Bums (1990) 16, (3), 203-206 Printed in Great Britain
Fate of mass burn casualties: implications for disaster
planning
D. P. Mackie’ and H. M. Koning’
‘Rode Kruis Ziekenhuis, Beverwijk and ‘Medisch Centrum,
A survey of I I fire disasters which have occurred since 1970, showed that
incidents occurring o&oors m&d in larger numbers of hospital
admissions, with more severe injuries, than incidents occurring indoors
While the majority of bum casuallies sustained burns covering less than 30
per cent body surface area (BSA), outdoor disasters resulted in the
admission of a significant number of patients wifh burns coverkg more
&an 70 per cent BSA. Expert friage may therefor minimize the
requirement for specialized bum be& However, the scakty of bum
facilities is such that involvement of distant centres may be anficipakd
following large disasters. While effective early management extends the
time available for the dispersul of casualties, dehys may be avoided by
prior planning, especially if the inkrnational tran5fer of patients is
envisaged.
Introduction
Recent incidents involving mass burn casualties have dem-
onstrated that the specific needs of severely burned patients
cannot be ignored in disaster planning. In addition to the
early requirement for controlled fluid therapy, the relative
scarcity of specialized facilities and expertise for the treat-
ment of extensive burns is of particular concern. However,
despite the evidence available from past disasters, adequate
provision for the management of bum casualties is still
lacking in most disaster plans.
In order to illustrate the scale and nature of fire disasters,
the fate of the victims of incidents which have occurred
within the past 20 years has been analysed. An effort has
been made to identify features which might be relevant to
mass casualty management.
Materials and methods
Reports were obtained of 11 disasters since I970 which
resulted in multiple bum casualties. Data on eight incidents
were revealed in a search of the medical literature. Informa-
tion on the three most recent disasters has been provided by
clinicians directly involved in the management of casualties.
Summary details of the incidents are given in Tables I and II
Two additional fire disasters which have been reported in
detail were excluded from the analysis. The catastrophe at
San Juanico, Mexico, in which 300 people were killed, 7000
cci 1990 Butterworth-Heinemann Ltd
0305-4179/90/030203-04
to3
Leeuwarden, The Netherlands
injured and 60 000 evacuated (Pietersen and Huerta, 1984;
Arturson, 1987) was omitted because a disaster of this
magnitude is highly improbable in Western Europe, and
because the management of such an incident requires
planning on an entirely different scale from that appropriate
for ‘conventional’ civilian disasters. The MGM Hotel fire in
Las Vegas resulted in the hospital admission of 300
individuals, many of whom had inhaled smoke. However,
no burn injuries were reported (Buerk ef al., 1982).
Data from the 11 incidents suggested that the outcome
might be related to the presence of smoke. Therefore the fate
of those involved in disasters which occurred indoors (n = 6)
was compared with that of outdoor disasters (n = 5) (Table
II). Statistical significance was determined using Chi’ analy-
sis. Sufficient information was available on all the disasters
except Ramstein, to enable comparison of the severity of
injuries sustained by those admitted to hospital.
Findings
The results of the comparison between outdoor and indoor
incidents are summarized in Table III.
The number of people involved in the disasters was
defined as the sum of the number killed outright and the
number admitted to hospital with bums. A higher percent-
age of those involved in outdoor disasters was admitted to
hospital. The hospital mortality rate, expressed as a percent-
age of admissions, was also higher after outdoor fires.
Conversely, in indoor disasters a greater proportion of those
involved were killed outright, while for those reaching
hospital alive the mortality rate was low. Despite this, the
cumulative death rate was higher following indoor fires.
Differences were also found in the severity of injuries
sustained by those subsequently admitted to hospital
(Figure I). The majority of victims (58 per cent of those
admitted) sustained bums covering less than 30 per cent of
the body surface area (BSA). Following indoor fires, very
few patients were admitted with extensive bums. However,
outdoor fires resulted in the admission of a significant group
of victims with burns covering more than 70 per cent BSA.
Few casualties (14 per cent of those admitted) with bum
wounds covering 30-70 per cent BSA were encountered
following both kinds of disaster.
204 Bums (1990) Vol. 16/No. 3

Table I. Summary description of 11 disasters causing mass bum casualties since 1970 (including main references)

Name Country Description Main reference

Outdoor disasters
Nakivubo
(13 Jan. 1973) Kampala, Uganda Petrol tanker crash in market place Carswell and Rambo (1976)
Los Alfaques
(11 Jul. 1978) Spain LPG tanker crash at campsite Arturson (1981)
Bangalore
(7 Feb. 1981) India Circus fire Das (1983)
Bradford
(11 May 1985) UK Fire in football stadium Sharpe et al. (1985)
Ramstein
(28 Aug. 1988) FRG Plane crash at airshow P. R. Zellner (personal communication)
Indoor disasters
Summerland Isle of Man
(2 Aug. 1973) (UK) Fire in leisure complex Hart et al. (1975)
Dublin
(Feb. 1981) Ireland Fire in discotheque Duignan et al. (1984)
Cardowan
(27 Jan. 1984) UK Coal mine explosion Allister and Hamilton (1983)
Manchester
(22 Aug. 1985) UK Fire in aircraft on runway O’Hickey et al. (1987)
King’s Cross
(24 Jun. 1988) UK Fire in underground station M. Brough (personal communication)
Piper Alpha
(6 Jul. 1988) UK Fire on oil platform C. Rayner (personal communication)

Table II. Fate of bum casualties following fire disasters (figures of the disasters marked with an asterix are provisional)

Immediate Time to arrival Late Transfer to

Name deaths in hosp. No. admitted deaths other hosps.

