Trauma/Burn Clinical Guidelines

Transcription

1 D Trauma/Burn Clinical Guidelines I S A A Quick Guide for the Management of Trauma/Burn Disasters for Emergency Department Personnel S Rev. August 2013 T E R

2 Emergency Information for Trauma/Burn Emergencies ORGANIZATION Local Police State Police Federal Bureau of Investigation (FBI) Department of Homeland Security Local Burn Center Local Hyperbaric Chamber Organization-Specific Contacts [see below] PHONE NUMBER Emergency Trauma/Burn Management Websites ORGANIZATION American Burn Association CDC: Explosions and Blast Injuries CDC: Mass Casualties: Burns US Health & Human Services: Burn Triage and Treatment - Thermal Injuries WEBSITE explosions.asp burns.asp Yale New Haven Health System Center for Emergency Preparedness and Disaster Response. None of this publication may be reproduced or transmitted in any form without permission from Yale New Haven Health System Center for Emergency Preparedness and Disaster Response. Page 1

3 Introduction: This guide is a quick reference for the hospital s initial response to Trauma/Burn emergencies. Based on the word DISASTER*, it facilitates the ongoing qualitative and quantitative assessment of the incident. D I S A S T E R Detection ICS Safety/Security Assessment Support Triage and Treatment Evacuate Recovery This guide includes components of the Hospital Incident Command System (HICS) version IV and utilizes components of MASS, START and Jump START triage systems. This reference guide provides a framework for a coordinated, effective hospital response to a trauma/burn incident. Upon initial notification of a mass casualty event, hospital staff needs to be aware that the first casualties of the event may arrive at the hospital without transport by EMS. If a larger number of casualties are expected, the staff may need to utilize mass casualty triage methods. Also note there may be additional hazards. If the explosion was caused by a chemical event, casualties may need to be decontaminated or a risk that a bomb was a radiological dispersion device (RDD), also known as a dirty bomb, See the appropriate guidelines for appropriate interventions. * The mnemonic, D-I-S-A-S-T-E-R, is taken from the National Disaster Life Support program and is used with the gracious permission of the American Medical Association and the National Disaster Life Support Educational Foundation. Page 2

4 DETECTION Based 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 lifethreatening injuries require significant 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 notified 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 ED Types and severity of injuries Whether casualties may have been exposed to chemical or radiological contamination Estimated time of arrival of the first victim Whether incident directly involves people with medical dependencies including, children and the estimated number of these types of patients Contact information for the reporting person or agency Notifies the Administrator-on-Duty if a large number of casualties are anticipated Directs EMS personnel to deliver casualties to designated triage area D Detection I Incident Command System S Safety and Security A Assessment S Support T Triage and Treatment 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 victim s families to designated area Notifies Regional EMS communication center of event status and status of the hospital e.g., bed availability, or ED status to accept additional patients E Evacuate R Recovery Appendices Page 3

5 INCIDENT COMMAND SYSTEM Upon notification or determination of a trauma/burn event affecting a large number of patients: D Detection Incident Commander (Administrator-on-Duty) Activates HICS positions as needed Activates Emergency Operations Plan (EOP) as appropriate I Incident Command System Incident Commander Public Information Officer Safety Officer S Safety and Security Liaison Officer Medical / Technical Specialist A Assessment Operations Section Chief Planning Section Chief Logistics Section Chief Finance / Administration Section Chief Staging Manager Resources Unit Leader Service Branch Director Time Unit Leader S Support Medical Care Branch Director Infrastructure Branch Director Casualty Care Unit Leader Triage Unit Leader Minor Treatment Unit Leader Immediate Treatment Unit Leader Situation Unit Leader Documentation Unit Leader Support Branch Director Procurement Unit Leader Compensation/ / Claims Unit Leader T Triage and Treatment HazMat Branch Director Security Branch Director Delayed Treatment Unit Leader Decedent/ Expectant Unit Leader Demobilization Unit Leader Legend Cost Unit Leader E Evacuate Business Continuity Branch Director Activated Position R Recovery Modified from CEMSA Hospital Incident Command System (HICS) Appendices Page 4

