OUR LADY OF GUADALUPE COLLEGES
COLLEGE OF NURSING
NCM 121: Disaster Nursing
BURNS
● Endotracheal tubes should be secured with twill
BURN TRIAGE IN MASS CASUALTY INCIDENTS tape in patients with facial burns, as the adhesive
does not stick to burned skin.
PRIMARY TRIAGE ● Smoke inhalation injury and carbon monoxide
● Occurs at the disaster site or the hospital poisoning patients should immediately receive
receiving patients from the scene. 100% oxygen.
SECONDARY TRIAGE SIGNS OF SMOKE INHALATION INJURY
● Occurs at the hospital or burn center ● Hoarseness
● Wheezing
NOTE! ● Facial burns
All burn patients should be transferred to a burn ● Singed facial hair
center within 24 hours of injury ● Carbon deposits in the oropharynx or
carbonaceous sputum.
A definitive diagnosis of inhalation injury can be
NOTE!
made with BRONCHOSCOPY
The larger the burn size, the greater the fluid loss
will be.
BEGIN FLUID RESUSCITATION
MANAGEMENT OF MASS CASUALTY BURN PATIENT
● Two large-bore peripheral intravenous (IV) catheters
should be placed to begin fluid resuscitation, through
Initial burn patient management includes:
nonburned tissue if possible.
● Stop the burning process
○ If the catheters must be placed through burned
● Manage airway, breathing, and circulation
skin, they should be sutured in place –
● Begin fluid resuscitation
adhesives do not stick to burned skin
● Keep the patient warm
● Second- or third-degree burns greater than 20%
● Evaluate for other life- or limb-threatening injuries
TBSA and patients with significant smoke
inhalation injury will require fluid resuscitation.
PRIMARY SURVEY
● Before calculation can be done, it is necessary to
STOP THE BURNING PROCESS determine the patient’s weight (in kilograms) and
● Smoldering clothes should be removed and correctly estimate the percentage TBSA burned.
chemicals should be brushed away or irrigated as
indicated.
● DO NOT USE ICE OR ICE WATER! CONSIDERATIONS!
○ This can cause vasoconstriction → ischemia to ● Blood pressure and heart rate are misleading
the burn tissue → further injury indicators of adequate fluid resuscitation due to
● IF UNRESPONSIVE, immobilize the cervical spine physiological factors including progressive
until injury is ruled out. edema to burned extremities, cellular fluid
shifts, vasoconstriction, and pain.
MANAGE AIRWAY, BREATHING, AND CIRCULATION ● URINE OUTPUT is an effective indicator of
● It is critical for patients with inhalation injuries to be organ perfusion; therefore, it is used to evaluate
intubated as soon as possible due to the significant the effectiveness of fluid resuscitation and to
increase in airway edema. guide rate titrations as needed.
● Immediate intubation for patients with signs of: ○ An indwelling urine catheter should be placed
○ Severe respiratory distress to accurately measure urine output; urine
○ Inhalation injury output should be measured at least hourly.
○ Decreased LOC ● A good estimation tool for children and
○ Inability to protect the airway scattered burns is the palmar method: the size
of the patient’s hand, including the fingers,
represents approximately 1% of his/her
NOTE! TBSA.
● Traumatic and multiple attempts of intubation can
worsen airway edema therefore, the most skilled
personnel must manage the airway.
● Large burns and facial burns do not always need
immediate intubation but may require it once fluid
resuscitation begins, before edema creates a
difficult airway.
LR is the crystalloid of choice because its pH and
osmolality most closely resemble human plasma.
Timing is one of the most important considerations in
calculating fluid needs in the first 24 hours post burn.
REMEMBER, the starting point is the time of injury—not
the time of arrival to the treating facility. COLLOID (5%
albumin, plasma, hetastarch) is given on the second
24hrs.
PARKLAND/BAXTER FORMULA
● Day 1 – LR
● Day 2 – Colloid is added
FIRST 24 HRS
● Allocation of Fluids Replacement for the first
24hrs equating to 100%:
○ 1st 8hrs = 50%
○ 2nd 8hrs = 25%
○ 3rd 8hrs = 25%
Formula
4 mL LR × patient’s weight in kilograms × %TBSA
Example:
4mL x 90kg x 22% = 7,920 mL
1st 8hrs (50%) = 7,920 mL x .50 = 3,960 mL
2nd 8hrs (25%) = 3,960 mL x .25 = 1,980 mL
3rd 8hrs (25%) = 1,980 mL
SECOND 24 HRS
Formula
● (0.5 mL Colloid X Weight in kg X TBSA) + 2000 mL
D5W to run concurrently over the 24hour period.
