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Alruqi F, Aglago EK, Cole E, Brohi K. Factors Associated With Delayed Pre-Hospital Times During Trauma-Related Mass Casualty Incidents: A Systematic Review. Disaster Med Public Health Prep 2023; 17:e525. [PMID: 37947290 DOI: 10.1017/dmp.2023.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Critically injured patients have experienced delays in being transported to hospitals during Mass Casualty Incidents (MCIs). Extended pre-hospital times (PHTs) are associated with increased mortality. It is not clear which factors affect overall PHT during an MCI. This systematic review aimed to investigate PHTs in trauma-related MCIs and identify factors associated with delays for triaged patients at incident scenes. METHODS This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Web of Science, CINAHL, MEDLINE, and EMBASE were searched between January and February 2022 for evidence. Research studies of any methodology, and grey literature in English, were eligible for inclusion. Studies were narratively synthesized according to Cochrane guidance. RESULTS Of the 2025 publications identified from the initial search, 12 papers met the inclusion criteria. 6 observational cohort studies and 6 case reports described a diverse range of MCIs. PHTs were reported variably across incidents, from a median of 35 minutes to 8 hours, 8 minutes. Factors associated with prolonged PHT included: challenging incident locations, concerns about scene safety, and adverse decision-making in MCI triage responses. Casualty numbers did not consistently influence PHTs. Study quality was rated moderate to high. CONCLUSION PHT delays of more than 2 hours were common. Future MCI planning should consider responses within challenging environments and enhanced timely triage decision-making.
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Affiliation(s)
- Fayez Alruqi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Emergency Medical Services Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Elom K Aglago
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
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Leclerc T, Sjöberg F, Jennes S, Martinez-Mendez JR, van der Vlies CH, Battistutta A, Lozano-Basanta JA, Moiemen N, Almeland SK. European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan. Burns 2023; 49:275-303. [PMID: 36702682 DOI: 10.1016/j.burns.2022.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 12/19/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND A European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities. METHODS The European Burns Association's disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022. RECOMMENDATIONS The resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.
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Affiliation(s)
- Thomas Leclerc
- Percy Military Teaching Hospital, Clamart, France; Val-de-Grâce Military Medical Academy, Paris, France
| | | | - Serge Jennes
- Charleroi Burn Wound Center, Skin-burn-reconstruction Pole, Grand Hôpital de Charleroi, Charleroi, Belgium
| | | | - Cornelis H van der Vlies
- Department of Trauma and Burn Surgery, Maasstad Hospital, Rotterdam, the Netherlands; Trauma Research Unit Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Anna Battistutta
- Directorate-General for European Civil Protection and Humanitarian Aid Operations (DG-ECHO), European Commission, Brussels, Belgium
| | - J Alfonso Lozano-Basanta
- Emergency Response Coordination Center, Directorate-General for European Civil Protection and Humanitarian Aid Operations (DG-ECHO), European Commission, Brussels, Belgium
| | - Naiem Moiemen
- University Hospitals Birmingham Foundation Trust, Birmingham, UK; University of Birmingham, College of Medical and Dental Sciences, Birmingham, UK
| | - Stian Kreken Almeland
- Norwegian National Burn Center, Department of Plastic, Hand, and Reconstructive Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway; Norwegian Directorate of Health, Department of Preparedness and Emergency Medical Services, Oslo, Norway.
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Almeland SK, Hughes A, Leclerc T, Ogura T, Hayashi M, Mills JA, Norton I, Potokar T. "Reply: Letter to the Editor on recommendations for burns care in mass casualty incidents: WHO Emergency Medical Teams Technical Working Group on Burns (WHO TWGB) 2017-2020.". Burns 2022; 48:482-484. [PMID: 34903407 DOI: 10.1016/j.burns.2021.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/04/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Stian Kreken Almeland
- Department of Plastic, Hand and Reconstructive Surgery, Norwegian National Burn Center, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway.
| | - Amy Hughes
- Interburns, International Network for Training, Education and Research in Burns, Swansea, Wales, UK; Humanitarian and Conflict Response Institute (HCRI), University of Manchester, UK; Cambridge Hospital NHS Foundation Trust (Addenbrookes), Paediatric ICU Department, UK.