6 SAFETY AND SECURITY Upon notification or determination of a trauma/burn event affecting a large number of patients: D Detection Security Branch Director: Assesses security needs and capabilities Follows 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 Officer: Assigns a safety officer to the emergency department as necessary Monitors staff use of appropriate safety and infection control procedures Monitors the transportation routes to provide safe and efficient ingress and egress for vehicles bringing casualties and other personnel wishing to gain access to the ED I Incident Command System S Safety and Security A Assessment S Support 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 T Triage and Treatment E Evacuate R Recovery Appendices Page 5

7 ASSESSMENT Upon notification or determination of a trauma/burn event affecting a large number of patients: D Detection 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 increase bed availability for trauma/burn casualties Determines criteria for transferring casualties to other facilities (trauma centers, burn centers, pediatric centers, etc.) Other Medical/Technical Specialists may be required if additional hazards are suspected. Toxicologist if chemical contamination is suspected Radiation Safety Officer 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 I Incident Command System S Safety and Security A Assessment S Support T Triage and Treatment E Evacuate Casualty Care Unit Leader: Assesses ongoing patient needs and capacities and reports to Medical Care Branch Director Assesses ongoing resource needs including trauma/burn specific resources and reports to Operations Section Chief Assesses need for additional bed capacity due to patient surge and reports to Operations Section Chief R Recovery Appendices Page 6

8 SUPPORT Upon notification or determination of a trauma/burn event affecting a large number of patients: D Detection Incident Commander: Considers need to activate Emergency Operations Plan Notifies senior hospital leadership of the situation Activates HICS positions as indicated Establishes operational periods and the schedule for briefings 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 I Incident Command System S Safety and Security A Assessment 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 S Support Logistic Section Chief: Ensures an adequate supply of all resources necessary for patient care activities T Triage and Treatment NOTES: E Evacuate R Recovery Appendices Page 7

9 TRIAGE AND TREATMENT Upon notification or determination of a trauma/burn event affecting a large number of patients: D Detection Operations Section Chief: Shares information and plans with Branch and Unit Leaders to assure emergency treatment plans and victim dispositions are properly and completely implemented I Incident Command System 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 APLS before decontamination, including: Maintains C-spine precautions, if appropriate Secures airway, provides ventilation with 100% oxygen IV fluid resuscitation Assesses and treats burn casualties according to the principles of Advanced Burn Life Support (See Appendix 5 and 6) Assesses and treats traumatic injuries including blast injuries (See Appendix 7) and/or crush injury/compartment syndrome (See Appendix 8) Establishes area(s) for the cohort of patients based on triage levels S Safety and Security A Assessment S Support T Triage and Treatment Inpatient Unit Leader: Assures continued care for inpatients Burn injuries (See Appendix 5 and 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 E Evacuate R Recovery Appendices Page 8

10 EVACUATE Upon notification or determination of a trauma/burn event affecting a large number of patients: D Detection 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) I Incident Command System S Safety and Security 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 A Assessment S Support Potential For Emergency Evacuation Of The Emergency Department T Triage and Treatment 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 E Evacuate R Recovery Appendices Page 9

11 RECOVERY Upon notification or determination of a trauma/burn event affecting a large number of patients: D Detection 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 staffing 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 I Incident Command System S Safety and Security A Assessment S Support T Triage and Treatment NOTES: E Evacuate R Recovery Appendices Page 10

12 D Detection I Incident Command System Appendices Appendix 1: Event Characteristics and Anticipated Impact on Hospitals Appendix 2: Principles of Care of Children from MCI Incident Resulting in Traumatic/Burn Injuries Appendix 3: Mass Casualty Triage Tags Appendix 4: Mass Triage Systems 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 S Safety and Security A Assessment S Support T Triage and Treatment E Evacuate R Recovery Appendices Page 11

