Annals of the MBC - vol. 5 - n' 4 - December 1992


Masellis M., Ferrara M.M., Gunn S.W.A.

Divisione di Chirurgia Plastica, Ospedale Civico, Palermo, Italy

SUMMARY. This article considers the various problems caused by burn disasters, particularly with regard to relief to the victims. After a comparison of the concepts of immediate care and organized relief, ten guidelines are given for the immediate care of burn victims by rescue workers, followed by a further ten guidelines for first aid to burn victims by trained teams. In conclusion there are some remarks on health education and training of the public for assistance in burn disasters. It is stressed that the acquisition of emergency professionality by ordinary people is a reflection of the civil progress of society.

Fire is a dramatic disaster not only because of its devastating effects on property and individuals but also, and above all, because of the panic it engenders in all those who suddenly find themselves face to face with the spread of flames.
In the presence of fire, a certain degree of panic is the most natural, almost physiological reaction, occurring in every living creature from insect to man.
An initial moment of psychological paralysis is common in all persons, followed by total inability to think rationally, which in turn leads to acts of instinctive behaviour with a single aim: escape to safety.
This sequence of actions not infrequently serves only to worsen the amount of damage caused and to create an even more dramatic and tragic situation. This may indeed be the only reaction possible in animals, which are purely instinctive, but in man, who possesses reason, there is another option which at first sight may seem almost paradoxical: to keep calm and take rational decisions. This can be achieved in one way only: through information about the risks involved, through understanding of the dangers, and through instruction about how to behave in case of fire.

Burn disaster
Whether a fire disaster strikes a building, a hospital, an airport, a ship, a factory, a sports stadium or a campsite, it is inevitably a highly devastating event because of the social and public context of these structures.
The extent of the disaster is determined by the distribution of material goods and, above all, by the number of persons involved. Those who escape death may suffer extensive burns which may be immediately life-endangering.
The problems of the involvement of human beings in a fire disaster are expressed precisely in the concept of "burn disaster", which may be defined as:
"The overall effects on living persons caused by the massive action from a known thermal agent. It is characterized by a high number of deaths and of seriously burned patients with a high rate of potential mortality and disability. It may be aggravated if appropriate rescue operations are delayed."
Some information about specific aspects of burn pathology, such as may occur in fire disasters, will help in the understanding of this definition:

  • The inhalation of combustion gases, fumes and hot air can cause life-endangering damage to the airways, even if the actual burns are limited in extent.
  • Burns involving more than 20% BSA in the adult and 15% BSA in the child cause a progressive state of hypovolaemic shock requiring reanimation within the first three hours.
  • The burn is often associated with other trauma (fractures, wounds, electrocution, etc.) which may complicate the prognosis quoad vitam, if not treated in good time.

Immediate care and first aid
The characteristics of relief action in a burn disaster are closely linked to the particular nature of the damage that fire causes in living persons and material goods, the manner of its occurrence, the dangers to which the rescue workers are exposed, and the specific type of care that has to be given to the victims.
The timeliness and the effective impact of relief work depend on both general and local factors.
In the specific case of the "burn disaster", as defined above, particular circumstances - such as the moment when the disaster occurs (night, day-time, public holiday, unfavourable weather conditions), the place of the disaster (residential area, skyscraper, isolated locality), the degree of accessibility, and the distance from operational rescue forces - all acquire importance because any delay will prevent relief work from being immediately available.
A decisive role is therefore played by local intervention factors which chiefly depend on the behaviour of the people present at the scene of the disaster, and on the action of the operative teams that arrive rapidly on the scene.
The peculiar nature of the burn disaster therefore necessitates well-defined chronological and qualitative operative phases. A person with burns of the airways and associated trauma needs immediate care of a different type from that given to the victim of an earthquake, flood or cyclone. It is also of fundamental importance, for prognostic reasons, that pending the arrival of organized relief some medical and/or surgical first aid must be given within a very short time according to the type of pathology present. The prognosis of burn disaster victims is thus conditioned by the degree of preparedness of the population facing the fire emergency and by the operational capacity of volunteers, physicians and nurses present in the area or in the immediate vicinity who have received previous training in this specific type of relief work. If people are to be able to give immediate care either to themselves or to others, they must know precisely what they have to do, they must have information not only about behaviour guidelines that will enable them to save themselves (self-rescue) but also about some elementary principles necessary for immediate help to others.
Understanding the danger represented by fire also means how to tackle it and how to defend oneself from it.
The more specific aim of first aid is to contain the injury and to reduce the risk of mortality. This is the responsibility of the already mentioned trained groups who get organized within two or three hours of the disaster.
These groups, consisting of physicians, nurses and volunteers with well-defined tasks, perform the first emergency triage and, bearing in mind the particular evolution of the initial phase of the bum disease, set into motion all the procedures necessary for initial resuscitatory therapy and local treatment of the burns.

