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Trauma/Burn Clinical Guidelines

Trauma/Burn Clinical Guidelines A Quick Guide for the Management of Trauma/Burn Disasters for Emergency Department Personnelwww.ynhhs.org/cepdr D I S A S T E R " id="pdf-obj-0-5" src="pdf-obj-0-5.jpg">

A Quick Guide for the Management of Trauma/Burn Disasters for Emergency Department Personnel

Rev. August 2013

Trauma/Burn Clinical Guidelines A Quick Guide for the Management of Trauma/Burn Disasters for Emergency Department Personnelwww.ynhhs.org/cepdr D I S A S T E R " id="pdf-obj-0-11" src="pdf-obj-0-11.jpg">

D

I

S

A

S

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Emergency Information for Trauma/Burn Emergencies

ORGANIZATION

PHONE NUMBER

Local Police

State Police

Federal Bureau of Investigation (FBI)

Department of Homeland Security

Local Burn Center

Local Hyperbaric Chamber

Organization-Specific Contacts [see below]

 

Emergency Trauma/Burn Management Websites

ORGANIZATION

WEBSITE

American Burn Association

CDC: Explosions and Blast Injuries

CDC: Mass Casualties: Burns

US Health & Human Services: Burn Triage and Treatment - Thermal Injuries

Emergency Information for Trauma/Burn Emergencies ORGANIZATION PHONE NUMBER Local Police State Police Federal Bureau of Investigationwww.ameriburn.org/ CDC: Explosions and Blast Injuries http://emergency.cdc.gov/masscasualties/ explosions.asp CDC: Mass Casualties: Burns http://emergency.cdc.gov/masscasualties/ burns.asp US Health & Human Services: Burn Triage and Treatment - Thermal Injuries http://chemm.nlm.nih.gov/burns.htm © Yale New Haven Health System Center for Emergency Preparedness and Disaster Response. None of this publication may be reproduced or trans- mitted in any form without permission from Yale New Haven Health System Center for Emergency Preparedness and Disaster Response. Page 1 Trauma/Burn Guidelines " id="pdf-obj-1-91" src="pdf-obj-1-91.jpg">

© Yale New Haven Health System Center for Emergency Preparedness and Disaster Response. None of this publication may be reproduced or trans- mitted in any form without permission from Yale New Haven Health System Center for Emergency Preparedness and Disaster Response.

Page 1

Trauma/Burn Guidelines

Introduction:

This guide is a quick reference for the hospital’s initial response to Trauma/Burn emergencies. Based on the word DISASTER*, it facilitates the ongoing qualitative and quantitative assessment of the incident.

D

Detection

I

ICS

S

Safety/Security

A

Assessment

S

Support

T

Triage and Treatment

E

Evacuate

R

Recovery

This guide includes components of the Hospital Incident Command System (HICS) version IV and utilizes components of MASS, START and Jump START triage systems. This reference guide provides a framework for a coordinated, effective hospital response to a trauma/burn incident.

Upon initial notification of a mass casualty event, hospital staff needs to be aware that the first casualties of the

event may arrive at the hospital without transport by EMS. If a larger number of casualties are expected, the staff may need to utilize mass casualty triage methods.

Also note there may be additional hazards. If the explosion was caused by a chemical event, casualties may need to be decontaminated or a risk that a bomb was a radiological dispersion device (RDD), also known as a “dirty bomb”, See the appropriate guidelines for appropriate interventions.

* The mnemonic, D-I-S-A-S-T-E-R, is taken from the National Disaster Life Support program and is used with the gracious permission of the American Medical Association and the National Disaster Life Support Educational Foundation.

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Trauma/Burn Guidelines

 

DETECTION

 
 

Based upon information received, the hospital may need to prepare to

receive numerous multi system trauma patients. Events have shown that

there is a limited number of specialty centers e.g., critical care burn beds,

pediatric ICU beds. If transport to a higher level of care is anticipated, those

 

D – Detection

a high percentage of casualties from any mass casualty event are not seriously injured (See Appendix 1). However, those that have sustained life-

I

Incident

threatening injuries require significant resources. It should also be noted that

Command

System

facilities should be notified as soon as possible.

 

Announced event (from EMS, FD, etc):

S

Safety and

ED Nurse or Physician:

Security

 

Determines:

 
 
 

Type, time, and scope of the event Type of exposure (shrapnel, collapse, etc.) Estimated number of casualties being sent to your ED Types and severity of injuries

A – Assessment

Whether casualties may have been exposed to chemical or radiological contamination Estimated time of arrival of the first victim Whether incident directly involves people with medical dependencies including, children and the estimated number of these types of

S

Support

patients Contact information for the reporting person or agency

T – Triage and

 

Notifies the Administrator-on-Duty if a large number of casualties are

Treatment

 

anticipated

 

Directs EMS personnel to deliver casualties to designated triage area

 

Unannounced event (victim(s) appear at the Emergency Department) ED Nurse or Physician:

 

E – Evacuate

• Begins triaging and treating the victim(s) as usual

• Begins to obtain as much pertinent information as possible from the

 
 

casualties and the agency or public service answering point (PSAP) having jurisdiction where incident occurred (see above)

R – Recovery

 

• Directs all “walking wounded,” as well as worried well and victim’s

 
 

families to designated area

 
 

• Notifies Regional EMS communication center of event status and status

 

of the hospital e.g., bed availability, or ED status to accept additional patients

Appendices

Page 3

Trauma/Burn Guidelines

Upon notification or determination of a trauma/burn event affecting a

INCIDENT COMMAND SYSTEM

large number of patients:

• Activates HICS positions as needed • Activates Emergency Operations Plan (EOP) as appropriate

Incident Commander (Administrator-on-Duty)