| | - Thomas Leclerc
- Burn Centre, Percy Military Teaching Hospital, Clamart, France; Val-de-Grâce Military Medical Academy, Paris, France.
| | - Takayuki Ogura
- Tochigi Emergency and Critical Care Centre, Imperial Foundation Saiseikai, Utsunomiya Hospital, Japan.
| | - Minoru Hayashi
- St.Mary's Hospital, Department of Plastic and Reconstructive Surgery, Japan.
| | - Jody-Anne Mills
- Rehabilitation Programme, Department of NCD, World Health Organization, Geneva, Switzerland.
| | - Ian Norton
- World Health Organization (2014-2019), Geneva, Switzerland; Respond Global, Australia.
| | - Tom Potokar
- Interburns, International Network for Training, Education and Research in Burns, Swansea, Wales, UK; Centre for Global Burn Injury Policy and Research, Swansea University, Wales, UK; World Health Organization, Emergency Medical Teams Technical Working Group on Burns, Switzerland.
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A simplified fluid resuscitation formula for burns in mass casualty scenarios: Analysis of the consensus recommendation from the WHO Emergency Medical Teams Technical Working Group on Burns. Burns 2021; 47:1730-1738. [PMID: 33707086 DOI: 10.1016/j.burns.2021.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 01/18/2021] [Accepted: 02/16/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Burn fluid resuscitation guidelines have not specifically addressed mass casualty with resource limited situations, except for oral rehydration for burns below 40% total body surface area (TBSA). The World Health Organization Technical Working Group on Burns (TWGB) recommends an initial fluid rate of 100 mL/kg/24 h, either orally or intravenously, beyond 20% TBSA burned. We aimed to compare this formula with current guidelines. METHODS The TWGB formula was numerically compared with 2-4 mL/kg/%TBSA for adults and the Galveston formula for children. RESULTS In adults, the TWGB formula estimated fluid volumes within the range of current guidelines for burns between 25 and 50% TBSA, and a maximal 20 mL/kg/24 h difference in the 20-25% and the 50-60% TBSA ranges. In children, estimated resuscitation volumes between 20 and 60% TBSA approximated estimations by the Galveston formula, but only partially compensated for maintenance fluids. Beyond 60% TBSA, the TWGB formula underestimated fluid to be given in all age groups. CONCLUSION The TWGB formula for mass burn casualties may enable appropriate fluid resuscitation for most salvageable burned patients in disasters. This simple formula is easy to implement. It should simplify patient management including transfers, reduce the risk of early complications, and thereby optimize disaster response, provided that tailored resuscitation is given whenever specialized care becomes available.
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Dries DJ. Burn care: before the burn center. Scand J Trauma Resusc Emerg Med 2020; 28:97. [PMID: 33008448 PMCID: PMC7531144 DOI: 10.1186/s13049-020-00792-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/24/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- David J Dries
- Department of Surgery, HealthPartners Medical Group, St. Paul, USA. .,Department of Surgery, University of Minnesota, Mpls, USA. .,Regions Hospital, 640 Jackson Street, #11503C, St. Paul, MN, 55101, USA.
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Pham C, Collier Z, Gillenwater J. Changing the Way We Think About Burn Size Estimation. J Burn Care Res 2020; 40:1-11. [PMID: 30247559 DOI: 10.1093/jbcr/iry050] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Burn size estimation is a crucial component of acute burn management that guides referral to burn centers, fluid resuscitation parameters, hospital resource distribution, and mortality-based interventions. Referring providers often misestimate the total BSA (TBSA) of burn injury, which contributes to unnecessary healthcare costs, misappropriation of limited resources, and delay in provision of appropriate patient care. A systematic literature review of articles available on PubMed, Scopus, Google Scholar, OvidSP Medline, and Web of Science was performed. All articles were evaluated in a standardized fashion by a panel of reviewers to assess applicability to the research question. Twenty-six relevant articles identified pervasive TBSA miscalculations ranging from 5% to 339% regardless of provider level with < 20% TBSA burns being disproportionately overestimated. This resulted in up to 77% of burns being inappropriately transferred to burn centers from referring hospitals. Improper use of TBSA estimation tools (palm, hand, Rule of 9s) without considering patient body mass index, race, age, and sex standards contributes to TBSA misestimation. Few studies with limited sample sizes argue that TBSA misestimations significantly affect fluid resuscitation volume, although the findings suggest that small burns (<20% TBSA) are over-estimated and over-resuscitated-the opposite of larger burns. TBSA misestimation is associated with an increased incidence of inappropriate transfers to burn centers and the associated costs. The data remains lacking, however, and larger studies are required to further elucidate the clinical impact of such errors. A systematic approach with telemedicine-facilitated computer-based burn assessments is required.
