Annals ofBurns and Fire Disasters - vol. IX - n. 4 - December 1996

BEHAVIOUR DURING A MASS INDUSTRIAL BURN DISASTER

Hadjiiski 0.

Burns and Plastic Surgery Centre, Pirogov Scientific Institute of Emergency Medicine, Sofia, Bulgaria


SUMMARY. A severe industrial accident is described in which a tank containing 2000 m' of hot water (90 'C) exploded, causing a wave 4-5 m high to cascade over 25 workers. All suffered tbird-degree burns (30-100% total body surface area [TBSA]) and steam inhalation. Six persons, with 100% TBSA burns, steam inhalation and multiple traumatic injuries, died immediately. The others were transferred first to a small regional hospital and some hours later to the nearest district hospital, where three patients with 100% TBSA burns and steam inhalation died within three days. Six hours post-bum four patients were transported 100 km by helicopter to a small burn care unit, where two with minor burns survived and two with 50% TBSA burns died respectively on days 3 and 7 post-bum. Between 7 and 10 hours postburn the remaining twelve patients (one with 30% TBSA burns and eleven with 70-100% TBSA burns) were transferred by air 200 km to the largest burn care centre in Bulgaria. Of this group of twelve patients, the eleven with over 70% TBSA burns died between days 1 and 19 post-burn (total number of days of hospitalization, 8 1), while the patient with only 30% TBSA burns survived. A description is given of fluid resuscitation during burn shock, local and surgical treatment, and the medical supplies used. Despite the poor prognosis of such patients, the importance is emphasized of the necessity of treating them in specialized burns centres.

Introduction

Mass industrial burn accidents are frequent and wide spread occurrences and may involve people of all age groups. During the moments of the atastrophe the actions of the victims and those providing emergency aid are char acterized by panic and confusion. Together with trauma the psychological effects are always considerable.
Prognosis depends mainly on the injuries themselves, the quality of first aid, and the means and times of transporting the victims to the nearest ospital and specialized burns centres. In mass industrial accidents causing severe inju ries, the immediate intervention of professional teams of importance. specialists who know the clinical development and treat ment of trauma in every detail is absolutely mandatory.` It also has to be remembered that flame and steam burns are often accompanied by inhalation of toxic substances as well as injuries of the upper airways and other organs and systems, which if undetected usually prove fatal. First aid and successful transport to the nearest hospital or burns unit require a high evel of professional qualification in decisions regarding the triage of casualties and the establishment of action priorities. Various factors - evaluation of airway efficiency, respiration, circulation and haemostasis, the assessment of concomitant multiple traumatic injuries at the site of the accident, and the immediate initiation of fluid resuscitation - can save lives and minimize late complications such as shock, infection, etc.
To comprehend the situation and the need for medical care, every accident should be assessed on the basis of the following considerations, which may be defined as:

  • technical - assessment of injury (body surface area involved and type of injury), action of persons giving first aid immediately after the accident

  • clinical - number of victims, age, concomitant trauma and development of the disease in the first postaccident hours

  • organizational ~ co-ordination of first aid in order to save casualties from additional injury and other irreversible changes in important vital organs and systems before specialized care can be provided

The triage of casualties on the spot is of exceptional

The accident

Here we analyse a mass industrial accident in which a tank containing 2000 m' of hot water (90') exploded, causing a wave 4-5 m high to cascade over 25 workers aged 25 to 59 years. All the workers were scalded, sustaining burns in 30-100% total body surface area (TBSA). Six died immediately on site, having suffered 100% TBSA burns, steam inhalation and multiple traumatic injuries in the head, chest, abdomen and extremities.
irst aid was provided by other workers and staff from the medical service of the enterprise. The nineteen survivors were immediately taken by car and minibus to a small hospital some kilometres away, where they were assessed for the first time. All the patients were in a state of severe shock and presented significant burns, according to the ASA classification. After assessment of airways and respiration and initiation of fluid resuscitation, all the casualties were transferred to a general hospital 20 km away. Here the entire staff was mobilized for their treatment and a considerable portion of the medical supplies was used. Five hours after the accident a medical team flew in, consisting of ten specialists from the largest burns centre in the country (250 km away) and one specialist from a small burns unit (100 km away).
Bulgaria (area, 110 000 sq km) has a well~functioning network of emergency medicine centres, good communications, and ambulances, helicopters and aeroplanes equipped with medical supplies and qualified teams. Some years ago a new policy was adopted for the treatment of bum patients in specialized burns units, whatever the severity of their bum injury.` The specialized team therefore reassessed the casualties' conditions, considering the possibilities of their treatment in general hospitals and burns centres. Three patients with 100% TBSA burns and steam inhalation were left where they were for further treatment. Two of these were intubated because of acute respiratory failure. Four others were flown by helicopter to a small burns unit six hours post-burn. Of these four, two had minor burns and two had 50% TBSA burns. The remaining twelve patients were flown by aeroplane and helicopter to the largest bums centre in Bulgaria between seven and ten hours after the accident. One of the twelve presented 30% TBSA burns and the other eleven bums in 70-100% TBSA. No severe respiratory or circulatory complications were observed during transportation and the early post-burn hours, notwithstanding the patients' severe condition and the considerable percentage of body surface area burned.

