TraumaBurn ClinicalGuidelines Final PDF
TraumaBurn ClinicalGuidelines Final PDF
TraumaBurn ClinicalGuidelines Final PDF
I
Trauma/Burn Clinical Guidelines
S
www.ynhhs.org/cepdr
R
Emergency Information for Trauma/Burn Emergencies
ORGANIZATION PHONE NUMBER
Local Police
State Police
Federal Bureau of Investigation (FBI)
Department of Homeland Security
Local Burn Center
Local Hyperbaric Chamber
Organization-Specific Contacts [see below]
© Yale New Haven Health System Center for Emergency Preparedness and Disaster Response. None of this publication may be reproduced or trans-
mitted in any form without permission from Yale New Haven Health System Center for Emergency Preparedness and Disaster Response.
Page 1
Trauma/Burn Guidelines
Introduction:
This guide is a quick reference for the hospital’s initial response to Trauma/Burn emergencies. Based on the
word DISASTER*, it facilitates the ongoing qualitative and quantitative assessment of the incident.
D Detection
I ICS
S Safety/Security
A Assessment
S Support
T Triage and Treatment
E Evacuate
R Recovery
This guide includes components of the Hospital Incident Command System (HICS) version IV and utilizes
components of MASS, START and Jump START triage systems. This reference guide provides a framework
for a coordinated, effective hospital response to a trauma/burn incident.
Upon initial notification of a mass casualty event, hospital staff needs to be aware that the first casualties of the
event may arrive at the hospital without transport by EMS. If a larger number of casualties are expected, the
staff may need to utilize mass casualty triage methods.
Also note there may be additional hazards. If the explosion was caused by a chemical event, casualties may
need to be decontaminated or a risk that a bomb was a radiological dispersion device (RDD), also known as a
“dirty bomb”, See the appropriate guidelines for appropriate interventions.
* The mnemonic, D-I-S-A-S-T-E-R, is taken from the National Disaster Life Support program and is used with the gracious
permission of the American Medical Association and the National Disaster Life Support Educational Foundation.
Page 2
Trauma/Burn Guidelines
DETECTION
Based upon information received, the hospital may need to prepare to D – Detection
receive numerous multi system trauma patients. Events have shown that
a high percentage of casualties from any mass casualty event are not
seriously injured (See Appendix 1). However, those that have sustained life-
threatening injuries require significant resources. It should also be noted that
I – Incident
Command
there is a limited number of specialty centers e.g., critical care burn beds,
System
pediatric ICU beds. If transport to a higher level of care is anticipated, those
facilities should be notified as soon as possible.
Page 3
Trauma/Burn Guidelines
INCIDENT COMMAND SYSTEM
Upon notification or determination of a trauma/burn event affecting a D – Detection
large number of patients:
Incident Commander
S – Safety and
Public
Security
Safety
Information
Officer
Officer
A
Medical /
Liaison
Technical
– Assessment
Officer
Specialist
Finance /
Operations Planning Logistics
Administration
Section Chief Section Chief Section Chief
Section Chief
S
Staging Time
Time
– Support
Resources Service
Manager Unit Leader Branch Director Unit Leader
Unit Leader
T
Triage
– Triage and
Unit Leader
Infrastructure Minor
Branch Director Treatment
Unit Leader Documentation
Compensation /
Compensation
Claims
Claims
Treatment
Unit Leader Unit Leader
Unit Leader
Immediate
Treatment
Unit Leader
HazMat Delayed
Branch Director Treatment
Unit Leader Demobilization Cost
Cost
E
Unit Leader Unit Leader
Unit Leader
Decedent/
Expectant
Unit Leader – Evacuate
Security
Branch Director
Legend
Activated
Business Position
Continuity
Branch Director
R – Recovery
Appendices
Page 4
Trauma/Burn Guidelines
SAFETY AND SECURITY
Upon notification or determination of a trauma/burn event affecting a D – Detection
large number of patients:
Note:
• Secondary hazards should be suspected, if the event appears to be an
act of terrorism T – Triage and
• Secondary hazards may include: Treatment
– Secondary explosive devices being placed at the hospital
– Chemical contamination of the victims
• Refer to Chemical Clinical Guidelines if suspected
– Radiological contamination of the victims E – Evacuate
• Refer to Radiation Clinical Guidelines if suspected
R – Recovery
Appendices
Page 5
Trauma/Burn Guidelines
ASSESSMENT
Upon notification or determination of a trauma/burn event affecting a D – Detection
large number of patients:
Page 6
Trauma/Burn Guidelines
SUPPORT
Upon notification or determination of a trauma/burn event affecting a D – Detection
large number of patients:
NOTES:
E – Evacuate
