SUMMARY. Suggestions are made for the management of bum injuries in the event of mass casualties. The causes of mass burns are considered and methods for sorting described, together with progressive steps in therapy. The experience of an actual occurrence of mass bums casualties is recorded. This was result of a military engagement, and the main cause of the bums was napalm.

The published experience regarding the management of burn injuries in mass casualties is rather limited. Those who deal with such injuries may meet this problem once during their practice or may never have the chance to deal with this difficult and troubling experience.

Causes of burns in mass casualties

1. Civilian causes: Fire in meeting places, especially confined ones: Theatres, lecture rooms, circuses and cinemas.
2. War Injuries: Flame throwers and napalm: direct injury with these agents is fatal or causes charring of the injured parts.

Thermonuclear weapons: these are accompanied by the release of an enormous amount of kinetic energy, 80% of which is in the form of ordinary heat. Tens of thousands of burn casualties would result from a major thermonuclear blast.

Our aim should be to provide the maximum care for the maximum number of patients and to avoid any procedure that might reduce a patient's ability to care for himself.
The most experienced person should be responsible for deciding and outlining necessary compromises in therapy. The medical sorting of the casualties depends on the number of injured, the available facilities and the personnel, e.g.: if only ten litres of bood are available and there are 5 casualties who could recover if each received two litres, these receive priority for transfusion, before one casualty who needs ten litres.

The percentage of surface area burnt and depth of bum is the accepted rule:

1. Patients with second- and third-degree bums involving more than 40% and patients with combined mechanical and radiation injury of less than 40% will not survive. They will need expectant treatment and are made as comfortable as possible with adequate doses of morphine. They should not receive definitive treatment until all patients in higher priority groups are cared for.
2. Patients with 15-40% will need careful therapy.
3. Patients with less than 15% superficial burns may be discharged to self-care if the location of the burn does not interfere with ambulation, after being supplied with food, electrolytes and antibiotics. Patients in this group atTected in the face and legs could be referred to general local hospitals where untrained personnel could care for their daily needs.

Patients with minor injuries can care for those more severely injured.

Steps in therapy

1. Relief of pain: full-thickness burns are painless; patients with partial -thickness injuries are given morphine intravenously. The bums become painless after a few hours, with the formation of a dry crust.
2. Supportive therapy: if facilities allow, intravenous therapy is given with the use of a formula. If this is not available, the requirements are given orally: 3 gin salt and 1.5 gin sodium bicarbonate in a litre of water. This can be supplied in a package together with some type of water purification tablets. It may also be used for burns of less than 30%; blood may be given to correct anaemia several days later.
3. The bum wound: in ideal circumstances, clean the surface with mild soap or detergent. Exposure is the mode of choice, reserving dressings for mechanical injuries. Blankets and other types of coverage should be used in cold weather. If time permits and dressings are available, they are utilized for individuals who will most benefit from their use.
4. Antibiotics: oral antibiotics should be used to prevent infection by haemolytic streptococci.

Certain hospitals are designated as Burn Centres, where trained staff and proper equipment are available. Compromise therapy and sorting should also be performed in these centres. Casualties needing one grafting procedure should be taken to the operating theatre first. Mesh grafting is the preferable procedure for extensive bums. Cadaver homografting is used as a dressing in cases who have to wait for their turn in autografting and for cases whose general condition necessitates it.

As mentioned before, published experience is rather limited. Wells recorded 150 burned patients admitted to various hospitals after a circus fire at Hartford, USA, in July 1944. In Hiroshima, out of a population of 300,000, 100,000 were injured, the majority suffering bums.
During the aggression of 5th June 1967 we received 150 bum casualties at Helmiah Military Hospital, where the bulk of war casualties were taken. The Plastic and Burns Unit had to deal with these cases in addition to hundreds of cases of maxillo-facial, degloving, hand and open fracture casualties.
The bums were caused mainly by napalm. I would like to stress that direct injury by napalm is fatal, and the cases we treated were caused by napalm flame.
Petrol and explosions were responsible for about a third of the cases.
The sites injured were mainly the exposed parts of the body.

50% of the cases involved 20-46% surface area. 20% involved 10-20% surface area. The rest concerned less than 10% surface area. Most of the cases were deep and needed grafting.

Most of the cases arrived 48 hours after injury. Organization: two teams were formed, each consisting of. - a general surgeon with knowledge in plastic surgery - an anaesthetist - a qualified nurse (Hakima) - a trained junior nurse - two orderlies.
Each team was supervised by a qualified plastic surgeon and was responsible for the care of half of the cases. The dressings were performed in a well-equipped theatre twice weekly for each case.

This organization and planning allowed us to achieve the following results:

1. Early grafting of deep burns and early healing of superficial ones. Fresh volunteer grafting was needed for four of the extensive injuries.
2. Low morbidity rate: Two cases developed contractures deforming the hands. One case developed neck contracture. One case developed ectroplon of the eye lids.All were suitably dealt with. These four cases were received, with infected burns, a week or more after injury.
3. Low mortality rate: four cases only.

One case was due to renal failure - with a history of chronic nephritis.
One case was due to cardiac arrest, during anaesthesia.
One case was due to over-transfusion.
The fourth died of septicaemia.

RÉSUMÉ. L'Auteur fait des propositions pour la gestion des brûlures en cas d'un nombre massif de blessés. Après avoir considéré les causes des brûlures en masse et décrit les méthodes de triage et les étapes progressives de la thérapie, il racconte l'expérience d'un cas réel de brûlures en masse, à la suite d'une action militaire dans laquelle la cause principale des brûlures était le napalm.