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Affiliation(s)
- Christopher Pham
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Zachary Collier
- Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Justin Gillenwater
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles.,Division of Plastic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles
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Ryan K, George D, Liu J, Mitchell P, Nelson K, Kue R. The Use of Field Triage in Disaster and Mass Casualty Incidents: A Survey of Current Practices by EMS Personnel. PREHOSP EMERG CARE 2018; 22:520-526. [DOI: 10.1080/10903127.2017.1419323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Disaster planning: the basics of creating a burn mass casualty disaster plan for a burn center. J Burn Care Res 2014; 35:e1-e13. [PMID: 23877135 DOI: 10.1097/bcr.0b013e31829afe25] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In 2005, the American Burn Association published burn disaster guidelines. This work recognized that local and state assets are the most important resources in the initial 24- to 48-hour management of a burn disaster. Historical experiences suggest there is ample opportunity to improve local and state preparedness for a major burn disaster. This review will focus on the basics of developing a burn surge disaster plan for a mass casualty event. In the event of a disaster, burn centers must recognize their place in the context of local and state disaster plan activation. Planning for a burn center takes on three forms; institutional/intrafacility, interfacility/intrastate, and interstate/regional. Priorities for a burn disaster plan include: coordination, communication, triage, plan activation (trigger point), surge, and regional capacity. Capacity and capability of the plan should be modeled and exercised to determine limitations and identify breaking points. When there is more than one burn center in a given state or jurisdiction, close coordination and communication between the burn centers are essential for a successful response. Burn surge mass casualty planning at the facility and specialty planning levels, including a state burn surge disaster plan, must have interface points with governmental plans. Local, state, and federal governmental agencies have key roles and responsibilities in a burn mass casualty disaster. This work will include a framework and critical concepts any burn disaster planning effort should consider when developing future plans.
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Disaster planning: the past, present, and future concepts and principles of managing a surge of burn injured patients for those involved in hospital facility planning and preparedness. J Burn Care Res 2014; 35:e33-42. [PMID: 23817001 DOI: 10.1097/bcr.0b013e318283b7d2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The 9/11 attacks reframed the narrative regarding disaster medicine. Bypass strategies have been replaced with absorption strategies and are more specifically described as "surge capacity." In the succeeding years, a consensus has coalesced around stratifying the surge capacity into three distinct tiers: conventional, contingency, and crisis surge capacities. For the purpose of this work, these three distinct tiers were adapted specifically to burn surge for disaster planning activities at hospitals where burn centers are not located. A review was conducted involving published plans, other related academic works, and findings from actual disasters as well as modeling. The aim was to create burn-specific definitions for surge capacity for hospitals where a burn center is not located. The three-tier consensus description of surge capacity is delineated in their respective stratifications by what will hereinafter be referred to as the three "S's"; staff, space, and supplies (also referred to as supplies, pharmaceuticals, and equipment). This effort also included the creation of a checklist for nonburn center hospitals to assist in their development of a burn surge plan. Patients with serious burn injuries should always be moved to and managed at burn centers, but during a medical disaster with significant numbers of burn injured patients, there may be impediments to meeting this goal. It may be necessary for burn injured patients to remain for hours in an outlying hospital until being moved to a burn center. This work was aimed at aiding local and regional hospitals in developing an extemporizing measure until their burn injured patients can be moved to and managed at a burn center(s).