Unit Leader Branch Director Logistics Liaison Officer Medical / Technical Specialist Cost Demobilization Service Unit Leader
Unit Leader
Branch Director
Logistics
Liaison
Officer
Medical /
Technical
Specialist
Cost
Demobilization
Service
Unit Leader
Decedent/
Expect ant
Unit Leader
Delayed
Treatment
Unit Leader
HazMat
Branch Director
Section Chief
Time
Unit Leader
Resources
Unit Leader
St aging
Manager
Medical Care
Planning
Operations
Security
Finance /
Administration
Section Chief
Section Chief
Casu alty Care
Section Chief
Time
Unit Leader
Unit Leader
Branch
Director
Triage
Unit Leader
Immediat e
Branch Director
Unit Leader
Minor
Treatment
Unit Leader
Unit Leader
Treatment
Infrastructure
Branch Director
Support
Procurement
Unit Leader
Compensation /
Claims
Incident Commander
Branch Director
Legend
Cost
Unit Leader
Public
Information
Officer
Officer
Safety
Unit Leader
Procurement
Unit Leader
Compensation/
Claims
Unit Leader
Situation
Unit Leader
Document ation
Modified from CEMSA Hospital Incident Command System (HICS) Continuity Br anch Director Activated Position Business
Modified from CEMSA Hospital Incident Command System (HICS)
Continuity
Br anch Director
Activated
Position
Business

D – Detection

Command Incident System I –
Command
Incident
System
I –
Safety and Security S –
Safety and
Security
S –

A – Assessment

Support S –
Support
S –

T – Triage and

Treatment

E – Evacuate

R – Recovery

Appendices
Appendices

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Trauma/Burn Guidelines

 

SAFETY AND SECURITY

 

Upon notification or determination of a trauma/burn event affecting a

D – Detection

large number of patients:

Security Branch Director:

I

Incident

Assesses security needs and capabilities

Command

Follows guidance from Operations Section Chief regarding possible

System

screening and visitor restriction Establishes and secure access and egress for vehicles delivering all

 
 

patients during the time of the event

S

Safety and

 

Security

 

Safety Officer:

   

Assigns a safety officer to the emergency department as necessary

 

Monitors staff use of appropriate safety and infection control procedures

A – Assessment

Monitors the transportation routes to provide safe and efficient ingress

 

and egress for vehicles bringing casualties and other personnel wishing to gain access to the ED

S

Support

   

Note:

   
 

Secondary hazards should be suspected, if the event appears to be an

 

act of terrorism

T – Triage and

 

Secondary hazards may include:

Treatment

 

Secondary explosive devices being placed at the hospital

Chemical contamination of the victims

 

Refer to Chemical Clinical Guidelines if suspected

– Radiological contamination of the victims Refer to Radiation Clinical Guidelines if suspected

E – Evacuate

 

R – Recovery

Appendices

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Trauma/Burn Guidelines

 

ASSESSMENT

   

Upon notification or determination of a trauma/burn event affecting a

D – Detection

large number of patients:

Medical/Technical Specialist (Trauma Chief or Critical Care Chief):

I

 
 

Incident

 

• Provides guidance to the Incident Commander and Operations Section

Chief regarding:

 

Command

System

 

– Appropriate methods of treating casualties based on their severity – Assesses and ensures necessary resources

 

• Number of casualties needing immediate surgery or other

S

 

treatments

Safety and

• Number of casualties that could have delayed surgery or other

 

Security

treatments

 

• Number of pediatric casualties (See Appendix 2) • Determines the need to cancel elective surgeries; early transfer

 

of critical care patients, and/or early patient discharge to increase bed availability for trauma/burn casualties

A – Assessment

• Determines criteria for transferring casualties to other facilities

 

(trauma centers, burn centers, pediatric centers, etc.)

 

S

 
 

Other Medical/Technical Specialists may be required if additional hazards are suspected.

 

Support

Toxicologist if chemical contamination is suspected

 

Radiation Safety Officer if radiation exposure or contamination is

T – Triage and

 

suspected

Treatment

 

Operations Section Chief:

 
 

Shares information and plans with Branch and Unit Leaders to assure

 

emergency treatment plans and victim dispositions are properly implemented

E – Evacuate

 

Casualty Care Unit Leader:

   

Assesses ongoing patient needs and capacities and reports to Medical Care Branch Director

R – Recovery

Assesses ongoing resource needs including trauma/burn specific

 

resources and reports to Operations Section Chief

 

Assesses need for additional bed capacity due to patient surge and reports to Operations Section Chief

Appendices

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Trauma/Burn Guidelines

SUPPORT

   

Upon notification or determination of a trauma/burn event affecting a

D – Detection

large number of patients:

   

Incident Commander:

I

Incident

• Considers need to activate Emergency Operations Plan

 

Command

• Notifies senior hospital leadership of the situation • Activates HICS positions as indicated • Establishes operational periods and the schedule for briefings

 

System

 

S

Safety and

Casualty Care Unit Leader:

 

Security

• Maintains contact with the regional EMS communication centers • Ensures appropriate control procedures are followed by all staff, patients and visitors Establishes area(s) for the cohort of patients based on triage levels

A – Assessment

Inpatient Unit Leader:

   

Assures continued care for inpatients Manages the inpatient care areas Provides for early patient discharge, if indicated Facilitates rapid admission of casualties to appropriate care areas

S

Support

Logistic Section Chief:

T – Triage and

• Ensures an adequate supply of all resources necessary for patient care

Treatment

activities

   

NOTES:

 

E – Evacuate

R – Recovery

Appendices

     

Page 7

Trauma/Burn Guidelines

 

TRIAGE AND TREATMENT

 

Upon notification or determination of a trauma/burn event affecting a

D – Detection

large number of patients:

Operations Section Chief:

I

Incident

Shares information and plans with Branch and Unit Leaders to assure

Command

 

emergency treatment plans and victim dispositions are properly and

System

completely implemented

 
 

Casualty Care Unit Leader:

S

Safety and

Uses established triage guidelines (See Appendix 3 and 4)

before decontamination, including:

Security

Prioritizes patients according to severity of injury

 

Ensures that casualties with immediate life-threatening injuries receive

 
 

life-saving treatment to stabilize the casualties as needed according to the principles of ABLS, ACLS, ADLS, AHLS, ATLS, PALS, and/or APLS