Ten guidelines for the immediate care of burn victims by rescue workers

1. SeIC-control

The first rule to follow in the event of a fire is: "Don't panic". Rescuers must behave rationally and avoid any heedless action. The first thing to do is to examine the situation, assess the gravity of the fire and opt for the appropriate behaviour. To help others one must first be able to protect oneself

2. Seff-protection

Rescue workers must know how to protect themselves from flames, fumes, toxic gases, falling masonry and other hazards to their personal safety.
Therefore they must:

  • not walk over ground covered with easily flammable material (paper, sawdust, brushwood, etc.);
  • keep away from anything containing flammable liquid that might explode. Open containers holding liquids that burn at low temperature (e.g. petrol or kerosene) radiate heat that may be sufficient to ignite them;
  • not cross floors or lofts, or use stairs, or walk under ceilings exposed to the flames;
  • not stand downwind from the flames and must anticipate a sudden change in the direction of the fire. Even in the absence of wind, crossing zones exposed to air currents (tunnel exits, air-shafts, narrow passageways) becomes risky;
  • consider the possible direction in which the fire may spread to protect themselves from the flames;
  • if possible, use protective clothing and devices: for example, helmets, which protect the head and prevent the hair from catching fire; dark glasses, even ordinary sun-glasses, to protect the eyes from glare, sudden blazes and flying flaming particles; gloves, a welder's apron, etc.; a safety-belt, if available, which can be worn and tied to a rope held by another rescue worker, when carrying an injured person; and dust-masks, which prevent the inhalation of solid particles liberated by the fire and thus prevent irritation phenonema of the upper airways.

3. Diminishing the action of the fire

Pending the arrival of the fire brigade the rescue worker must:

  • evacuate all people at risk, beginning with those in places most immediately threatened;
  • remove from the area of the fire all flammable material, gas cylinders, etc.
  • switch off ventilation and air-conditioning systems to keep out fresh air which feeds the fire and to prevent the flammable and toxic gases and vapours from spreading;
  • switch on any fixed extinguishing equipment such as water-jets and sprinklers;
  • use correctly the available portable fireextinguishers;
  • avoid using water to extinguish flames on or near electric plants (the material that such structures are made of can react by considerably increasing in temperature or by releasing flammable and noxious gases).

4. Extraction and transfer of victims to the open air

Before entering a burning room one must:

  • put a wet cloth over the mouth, or wear a gas-mask;
  • enter the room on all fours and crawl forward in this position, as smoke tends to rise;
  • if there are flames in the room, wrap oneself in a blanket and advance on all fours;
  • crawl backwards down any stairs in order to avoid tripping;
  • before a closed door, feel the handle or the door itself before opening it; one could be caught in a blast of flames and smoke as soon as it is opened;
  • watch out for glass surfaces (doors, windows) because the heat and pressure generated by fire can cause them to explode;
  • approach cautiously air-shafts or small rooms without any ventilation. Before doing so, a rope guide is useful;
  • avoid passenger or goods lifts as a power breakdown can transform them into traps and they also become flame shafts;
  • if trapped in a room remember that the best thing to do is to shout for help from the window;
  • not stay any longer than necessary in a room, not be too sure of oneself, in other words not do anything rash.

5. What to do when clothing is on fire

It is extremely distressing to feel oneself wrapped in flames or to see another person transformed into a human torch. In these circumstances it is more than ever essential to remain calm and to know precisely what to do:

  • to extinguish flames in one's own clothing, one must clasp one's arms around the chest, and roll about on the floor;
  • to extinguish other people's clothing, it is best to throw them to the ground (tripping them up if necessary), to get them into a horizontal position, and to wrap them in a blanket or carpet or any other heavy material that can be rolled up (if they remain standing or sitting the flames will rise to their face and inevitably they will inhale hot air, smoke, etc.);
  • burning clothing should not be extinguished with violent jets of water aimed directly at the person: this can increase pain and the state of shock. Jets of water containing large amounts of oxygen can increase the combustion of petroleum and of synthetic clothes.