Outdoor disasters
Nakivubo (K) 11 -=l h 71 26 No
Los Alfaques (LA) 102 1-6h 140 108 Limited
Bangalore (Ba) 92 cl h 77 17 No
Bradford (Br) 53 ~1 h 83 5 Limited
Ramstein’ (R) 34 <2h 344 37 Yes
Indoor disasters
Summerland (S) 48 ~1 h 24 2 No
Dublin (D) 48 ‘Rapid’ 44 2 No
Cardowan (C) 0 c2h 36 0 Yes
Manchester (M) :: <l h 15 1 No
King’s Cross’ (KX) ~1 h 29 1 ?
Piper Alpha’ (PA) 167 Several hours 11 1 No

Table III. Fate of burn casualties: comparison between indoor and outdoor disasters

indoors Outdoors

Mean no. involved (range) 201 NS

(3::78) (82-378)
Immediate death rate (% no. involved) 68.5 29.1 P< 0.05
Hospital death rate (% per hosp. admissions) 4.4 26 P< 0.05
Final death rate (% no. involved) 69.8 48.3 P< 0.05

smallest number admitted to hospital following an outdoor

Discussion
Not all fire disasters result in mass burn casualties, and
relatively few incidents have been described in detail in the
medical literature. The series reviewed in this paper is
therefore unlikely to be representative of fire disasters as a
whole. However, the diversity of the incidents included may
serve to illustrate the scale and nature of the problems faced
by the medical services in dealing with mass bum casualties.
In terms of the numbers wounded, the worst disasters
occurred outdoors (Fipre2). None of the indoor incidents
resulted in more than 50 hospital admissions, while the
incident was 71. However, only two disasters in the series
resulted in more than 100 admissions. Even taking the recent
Siberian gas explosion into account, which is estimated to
have caused at least 600 severe burn injuries (Pietersen,
1989), very large disasters remain uncommon. Although
Layton and Elhauge (1982) found that conflagrations in the
USA have become less frequent since the 1940s, the
incidence of major fires in Europe has increased in recent
years (Schweizer Rkk, 1989).
The severity of the injuries of those admitted to hospital
was distinctive (Figure I). The data suggests either that those
Mackie and Koning: Fate of mass burn casualties
11-20 31-40 51-60 71-80 91-100
Size of burn (% BSA)
Figure 1. Frequency distribution of burn severity (hospital admis-
sions). ?,?
Outdoors; ? ,?
indoors.
involved could escape rapidly, sustaining relatively small
bums (less than 30 per cent BSA), typically to exposed areas
of skin, or that timely escape was impossible and victims
were engulfed, sustaining lethal injuries (more than 70 per
cent BSA). In indoor fires, those who failed to escape
presumably died rapidly from a combination of hypoxia and
inhalation of poisonous compounds (Davies, 1986; Clark
and Nieman, 1988). Following outdoor incidents, however,
considerable numbers of lethally injured victims reached
hospital alive. The poor prognosis of these patients has been
emphasized (Arturson, 1981; Sharpe et al., 1985), and is
reflected in the high hospital mortality following outdoor
disasters.
The numbers admitted with bums in the range JO-70 per
cent BSA were consistently low (Figtlre 7). This finding is
relevant, because patients with this size of bum potentially
obtain the greatest benefit from referral to a bum centre.
Since bed availability in specialized centres is limited, it is
clear that accurate triage is essential. Detailed assessment of
casualties will obviously take some time, and is therefore
only practicable in a clinical environment where facilities and
personnel are available for the management of fluid therapy
and for the treatment of urgent complications. The rapid
evacuation of casualties to nearby hospitals is a realistic aim
for all but the most isolated locations (T&k II), aided by the
fact that most burn victims are themselves initially mobile
and cooperative. It has been pointed out that sorting should
ideally be performed by an expert in bums (Griffiths, 1985;
Barclay, 1986), as the actual disposal of patients will be
influenced not only by the total number of casualties and
bed availability, but also by such factors as the depth and
location of the wounds, complications such as inhalation
injury, and extremes of age.
With effective triage, the demand for specialized bum
care can be minimized. Nevertheless, the figures indicate
that even a moderate disaster might fill all available bum
beds over a wide area, and in smaller countries, such as the
Netherlands (Editorial, 1989b), the total bums capacity
could be saturated. Following very large disasters, of the
scale of Ramstein (Bayer, 1988), optimal care of severely
burned victims will only be achieved if distant bum centres
are also involved. Effective fluid therapy during the first 24 h
provides an interval in which the transfer of patients may be
organized. However, the importance of timing and coordi-
nation in the transport of burn patients has been emphasized
Uudkins, 1988), and delays may occur, especially if intema-
205
PA M S KX C D K Ba Br 1-A R