A – Assessment

Maintains C-spine precautions, if appropriate Secures airway, provides ventilation with 100% oxygen IV fluid resuscitation Assesses and treats burn casualties according to the principles of Advanced Burn Life Support (See Appendix 5 and 6)

S

Support

Assesses and treats traumatic injuries including blast injuries (See Appendix 7) and/or crush injury/compartment syndrome (See Appendix 8)

T – Triage and Treatment

 

Establishes area(s) for the cohort of patients based on triage levels

Inpatient Unit Leader:

 

Assures continued care for inpatients Burn injuries (See Appendix 5 and 6)

E – Evacuate

Blast injuries (See Appendix 7) Crush injury/compartment syndrome (See Appendix 8) Manages the inpatient care areas

 

Provides for early patient discharge, if indicated

R – Recovery

Promotes rapid admission of casualties to appropriate care areas

 

Appendices

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Trauma/Burn Guidelines

 

EVACUATE

 

Upon notification or determination of a trauma/burn event affecting a

D – Detection

large number of patients:

Casualty Care Unit Leader:

I

Incident

• In consultation with the senior emergency department physican:

Command

– Prepares the ED by making prompt disposition decisions: discharge

System

to home, or admission to hospital – Implements internal surge plans as necessary – Transfers to a higher level of care or to another facility for continued

S

Safety and

care (e.g., pediatric intensive care, burn center or rehabilitation facility)

Security

Inpatient Unit Leader:

 

• In consultation with Medical Care Branch Director:

A – Assessment

– Prepares the various inpatient units by making prompt disposition

decisions: early discharge, cancellation of elective procedures, in accordance with internal surge plans – Ensures secondary distribution to another facility for continued care (e.g., pediatrics, burn casualties, long-term care patients

S

Support

   
 

Potential For emergency evacuation oF the emergency DePartment

T – Triage and Treatment

Secondary hazards should be suspected, if the event appears to be an act of terrorism

 

Secondary hazards may include:

E – Evacuate

• Secondary explosive devices being placed in or around the hospital

 

• Chemical contamination of the victims

– Refer to chemical clinical guidelines if suspected

R – Recovery

• Radiological contamination of the victims

– Refer to radiation clinical guidelines if suspected

 
 

Appendices

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Trauma/Burn Guidelines

RECOVERY

   

Upon notification or determination of a trauma/burn event affecting a

D – Detection

large number of patients:

   

Behavioral Health Unit Leader:

I

Incident

• Aids recovery by addressing the behavioral health needs of patients,

 

Command

visitors and healthcare personnel

 

System

• If needed, enlists the services of:

– Social Services Department

   

– Pastoral Care department

S

Safety and

– Department of Psychiatry

 

Security

– Child Life Specialists – Employee Assistance Services – Other, outside behavioral health services

A – Assessment

Casualty Care Unit Leader:

   

• Monitors staff for signs/symptoms of injury • Relieves staff showing signs of excessive fatigue or stress • Monitors triage and treatment area staffing patterns and adjust

S

Support

according to anticipated needs

   

• Has all unneeded equipment cleaned and returned to the staging area,

   

or returned to its original location

   

• Returns all unused supplies to staging or to their original location

T – Triage and Treatment

NOTES:

   

E – Evacuate

R – Recovery

Appendices

     

Page 10

Trauma/Burn Guidelines

 

D – Detection

I

Incident

Command

System

S

Safety and

Appendices

Security

Appendix 1: Event Characteristics and Anticipated Impact on Hospitals

A – Assessment

Appendix 2: Principles of Care of Children from MCI Incident Resulting in Traumatic/Burn Injuries

 

Appendix 3: Mass Casualty Triage Tags Appendix 4: Mass Triage Systems Appendix 5: General Burn Guidelines

S

Support

Appendix 6: Burn Care and Treatment Appendix 7: Blast Injuries Care and Treatment Appendix 8: Crush Injury/Compartment Syndrome Care and Treatment

T – Triage and Treatment

Appendix 9: Abbreviations

E – Evacuate

R – Recovery

Appendices

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Trauma/Burn Guidelines

Appendix 1: Event Characteristics and Anticipated Impact on Hospitals

 

Injury severity

Variable – more minor and more serious injuries

in severity

in severity

in severity

in severity

   

Anticipated impact

Injury frequency

minor injuries “worried well”

Variable

Primary blast injury, traumatic amputations,

flash burns

Secondary blast injury

 

Primary blast injury, amputations, burns

Number of injured survivors seeking

emergency care at nearby hospitals

May produce 100s to 1,000s of injured survivors

number of injured survivors

May produce up to 200 injured survivors, many with minor injuries

 

Usually produces < 100 injured survivors

 

Appendix 1

 

Implication

number of injured survivors will arrive at ED without EMS transport

EMS transport time to hospital explosive magnitude, structural collapse possible

immediate deaths close to detonation point or inside collapse

distance between potential victims and detonation point

number at risk

Blast energy dissipated, but spread over greater area, structural collapse

unlikely

number of immediate deaths

Blast energy potentiated, but contained in lesser area number of immediate deaths inside space

number of injured exposed to blast effects

effects in smaller space (e.g., bus)

 

Event characteristic

Event near hospital

Vehicle delivery system in explosions

Pre-explosion or pre-collapse evacuation

Open-air explosions

Confined space

explosions

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Trauma/Burn Guidelines

Appendix 2: Principles of Care of Children from MCI Incident Resulting in Traumatic/Burn Injuries

 

No widely utilized system for rapid triage of children in MCIs. Jump START is the most widely known Children and their parents should not be separated during triage. (Injured children should be reunited with responsible parent or caregiver as soon as possible, since anxiety exacerbated by separation from parents or caregivers often confounds their evaluation.) Children have incompletely developed motor skills and cognition. (Therefore, they may not be able to escape site of an incident and may not be able to follow directions.) Injured children should be managed according to the general principles of PALS and ATLS.

Injured children are at higher risk for hypothermia, with significantly greater thermo-regulatory problems in younger

children. With smaller circulating blood volume, (despite greater tolerance of volume loss per kilogram), decomposition

into shock may be more rapid and more difficult to reverse.