6. Removal of burning clothing

It is advisable:

  • to cut away belts, sleeves and tight clothing with great care;
  • to remove rings, bracelets and other constricting items: as the burn oedema develops these can cause ischaemia;
  • not to tear off violently clothing, especially socks and shoes, adhering to burned surfaces, as this would also tear away skin that would be useful in the healing process;
  • to remove at once, having first cooled them, if possible, with cold water, clothes impregnated with boiling liquids.

7. Emergency treatment of burned areas

To prevent burn lesions from deteriorating, it is essential:

  • not to burst any blisters, or remove the epidermis. Exposure of the dermis only increases the loss of body fluids and heat, besides increasing pain and the risk of infection;
  • to cool the burned parts with water or wet cloth. This stops the action of the thermal agent and considerably reduces pain. Very extensive burns must be treated either by immersing the part in water at room temperature or by covering the part with damp cloth. The cooling operation should generally not exceed 20 minutes. It should be guided by the patient's general condition and the degree of pain relief achieved. Cooling a patient must be stopped if he begins to shiver, as this can lead to hypothermia. Children and elderly persons and those in a state of shock must be treated with even greater care, with less energetic and shorter cooling. Non-extensive burns can be soothed with ice-packs or by placing the part under a running tap;
  • to use clean plastic bags, if available, to wrap burned hands and feet, or to spread out like adhesive flaps over burns on the thorax, limbs, etc.;
  • to wrap burned parts or the entire body in a freshly laundered dry sheet, towel or cotton or linen cloth, and not to apply dressings as these would cause constriction as the burn oedema increases;
  • not to medicate burned parts with ointments or other drugs as these would only mask the picture.

8. Pending more complete relief

It is necessary to:

  • check for other associated trauma, such as bleeding, fractures, head injury and respiratory distress;
  • use a belt, cord, etc., as a tourniquet to stop haemorrhage;
  • plug the wound with a tampon, if available;
  • lay the patient flat and apply splints to fractures;
  • clear the airways by extending the head of the victim and to begin mouth-to-mouth respiration;
  • give just coffee or tea or even a little water (but not more than 100-150 cc). Stop giving liquids if the patient vomits. No alcohol;
  • keep the patient warm by covering him with a blanket;
  • reassure the patient.

9. Chemical burns

The following three rules are helpful:

  1. First, wash the part that has been exposed to the chemical with copious amounts of water (eyes and face with greater care). Remove impregnated clothing and wash any parts previously covered;
  2. Without delay establish the chemical's pH by one of the following simple tests:
    • Tip- of- the- tongue test. Touch the burned skin and place the finger on the tip of the tongue; if the chemical is acid, there will be a bitter taste; if it is alkaline there will be no particular taste but a pungent and dry sensation. This test is safe and reliable.
    • Saliva test. Spread a little saliva with the fingers over the burned skin. If the chemical is alkaline a soapy emulsion will form between the fingers. An acid will cause no reaction.
    • Bicarbonate test. Sprinkle some bicarbonate over the burned skin. An acid, not an alkali, will produce effervescence.
  3. If possible, apply mildly tamponading substances to the washed parts: kitchen vinegar ( 1 acetic acid) diluted with 50% . water in alkali bums; household sodium bicarbonate (two teaspoonfuls in a litre of water) for acid burns. The eyes must be washed using water only.

It is important to obtain all information on the nature of the chemical and to relay it to the hospital where the victim is taken, so that the appropriate antidote can be applied.

10. Electrical burns

When faced with a bum due to electrical power it is necessary to:

  • switch off the current if the victim is still in contact with a conductor. If this is not possible, and if the current is less than 500 V, separate the part of the body in contact using a pole, broom-handle, wooden plank or any other insulating material, or with insulating gloves, rubber shoes, etc.;
  • lay the victim flat on the ground;
  • if fainted but breathing, lay him on one side;.
  • if unconscious and not breathing, place one hand under the back of his neck and stretch the head back. This will allow air to pass through the upper airways which have been obstructed by the root of the tongue or by the dropping of the jaw;
  • if still not breathing, start mouth-to-mouth respiration immediately;
  • if unconscious, not breathing, no carotid pulse and dilated pupils, start artificial respiration and external cardiac massage and continue until medical relief arrives.