Example:
● 0.5 mL x 70kg x 80% = 2,800mL Colloid + 2,000mL
D5W
○ 2,800mL/24hrs = 117mL Colloid/hr
○ 2,000/24hrs = 84 mL D5W/h
NOTE! D5W is given for insensible losses
Nursing Responsibilities
● Monitor weight daily
● Monitor laboratory changes
● Monitor UO (must be maintained at 30-50 mL/hr but
the desired is 70 - 100 mL/hr.
● Cautiously administer fluids to prevent further fluid
shifting and evaporative fluid loss.
● Decrease the rate of IV fluids if Hgb and Hct
decreases
An indwelling urinary catheter is inserted to permit accurate
monitoring of urine output and fluid needs and as a
measure of kidney function for patients with moderate to
severe burns.
Successful Fluid Resuscitation
● Stable VS
● Palpable peripheral pulse
● Adequate UO – monitor hourly
● Clear Sensorium
● URINARY OUTPUT – is the most sensitive
assessment parameter for cardiac output and tissue
perfusion.
○ Earrings should also be removed as they can
FLUID RESUSCITATION CONSIDERATIONS cause pressure necrosis in a swollen ear
● Digital vessels of each finger, radial, palmar arch,
1.The titration should reflect the amount of urine posterior tibial, and dorsalis pedis pulses should be
the patient is producing with a goal of 0.5 mL/kg/ checked hourly for progressive decrease in signal or
hr of output in adults and 1 mL/kg/hr in children total loss.
less than 30 kg.
2.A good rule of thumb is to decrease the fluid rate
by 10% every hour that the patient has made the NOTE!
goal for urine output. When the primary survey is complete, a thorough
3.If at any point the patient is not meeting the head-to-toe evaluation is conducted to assess for other
hourly output goal, increase the fluid rate by 20% injuries.
and observe over the next hour. Ideally, the fluid
is titrated down to a maintenance rate by 24
SECONDARY SURVEY
hours after the injury.
Should include:
4.The adult maintenance fluid requirement is 30
● Accurate history
mL/kg/d plus an estimation of insensible
● Circumstances of the injury and medical history
losses—1 mL/kg/% TBSA burned.
● Complete examination to evaluate for other traumas
5.Small children less than 30 kg require
such as fractures, contusions, shrapnel, or corneal
maintenance fluids throughout fluid resuscitation
injury.
in addition to the calculated Parkland formula
rate.
Following is a patient pretransport checklist (before
6.A maintenance solution with 5% dextrose is best
secondary triage to another healthcare facility):
to prevent rapid loss of the child’s glycogen
● Primary and secondary surveys are complete.
stores.
● All urgent issues are addressed and the patient is
hemodynamically stable.
KEEP THE PATIENT WARM ● IV fluid resuscitation is initiated.
● Patient is warm and wrapped in sufficient clean,
● The patient’s entire body should be briefly exposed
dry blankets.
to assess for burn size and depth and any
● Endotracheal tube, IV catheters, urine catheter,
concomitant injuries.
and nasogastric tube are secure and functioning.
● In skin loss, the body loses its ability to regulate
● Documentation is complete and with the patient.
body temperature.
● After the examination, it is important to keep the
patient warm using rescue blankets or dry sheets at BURN WOUND CARE
the scene and warmed IV fluids, warm blankets, and ● PRINCIPLES: Keep the wound clean, moist, and
approved body warmers at the hospital. covered.
● At the scene of a disaster, or when waiting for
EVALUATE FOR OTHER LIFE- OR LIMB-THREATENING transport to the receiving facility, it is sufficient to
INJURIES cover the burn wound with a clean, dry sheet.
● If there is an alteration in mental status, consider the
following: associated traumatic injury, carbon NOTE!
monoxide poisoning, hypoxia, intoxication, or When the patient arrives at the receiving facility:
preexisting medical conditions.
● Burned tissue can swell significantly, so all 1. First step in burn wound care is to cleanse with mild
constricting clothing and jewelry should be removed soap and warm water. Remove any debris and loose,
immediately to prevent circulatory compromise. dead skin, and pat dry.