13 Appendix 1: Event Characteristics and Anticipated Impact on Hospitals Anticipated impact Event characteristic Implication Event near hospital number of injured survivors will arrive at ED without EMS transport Number of injured survivors seeking emergency care at nearby hospitals minor injuries worried well Injury frequency Injury severity Variable more minor and more serious injuries Vehicle delivery system in explosions EMS transport time to hospital explosive magnitude, structural collapse possible May produce 100s to 1,000s of injured survivors Variable in severity Pre-explosion or pre-collapse evacuation immediate deaths close to detonation point or inside collapse distance between potential victims and detonation point number at risk Open-air explosions Blast energy dissipated, but spread over greater area, structural collapse unlikely number of injured survivors May produce up to 200 injured survivors, many with minor injuries Primary blast injury, traumatic amputations, flash burns in severity Secondary blast injury in severity Confined space explosions number of immediate deaths Blast energy potentiated, but contained in lesser area number of immediate deaths inside space Usually produces < 100 injured survivors Primary blast injury, amputations, burns in severity number of injured exposed to blast effects effects in smaller space (e.g., bus) Appendix 1 Page 12

14 Appendix 2: Principles of Care of Children from MCI Incident Resulting in Traumatic/Burn Injuries General Principles No widely utilized system for rapid triage of children in MCIs. Jump START is the most widely known Children and their parents should not be separated during triage. (Injured children should be reunited with responsible parent or caregiver as soon as possible, since anxiety exacerbated by separation from parents or caregivers often confounds their evaluation.) Children have incompletely developed motor skills and cognition. (Therefore, they may not be able to escape site of an incident and may not be able to follow directions.) Injured children should be managed according to the general principles of PALS and ATLS. Trauma/Burn Injured children are at higher risk for hypothermia, with significantly greater thermo-regulatory problems in younger children. With smaller circulating blood volume, (despite greater tolerance of volume loss per kilogram), decomposition into shock may be more rapid and more difficult to reverse. Airway is smaller, increasing risk of airway edema. Children are at greater risk of head injury because of disproportionately larger head size. Head injury severity is the main determinant of a pediatric patient s outcome. Cervical spine and spinal cord injuries are less common in children because of greater flexibility and mobility. (Conversely, spinal cord injuries in the absence of radiographic abnormalities are more likely to be present.) Damage to internal organs is greater due to increased chest wall compliance and greater transfer of energy to internal organs, while rib fractures and flail chest are relatively uncommon. (If rib fractures are present, there is a much greater risk of intrathoracic injuries.) Behavioral Health Greater risk of psychological trauma. Children s reactions to situations vary, and depend on a child s developmental level (cognitive, physical, educational and social). Child s behavior may depend on emotional state of caretakers. Behavior may appear oppositional, based on cognitive ability and fear. Behavioral healthcare should include age-appropriate interventions. Long-term psychological impacts and behavioral disturbances may occur. Appendix 2 Page 13

15 Appendix 3: Mass Casualty Triage Tags Mass Casualty Triage Tag A FRONT BACK Page 14

16 Appendix 3: Mass Casualty Triage Tags Mass Casualty Triage Tag B FRONT BACK Page 15

17 Appendix 3: Mass Casualty Triage Tags SMART Triage Tag System Page 16

18 Appendix 4: Mass Triage Systems START Adult Triage System Adapted from Page 17

19 Appendix 4: Mass Triage Systems JumpSTART Pediatric Triage System Adapted from Page 18

20 Appendix 4: Mass Triage Systems SALT Mass Casualty Triage System Adapted from: SALT mass casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med Public Health Prep Dec;2(4): [PubMed Citation] Page 19

21 Appendix 5: General Burn Guidelines Burn Severity Percent of total body surface area (TBSA) involvement Burns >20-25% TBSA require IV fluid 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 smaller legs (13% in infants) than adults (See chart) Lund-Browder diagrams improve the accuracy of the % TBSA for children. Palmar hand surface is approximately 1% TBSA Depth of Burn Injury Superficial Burns First-degree burns Damage above basal layer of epidermis Dry, red, painful ( sunburn ) Deep Burns [Deep burns usually need skin grafts to optimize results and lead to hypertrophic (raised) scars if not grafted] Second-degree burns Damage into dermis Skin adnexa (hair follicles, oil glands, etc,) remain Heal by re-epithelialization from skin adnexa Moist, red, blanching, blisters, extremely painful Superficial burns heal by re-epithelialization and usually do not scar if healed within 2 weeks Deep second-degree burns (deep partial-thickness) Damage to deeper dermis Less moist, less blanching, less pain Heal by scar deposition, contraction and limited reepithelialization Factors Increasing Morbidity and Mortality Age Smoke Inhalation Injury Associated Injuries Delay in Resuscitation Other factors increasing morbidity and mortality 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) Mortality for any given burn size increases with age Children/young adults can survive massive burns Children require more fluid per TBSA burns Elderly may die from small (<15% TBSA) burns Smoke inhalation injury doubles the mortality relative to burn size Other trauma increases severity of injury Delay increases fluid requirements Need for escharotomies and fasciotomies Excessive use of alcohol or drugs Page 20