There is absolute priority for hospital transfer.

Ten guidelines for first aid to burn victims by trained teams

1. Immediate triage of seriously ill victims

The victim of a fire disaster may also have suffered cranial, thoracic, spinal or abdominal trauma which can be masked by the overall picture of extensive burns. It is necessary to establish the priority of treatment and whether the patient's life is in danger. The first thing to look for is haemorrhage and breathing difficulties.

2. Inspection of the upper airways

Involvement of the upper airways should be suspected in face and neck bums. It is necessary to check to see if the nose hair is burned, if the oral mucosa shows bums, if there are carbon particles in the sputum, if there is a wheezing, hacking cough, dyspnoea, difficulty in expelling secretions, or hoarseness.
The more serious the thermal damage to the upper airways, the more rapidly and the more seriously oedema of the glottis will set in with subsequent obstruction of the airways.
In serious cases it is necessary to perform endotracheal intubation. This must be done by an expert because the oedema often conceals the vocal chords and the manoeuvre may stimulate reflex acute spasm of the glottis. In acute obstruction of the airways the only manoeuvre possible is tracheostomy.
Inhalation of hot gases can cause bums in the lower terminal bronchi. Inhalation of boiling steam produces alveolar damage. Inhalation of smoke causes corrosive pulmonary damage by the action of combustion products such as hydrochloric acid and phosgene.
The thick black smoke released by burning polyurethane foam contains cyanide compounds that can cause rapid unconsciousness and death. In such cases the patient should be made to breathe; if a manual vent ilator is available (Ambu type), ventilate the patient until medical relief arrives. If an oxygen cylinder is available, oxygen (100%) should be given, using a high-pressure mask.

3. Qualitative assessment of the burns

This can necessarily be only approximate. It is necessary to distinguish between:

  • superficial burns (Ist and 2nd degree): with red areas alternating with areas of healthy skin, or deepithelialized areas with the underlying healthy dermis red and wet. These are very painful when exposed to the air. They secrete a considerable amount of fluid, which facilitates the onset of shock;
  • deep bums (3rd degree): with areas of dead whitish tissue beneath a thin carbonized stratum that is easily removed, or dark, dry, very adhesive areas. Deep bums are not painful.

4. Quantitative assessment of the patient's burns

This must be done after removing the patient's clothing.
The Rule of 9: For adults, 9% for each upper limb and for the head, 18% for each lower limb and for the front and back of the thorax. For the other parts, with less extensive burns, the surface of the palm is equal to 1%. Erythema is not calculated.
In children the head is equal to 20% of the entire body surface area (BSA).

  • Moderately serious bums: these are 20-40% BSA 2nd-degree burns and 20% 3rd-degree burns;
  • Serious bums: these are 2nd- and 3rd-degree bums involving over 40% BSA;
  • Very serious burns: these involve over 60% BSA.

5. Intravenous resuscitatory therapy

Infusion therapy is necessary if the burned surface exceeds 15-20% in the adult, or 10-15% in the child. If it is impossible to administer infusion therapy, the patient should . sip water containing a little salt (1 litre+ 5 ing salt) with a spoonful of bicarbonate of soda. If the burned surface is more than 25-30% infusion resuscitatory therapy is essential and urgent.
The veins of choice for needle puncture are those of the upper limb (forearm or fold of the elbow), if the area is free of burns. If the veins are not visible a cut-down will be necessary, even through the burned area. The venous catheters should be of good calibre and not too long.
Analgesia is not necessary in cutting through burned surfaces and accurate closure of the surgical wound is not essential. Before connecting the i.v. infusion set, blood samples are taken for lab tests. If it is not possible to obtain blood from the catheter, don't insist.
Lv. fluids containing 130/150 mmol NaCl should be given; failing this, normal physiological solution. It is also possible to use protein colloidal solutions, plasma, Ringer's lactate or acetate, as available.
If more than I hour has passed since the accident it is possible to use colloidal solutions of low molecular weight (Hemalgel, Macrodex). These enhance renal osmotic excretion of haemolytic pigments in the glomerular filtrate.
The fluid requirements in the first 4 hours can be calculated as between 0.5 and 0.65 ml/kg/% of the burned body area. If 2000 cc of fluid have to be infused in the first 4 hours, the infusion rate should be calculated as 500 cc per hour (7 drops per minute).
If infusive therapy begins after 30 minutes, the infusion rate must be speeded up in order to make up for the delay.