2. A petrolatum-based ointment can be applied to wounds
○ Finger rings should be removed as soon as on the head and neck and be left uncovered. The
possible, with a ring cutter if necessary. Hand ointment will need to be reapplied throughout the day to
and finger swelling will make later removal very keep the wounds moist.
difficult. 3. Leaving the face uncovered allows better visual
assessment and permits interaction with the patient.
4. MAFENIDE ACETATE can be applied to nose and ear ELECTRICAL INJURY
burns as it is more effective on cartilaginous tissue. ● Appearance of electrical injuries can be
5. Other burn wounds can be treated with a clear topical deceiving: The surface injury may be small, but
antibacterial ointment such as BACITRACIN, followed
by a nonadherent mesh dressing and a gauze wrap to
damage below the epidermis can be significant.
secure into place. ● Many factors will influence the degree of tissue
6. SILVER SULFADIAZINE should be avoided until the damage, including type and voltage of electrical
burns are evaluated by the burn center; this cream is current, resistance, pathway of transmission in
thick and opaque, making it difficult to easily assess the the body, and duration of contact.
burn wound ● Deep conductive electrical burns, arc injuries,
surface thermal burns, associated trauma
(musculoskeletal, neurologic, etc.), cardiac
PAIN CONTROL arrhythmias, and compartment syndromes are
● Full-thickness burns tend to be less painful since the all sequelae of electrical injuries.
cutaneous nerves have been damaged or ● Arrhythmias occur with injury to the myocardium
destroyed. caused by the electric current at the moment of
● Partial-thickness burns, however, are known to injury and the resulting ischemia.
cause variable degrees and types of pain. ● Patients who sustain electrical conduction
● IV narcotics are usually required to maintain injuries are at risk for the development of
adequate pain control during wound care. compartment syndrome and may require a
● Oral and subcutaneous routes should be avoided in fasciotomy to decompress tissue
burns greater than 20% TBSA because of compartments.
decreased reliability of absorption secondary to burn ● Electrical injuries often require more extensive
shock. IV fluid resuscitation than calculated by the
Parkland formula because the visible cutaneous
CHEMICAL BURN INJURY injury is not reflective of the extent of deep tis
● CATEGORIES: [1] Alkalis, [2] Acids, [3] sue involvement.
Organics ● Dark red pigment in the urine is usually a sign
● Alkalis and acids may be found in home and of myoglobin or muscle breakdown caused by
commercial cleaning products. deep tissue injury. An indicator of adequate fluid
● Organic compounds are usually found in resuscitation is the clearance of the pigment
petroleum products. from the patient’s urine.
● ACIDS – injure by causing tissue coagulation
● ALKALIS – cause liquefaction necrosis RADIATION INJURY
● Alkali burns can be potentially more destructive ● The physical appearance of radiation burns and
to tissues than acids because liquefaction thermal burns may be the same. The difference
enables the chemical to continue penetrating between these two types of injuries lies not only
deeper into tissue. in their etiology but in the time it takes for the
● Liquid chemicals should be copiously irrigated wound to appear.
off the skin until pain symptoms subside; this ○ Thermal injury is visible almost
may take at least 30 minutes. instantaneously.
● Neutralizing agents are not recommended. ○ Radiation injury can take days to weeks to
Powdered chemicals should be brushed off appear, depending on the dose and length of
before skin irrigation begins. exposure.
● Chemical burns to the eye require continuous ● A visible injury is an indication of a high
irrigation with clean water or normal saline for at localized dose of radiation. Although the
least 15 minutes. patient’s wound may be indicative of a large
● When there is no access to running water, an radiation exposure, the patient and the wound
improvised eyewash station can be made by are not radioactive.
spiking a bag of normal saline with IV tubing, ● The use of radiation dispersal devices (RDD),
cutting the tubing, and fitting the connector end commonly referred to as “dirty bombs,” is
of a new nasal cannula oxygen tubing over the particularly concerning for disaster-planning and
IV tubing. emergency-preparedness personnel. An RDD is
● The saline will flow from the nasal prongs in two an explosive device designed to spread
streams, one for each eye. radioactive material without a nuclear explosion
● In the event of a suspected chemical injury to a (Briggs & Brinsfield, 2003).
patient, first responders and clinicians must ● The initial blast from the explosion can kill or
remember to wear appropriate personal inflict mechanical trauma on those who are
protective equipment to prevent secondary close in proximity to the explosion while the
exposure. radioactive material is dispersed.