Airway is smaller, increasing risk of airway edema. Children are at greater risk of head injury because of disproportionately larger head size.

Head injury severity is the main determinant of a pediatric patient’s outcome.

Cervical spine and spinal cord injuries are less common in children because of greater flexibility and mobility.

(Conversely, spinal cord injuries in the absence of radiographic abnormalities are more likely to be present.) Damage to internal organs is greater due to increased chest wall compliance and greater transfer of energy to internal

organs, while rib fractures and flail chest are relatively uncommon. (If rib fractures are present, there is a much greater

risk of intrathoracic injuries.)

Greater risk of psychological trauma. Children’s’ reactions to situations vary, and depend on a child’s developmental level (cognitive, physical, educational and social).

Child’s behavior may depend on emotional state of caretakers. Behavior may appear oppositional, based on cognitive ability and fear. Behavioral healthcare should include age-appropriate interventions. Long-term psychological impacts and behavioral disturbances may occur.

 

Appendix 2

   
 

General Principles

Trauma/Burn

Behavioral Health

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Trauma/Burn Guidelines

Appendix 3: Mass Casualty Triage Tags

Mass Casualty Triage Tag A

FRONT BACK
FRONT
BACK

Page 14

Trauma/Burn Guidelines

Appendix 3: Mass Casualty Triage Tags

Mass Casualty Triage Tag B

FRONT BACK
FRONT
BACK

Page 15

Trauma/Burn Guidelines

Appendix 3: Mass Casualty Triage Tags

SMART Triage Tag System

Appendix 3: Mass Casualty Triage Tags SMART Triage Tag System Page 16 Trauma/Burn Guidelines

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Trauma/Burn Guidelines

Appendix 4: Mass Triage Systems

START Adult Triage System

Appendix 4: Mass Triage Systems START Adult Triage System Adapted from http://www.start-triage.com/ Page 17 Trauma/Burn Guidelines

Adapted from http://www.start-triage.com/

Appendix 4: Mass Triage Systems START Adult Triage System Adapted from http://www.start-triage.com/ Page 17 Trauma/Burn Guidelines

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Trauma/Burn Guidelines

Appendix 4: Mass Triage Systems

JumpSTART Pediatric Triage System

Appendix 4: Mass Triage Systems JumpSTART Pediatric Triage System Adapted from <a href=http://www.jumpstarttriage.com/ Page 18 Trauma/Burn Guidelines " id="pdf-obj-18-6" src="pdf-obj-18-6.jpg">
Appendix 4: Mass Triage Systems JumpSTART Pediatric Triage System Adapted from <a href=http://www.jumpstarttriage.com/ Page 18 Trauma/Burn Guidelines " id="pdf-obj-18-11" src="pdf-obj-18-11.jpg">

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Trauma/Burn Guidelines

Appendix 5: General Burn Guidelines

     

Burn Severity

Percent of total body surface

Burns >20-25% TBSA require IV fluid resuscitation

area (TBSA) involvement

Burns >30-40% TBSA may be fatal without treatment.

  • - In adults: “Rule of Nines” is used as a rough indicator of % TBSA (See chart)

  • - In children, adjust percents because they have proportionally larger heads (up to 20%) and smaller legs (13% in infants) than adults (See chart) Lund-Browder diagrams improve the accuracy of the

% TBSA for children. Palmar hand surface is approximately 1% TBSA

Depth of Burn Injury

Superficial Burns

First-degree burns

Damage above basal layer of epidermis

Dry, red, painful (“sunburn”)

Second-degree burns

Damage into dermis

Skin adnexa (hair follicles, oil glands, etc,) remain

Heal by re-epithelialization from skin adnexa

Moist, red, blanching, blisters, extremely painful

Superficial burns heal by re-epithelialization and

usually do not scar if healed within 2 weeks

Deep Burns

Deep second-degree burns (deep partial-thickness)

[Deep burns usually need skin

grafts to optimize results and

lead to hypertrophic (raised)

scars if not grafted]

Damage to deeper dermis

Less moist, less blanching, less pain

Heal by scar deposition, contraction and limited re-

epithelialization

 

Third-degree burns (full-thickness)

Entire thickness of skin destroyed (into fat)

Fourth-degree burns

Any color (white, black, red, brown), dry, less painful

(dermal plexus of nerves destroyed) Heal by contraction and scar deposition (no epithelium

left in middle of wound)

Burn into muscle, tendon, bone

Need specialized care (grafts will not work)

Factors Increasing

Age

Mortality for any given burn size increases with age

Morbidity and Mortality

Children/young adults can survive massive burns

 

Children require more fluid per TBSA burns

Elderly may die from small (<15% TBSA) burns

Smoke Inhalation Injury

Smoke inhalation injury doubles the mortality relative to burn size

Associated Injuries

Other trauma increases severity of injury

Delay in Resuscitation

Delay increases fluid requirements

Other factors increasing

Need for escharotomies and fasciotomies

morbidity and mortality

Excessive use of alcohol or drugs

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Trauma/Burn Guidelines

Appendix 5: Rule of Nines

A
A

Head and neck - 9%

Trunk

Anterior 18%

Posterior 18%

Arm - 9% (each)

Genitalia and Perineum - 1%

Leg - 18% (each)

B

Anterior 1 2 13 2 1 ¾ 1 ½ 1 ½ 1 ½ 1 ½ b
Anterior
1
2
13
2
1 ¾
1 ½
1 ½
1 ½
1 ½
b
b
c
c
a
1

1 ½

1 ½

1 ½ 1 ½ 1 ¾ a 1 2 13 2 2 ½ 2 ½ b
1 ½
1 ½
1 ¾
a
1
2
13
2
2 ½
2 ½
b
b
c
c

Posterior

Relative percentage of body surface area (%BSA) affected by growth

 

Age

Body Part

0 yr

1 yr

5yr

10yr

15 yr

a= 1/2 of head

9 ½

8 ½

6 ½

5 ½

4 ½

b = 1/2 of 1 thigh

2 ¾

3 ¼

4

4 ¼

4 ½

c = 1/2 of 1 lower leg

2 ½

2 ½

2 ¾

3

3 ¼

Provided by:

http://www.merckmanuals.com/professional/injuries_poisoning/burns/burns.html?qt=rule%20of%20nines&alt=sh