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Kearns RD, Holmes JH, Skarote MB, Cairns CB, Strickland SC, Smith HG, Cairns BA. Disasters; the 2010 Haitian earthquake and the evacuation of burn victims to US burn centers. Burns 2014; 40:1121-32. [PMID: 24411582 DOI: 10.1016/j.burns.2013.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 12/16/2013] [Accepted: 12/17/2013] [Indexed: 10/25/2022]
Abstract
Response to the 2010 Haitian earthquake included an array of diverse yet critical actions. This paper will briefly review the evacuation of a small group of patients with burns to burn centers in the southeastern United States (US). This particular evacuation brought together for the first time plans, groups, and organizations that had previously only exercised this process. The response to the Haitian earthquake was a glimpse at what the international community working together can do to help others, and relieve suffering following a catastrophic disaster. The international response was substantial. This paper will trace one evacuation, one day for one unique group of patients with burns to burn centers in the US and review the lessons learned from this process. The patient population with burns being evacuated from Haiti was very small compared to the overall operation. Nevertheless, the outcomes included a better understanding of how a larger event could challenge the limited resources for all involved. This paper includes aspects of the patient movement, the logistics needed, and briefly discusses reimbursement for the care provided.
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Affiliation(s)
- Randy D Kearns
- North Carolina Burn Disaster Program, EMS Performance Improvement Center, University of North Carolina School of Medicine, United States.
| | - James H Holmes
- WFBMC Burn Center, Wake Forest Baptist Health System, Wake Forest University School of Medicine, United States
| | - Mary Beth Skarote
- Healthcare System and Hospital Preparedness Program Coordinator, North Carolina Office of EMS, United States
| | - Charles B Cairns
- Department of Emergency Medicine, University of North Carolina School of Medicine, United States
| | - Samantha Cooksey Strickland
- ESF8 Program Manager, Bureau of Preparedness and Response, Emergency Preparedness and Community Support/Florida Department of Health, United States
| | - Howard G Smith
- Burn Center, Orlando Regional Medical Center, University of Central Florida College of Medicine, United States
| | - Bruce A Cairns
- North Carolina Jaycee Burn Center, University of North Carolina School of Medicine, United States
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Postma ILE, Weel H, Heetveld MJ, van der Zande I, Bijlsma TS, Bloemers FW, Goslings JC. Mass casualty triage after an airplane crash near Amsterdam. Injury 2013; 44:1061-7. [PMID: 23683832 DOI: 10.1016/j.injury.2013.03.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 03/10/2013] [Accepted: 03/31/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Triage is an important aspect of the management of mass casualty incidents. This study describes the triage after the Turkish Airlines Crash near Amsterdam in 2009. The results of the triage and the injuries of P3 casualties were evaluated. In addition, the role of the trauma mechanism and its effect on spinal immobilisation during transport was analysed. METHODS Retrospective analysis of investigational reports, ambulance forms, and medical charts of survivors of the crash. Outcomes were triage classification, type of injury, AIS, ISS, emergency interventions and the spinal immobilisation during transport. RESULTS A minimal documentation of prehospital triage was found, and no exact numbers could be recollected. During inhospital triage 28% was triaged as P1, 10% had an ISS ≥ 16 and 3% met the modified Baxt criteria for emergency intervention. 40% was triaged P3, 72% had an ISS ≤ 8 and 63% was discharged from the Emergency Department after evaluation. In hospital over-triage was up to 89%. Critical mortality rate was 0%. Nine per cent of P3 casualties and 17% of 'walking' casualties had serious injuries. Twenty-two per cent of all casualties was transported with spinal immobilisation. Of the casualties diagnosed with spinal injury 22% was not transported with spinal immobilisation. CONCLUSION After the Turkish Airlines Crash documentation of prehospital triage was minimal. According to the Baxt criteria the overtriage was high. Injuries sustained by plane crash survivors that seem minimally harmed must not be underestimated. Considering the high energy trauma mechanism, too little consideration was given to spinal immobilisation during transport.
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Affiliation(s)
- Ingri L E Postma
- Academic Medical Centre, Trauma Unit Department of Surgery, Amsterdam, The Netherlands.
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