Annals of Burns and Fire Disasters - vol. XII - n. 1 - March 1999

GUIDELINES FOR FIRE DISASTER MEDICAL MANAGEMENT IN THE MEDITERRANEAN COUNTRIES

Magliacani G.,* Masellis M. **

* Department of Plastic Surgery and Burn Centre, Turin, Italy
** Department of Plastic Surgery and Burn Treatment, Palermo, Italy

SUMMARY. Guidelines are suggested for fire disaster medical management in the Mediterranean countries. Three phases of management are distinguished: pre-hospital response (on the site of the disaster), first-level hospital response (continuation of medical response in the nearest hospital(s), and second-level hospital response (final stage of medical assistance, with definitive hospitalization). The three phases are described in detail. With proper planning it will be possible to improve overall rescue operations, to prevent overcrowding in specialized burns centres, and to transform a dramatic and chaotic circumstance into a situation that is as normal as possible, with the result that the emergency situation can be rationally resolved.

Burns may be present in a fire disaster or in any other kind of catastrophic event. Owing to its particular pathology, to the high number of accidents in which burns may be present, and to the absolute importance of immediate medical treatment, it is imperative to adopt a specific strategy that involves not only all the necessary knowledge of the technical, clinical, and operative aspects of a disaster but also an understanding of heat trauma and experience in its treatment, all of which requires specific health facilities and equipment.
Also, fire disasters frequently occur in inaccessible areas where medical assistance is inadequate, with victims mostly suffering from extensive burns which in many cases are associated with other traumas, as also patients whose general condition is precarious.
For these reasons, and contrary to what happens in other types of disaster, an accident causing 25 or more deaths' and/or involving 50 or more persons with burns must be considered a disaster, especially when it is provoked by man and limited to a well-defined geographical area, even if this limitation does not reduce the impact on health facilities.
From the health point of view, burns imply a different concept of disaster because it requires the activation of an exceptional health response, the intervention of specialists, and the presence of adequate hospitalization facilities.
Generally speaking, this last requirement can only be satisfied through the use of other burn centres in the territory. However, in some Mediterranean countries, because of the limited number of specialized bed places this type of solution cannot be sufficient and international collaboration will be necessary. A situation of this type reflects a real disproportion between real needs and the means available and justifies a different approach and a specific management of fire disasters, with careful preparation of dedicated rescue programmes, especially as regards the patients' final destination.
The distinction between thermal agent disaster and burn disaster' is useful not only for didactic purposes but also constitutes a basis for the effective and specific programming of rescue work.
The management of a fire disaster must be in three phases:

• Phase 1: Pre-hospital Response, i.e., on the site of the disaster

• Phase 2: First-level Hospital Response, i.e., the continuation of medical response in the nearest hospital(s)

• Phase 3: Second-level Hospital Response, i.e., final stage of medical assistance realized with definitive hospitalization either in the first facility used or in a burns centre

Phase I
In order to be able to concentrate all efforts on the casualties who, with appropriate early treatment, have the greatest prospects of survival, it is imperative to initiate a series of rigidly programmed diagnostic, prognostic, and therapeutic procedures at the site of the disaster.
Rescue work must therefore include:

• a rapid diagnosis that is as complete as possible
• first-aid therapy
• rational and co-ordinated choice of final destination hospital for continuation of treatment
• medicalized transport after stabilization, perforined in optimal conditions

The first step is triage, the purpose of which is to make a precise assessment of the burn patient in order to establish treatment priorities, style of approach, and transfer time, as well as the medical facility of final destination.
In the presence of a large number of victims, and considering the environmental difficulties in which it is necessary to act, only patients with a reasonably favourable prognosis should receive treatment if we are to guarantee survival to as many patients as possible.
The most reliable and important parameters for diagnostic assessment in heat trauma are the age of the patient and the body surface area burned.
However, in view of the difficult and precarious conditions in which triage has to be effected in the field, a simplification of triage criteria has been recommended, at least in the initial phases of triage.
A reasonable compromise is to treat only - or at least first of all - patients whose prospects of survival are 50% or more.
Potential survival is related at any given burned BSA to the patient's age and is at its maximum between 15 and 30 years, decreasing gradually towards the two extremes of age.
If we examine the relationship between 50% death rate and burn percentage in the various age groups we see that the size of burn that is fatal to half the patients is approximately 83% in young adults,' while in burned children younger than 15 yr the rate approaches 90%,' and includes burns up to 35% in elderly patients.
In order to simplify procedures during the first phases of rescue work, we can fix 60% BSA as the maximum limit for inclusion in the group of patients to be treated, without any distinction of age, postponing until later a more precise evaluation a new and definitive classification that can be performed in the health facility where patients are subsequently hospitalized.
It must be remembered that the presence of burns in the upper airways represents an aggravating circumstance which can reduce survival prospects by over 50%, independently of age and/or burn surface.
The first provisional triage will make it possible to divide the burn patients into three groups:

1. Patients with burns in more than 20% and less than 60%. This represents First Urgency, as these patients require immediate medical treatment, priority transfer, and hospitalization in specialized departments. Because of the lack of precise rules, we suggest this group should be identified by means of a red tag.
2. Patients with burns in more than 60% BSA. These patients are put on standby for hospitalization, which will be effected as soon as Group I patients have been processed. These patients should receive a blue tag (Second Urgency).
3. Patients with burns in less than 20% BSA. If there is involvement of functional areas (face, hands, perineurn and genitals, feet, major joints), this is considered Third Urgency. The patients need immediate admission to specialized departments.