6. Analgesia therapy

Good analgesic therapy must:

  • reduce clinical shock;
  • maintain and even increase blood pressure;
  • ensure that breathing is not impaired by the produce amnesia in the distressed patient; make use of the simplest method for pain relief, avoid using drugs that lead to addiction;

use only drugs with a wide margin of safety.
Third-degree bums are not painful and more superficial bums do not always require analgesic therapy.
The following drugs are preferable:

  • tilidine hydrochloride (Valoron) in drops, administered sublingually. Dosage: I drop per year of age in children. Generally it is possible to give 5 drops at the beginning, repeated after 5 hours. Adults: 20 drops. This drug does not cause amnesia. It may prove difficult to administer to a crying child;
  • ketamine hydrochloride (Ketalar) - preferably administered intramuscularly, because in the circumstances it may be difficult to find a vein. The action is prolonged if administered intramuscularly. This drug appears to possess all the requirements of analgesia but as it is a general anaesthetic it is not without danger. It must be administered by physicians in subanaesthetic doses of 0.3 mmg per kg body weight.

If these drugs are not available and if pain has not diminished on application of cold packs, small doses of diluted morphine sulphate (10 ing of morphine sulphate in 10 nil) may be given intravenously in doses of 0.1-0.2 ming per kg body weight. The injection must not be intramuscular or subcutaneous because the cumulated drug may be reabsorbed when the circulation improves, causing sudden and unexpected respiratory distress.

7. Bladder catheterization

It is necessary to:

  • insert an in-dwelling urinary catheter;
  • connect it to a drainage bag;
  • measure total and hourly urine volume.

8. Pressure- relieving incisions

If more than 2 hours have elapsed since the accident, it is necessary to incise the burned areas down to the healthy fascia level in order to eliminate compression on the underlying tissues. Because of the non-elasticity of the skin and the worsening oedema, deep circumferential burns that *Involve the neck, thorax, limbs and hands can prevent thorax expansion and constrict arteries and veins, thus obstructing the circulation.

9. Re-examination of the patient

Soon after immediate care is given, it is safe practice to:

  • recheck respiratory capacity;
  • recheck the percentage of burned body areas;
  • reassess fluid therapy on the basis of the amount predicted and the amount actually administered.

10. Hospital transfer

It is important to assess whether it is possible to transfer the patient by ambulance, helicopter or aeroplane.
If transfer is immediately possible and transport time is 15-20 minutes the burn victim can be sent immediately (even without initiating therapy). It is necessary to find out in advance where the patient is to be sent and to calculate the journey time, bearing in mind traffic hold-ups and other possible delays. The ambulance or other transport team must be informed about the procedures they must observe to ensure continuation of the infusion therapy that has already been initiated.
Fractured, immobilized limbs must be supported in the non-pressure position. It is essential to accompany the patient if there are respiratory problems.

Health education and training of the public for assistance in burn disasters
The above-mentioned considerations indicate that the procedures initiated to assist the victims of a burn disaster, either by the first rescuers present on the spot or by the better organized relief forces arriving soon afterwards on the scene, are of particular importance. All assistance to persons who have been exposed to fire and have extensive burns must be specific, precise, considered and timely. At the same time rescue workers, must defend themselves from the risks of fire and be fully aware of the difficulties they face when saving fire victims. Education and training programmes thus assume particular importance. These have to tackle three aspects of the disaster: the technical aspect, the clinical aspect and the operational aspect:

  • the technical aspect, aimed at the analysis of the extent of the damage caused by the fire and of the immediate behaviour of the people directly involved;
  • the clinical aspect, assessing the extent of the damage to persons, the evolution of the various phases of the burn, and the specific type of therapy to be given
  • the operational aspect, concerned with plans for coordinated and effective relief, ranging from self-relief to immediate 'assistance and, specific first-aid measures.

The implementation of these plans must follow well-defined programmes:

  • teaching at school, starting from primary school level, through educational civil defence courses;
  • periodic refresher courses for physicians, nurses, voluqteers, Red Cross, fire brigade, police, etc.;
  • periodic exercises with simulated fire,disasters, with the involvement of the general population and the local rescue forces.