(Redrawn from Artz CP, JA Moncrief: The Treatment of Burns, ed. 2. Philadelphia, WB Saunders Company, 1969)

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Trauma/Burn Guidelines

Appendix 6: Burn Care and Treatment

Primary Burn Care and Treatment

 

Airway

Extensive burns may lead to massive edema

  • - Hoarseness or change in voice

Obstruction may result from upper airway swelling

 

Signs of airway obstruction

  • - Use of accessory respiratory muscles

  • - High anxiety

Risk of upper airway obstruction increases with

  • - Massive burns

  • - All patients with deep burns (>35-40% TBSA should be endotracheally intubated )

  • - Burns to the head

  • - Burns inside the mouth

Intubate early if massive burn or signs of obstruction

  • - Intubate if patients require prolonged transport and/or any concern with potential for obstruction

  • - If any concerns about the airway, it is safer to intubate earlier than when the patient begins to decompensate Tracheotomies not needed during resuscitation period

Breathing

Carbon Monoxide (CO)

 

Pathophysiology

 
  • - Byproduct of incomplete combustion

  • - Binds hemoglobin with 200 times the affinity of oxygen

  • - Leads to inadequate oxygenation

Diagnosis

 
 
  • - PaO 2 (partial pressure of O 2 dissolved in serum)

  • - Oximeter (difference in oxy- and deoxyhemoglobin)

  • - Carboxyhemoglobin levels

• <10% is normal • >40% is severe intoxication

Treatment

 
 
  • - Remove source

  • - 100% oxygen until CO levels are <10%

  • - Consider hyperbaric therapy

Smoke Inhalation Injury

 

Pathophysiology

 
  • - Smoke particles settle in distal bronchioles

  • - Sloughing

  • - Distal atelectasis

  • - Increase risk for pneumonia

Diagnosis

 
 
  • - History of being in a smoke-filled enclosed space

  • - Early chest x-ray

  • - Early blood gases

  • - Bronchoscopy

• Soot in sputum or saliva

• Singed facial hair • Soot beneath the glottis

• Airway edema, erythema, ulceration • Treatment

 
 
  • - Supportive pulmonary management (including intubation)

  • - Aggressive respiratory therapy

  • - IV Steroids

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Trauma/Burn Guidelines

Appendix 6: Burn Care and Treatment (continued)

Primary Burn Care and Treatment

 

Circulation

Obtain IV access anywhere possible

  • - Unburned areas preferred

  • - Burned areas acceptable

  • - Central access more reliable

Fluid Resuscitation (first 24 hours) (see Parkland Formula below)

  • - Massive capillary leak occurs after major burns

  • - Fluids shift from intravascular space to interstitial space

  • - IV fluid rate dependent on physiologic response

Place Foley catheter to monitor urine output

Goal for adults: urine output of 0.5 ml/kg/hour

Goal for children: urine output of 1 ml/kg/hour

If urine output below these levels, increase fluid rate

Preferred fluid: Lactated Ringer’s Solution

  • - Isotonic

  • - Inexpensive

  • - Easily stored

 

Parkland Formula

IV fluid

Lactated Ringer’s Solution

Fluid calculation:

4 x weight in kg x %TBSA burn

Give 1/2 of that volume in the first 8 hours

Give other 1/2 over next 16 hours

Warning: Despite the formula suggesting cutting the fluid rate in half at 8 hours, the fluid rate should be gradually reduced throughout the resuscitation to maintain the targeted urine output,( e.g., do not

follow the second part of the formula that says to reduce the rate at 8 hours, adjust the rate based on

the urine output).

Example of Fluid Calculation 100-kg man with 80% TBSA burn

 

Parkland formula:

4 x 100 x 80 = 32,000 ml

Give 1/2 in first 8 hours = 16,000 ml in first 8 hours

Starting rate = 2,000 ml/hour

Resuscitation formulas are just a guide for initiating resuscitation

  • - Adjust fluid rate to maintain urine output of 50 ml/hr for adults

Albumin may be added toward end of 24 hours if not adequate response

When maintenance rate is reached (approximately 24 hours), change fluids to D5/.5 NS with 20 mEq KCl at maintenance fluid rate (see below)

  • - Maintenance fluid rate Adult maintenance fluid rate: 1500cc x total body surface area (TBSA) (for 24 hrs)

Pediatric maintenance fluid rate: May use 100 ml/kg for 1st 10 kg; 50 ml/kg for 2nd 10 kg; 20 ml/kg for remaining kg for 24 hrs

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Trauma/Burn Guidelines

Appendix 6: Burn Care and Treatment (continued)

Complications of Over-Resuscitation

 

Compartment

Limb Compartment Syndrome

Syndrome

  • - Symptoms of severe pain (worse with movement), numbness, cool extremity, tight feeling

(Transfer to

compartments

Verified Burn

  • - Distal pulses will be lost when the compartment pressure exceeds the systolic blood pressure

Center*, if

  • - Compartment pressure >30 mmHg may compromise muscle/nerves

possible)

  • - Measure compartment pressures with arterial line monitor (place needle into compartment)

  • - Escharotomies may save limbs

Performed laterally and medially throughout entire limb

  • - Fasciotomies may be needed if pressure does not drop to <30 mmHg

Performed with arms supinated

Hemostasis is required

Requires surgical expertise

 

Hemostasis is required

Chest Compartment Syndrome

  • - Increased peak inspiratory pressure (PIP) due to circumferential trunk burns

  • - Escharotomies through mid-axillary line, horizontally across chest/abdominal junction Abdominal Compartment Syndrome

  • - Pressure in peritoneal cavity > 30 mmHg

Measure through Foley catheter

  • - Signs: increased peak inspiratory pressure (PIP), decreased urine output despite massive

fluids, hemodynamic instability, tight abdomen

  • - Treatment Abdominal escharotomy

 

