Burn Triage at a Major Incident

Attack One responds to a fire, alongside multiple fire units and EMS providers. This terrible event has resulted in multiple casualties from burn injuries and smoke inhalation. The Attack One crew is assigned to oversee triage. There are dozens of patients sitting or lying in front of the building, with more inside being rescued by firefighters. It is a cold, breezy night, with temperatures just below freezing.

Prehospital Care Resources

A large number of fire units are available for the incident. EMS resources are more scarce, and it will take some time to get a large number of transport ambulances to the scene. Currently, five transport ambulances are present.

Hospital Resources

The community is served by several hospitals; one, located about 15 miles from the scene, serves as a burn center. A separate hospital has a hyperbaric chamber capable of managing emergency treatment of carbon monoxide exposures.

The ABCDE Approach to Patients Presenting for Triage

Airway—Assess for patency, burn, swelling or bleeding that will compromise the patient in a short time.

Breathing—Most patients will be coughing. Assess for respiratory distress, wheezing, crouping and evidence of significant inhalation of products of combustion.

Circulation—Assess for perfusion by level of consciousness, capillary refill, diaphoretic skin, pulse, blood pressure.

Disability—Determine responsiveness, looking for compromise of brain or spinal cord.

Exposure of other major problems—Significant pain, inhalation of dangerous substances, wounds (including those threatening limbs).

Further Evaluation Needed to Determine Triage Priority

Burn incidents generally have a few critical scene considerations. Scene safety is a priority, and any continued burning must be stopped. In general, burn triage can be performed using no equipment. Partial-thickness burns produce intense pain, so the experienced provider knows that “quiet is bad.” Burn deaths are related to the degree and thickness of burn, the inhalation of toxic products, associated trauma, age and associated medical problems. Any factors that increase the risk of infection increase burn mortality. This is particularly evident in inhalation, which increases the incidence of pneumonia and death. A simple rule relates the problem of burns in the elderly: Burn mortality = age + percent of third-degree burn.

Victim considerations in a major burn incident must include those factors that will salvage the most patients in the long term. Fire incidents can produce a large number of casualties, and long-term survival is the priority. Therefore, triage personnel must first place those patients who have serious but salvageable wounds. That would include patients with moderate full-thickness burns, those with airway or breathing compromise and mild to moderate burns, and those with traumatic wounds that need rapid surgical intervention. Next come those patients with significant smoke inhalation that will produce respiratory compromise in a short time, or complications from carbon monoxide inhalation. Moderate burn patients come third; then those who have severe full-thickness burns and inhalation; those with small burns; and the walking wounded.

It may be necessary, in catastrophic incidents, to pass over certain patients until all salvageable patients have been stabilized. This is a difficult task, and fortunately has rarely been required in this country over the last 50 years. The “delayed care” patients in catastrophic incidents include those with obvious fatal injuries and burns, those with no vital signs, those in profound shock and severe burns, and those with major full-thickness burns and breathing or airway compromise. In a catastrophic incident, this does not mean “don’t treat.” These victims should be kept warm, provided comfort and pain control using resources that are not committed to caring for salvageable patients, and then removed if they are still alive when transport is available.

Organizing Patient Management

Many fire and EMS organizations use triage systems that result in patients being numbered in sequential fashion. The emergency assessment box (Figure 1) represents the results of that triage process. The crews triaged 80 patients, and categorized them by compromise of the ABCDE body systems. Eighteen patients were classified red and transported as rapidly as units were available to the hospital that serves as the burn and trauma center. Thirteen patients with suspected carbon monoxide inhalation were transported to a hospital with hyperbaric facilities. The 40 green victims were disseminated to other local hospitals. Unfortunately, the two elderly victims that were not breathing, and the seven victims with near total burns, were classified as black, and no resuscitative efforts were initiated. In overwhelming circumstances, the attempted resuscitation of those patients would compromise the care of salvageable victims, and the probable success of the resuscitation attempt is zero.

Case Assessment

The crews in this incident organized a large number of burn patients using ABCDE assessment, then burn triage. Cold temperatures made rapid transportation a priority, since burns compromise the thermal stability of the body. The moderate burns and trauma patients were removed to the trauma and burn center. Those with altered levels of consciousness were taken to the center with hyperbaric capability. The patients with breathing compromise were removed to the closest local hospitals for respiratory stabilization. If their burns were severe enough to need burn center care, they were transferred later to another regional burn center (the local burn center was at capacity with the victims taken directly to it). The fatally burned patients were also taken to the closest hospitals for supportive comfort care. Finally, the minor burns and walking wounded were removed to more distant hospitals.