22 Appendix 5: Rule of Nines Head and neck - 9% Trunk Anterior 18% Posterior 18% Arm - 9% (each) a a Genitalia and Perineum - 1% 1 ½ 1 ½ 1 1 ½ 1 ½ 1 ½ 1 ½ 2 ½ 2 ½ 1 ½ 1 ½ Leg - 18% (each) b b b b c c c c 1 ¾ 1 ¾ A B Anterior Posterior Relative percentage of body surface area (%BSA) affected by growth Age Body Part 0 yr 1 yr 5yr 10yr 15 yr a= 1/2 of head 9 ½ 8 ½ 6 ½ 5 ½ 4 ½ b = 1/2 of 1 thigh 2 ¾ 3 ¼ 4 4 ¼ 4 ½ c = 1/2 of 1 lower leg 2 ½ 2 ½ 2 ¾ 3 3 ¼ Provided by: (Redrawn from Artz CP, JA Moncrief: The Treatment of Burns, ed. 2. Philadelphia, WB Saunders Company, 1969) Page 21

23 Appendix 6: Burn Care and Treatment Primary Burn Care and Treatment Airway Breathing Extensive burns may lead to massive edema Obstruction may result from upper airway swelling Signs of airway obstruction - Hoarseness or change in voice - Use of accessory respiratory muscles - High anxiety Risk of upper airway obstruction increases with - Massive burns - All patients with deep burns (>35-40% TBSA should be endotracheally intubated ) - Burns to the head - Burns inside the mouth Intubate early if massive burn or signs of obstruction - Intubate if patients require prolonged transport and/or any concern with potential for obstruction - If any concerns about the airway, it is safer to intubate earlier than when the patient begins to decompensate Tracheotomies not needed during resuscitation period Carbon Monoxide (CO) Pathophysiology - Byproduct of incomplete combustion - Binds hemoglobin with 200 times the affinity of oxygen - Leads to inadequate oxygenation Diagnosis - PaO 2 (partial pressure of O 2 dissolved in serum) - Oximeter (difference in oxy- and deoxyhemoglobin) - Carboxyhemoglobin levels <10% is normal >40% is severe intoxication Treatment - Remove source - 100% oxygen until CO levels are <10% - Consider hyperbaric therapy Smoke Inhalation Injury Pathophysiology - Smoke particles settle in distal bronchioles - Sloughing - Distal atelectasis - Increase risk for pneumonia Diagnosis - History of being in a smoke-filled enclosed space - Early chest x-ray - Early blood gases - Bronchoscopy Soot in sputum or saliva Singed facial hair Soot beneath the glottis Airway edema, erythema, ulceration Treatment - Supportive pulmonary management (including intubation) - Aggressive respiratory therapy - IV Steroids Page 22