NG tube

Possible placement of peritoneal catheter to drain fluid

Laparotomy as last resort

Acute

Increased risk if fluid resuscitation to aggressive

Respiratory

Supportive treatment

Distress

 

Syndrome

(ARDS)

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Trauma/Burn Guidelines

Appendix 6: Burn Care and Treatment (continued)

Secondary Burn Care and Treatment

 

Wound Care

During initial or emergent care, wound care is of secondary importance

Acute

Advanced Burn Life Support recommendations

Respiratory

  • - Cover wound with clean, dry sheet or dressing. NO MOIST DRESSINGS if TBSA> 10%, pt will

Distress

become hypothermic

Syndrome

Sterile dressings are preferred but not necessary

(ARDS)

Covering wounds decreases pain

Elevate burned extremities

  • - Maintain patient’s body temperature (keep patient warm)

While cooling may make a small wound more comfortable, cooling any wound >10% TBSA may cause hypothermia If providing prolonged care

  • - Wash wounds with soap and water (sterility is not necessary)

  • - Maintain body temperature

 
  • - Topical antimicrobials help prevent infection but do not eliminate bacteria

Silver sulfadiazine for deep burns

Bacitracin and nonstick dressings for more superficial burns

Skin grafting

 
  • - Deep burns require skin grafting

  • - Grafting may not be necessary for days

  • - Preferable to refer patients with need for grafting to Verified Burn Center* or, if not available,

others trained in surgical techniques

 

Grafting of extensive areas may require significant amounts of blood

Patient’s temperature must be watched

Anesthesia requires extra attention

Medications

 
  • - All pain medication should be given IV

  • - Tetanus prophylaxis should be given as appropriate

  • - Prophylactic antibiotics are contraindicated Systemic antibiotics are only given to treat infections

Special Burn

Electrical injuries

 

Considerations

  • - Extent of injury may not be apparent

(often require

Damage occurs deep within tissues

specialized

Damage frequently progresses

care, transfer

Electricity contracts muscles, so watch for associated fractures and tissue injury

to Verified

  • - Cardiac arrhythmias may occur

 

Burn Center* if

All patients with electrical burns need cardiac monitoring

possible)

  • - Myoglobinuria may be present

 

Color best indicator of severity

If urine is dark (black, red), myoglobinuria needs to be treated

  • - Increase fluids to induce urine output of 75-100 ml/hr in adults

  • - In children, target urine output of 2 ml/kg/hour

  • - Alkalinize urine (give NaHCO3)

  • - Mannitol as last resort

  • - Compartment syndromes are common

 
  • - Long-term neuro-psychiatric problems may result

Chemical Burns

 
  • - Decontamination as advised (per hazard risk assessment)

  • - Prolonged irrigation may be required

 
  • - Do not seek antidote

 

Delays treatment May result in heat production

  • - Special chemical burns require contacting a Poison Control Center and/or Verified Burn

Center*, for example: Hydrofluoric acid burn

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Trauma/Burn Guidelines

Appendix 6: Burn Care and Treatment (continued)

*American Burn Association Burn Unit Referral Criteria

  • 1. Second- and third-degree burns greater than 10% TBSA in patients under 10 or over 50 years of age

  • 2. Second- and third-degree burns greater than 20% TBSA in other age groups

  • 3. Second- and third-degree burns that involve the face, hands, feet, genitalia, perineum and major joints

  • 4. Third-degree burns greater than 5% TBSA in any age group

  • 5. Electrical burns, including lightning injury

  • 6. Chemical burns

  • 7. Inhalation injury

  • 8. Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery or

affect mortality (e.g., significant radiation exposure)

  • 9. Any patients with burns and concomitant trauma (e.g., fractures, blast injury) where burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be treated initially in a trauma center until stable before being transferred to a burn center. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols appropriate for the incident

  • 10. Hospitals without qualified personnel or equipment for the care of children should transfer children with burns to a

Burn Center with these capabilities

  • 11. Burn injury in children who will require special social/emotional and/or long-term rehabilitative support, including cases involving suspected child or substance abuse

Note: Criteria not established for very large mass casualty incidents (MCI)

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Trauma/Burn Guidelines

Appendix 7: Blast Injuries Care and Treatment

Pearls for Clinical Practice

 

Wound Care

Expect an “upside-down” triage - the most severely injured arrive after the less injured, who by-

Acute

pass EMS triage and go directly to the closest hospitals

Respiratory

If structural collapse occurs, expect increased severity and delayed arrival of casualties

Distress

Clinical signs of blast-related abdominal injuries can be initially silent until signs of acute

Syndrome

abdomen or sepsis are advanced.

(ARDS)

Standard penetrating and blunt trauma to any body surface is the most common injury seen among survivors. Primary blast lung and blast abdomen are associated with a high mortality rate. “Blast Lung” is the most common fatal injury among initial survivors

Isolated tympanic membrane rupture is not a marker of morbidity; however, traumatic amputation

of any limb is a marker for multi-system injuries. Air embolism is common, and can present as stroke, MI, acute abdomen, blindness, deafness, spinal cord injury, or claudication. Hyperbaric oxygen therapy may be effective in some cases

Determinants of Injury from Blasts

 
  • - Size of the explosion – larger blasts create a larger pressure differential which cause injury and structural damage

  • - The initial pressure wave from a high energy explosive is a sharp overpressure, followed by a slight negative pressure before returning to baseline

  • - Distance from the blast – the further the victim from the center of the blast, the less injury they might experience

  • - Protection – solid walls can provide protection from the pressure wave, shrapnel, and heat

If the victim is in front of the wall, the pressure wave will hit them in the front, bounce off

  • - Casualties may have increased chances of survival if they are in an open field, rather than

the wall and hit them again in the back If in a corner of two walls, the pressure wave may hit the victim three times

being in a confined room

  • - Body armor may increase the amount of trauma to lungs

 

Category

 

Characteristics

Body Parts Affected

Types of Injuries

Primary

 

Results from the impact of the

Gas filled structures are most

Blast lung (pulmonary

over-pressurization wave with

susceptible

barotrauma)

body surfaces.