R – Recovery
Appendices
Page 7
Trauma/Burn Guidelines
TRIAGE AND TREATMENT
Upon notification or determination of a trauma/burn event affecting a D – Detection
large number of patients:
Appendices
Page 8
Trauma/Burn Guidelines
EVACUATE
Upon notification or determination of a trauma/burn event affecting a D – Detection
large number of patients:
Appendices
Page 9
Trauma/Burn Guidelines
RECOVERY
Upon notification or determination of a trauma/burn event affecting a D – Detection
large number of patients:
NOTES:
E – Evacuate
R – Recovery
Appendices
Page 10
Trauma/Burn Guidelines
D – Detection
I – Incident
Command
System
S – Safety and
Appendices
Security
Treatment
Appendix 9: Abbreviations
E – Evacuate
R – Recovery
Appendices
Page 11
Trauma/Burn Guidelines
Appendix 1: Event Characteristics and Anticipated Impact on Hospitals
Anticipated impact
Event characteristic Implication Number of injured
survivors seeking Injury frequency Injury severity
emergency care
Event near hospital ↑ number of injured survivors will ↑ at nearby hospitals ↑ minor injuries Variable – more minor
arrive at ED without EMS transport ↑ “worried well” and more serious injuries
Page 12
unlikely with minor injuries
Trauma/Burn Guidelines
↓ number of immediate deaths
Confined space Blast energy potentiated, but ↓ Usually produces < 100 ↑ Primary blast injury, ↑ in severity
explosions contained in lesser area injured survivors amputations, burns
↑ number of immediate deaths inside
space
Appendix 1
Appendix 2: Principles of Care of Children from MCI Incident Resulting in Traumatic/Burn Injuries
General Principles • No widely utilized system for rapid triage of children in MCIs. Jump START is the most widely known
• Children and their parents should not be separated during triage. (Injured children should be reunited with responsible
parent or caregiver as soon as possible, since anxiety exacerbated by separation from parents or caregivers often
confounds their evaluation.)
• Children have incompletely developed motor skills and cognition. (Therefore, they may not be able to escape site of an
incident and may not be able to follow directions.)
• Injured children should be managed according to the general principles of PALS and ATLS.
Trauma/Burn • Injured children are at higher risk for hypothermia, with significantly greater thermo-regulatory problems in younger
children. With smaller circulating blood volume, (despite greater tolerance of volume loss per kilogram), decomposition
into shock may be more rapid and more difficult to reverse.
• Airway is smaller, increasing risk of airway edema.
• Children are at greater risk of head injury because of disproportionately larger head size.
• Head injury severity is the main determinant of a pediatric patient’s outcome.
• Cervical spine and spinal cord injuries are less common in children because of greater flexibility and mobility.
(Conversely, spinal cord injuries in the absence of radiographic abnormalities are more likely to be present.)
• Damage to internal organs is greater due to increased chest wall compliance and greater transfer of energy to internal
organs, while rib fractures and flail chest are relatively uncommon. (If rib fractures are present, there is a much greater
risk of intrathoracic injuries.)
Behavioral Health • Greater risk of psychological trauma.
Page 13
• Children’s’ reactions to situations vary, and depend on a child’s developmental level (cognitive, physical, educational
and social).
Trauma/Burn Guidelines
• 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
Appendix 3: Mass Casualty Triage Tags
FRONT BACK
Page 14
Trauma/Burn Guidelines
Appendix 3: Mass Casualty Triage Tags
FRONT BACK
Page 15
Trauma/Burn Guidelines
Appendix 3: Mass Casualty Triage Tags
Page 16
Trauma/Burn Guidelines
Appendix 4: Mass Triage Systems
Page 17
Trauma/Burn Guidelines
Appendix 4: Mass Triage Systems
Page 18
Trauma/Burn Guidelines
Appendix 4: Mass Triage Systems
Adapted from:
SALT mass casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma,
American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury
Prevention Directors Association. Disaster Med Public Health Prep. 2008 Dec;2(4):245-6. [PubMed Citation]
Page 19
Trauma/Burn Guidelines
Appendix 5: General Burn Guidelines
Burn Severity Percent of total body surface • Burns >20-25% TBSA require IV fluid resuscitation
area (TBSA) involvement • Burns >30-40% TBSA may be fatal without treatment.
- In adults: “Rule of Nines” is used as a rough
indicator of % TBSA (See chart)
- In children, adjust percents because they have
proportionally larger heads (up to 20%) and smaller
legs (13% in infants) than adults (See chart)
• Lund-Browder diagrams improve the accuracy of the
% TBSA for children.