24 Appendix 6: Burn Care and Treatment (continued) Primary Burn Care and Treatment Circulation Obtain IV access anywhere possible - Unburned areas preferred - Burned areas acceptable - Central access more reliable Fluid Resuscitation (first 24 hours) (see Parkland Formula below) - Massive capillary leak occurs after major burns - Fluids shift from intravascular space to interstitial space - IV fluid rate dependent on physiologic response Place Foley catheter to monitor urine output Goal for adults: urine output of 0.5 ml/kg/hour Goal for children: urine output of 1 ml/kg/hour If urine output below these levels, increase fluid rate Preferred fluid: Lactated Ringer s Solution - Isotonic - Inexpensive - Easily stored Parkland Formula IV fluid Lactated Ringer s Solution Fluid calculation: 4 x weight in kg x %TBSA burn Give 1/2 of that volume in the first 8 hours Give other 1/2 over next 16 hours Warning: Despite the formula suggesting cutting the fluid rate in half at 8 hours, the fluid rate should be gradually reduced throughout the resuscitation to maintain the targeted urine output,( e.g., do not follow the second part of the formula that says to reduce the rate at 8 hours, adjust the rate based on the urine output). Example of Fluid Calculation 100-kg man with 80% TBSA burn Parkland formula: 4 x 100 x 80 = 32,000 ml Give 1/2 in first 8 hours = 16,000 ml in first 8 hours Starting rate = 2,000 ml/hour Resuscitation formulas are just a guide for initiating resuscitation - Adjust fluid rate to maintain urine output of 50 ml/hr for adults Albumin may be added toward end of 24 hours if not adequate response When maintenance rate is reached (approximately 24 hours), change fluids to D5/.5 NS with 20 meq KCl at maintenance fluid rate (see below) - Maintenance fluid rate Adult maintenance fluid rate: 1500cc x total body surface area (TBSA) (for 24 hrs) Pediatric maintenance fluid rate: May use 100 ml/kg for 1st 10 kg; 50 ml/kg for 2nd 10 kg; 20 ml/kg for remaining kg for 24 hrs Page 23

25 Appendix 6: Burn Care and Treatment (continued) Complications of Over-Resuscitation Compartment Syndrome (Transfer to Verified Burn Center*, if possible) Acute Respiratory Distress Syndrome (ARDS) 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 Requires surgical expertise Hemostasis is required Chest Compartment Syndrome - Increased peak inspiratory pressure (PIP) due to circumferential trunk burns - Escharotomies through mid-axillary line, horizontally across chest/abdominal junction Abdominal Compartment Syndrome - Pressure in peritoneal cavity > 30 mmhg Measure through Foley catheter - Signs: increased peak inspiratory pressure (PIP), decreased urine output despite massive fluids, hemodynamic instability, tight abdomen - Treatment Abdominal escharotomy NG tube Possible placement of peritoneal catheter to drain fluid Laparotomy as last resort Increased risk if fluid resuscitation to aggressive Supportive treatment Page 24

26 Appendix 6: Burn Care and Treatment (continued) Secondary Burn Care and Treatment Wound Care Acute Respiratory Distress Syndrome (ARDS) Special Burn Considerations (often require specialized care, transfer to Verified Burn Center* if possible) 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 will become hypothermic Sterile dressings are preferred but not necessary Covering wounds decreases pain Elevate burned extremities - Maintain patient s body temperature (keep patient warm) While cooling may make a small wound more comfortable, cooling any wound >10% TBSA may cause hypothermia If providing prolonged care - Wash wounds with soap and water (sterility is not necessary) - Maintain body temperature - Topical antimicrobials help prevent infection but do not eliminate bacteria Silver sulfadiazine for deep burns Bacitracin and nonstick dressings for more superficial burns Skin grafting - Deep burns require skin grafting - Grafting may not be necessary for days - Preferable to refer patients with need for grafting to Verified Burn Center* or, if not available, others trained in surgical techniques Grafting of extensive areas may require significant amounts of blood Patient s temperature must be watched Anesthesia requires extra attention Medications - All pain medication should be given IV - Tetanus prophylaxis should be given as appropriate - Prophylactic antibiotics are contraindicated Systemic antibiotics are only given to treat infections Electrical injuries - Extent of injury may not be apparent Damage 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 fluids to induce urine output of ml/hr in adults - In children, target urine output of 2 ml/kg/hour - Alkalinize urine (give NaHCO3) - Mannitol as last resort - Compartment syndromes are common - Long-term neuro-psychiatric problems may result Chemical Burns - Decontamination as advised (per hazard risk assessment) - Prolonged irrigation may be required - Do not seek antidote Delays treatment May result in heat production - Special chemical burns require contacting a Poison Control Center and/or Verified Burn Center*, for example: Hydrofluoric acid burn Page 25

