MASS BURNS RESCUE OPERATIONS: ORGANIZATION AND MEDICOSURGICAL THERAPIES

Magliacane G.

Centro Traurnatologico di Torino, Divisione di Chirurgia Plastica, Centro Grandi Ustioni, Torino, Italia

SUMMARY. A description is given of general organization in a disaster area, and criteria for triage of patients are. given. Three homogeneous groups are distinguished on the basis of expectation of survival: 1) burn patients certain to die with UBS > 100 2) burn patients with UBS < 100 3) bum patients with lesions < 10-20%. Once the patients have been subdivided, they follow different routes and therapeutic procedeures, according to their grouping. In conclusion it is recommended that there should be permanent communication between the various Burns Centres and between the Centres and decentralized hospital structures, using information systems with a supporting 2-level infrastructure integrated by a third nucleus which itself is organized at different levels.

A catastrophe is characterized not only by the gravity of the event, i.e. the extent of the destruction and the number of victims, but also by the disproportion between immediate needs and actual means available, which are never adequate to meet demands. This disproportion is due both to a real shortage of means and to the difficulty of making full use of them in disaster situations.
It is therefore of paramount importance that all available resources should be properly employed if full efficiency is to be achieved.
It follows that a good rescue organization is indispensable for optimal performance and a positive cost / benefit ratio.
These opening remarks, which may seem superfluous, are based on the indisputable observation made on the basis of a study of the literature that after every disaster rescue operations have always been conducted in conditions of considerable confusion, although it should not be forgotten that it is not always easy to act methodically and rationally in a state of emergency when panic is rife.
The organization of rescue work begins at the site of the disaster and provides for a whole series of actions, which require for their successful performance a variety of territorial administrative structures, together with vehicles and means standing by for this specific purpose.
A large-scale accident with a considerable number of casualties imposes a sanitary approach with different ethics and deontological principles from those applying in normal conditions, since the physician has to make himself available for the largest number of patients possible, using for the less serious patients vehicles and means reserved in normal circumstances only for the most difficult cases.
This means that certain specialistic structures, normally intended for patients with little prospects of survival - and therefore employed as a qualitative criterion - must be reserved to casualties who have a chance of recovery. In this way the highest possible number of patients may be saved, i.e. the quantitative criterion must prevail.
In these occasions the task of the physician goes beyond mere therapy - he must personally cope with a variety of organizational problems.
In order to have a better understanding of rescue operations in all their complexity, it may be useful to outline their main characteristics.

The site of the disaster can be subdivided into two main areas: one zone of total destruction, which we will call Zone A, and, surrounding this, zone B, which can be considered the "operational area".
An advanced medication post (AMP) must be set up on the perimeter of Zone B, as near as possible to Zone A, with the purpose of making a preliminary evaluation of the conditions of the wounded and to decide upon their immediate destination. Further out, there must be field hospitals (FH), and depots for medicines, food and material, assembly points for rescue workers, and emergency quarters for those left homeless by the disaster.
Zone B is thus the operational nerve centre for medical rescue work, which has to be carried out in Phase 1 by local and possibly non-specialized personnel, and later by organized structures which must reach the zone as soon as possible.
Zone B is however also the site of the Local Operational Command, which in the initial phase must coordinate the various rescue activities, make
Group 2: burn patients with UBS < 100 and bum percentage > 18 - 20%;
Group 3: bum patients with lesions < 18-20%.
According to their group, patients will follow different therapeutic paths (Tab. 3).
As regards Group 1, if the number of victims is high and the resources limited, in terms of personnel and means, it may be necessary to make a painful, though inevitable, selection. Other casualties should not be deprived of necessary assistance, so that Group 1 patients will simply have to be sedated, if possible using a venous route for the infusion also of hydrating solutions, while being kept apart so that patients in Group 2 can be attended to.
Patients in Group 2 will be immediately sent on to a field hospital, resuscitated and evacuated with emergency procedures.
Group 3 patients will simply receive medication and be put on a stand-by transfer list, until Group 2 patients have been evacuated, or until they are dismissed if their burns are only slight.
In this triage phase it is useful to distinguish the three groups with differentiating marks (Tab. 4). In this way it is possible to obtain a homogeneous grouping and consequently a rapid identification of the group required and a further subdivision of the second group on the basis of therapeutic needs.

Tab. 1 VERY SERIOUS USB > 100 SERIOUS USB < 100 AND BURN < 18-20% SLIGHT BURN < 18-20% Tab. 2

As we have seen, the main therapeutic procedures concern the second group, which is the group that can best profit from treatment initiated immediately and correctly carried out. Emergency therapy consists of general and topical treatment (Tab. 5).