• Palmar hand surface is approximately 1% TBSA
Depth of Burn Injury Superficial Burns First-degree burns
• Damage above basal layer of epidermis
• Dry, red, painful (“sunburn”)
Second-degree burns
• Damage into dermis
• Skin adnexa (hair follicles, oil glands, etc,) remain
• Heal by re-epithelialization from skin adnexa
• Moist, red, blanching, blisters, extremely painful
• Superficial burns heal by re-epithelialization and
usually do not scar if healed within 2 weeks
Deep Burns Deep second-degree burns (deep partial-thickness)
[Deep burns usually need skin • Damage to deeper dermis
grafts to optimize results and • Less moist, less blanching, less pain
lead to hypertrophic (raised) • Heal by scar deposition, contraction and limited re-
scars if not grafted] epithelialization
Fourth-degree burns
• Burn into muscle, tendon, bone
• Need specialized care (grafts will not work)
Factors Increasing Age • Mortality for any given burn size increases with age
Morbidity and Mortality • Children/young adults can survive massive burns
• Children require more fluid per TBSA burns
• Elderly may die from small (<15% TBSA) burns
Smoke Inhalation Injury • Smoke inhalation injury doubles the mortality relative
to burn size
Associated Injuries • Other trauma increases severity of injury
Delay in Resuscitation • Delay increases fluid requirements
Other factors increasing • Need for escharotomies and fasciotomies
morbidity and mortality • Excessive use of alcohol or drugs
Page 20
Trauma/Burn Guidelines
Appendix 5: Rule of Nines
Trunk
Anterior 18%
Arm - 9% (each)
Posterior 18%
a a
1 1
13 2 13 2
2 2
1½ 1½ 1½
1½
1½ 1½
Genitalia and
1½ 1½ 2½ 2½
Perineum - 1% 1
c c c c
1¾ 1¾
Anterior Posterior
A B
Relative percentage of body surface area (%BSA) affected by growth
Age
Body Part 0 yr 1 yr 5yr 10yr 15 yr
a= 1/2 of head 9½ 8½ 6½ 5½ 4½
b = 1/2 of 1 thigh 2¾ 3¼ 4 4¼ 4½
c = 1/2 of 1 lower leg 2½ 2½ 2¾ 3 3¼
Provided by:
http://www.merckmanuals.com/professional/injuries_poisoning/burns/burns.html?qt=rule%20of%20nines&alt=sh
(Redrawn from Artz CP, JA Moncrief: The Treatment of Burns, ed. 2. Philadelphia, WB Saunders Company, 1969)
Page 21
Trauma/Burn Guidelines
Appendix 6: Burn Care and Treatment
Page 22
Trauma/Burn Guidelines
Appendix 6: Burn Care and Treatment (continued)
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).
Page 23
Trauma/Burn Guidelines
Appendix 6: Burn Care and Treatment (continued)
Complications of Over-Resuscitation
Compartment • Limb Compartment Syndrome
Syndrome - Symptoms of severe pain (worse with movement), numbness, cool extremity, tight feeling
(Transfer to compartments
Verified Burn - Distal pulses will be lost when the compartment pressure exceeds the systolic blood pressure
Center*, if - Compartment pressure >30 mmHg may compromise muscle/nerves
possible) - Measure compartment pressures with arterial line monitor (place needle into compartment)
- Escharotomies may save limbs
• Performed laterally and medially throughout entire limb
• Performed with arms supinated
• Hemostasis is required
- Fasciotomies may be needed if pressure does not drop to <30 mmHg
• Requires surgical expertise
• Hemostasis is required
• Chest Compartment Syndrome
- Increased peak inspiratory pressure (PIP) due to circumferential trunk burns
- Escharotomies through mid-axillary line, horizontally across chest/abdominal junction
• Abdominal Compartment Syndrome
- Pressure in peritoneal cavity > 30 mmHg
• Measure through Foley catheter
- Signs: increased peak inspiratory pressure (PIP), decreased urine output despite massive
fluids, hemodynamic instability, tight abdomen
- Treatment
• Abdominal escharotomy
• NG tube
• Possible placement of peritoneal catheter to drain fluid
• Laparotomy as last resort
Acute • Increased risk if fluid resuscitation to aggressive
Respiratory • Supportive treatment
Distress
Syndrome
(ARDS)
Page 24
Trauma/Burn Guidelines
Appendix 6: Burn Care and Treatment (continued)
Page 25
Trauma/Burn Guidelines
Appendix 6: Burn Care and Treatment (continued)
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
Trauma/Burn Guidelines
Appendix 7: Blast Injuries Care and Treatment
Page 27
Trauma/Burn Guidelines
Appendix 7: Blast Injuries Care and Treatment (continued)
• 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
Trauma/Burn Guidelines
Appendix 7: Blast Injuries Care and Treatment (continued)
• 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,
http://emergency.cdc.gov/BlastInjuries
Page 29
Trauma/Burn Guidelines
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
Trauma/Burn Guidelines
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
Trauma/Burn Guidelines
Appendix 9: Abbreviations
Page 32
Trauma/Burn Guidelines
www.ynhhs.org/cepdr