Lungs

TM rupture and middle ear

 

GI tract

damage

Middle ear

Abdominal hemorrhage and

 

perforation Globe (eye) rupture

Concussion (TBI without physical signs of head injury)

Secondary

 

Results from flying debris and

Any body part may be affected.

Penetrating ballistic

bomb fragments.

(fragmentation)

 

Blunt injuries

Eye penetration (may be occult)

Tertiary

 

Results from individuals being

Any body part may be affected.

Fracture

thrown by the blast wind.

Traumatic amputation

     

Closed and open brain injury

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Trauma/Burn Guidelines

Appendix 7: Blast Injuries Care and Treatment (continued)

Category

Characteristics

Body Parts Affected

Types of Injuries

Quaternary

All explosion-related

Any body part may be affected.

Burns (flash, partial and full

injuries, illnesses, or diseases not due to

thickness) Crush injuries

primary, secondary or tertiary mechanisms.

Closed and open brain injury

Includes exacerbation or

Asthma, COPD, or other

complications of existing conditions.

breathing problems from dust, smoke or toxic fumes Angina

 

Hyperglycemia

Hypertension

Note: Up to 10% of blast survivors have significant eye injuries.

 

Selected Blast Injuries

 

Lung Injury

 

“Blast lung” is a direct consequence of the over-pressurization wave. It is the most common fatal primary blast injury among initial survivors. Signs of blast lung are usually present at the time of initial evaluation, but they have been

reported as late as 48 hours after the explosion. Blast lung is characterized by the clinical triad of apnea, bradycardia,

and hypotension. Pulmonary injuries vary from scattered petechiae to confluent hemorrhages. Blast lung should be

suspected for anyone with dyspnea, cough, hemoptysis or chest pain following blast exposure. Blast lung produces

a characteristic “butterfly” pattern on chest X-ray. A chest X-ray is recommended for all exposed persons and a

prophylactic chest tube (thoracostomy) is recommended before general anesthesia or air transport is indicated if blast lung is suspected.

Clinical Presentation

 
  • - Symptoms may include dyspnea, hemoptysis, cough, and chest pain

 
  • - Signs may include tachypnea, hypoxia, cyanosis, apnea, wheezing, decreased breath sounds and hemodynamic instability

  • - Associated pathology may include bronchopleural fistula, air emboli, and hemothoraces or pneumothoraces

  • - Other injuries may be present

 

Diagnostic Evaluation

  • - Chest radiography is necessary for anyone who is exposed to a blast. A characteristic “butterfly” pattern may be

revealed upon X-ray

 
  • - Arterial blood gases, computerized tomography, and Doppler technology may be used

 
  • - Most laboratory and diagnostic testing can be conducted per resuscitation protocols and further directed based

upon the nature of the explosion (e.g., confined space, fire, prolonged entrapment or extrication, suspected

chemical or biologic event, etc.)

 

Management

  • - Initial triage, trauma resuscitation, treatment, and transfer should follow standard protocols; however some

diagnostic or therapeutic options may be limited in a disaster or mass casualty situation

 
  • - In general, managing blast lung injury is similar to caring for pulmonary contusion, which requires judicious fluid

use and administration ensuring tissue perfusion without volume overload

 

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Trauma/Burn Guidelines

Appendix 7: Blast Injuries Care and Treatment (continued)

 

Selected Blast Injuries

 

Lung Injury

Clinical Interventions

  • - All patients with suspected or confirmed BLI should receive supplemental high flow oxygen sufficient to prevent

hypoxemia (delivery may include non-rebreather masks, continuous positive airway pressure or endotracheal intubation)

  • - Impending airway compromise, secondary edema, injury, or massive hemoptysis requires immediate intervention

to secure the airway. Patients with massive hemoptysis or significant air leaks may benefit from selective

bronchus intubation

  • - Clinical evidence of or suspicion for a hemothorax or pneumothorax warrants prompt decompression.

  • - If ventilatory failure is imminent or occurs, patients should be intubated; however, caution should be used in

the decision to intubate patients, as mechanical ventilation and positive end pressure may increase the risk of alveolar rupture and air embolism

  • - High flow oxygen should be administered if air embolism is suspected, and the patient should be placed in prone,

semi-left lateral or left lateral positions. Patients treated for air emboli should be transferred to a hyperbaric chamber

 

Ear Injury

Primary blast injuries of the auditory system cause significant morbidity, but are easily overlooked. Injury is dependent

on the orientation of the ear to the blast. TM perforation is the most common injury to the middle ear.

Clinical Presentation

  • - Signs of ear injury are usually present at time of initial evaluation and should be suspected for anyone presenting with:

Hearing loss Tinnitus Otalgia Vertigo Bleeding from the external canal Tympanic membrane rupture Mucopurulent otorhea Clinical Interventions

  • - All patients exposed to blast should have an otologic assessment and audiometry

 

Abdominal Injury

Gas-containing sections of the GI tract are most vulnerable to primary blast effect. This can cause immediate bowel

perforation, hemorrhage (ranging from small petechiae to large hematomas), mesenteric shear injuries, solid organ lacerations, and testicular rupture.

Clinical Presentation

  • - Blast abdominal injury should be suspected in anyone exposed to an explosion with:

Abdominal pain Nausea, vomiting Hematemesis Rectal pain Testicular pain Unexplained hypovolemia • Any findings suggestive of an acute abdomen • Clinical findings may be absent until the onset of complications

 

Brain Injury

Primary blast waves can cause concussions or mild traumatic brain injury (MTBI) without a direct blow to the head. Consider the proximity of the victim to the blast particularly when given complaints of headache, fatigue, poor concentration, lethargy, depression, anxiety or insomnia. The symptoms of concussion and post traumatic stress disorder can be similar.