Tab. 3 LESION COLOUR MARK VERY SERIOUS BLACK CROSS SERIOUS RED HARE SLIGHT YELLOW TORTOISE Tab. 4 Tab. 5 NORMAL CRITERIA FOR ADMISSION TO A BURNS CENTRE TOTAL BURNS > 20% DEEP BURNS > 10% AIRWAYS BURNS FUNCTIONAL AREA BURNS Tab. 6 Tab. 7 Tab. 8 LINK-UP SYSTEMS 1 - "RINW' NETWORK (BCN) between Burn Centres 2 - "STAR" NETWORK (EN) between Centres and Decentralized structures 3 - OPERATIONAL CENTRE (TN) for transport, linked up with Centres Tab. 9

Fluid therapy must begin as soon as possible, in order to prevent shock; an indwelling venous catheter must therefore be inserted, if possible in a central vein, and a bladder catheter. It is advisable to use simple formulae and only one type of solution, e.g. Parkland's formula (4 ral x % burn x kg body weight) and Ringer solutions. If these are not available any other type of fluid containing sodium can be used, bearing in mind that intensive care therapy of the burn patient requires 0.4-0.6 mEq/kg/bum % of sodium.
Infusion therapy is easier to administer if 3-litre bottles are used, as these do not have to be changed so frequently. They can be prepared without great difficulty in the field hospital.
In less serious cases, particularly if the means available are inadequate for the number of victims, rehydrating therapy can be initiated per os and if necessary continued i.v.
Though not absolutely essential, it is recommended that rudimental laboratory facilities should be available. In this way it is possible to use micromethods to assess at least the haematocrit of burn patients who cannot be immediately transported to hospital.
It is advisable in all cases to monitor hourly diuresis.
Pharmacological treatment must be reduced, being limited to the use of cortisone preparations in cases of shock, sedatives and analgesics, as necessary.
Antibiotic therapy is counterindicated at this stage. This form of therapy is always reserved for later stages of the burn illness, in cases when sepsis is demonstrated and when a biogram has been performed.
Antitetanus and if necessary antigangrene therapy should be performed.
Mild antiseptics, e.g. chlorhexidine, must be used topically for summary cleansing, after careful removal of clothing, followed by the application of occlusive dressings with antibacterial agents, e.g. silver sulphadiazine.
In hand burns, the use is recommended of lisle gloves impregnated with silver sulphadiazine.
In caustic bums, the part afTected must be thoroughly washed in order to dilute the chemical agent and prevent deepening of the lesion. This phenomenon occurs not so much because of the thermal effect as of the chemical reaction between the caustic agent and the skin, due to oxidation, reduction and formation of salts, with protein coagulation; this continues until the reaction caused by the chemical agent is completely exhausted.
If the patient has been exposed to radiation, he must be isolated, subjected immediately to external decontamination by washing and prolonged showers and complete depilation; the lesions must be amply and radically cleansed, and then dressed. In cases of circumferential bums, releasing escharectomy must be performed in order to keep the circulation free in the limbs, or to allow normal breathing when the thorax is incarcerated.
If immediate transfer is expected it may be sufficient to wrap the patient in lengths of cloth or disposable sterile material, protecting the patient from heat loss which negatively atTects later metabolic imbalances.
Treatment on the spot necessarily has considerable limitations: the shortage of time available for each casualty and the impossibility of predicting when and how the patient will be transferred do not create ideal conditions for treatment, as the physician can never be sure of completing even the simplest of therapeutic protocols.
Another problem is that after the first 48-72 hours metabolic complications begin to appear, together with infective complications, and these cannot be treated at the disaster site.
At this point the patients have to be transferred to suitable hospital facilities. A further triage has to be carried out to distinguish between patients needing treatment in a Burns Centre and those who can be sent to a less specialized structure.
Let us recall the fundamental conditions that impose admission to a Bums Centre (Tab. 6):

• T13SA > 20%
• full-thickness burned area > 10%
• presence of burns in functionally important areas, such as the face, hands, perineum and joints
• electrocution
• bums to the airways
• bums complicated by associated traumas or concomitant and/or pre-existing diseases.