27 Appendix 6: Burn Care and Treatment (continued) *American Burn Association Burn Unit Referral Criteria 1. Second- and third-degree burns greater than 10% TBSA in patients under 10 or over 50 years of age 2. Second- and third-degree burns greater than 20% TBSA in other age groups 3. Second- and third-degree burns that involve the face, hands, feet, genitalia, perineum and major joints 4. Third-degree burns greater than 5% TBSA in any age group 5. Electrical burns, including lightning injury 6. Chemical burns 7. Inhalation injury 8. Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery or affect mortality (e.g., significant radiation exposure) 9. Any patients with burns and concomitant trauma (e.g., fractures, blast injury) where burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be treated initially in a trauma center until stable before being transferred to a burn center. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols appropriate for the incident 10. Hospitals without qualified personnel or equipment for the care of children should transfer children with burns to a Burn Center with these capabilities 11. Burn injury in children who will require special social/emotional and/or long-term rehabilitative support, including cases involving suspected child or substance abuse Note: Criteria not established for very large mass casualty incidents (MCI) Page 26

28 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 bypass 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 seen among survivors. Primary blast lung and blast abdomen are associated with a high mortality rate. Blast Lung is the most common fatal injury among initial survivors Isolated tympanic membrane rupture is not a marker of morbidity; however, traumatic amputation of any limb is a marker for multi-system injuries. Air embolism is common, and can present as stroke, MI, acute abdomen, blindness, deafness, spinal cord injury, or claudication. Hyperbaric oxygen therapy may be effective in some cases Determinants of Injury from Blasts - Size of the explosion larger blasts create a larger pressure differential which cause injury and structural damage - The initial pressure wave from a high energy explosive is a sharp overpressure, followed by a slight negative pressure before returning to baseline - Distance from the blast the further the victim from the center of the blast, the less injury they might experience - Protection solid walls can provide protection from the pressure wave, shrapnel, and heat If the victim is in front of the wall, the pressure wave will hit them in the front, bounce off the wall and hit them again in the back If in a corner of two walls, the pressure wave may hit the victim three times - Casualties may have increased chances of survival if they are in an open field, rather than being in a confined room - Body armor may increase the amount of trauma to lungs Category Characteristics Body Parts Affected Types of Injuries Primary Secondary Tertiary Results from the impact of the over-pressurization wave with body surfaces. Results from flying debris and bomb fragments. Results from individuals being thrown by the blast wind. Gas filled structures are most susceptible Lungs GI tract Middle ear Any body part may be affected. Any body part may be affected. Blast lung (pulmonary barotrauma) TM rupture and middle ear damage Abdominal hemorrhage and perforation Globe (eye) rupture Concussion (TBI without physical signs of head injury) Penetrating ballistic (fragmentation) Blunt injuries Eye penetration (may be occult) Fracture Traumatic amputation Closed and open brain injury Page 27

29 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 or complications of existing conditions. Note: Up to 10% of blast survivors have significant eye injuries. Selected Blast Injuries Any body part may be affected. Burns (flash, partial and full thickness) Crush injuries Closed and open brain injury Asthma, COPD, or other breathing problems from dust, smoke or toxic fumes Angina Hyperglycemia Hypertension Lung Injury Blast lung is a direct consequence of the over-pressurization wave. It is the most common fatal primary blast injury among initial survivors. Signs of blast lung are usually present at the time of initial evaluation, but they have been reported as late as 48 hours after the explosion. Blast lung is characterized by the clinical triad of apnea, bradycardia, and hypotension. Pulmonary injuries vary from scattered petechiae to confluent hemorrhages. Blast lung should be suspected for anyone with dyspnea, cough, hemoptysis or chest pain following blast exposure. Blast lung produces a characteristic butterfly pattern on chest X-ray. A chest X-ray is recommended for all exposed persons and a prophylactic chest tube (thoracostomy) is recommended before general anesthesia or air transport is indicated if blast lung is suspected. Clinical Presentation - Symptoms may include dyspnea, hemoptysis, cough, and chest pain - Signs may include tachypnea, hypoxia, cyanosis, apnea, wheezing, decreased breath sounds and hemodynamic instability - Associated pathology may include bronchopleural fistula, air emboli, and hemothoraces or pneumothoraces - Other injuries may be present Diagnostic Evaluation - Chest radiography is necessary for anyone who is exposed to a blast. A characteristic butterfly pattern may be revealed upon X-ray - Arterial blood gases, computerized tomography, and Doppler technology may be used - Most laboratory and diagnostic testing can be conducted per resuscitation protocols and further directed based upon the nature of the explosion (e.g., confined space, fire, prolonged entrapment or extrication, suspected chemical or biologic event, etc.) Management - Initial triage, trauma resuscitation, treatment, and transfer should follow standard protocols; however some diagnostic or therapeutic options may be limited in a disaster or mass casualty situation - In general, managing blast lung injury is similar to caring for pulmonary contusion, which requires judicious fluid use and administration ensuring tissue perfusion without volume overload Page 28