These patients should be distinguished by yellow and green tags.
The only exception to this order of treatment is represented by the presence of a severe associated pathology (card i ores p iratory arrest, grave haemorrhage). This constitutes an immediate risk for life and must be treated without delay.
These classification criteria should be regarded only as a general indication because when there are present together burns of the upper airways and/or intoxication by combustion products, or deep burn, or involvement of functional areas, or association with other traumas, the overall assessment must be subsequently modified.
In burn patients immediate medical treatment is basic for survival, and therefore an integral aspect of the triage operation is first-aid therapy, which must not only stabilize the patient but also allow sufficient time for a more careful and specific selection of final destination hospitals for continuation of treatment.
The most immediate indispensable treatment includes the following:

• immediate cooling (within 30 min) of burned surface area with water at environment temperature for at least 5-10 min
• covering with sterile cloth, blankets or aluminized material, in order to limit heat loss
• oxygen therapy with mask, or nasotracheal intubation and self-respirator in cases of severe burn damage of upper airways or inhalation intoxication
• intensive care with replacement fluid therapy, immediately after application of at least two peripheral venous lines. It is advisable to use hypotonic Ringer's lactate-type solutions
• nasogastric probe application, in order to counteract distension of the gastric walls, always present in burns of 25-30% and more, in post-prandial phase, and in the presence of vomiting. This is also indispensable in intubated and ventilated patients
• analgesia may be useful to reduce catecholamine release caused by pain and stress associated with diazepinies in the presence of psychomotor agitation states, as this condition is frequently more serious than the pain itself and capable of impeding rescue operations
• bladder catheterization for measuring urine output. This procedure can be postponed if hospitalization is expected soon

In this phase it is not necessary to use any drugs except antitetanus prophylaxis and cortisone. This is to be used only at the physician's discretion for burns of the airways or in cases of severe shock.
During the emergency phase it is not important, and indeed not advisable, to use topical drugs that can alter the appearance of burned surfaces (i.e., containing greasy or colouring material) or induce cross-resistance (antibiotics).
It is important to bear in mind that the choice of the hospital department where burn victims are to be dispatched, especially if numerous, is of basic importance. The dispatch of an excessive number of patients to a specialized centre can slow down and even paralyse rescue work.
It is therefore advisable that after initial triage casualties be sent on to the nearest medical facility.
With regard to this point, we must underline that immediate and uncontrolled transfer to a specialized centre does not represent a priority. The primary purpose of any rescue team is not to bring a patient to an ICU but to bring that level of care to the patient.

Phase 2
Burn patients who have received emergency treatment on the disaster site must be sent to the nearest hospital, where they will be registered and all clinical data related to the pathology will be recorded.
Here the patients will have their clothing removed and the initial diagnosis will be perfected on the basis of any new features that may be noted. A fresh triage operation is then performed. This last procedure will include new parameters (age, associated lesions) and will be based on other criteria (UBS, Baux index, Roi index) in order to make the patients' classification more consistent with their real clinical conditions.
At this point, when all first-aid protocol procedures have been completed, it will be necessary to review the question of intensive care, the beginning of . pharmacological support treatment, and local therapy.
After this phase it will be possible to consider the definitive transfer in more dedicated manner of patients who can derive most benefit from the potential services of a specialized centre.Various solutions may be possible, buti in all cases they must be well defined and previously included in the rescue plans in each single region, on the basis of population density, road communications, and.the number of beds in specialized departments.
If patients are immediately and correctly medicalized and stabilized, there is a wide window for their transfer, without any prejudice to their treatment.
Patients in Group 1 must be sent on to burns centres, while those in Group 2, unless differently reclassified, can remain in the facilities where they were first admitted or else they can be discharged if hospitalization proves unnecessary.

Phase 3
The third and final phase is that of definitive hospitalization. Non-nal treatment can begin, either in the burns centre or in the hospital where the patients are first sent, according to universally accepted protocols that are well known to all those who work in burn pathology. Every medical facility must be familiar with these emergency plans. Consequently, a correct specific disaster planning must be provided especially if burn injuries are expected.

The needs of specialized units, sufficient under normal conditions but inadequate in the case of disasters, make fire disaster a distinct event, absolutely different from all others.
This strategy will make it possible:

• to improve overall rescue operations
• to prevent the overcrowding of specialized centres, by sending to them only patients who can derive real benefit for their survival
• to transform a dramatic and chaotic circumstance, in which it is easy to commit errors of judgement that may compromise the patients' future, into a situation that is as normal as possible

In this way the emergency can be rationally organized and rationally handled, and will not be too different from a routine, first-aid procedure, even if applied to many patients.

RESUME. Les Auteurs proposent des lignes directrices pour la gestion médicale des désastres d'incendie dans les pays méditerranéens. Ils distinguent trois phases de la gestion: la réponse préhospitalière (au site du désastre), la réponse hospitalière de premier niveau (continuation de la réponse hospitalière dans l'hôpital ou les hôpitaux les plus proches) et la réponse hospitalière de deuxième niveau (phase finale des soins médicaux, avec l'hospitalisation définitive). Les Auteurs décrivent en détail les trois phases. Avec une planification appropriée il sera possible d'améliorer les opérations complessives de sauvetage, de prévenir l'entassement des centres des brûlés spécialisés et de transformer une circonstance dramatique et chaotique en une situation la plus normale possible, avec le résultat que la situation d'urgence peut être résolue.