Particular attention must be paid to teaching methods. These must be effective and suitable for separate age groups. In addition to illustrated brochures, stickers, colouring albums, posters, notices, etc., various audiovisual means, in particular videotapes, have been successful. These re-create and simulate situations, and propose actions for the assistance of the victims.
Among the training systems developed recently with regard to prevention of fire disasters, a simple user-friendly interactive instrument using the most advanced techniques has been developed.
This system comprises a personal computer, a videodisk reader and a touch-screen, i.e. a monitor sensitive to finger pressure. It combines the purely informative content of an ordinary documentary film with a number of educational elements put at the disposal of the user.
When users view the videodisk containing a film on prevention of industrial accidents, and go through the question-and-answer programme, they have access, in any sequential manner, to the various guidelines on prevention, behaviour and first aid described in the film.
The programme provides users with self-teaching and self-testing elements, which otherwise would be merely passive teaching. The self-teaching phase enables users to follow their own chosen training programme according to their individual learning capacities, and to review again and again the various guidelines and suggestions as they see fit. The self-testing phase enables users to assess their degree of leaming by simply touching the screen which answers the question indicating the right or wrong choice.
The clear advantages over traditional training methods (conventional audiovisual courses, and those based on the use of printed texts or photographic material, etc.), derive from the dynamic interaction between the user and the learning material.
Recent research on leaming capacity has in fact shown the importance of the interaction of the training instrument. Most people are able to learn 50% of what they hear and see at the same time, while they can learn 90% if they can themselves, at will, re-see and re-hear the educational material.
Multimedia presentation (audio, video, written text, graphics) of a subject provides various ways of gaining the user's attention and achieving greater effectiveness than the usual monomedia message. Clearly, such systems, which are essential not only for prevention but also for teaching, may also become fundamental in refresher courses.

The need to bring relief to bum victims within a very limited time interval and the importance of specific first-aid techniques make it necessary to consider, even during the planning stage, three distinct phases of relief operations: immediate assistance, first aid, and organized relief.
Immediate spontaneous assistance and first aid, provided by the people present on the spot and by teams of trained volunteers, physicians and nurses within 2-3 hours, are fundamental for the prognosis of fire disaster victims.
A timely, rational, safe and effective intervention is the main guarantee quoad vitam for the victims of a fire disaster. The first rescue workers must be aware of the tasks to perform, must be able to act autonomously, and must make sure that the work corresponds to the plans and needs.
They must know how to keep mutually coordinated as they constitute the spearhead of the more complex body of organized relief which will not be able to reach the scene for at least 6-7 hours.
As in any other disaster, plans for relief operations in a bum disaster will remain just so much paper if they are not tested by training programmes, if they are not made intelligible to the public, if they are not supported by the necessary management resources and if they are not implemented properly.
The acquisition of emergency professionality by ordinary people is a sign of civil and cultural progress. Thus the man in the street - the potential first rescue worker - must not only be able to receive specific training for emergency situations but, more importantly, be aware that he is in a state of preparedness to offer his aid methodically and effectively.


RÉSUMÉ. Les auteurs prennent en considération les divers probiémes causés par les catastrophes Wincendie, en particulier pour ce qui concerne le secours aux victimes. Aprés avoir comparé les concepts des soins immédiats et des secours organisés, i1s fournissent dix lignes directrices pour les soins immédiats aux brúlés par les premiers sauveteurs et dix lignes directrices pour les secours d'urgence aux brúlés par les équipes professionelles. Pour conclure, i1s discutent de l'éducation sanitaire et de I'importance d'instruire la population á cet égard. lls soutiennent que la capacité professionelle du peuple devant une catastrophe refléte le progrés civil d'une société.


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  2. Sorensen B.: Management of bums occurring as mass casualties after nuclear explosion. Burns, 6: 33-36, 1979,
  3. Evans R.: "Ernergency medicine". Butterworths, 1981.
  4. Reis N.D., Dolev E.: "Manual of disaster medicine".Springer-Verlag, Berlin, 1989.
  5. Sheeny S.B.: Manual of emergency care" (3rd ed.). Mosby, 1990..
  6. Masellis ~4., Gunn S.W.A.: Thermal agent disaster and burn disaster: definition, damage, assessment and relief operation. Ann. Medit. Burns Club, 4: 215-218, 1991.


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