30 Appendix 7: Blast Injuries Care and Treatment (continued) Selected Blast Injuries Lung Injury Clinical Interventions - All patients with suspected or confirmed BLI should receive supplemental high flow oxygen sufficient to prevent hypoxemia (delivery may include non-rebreather masks, continuous positive airway pressure or endotracheal intubation) - Impending airway compromise, secondary edema, injury, or massive hemoptysis requires immediate intervention to secure the airway. Patients with massive hemoptysis or significant air leaks may benefit from selective bronchus intubation - Clinical evidence of or suspicion for a hemothorax or pneumothorax warrants prompt decompression. - If ventilatory failure is imminent or occurs, patients should be intubated; however, caution should be used in the decision to intubate patients, as mechanical ventilation and positive end pressure may increase the risk of alveolar rupture and air embolism - High flow oxygen should be administered if air embolism is suspected, and the patient should be placed in prone, semi-left lateral or left lateral positions. Patients treated for air emboli should be transferred to a hyperbaric chamber Ear Injury Primary blast injuries of the auditory system cause significant morbidity, but are easily overlooked. Injury is dependent on the orientation of the ear to the blast. TM perforation is the most common injury to the middle ear. 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 hypovolemia Any findings suggestive of an acute abdomen Clinical findings may be absent until the onset of complications Brain Injury Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) without a direct blow to the head. Consider the proximity of the victim to the blast particularly when given complaints of headache, fatigue, poor concentration, lethargy, depression, anxiety or insomnia. The symptoms of concussion and post traumatic stress disorder can be similar. Modified from: CDC, Blast and bombing injuries: Fact sheet for professionals booklet, Page 29

31 Appendix 8: Crush Injury/Compartment Syndrome Care and Treatment Background Crush injury and crush syndrome may result from structural collapse after a bombing or explosion. Crush injury is defined as compression of extremities or other parts of the body that causes muscle swelling and/or neurological disturbances in the affected areas of the body. Typically affected areas of the body include lower extremities (74%), upper extremities (10%), and trunk (9%). Crush syndrome is localized crush injury with systemic manifestations. These systemic effects are caused by a traumatic rhabdomyolysis (muscle breakdown) and the release of potentially toxic muscle cell components and electrolytes into the circulatory system. Crush syndrome can cause local tissue injury, organ dysfunction, and metabolic abnormalities, including acidosis, hyperkalemia and hypocalcemia. Previous experience with earthquakes that caused major structural damage has demonstrated that the incidence of crush syndrome is 2-15% with approximately 50% of those with crush syndrome developing acute renal failure and over 50% needing fasciotomy. Of those with renal failure, 50% need dialysis. Clinical Presentation Sudden release of a crushed extremity may result in reperfusion syndrome acute hypovolemia and metabolic abnormalities. This condition may cause lethal cardiac arrhythmias. Further, the sudden release of toxins from necrotic muscle into the circulatory system leads to myoglobinuria, which causes renal failure if untreated. Hypotension - Massive third spacing occurs, requiring considerable fluid replacement in the first 24 hours; Patients may sequester (third space) more than 12 L of fluid in the crushed area over a 48-hour period - Third spacing may lead to secondary complications such as compartment syndrome, which is swelling within a closed anatomical space; compartment syndrome often requires fasciotomy - Hypotension may also contribute to renal failure Renal Failure - Rhabdomyolysis releases myoglobin, potassium, phosphorous, and creatinine into the circulation - Myoglobinuria may result in renal tubular necrosis if untreated - Release of electrolytes from ischemic muscles causes metabolic abnormalities Metabolic Abnormalities - Calcium flows into muscle cells through leaky membranes, causing systemic hypocalcemia - Potassium is released from ischemic muscle into systemic circulation, causing hyperkalemia - Lactic acid is released from ischemic muscle into systemic circulation, causing metabolic acidosis - Imbalance of potassium and calcium may cause life-threatening cardiac arrhythmias, including cardiac arrest; metabolic acidosis may exacerbate this situation Secondary Complications - Compartment syndrome may occur, which will further worsen vascular compromise (however, crush syndrome can occur in crush scenarios of less than 1 hour) Page 30