Modified from: CDC, Blast and bombing injuries: Fact sheet for professionals booklet,

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Trauma/Burn Guidelines

Appendix 8: Crush Injury/Compartment Syndrome Care and Treatment

 

Background

Crush injury and crush syndrome may result from structural collapse after a bombing or explosion. Crush injury is

defined as compression of extremities or other parts of the body that causes muscle swelling and/or neurological

disturbances in the affected areas of the body. Typically affected areas of the body include lower extremities (74%),

upper extremities (10%), and trunk (9%). Crush syndrome is localized crush injury with systemic manifestations. These

systemic effects are caused by a traumatic rhabdomyolysis (muscle breakdown) and the release of potentially toxic muscle cell components and electrolytes into the circulatory system. Crush syndrome can cause local tissue injury, organ dysfunction, and metabolic abnormalities, including acidosis, hyperkalemia and hypocalcemia.

Previous experience with earthquakes that caused major structural damage has demonstrated that the incidence of crush syndrome is 2-15% with approximately 50% of those with crush syndrome developing acute renal failure and over 50% needing fasciotomy. Of those with renal failure, 50% need dialysis.

 

Clinical Presentation

Sudden release of a crushed extremity may result in reperfusion syndrome—acute hypovolemia and metabolic abnormalities. This condition may cause lethal cardiac arrhythmias. Further, the sudden release of toxins from necrotic muscle into the circulatory system leads to myoglobinuria, which causes renal failure if untreated.

Hypotension

  • - Massive third spacing occurs, requiring considerable fluid replacement in the first 24 hours; Patients may sequester (third space) more than 12 L of fluid in the crushed area over a 48-hour period

  • - Third spacing may lead to secondary complications such as compartment syndrome, which is swelling within a

closed anatomical space; compartment syndrome often requires fasciotomy

  • - Hypotension may also contribute to renal failure

Renal Failure

  • - Rhabdomyolysis releases myoglobin, potassium, phosphorous, and creatinine into the circulation

  • - Myoglobinuria may result in renal tubular necrosis if untreated

  • - Release of electrolytes from ischemic muscles causes metabolic abnormalities

Metabolic Abnormalities

  • - Calcium flows into muscle cells through leaky membranes, causing systemic hypocalcemia

  • - Potassium is released from ischemic muscle into systemic circulation, causing hyperkalemia

  • - Lactic acid is released from ischemic muscle into systemic circulation, causing metabolic acidosis

  • - Imbalance of potassium and calcium may cause life-threatening cardiac arrhythmias, including cardiac arrest;

metabolic acidosis may exacerbate this situation

Secondary Complications

  • - Compartment syndrome may occur, which will further worsen vascular compromise (however, crush syndrome can occur in crush scenarios of less than 1 hour)

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Trauma/Burn Guidelines

Appendix 8: Crush Injury/Compartment Syndrome Care and Treatment (continued)

 

Initial Management

Sudden release of a crushed extremity may result in reperfusion syndrome—acute hypovolemia and metabolic abnormalities. This condition may cause lethal cardiac arrhythmias. Further, the sudden release of toxins from necrotic muscle into the circulatory system leads to myoglobinuria, which causes renal failure if untreated.

Hypotension

 

-

Massive third spacing occurs, requiring considerable fluid replacement in the first 24 hours; Patients may sequester (third space) more than 12 L of fluid in the crushed area over a 48-hour period

-

Third spacing may lead to secondary complications such as compartment syndrome, which is swelling within a

 

closed anatomical space; compartment syndrome often requires fasciotomy

 

-

Hypotension may also contribute to renal failure

Hypotension

 

-

Initiate (or continue) IV hydration—up to 1.5 L/hour

Renal Failure

 

-

Prevent renal failure with appropriate hydration, using IV fluids and mannitol to maintain diuresis of at least

 

300 cc/hr

 

-

Triage to hemodialysis as needed

Metabolic Abnormalities

-

Acidosis: Alkalinization of urine is critical; administer IV sodium bicarbonate until urine pH reaches 6.5 to prevent

 

myoglobin and uric acid deposition in kidneys

 

-

Hyperkalemia/Hypocalcemia: Consider administering the following (adult doses): calcium gluconate 10% 10cc or

 

calcium chloride 10% 5cc IV over 2 minutes; sodium bicarbonate 1 meq/kg IV slow push; regular insulin 5-10 U

and D5O 1-2 ampules IV bolus; kayexalate 25-50g with sorbitol 20% 100mL PO or PR

Cardiac Arrhythmias

 

-

Monitor for cardiac arrhythmias and cardiac arrest, and treat accordingly

 

Secondary Complications

Monitor casualties for compartment syndrome; monitor compartmental pressure if equipment is available; consider

emergency fasciotomy for compartment syndrome Treat open wounds with antibiotics, tetanus toxoid, and debridement of necrotic tissue

Apply ice to injured areas and monitor for the 5 P’s: pain, pallor, parasthesias, pain with passive movement and

pulselessness Observe all crush casualties, even those who look well

Delays in hydration of greater than 12 hours may increase the incidence of renal failure; delayed manifestations of

 

renal failure can occur

Disposition

 

Patients with acute renal failure may require up to 60 days of dialysis treatment; unless sepsis is present, patients

are likely to regain normal kidney function

Page 31

Trauma/Burn Guidelines

Appendix 9: Abbreviations

ABLS

Advance Burn Life Support

ACA

Ambulatory Care Area

ADLS

Advance Disaster Life Support

AHLS

Advanced Hazard Life Support

AOC

Administrator-on-Call

APLS

Advanced Pediatric Life Support

APR

Air Purifying Respirator

ATLS

Advance Trauma Life Support

CCLU

Casualty Care Unit Leader

CDC

Centers for Disease Control and Prevention

CTUT

Contaminated Triage Unit Team

DHHS

Department of Health and Human Services

DPH

Department of Public Health

ED

Emergency Department

EMP

Emergency Management Plan

EMS

Emergency Medical Services

EOC

Emergency Operations Center

EOP

Emergency Operations Plan

FDA

Food and Drug Administration

HICS

Hospital Incident Command System

ICS

Incident Command System

PALS

Pediatric Advanced Life Support

PAPR

Powered-Air Purifying Respirators

PPE

Personal Protective Equipment

SBD

Security Branch Director

TUT

Treatment Unit Team

WHO

World Health Organization

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Trauma/Burn Guidelines

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