The outcome

In all, three patients were restored to health and twenty-two died. Six patients succumbed at once at the place of the accident. In the general hospital the three patients with 100% TBSA bums died by day 3 post-bum. In the small burns unit two patients with minor burns were treated successfully, while two others with 50% TBSA bums died between days 3 and 7 post-burn. In the specialized burns centre one patient with 30% TBSA burns survived and eleven with 70-100% TBSA burns died between days 2 and 19 post-burn.

The treatment

The eleven patients who died in the bums centre totalled 81 days of hospitalization (mean, 7.4; range, 6.5). All were treated according to current principles in Bulgaria for the treatment of severely burned patients.
A modified Baxter's formula was used during the period of burn shock. The patients were treated with Ringer's lactate solution during the first 24 hours, and with 5% human serum albumin and free water during the second 24 hours. After the period of burn shock, treatment proceeded in relation to data from physical examination, laboratory tests and haemodynamic levels (blood, plasma, crystalloid, amino acid solutions, fat emulsions). Overall, a volume of 627 1 was infused: 27 1 blood, 24 1 albumin, 11 1 plasma expanders, 43 1 amino acids, 193 1 electrolytes, 322 1 glucosamines, and 7 1 lipids.
Six patients were treated locally with the open method, using Clinitron fluid beds. Five others were treated with the closed method, using dressings with antibacterial agents such as silver sulphadiazine and 10% povidone-iedine. Four patients were treated surgically, with two- or three-stage early excision. Various methods of combined allo/autografts were used to cover the wound surface - allografts, sandwich, stamps, etc. In the process of treatment the following medical supplies were used: 3500 large bandages, 2000 gauze compresses (40 and 20 sq em), 8100 sq m gauze, 97 kg cotton wool and a large quantity of different medicines.
As said, the 11 pati ents who died in the burns centre remained there for an overall total of 81 days. During the same period the other 48 patients in the centre totalled 1240 days. The division of the cost of treatment per day was 94% per non-survivor against 6% per survivor. The total cost per non-survivor was 80% against 20% for survivor

Conclusion

The main problem with patients such as those described, with severe prognosis, is where to treat them." Should they be transported to specialized burns centres where everything possible for their treatment can be done or is it more reasonable to keep them in the nearest general hospital where they can be treated symptomatically?"-" Should they be supported with mechanical ventilation for long periods of time, be operated on, and resuscitated with expensive blood transfusions, blood products, medicines and other medical supplies? The opinion of all centres in Bulgaria is that such patients should be treated in specialized bums units by experienced teams with adequate facilities and sufficient equipment. Casualties should be transferred to such units as soon as possible after the accident, whatever the risk. Transport is contraindicated only when a patient is very unstable, presenting conditions that might be severely and irreversibly aggravated by transport, and when the diagnosis is not clear.
Treatment should be accomplished according to all the rules, regardless of the poor prognosis. Our first aim must always be the patient's well-being, even if there is little possibility of survival - our intervention is the patient's only chance. We must not faWinto the position of people who know the price of everything and the real value of nothing. The organization of first aid, transport, and the quality of medical care must of course be discussed and improved.

RESUME. U Auteur décrit un grave accident industriel où un réservoir qui contenait 2000 rn' d'eau chaude (90 'Q a explosé, provoquant une onde haute de 4-5 m qui est tombée en cascade sur 25 ouvriers. Toutes les victimes ont été atteintes de brûlures de troisième degré (30- 100% de la surface corporelle totale [SCT]) et d'inhalation de vapeur. Six personnes, avec des brûlures en 100% SCT; inhalation de vapeur, et lésions traumatiques multiples, ont perdu la vie immédiatement. Les autres ont été transférées d'abord dans un petit t hôpital local et après quelques heures dans l'hôpital régional le plus proche, où trois patients atteints de brûlures en 100% SCT et d'inhalation de vapeur sont morts avant trois jours. Six heures après l'accident quatre patients ont été transportés en hélicoptère 100 km jusqu'à une petite unité de brûlures, où deux patients qui présentaient seulement des brûlures mineures ont survécu, tandis que les deux autres, atteints de brûlures en 50% SCT sont morts respectivement trois et sept jours après l'accident. Entre sept et dix heures après le désastre douze patients (dont un présentait brûlures en 30% SCT et onze en 70-100% SCT) ont été transportés par avion 200 km jusqu'au plus grand centre de brûlés en Bulgarie. De ce groupe, les onze patients atteints de brûlures en plus de 70% SCT sont morts entre le premier et le dix-neuvièmejour après l'accident (total de jours d'hospitali sation, 81), tandis que celui qui présentait des brûlures seulement en 30% SCT a survécu. L'Auteur, après avoir décrit les méthodes de réani mation liquide pratiquée pendant l'état de choc, le traitement local et chirurgique, et le matériel médical employé, insiste, malgré le mauvais pronostic de tels patients, sur l'importance de les traiter dans des centres de brûlés spécialisés.


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This paper was presented at the Ninth MBC Meeting in Tunis in May 1996.

Address correspondence to: Prof. Ognian Hadjiiski, Burns and Plastic Surgery Centre, Pirogov Scientific Institute of Emergency Medicine, Sofia, Bulgaria (Tel./Fax: 00359.2.546108).




 

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