32 Appendix 8: Crush Injury/Compartment Syndrome Care and Treatment (continued) Initial Management Sudden release of a crushed extremity may result in reperfusion syndrome acute hypovolemia and metabolic abnormalities. This condition may cause lethal cardiac arrhythmias. Further, the sudden release of toxins from necrotic muscle into the circulatory system leads to myoglobinuria, which causes renal failure if untreated. Hypotension - Massive third spacing occurs, requiring considerable fluid replacement in the first 24 hours; Patients may sequester (third space) more than 12 L of fluid in the crushed area over a 48-hour period - Third spacing may lead to secondary complications such as compartment syndrome, which is swelling within a closed anatomical space; compartment syndrome often requires fasciotomy - Hypotension may also contribute to renal failure Hypotension - Initiate (or continue) IV hydration up to 1.5 L/hour Renal Failure - Prevent renal failure with appropriate hydration, using IV fluids and mannitol to maintain diuresis of at least 300 cc/hr - Triage to hemodialysis as needed Metabolic Abnormalities - Acidosis: Alkalinization of urine is critical; administer IV sodium bicarbonate until urine ph reaches 6.5 to prevent myoglobin and uric acid deposition in kidneys - Hyperkalemia/Hypocalcemia: Consider administering the following (adult doses): calcium gluconate 10% 10cc or calcium chloride 10% 5cc IV over 2 minutes; sodium bicarbonate 1 meq/kg IV slow push; regular insulin 5-10 U and D5O 1-2 ampules IV bolus; kayexalate 25-50g with sorbitol 20% 100mL PO or PR Cardiac Arrhythmias - Monitor for cardiac arrhythmias and cardiac arrest, and treat accordingly Secondary Complications Monitor casualties for compartment syndrome; monitor compartmental pressure if equipment is available; consider emergency fasciotomy for compartment syndrome Treat open wounds with antibiotics, tetanus toxoid, and debridement of necrotic tissue Apply ice to injured areas and monitor for the 5 P s: pain, pallor, parasthesias, pain with passive movement and pulselessness Observe all crush casualties, even those who look well Delays in hydration of greater than 12 hours may increase the incidence of renal failure; delayed manifestations of renal failure can occur Disposition Patients with acute renal failure may require up to 60 days of dialysis treatment; unless sepsis is present, patients are likely to regain normal kidney function Page 31

33 Appendix 9: Abbreviations ABLS ACA ADLS AHLS AOC APLS APR ATLS CCLU CDC CTUT DHHS DPH ED EMP EMS EOC EOP FDA HICS ICS PALS PAPR PPE SBD TUT WHO Advance Burn Life Support Ambulatory Care Area Advance Disaster Life Support Advanced Hazard Life Support Administrator-on-Call Advanced Pediatric Life Support Air Purifying Respirator Advance Trauma Life Support Casualty Care Unit Leader Centers for Disease Control and Prevention Contaminated Triage Unit Team Department of Health and Human Services Department of Public Health Emergency Department Emergency Management Plan Emergency Medical Services Emergency Operations Center Emergency Operations Plan Food and Drug Administration Hospital Incident Command System Incident Command System Pediatric Advanced Life Support Powered-Air Purifying Respirators Personal Protective Equipment Security Branch Director Treatment Unit Team World Health Organization Page 32

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