators, monitoring devices, resuscitative equipment, surgical supplies, wound-care items, and rehabilitation equipment [29]. Harrington et al. reported that established protocols for burn care (e. g. resuscitation, wound care, ventilator management, donor site care, rehabilitation) streamlined the management of multiple burn patients and allowed for inexperienced providers to manage casualties effectively [38]. Yurt et al. noted that surgical management of multiple burn victims requires early and frequent coordination to maintain a smooth

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