In the event of a catastrophe, the use of hospital facilities will necessarily be determined by the relationship between the number of beds available and the number of patients needing admission.
If the number of casualties is high, it is advisable to create - in those hospitals which already possess a specialized Centre, or where there is a specialized medical team capable of handling bum victims -facilities that transform routine therapy wards into wards equipped for the treatment of bum victims, so that the number of casualties that can be admitted is considerably increased.
If the bum lesion is not particularly serious, and especially if accompanied by other traumas, the patient can be admitted to any large general hospital where he can be treated with specialist care.
If the lesions are of small account, but still require treatment, the patient can be admitted to small local hospitals.
Problems arise when there are not enough hospital beds for all the patients who could benefit from admission to a specialized Centre or from treatment given by bum specialists.
Although we are aware that in actual practice any theoretical suggestions have little chance of being followed, we would like to put forward some points that may be of some assistance to the physician on the spot when he has to proceed to the dispatch of patients to appropriate destinations, in relation to the clinical situation (Tab. 7).
Young patients and those with suspected damage to the airways, or with burns in the anatomical sites mentioned above which are important for functional recovery, should be transferred to Burn Centres, where they will receive the treatment they need.
The method of transfer and in particular the choice of vehicle depends on the distance from the site of the accident and the final destination -ambulances or buses may be sufficient for short journeys and aeroplanes for longer distance.

The scientific literature and the daily newspapers report numerous episodes of mass bums caused by natural disasters (earthquakes or forest fires), military incidents (apart from the battlefield), such as the explosion of ammunition dumps or acts of terrorism, and urban accidents of industrial origin or due to means of transport.
The first priority is that every nation should identify the zones, situations and the type of potential risk, so that rescue resources can be made immediately available and proper preparations can be made for keeping the disaster under control.
It is advisable to approach the problem from two directions, i.e. that of prevention and that of organization (Tab. 8).
The question of prevention is so complex that it needs to be treated separately.
With regard to organization it is possible to identify some fundamental points, which have to be constantly reviewed in order to improve on the results of previous experiences.
The first absolute priority is the creation of a national and supernational body that will centralize all information regarding the various types of disaster, with particular reference to medical data, such as the number of dead, the type of lesions, the measures undertaken, the results obtained and the deficiencies observed.
This would make it possible to create work groups capable of coordinating all the data collected and of making opportune proposals.
The medical and paramedical stafT operating in health facilities in the risk zones must learn the essential elements of burn pathology by attending refresher courses and attending specialized units. In this way it will be possible to achieve standardization of materials and methods.
It is also very important to create permanent communications between the various Burns Centres in the territory and between the Burns Centres and decentralized hospital structures. This can be done by means of distributed information systems, creating a supporting infrastructure at two distinct levels and completed by a third nucleus, which in turn is itself organized at different levels.
This purpose could be achieved by computer networks which, working together, could link up a number of widely distributed computers and organisms.
The structure of the system could include (Tab. 9):

1. a nationwide, interactive "ring" network connecting all specialized Centres, organized with several interacting computers (Burns Centre Network BCN);
2. A regional or multiregional "star" network, at a lower hierarchical level, linking up General Hospitals with the nearest Burns Centre, and enabling various organisms to link up with this Centre, interacting by computer in emergency situations in order to arrange admission to sanitary structures other than the Centre but dependent upon it (Emergency Network = EN);
3. an operational Centre responsible for nationwide patient transfer, linked up with the "ring" network (Transfer Network) = TN). The BCN will have to guarantee information flow, including the availability in real time of beds in the various national Centres.

The EN would permit the use of non-specialized units for the admission of burn patients under the diagnostic and therapeutic care of the principal Centre in the network.
In other words, in the event of mass burns, the ring" network would make it possible to fill all national Centres without any waste of time, after which the "star" network would make it possible to use the General Hospitals nearest to the disaster area.
The task of the TN is the organization of vehicles and operational details for providing transport. Thus, through its link-ups, it must locate and mobilize the necessary means of transport, prepare flight plans and/or other methods of transport necessary for the mission, and give advance warning to services in the place of destination so that land transport facilities are coordinated. This network can make use of pre-existing services in other organized structures, such as the Army, the Police, the Fire Brigade and the Red Cross. These organizations must however coordinate their activities, finalizing them to the same objective and linking up with the Burns Centres.

RESUME. L'Auteur, après avoir traité l'organisation générale dans la zone du désastre, considère les paramètres pour le triage des patients, qui sont divisés en trois groupes homogènes sur la base de leurs possibilités de survie: Groupe 1: brûlés avec pronostic sûrement funeste; Groupe 2: brûlés avec UBS < 100; Groupe 3: brûlés avec lésions < 10-20%. Une fois divisés, les patients suivent des percours et des procédés thérapeutiques différents, selon le groupe d'appartenance. Enfin l'Auteur propose la création d'un dialogue permanent entre les divers Centres des Brûlés et entre ceux-ci et les structures hospitalières périphériques, en utilisant les systèmes d'informatique avec une infrastructure de support à deux niveaux complétée par un troisième noyau à son tour organisé à divers niveaux.