Fire disaster
Figure 2. Numbers of casualties admitted to hospital.
? ,?Outdoors; 6, indoors. For definition of abbreviations, see
Table II.
tional transport by air is envisaged, unless communications
and cooperation are assured. The successful dispersal of
casualties will therefore be enhanced by prior awareness of
the location and capacity of specialized facilities (Editorial,
1989a), and by rehearsal of the procedures entailed in
coordinating the logistic response. Mobilization of the
resources necessary for the management of mass bum
casualties may be facilitated if indemnity by the relevant
authorities is established in advance.
Conclusions
The management of mass bum casualties presents major
problems in organization, particularly following large, out-
door disasters. Although specific measures for dealing with
injured victims will vary from region to region, the
consequences of a major fire disaster can be broadly
predicted. Accurate triage by clinicians experienced in burns
will minimize the requirement for scarce bum facilities.
Nevertheless, following large disasters, optimal care of the
injured may involve the transport of patients to distant
centres, implying the national and international transfer of
patients. While effective early care extends the time avail-
able for the dispersal of casualties, delays will be minimized
by prior contingency planning. Awareness of the scale and
nature of past disasters may aid the formulation of plans for
dealing with mass bum casualties in the future.
References
Allister C. and Hamilton G. M. (1983) Cardowan coal mine
explosion: experience of a mass burns incident. Br. Med. J 287,
403.
Arturson G. (1981) The Los Alfaques disaster: a boiling-liquid,
expanding-vapour explosion. Bum 7,233.
Arturson G. (1987) The tragedy at San Juanico - the most severe
LPG disaster in history. Bums 13, 87.
Barclay T. L. (1986) Planning for mass bums casualties. In: Wood
C. (ed.), Acci&trt and Emrgency Burns: Lessons from the Bradford
Disaster. Royal Society of Medicine Services, Round Table no. 3.
Bayer M. (1988) Rampenbestrijding verliep uitzonderlijk snel.
Alert 10,~.
Buerk C. A., Batdorf J. W., Cammack K. V. et al. (1982)The MGM
Grand Hotel fire. Arch. Surg. 117, 641.
206
Carswell J. W. and Rambo W. A. (1976) A fire at Nakivubo,
Kampala: a case report: I. Management of the burned patients.
Bums 2,178.
Clark W. R. and Nieman G. F. (1988) Smoke inhalation. Bzens 14,
473.
Das R. A. P. (1983) 1981 circus fire disaster in Bangalore, India:
causes, management of bum patients and possible presentation.
Burns lo, 17.
Davies J. W. L. (1986) Toxic chemicals versus lung tissue - an
aspect of inhalation injury revisited. 1. Bum Cure Rehubil. 7,213.
Duignan J. P., McEntee G. P., Scully B. et al. (1984) Report of a fire
disaster - management of bums and complications. Irish
Med. 1. 77, 8.
Editorial (1989a) Bum care facilities in the UK. Bums 15, 183.
Editorial (1989b) Speciahsed burn care facilities in the Netherlands.
Burns 15,338.
Griffiths R. W. (1985) Management of multiple casualties with
bums. Br. Med. 1. 12,518.
Hart R. J., Lee J. O., Boyles D. J. et al. (1975) The Summerland
disaster. Br. Med. 1. 1, 256.
Judlcins K. C. (1988) Aeromedical transfer of burned patients: a
review with special reference to European civilian practice.
Burns 14,171.
Tanner-Vandeput Prize for Bum Research
1990 Award
The 1990 Tanner-Vandeput Prize for Burn Research, consisting of a
cash payment, will be awarded at the 8th International Congress on
Burn Injuries of the ISBI, to be held November 11-16, 1990 in New
Delhi, India. The Prize will go to a person or person who, in the opinion
of the Prize Committee, has made a substantial and outstanding contri-
bution to any aspect of the burn field in their lifetime (i.e.‘, a ‘senior
investigator’s’ award). The recipient does not have to be a member of
the ISBI or a physician, but be responsible for a major advancement in
the treatment of burns.
Nominations for the 1998 Prize may be made by colleagues of those
who have made such a contribution to burn care in their lifetime. A
candidate may also make an application on his own behalf.
Anyone interested in applying for the 1990 Tanner-Vandeput Prize
for Burn Research should send the following information to the ISBI
Secretary-General at the address below.
Information regarding the Tanner-Vandeput
The Prize was established in I984 by Dr J. C. Tanner of Atlanta,
Georgia, co-inventor with Dr. Jacques Vandeput of the Tanner-
Vandeput Mesh Dermatome. This Prize was conceived and established
to promote the aims of the International Society for Burn Injuries and to
motivate individual investigators to do research, study, undertake
patient care and treatment and other aspects of the burns problem, and
will be awarded to one who has made a substantiai contribution to bum
care in their lifetime (a ‘senior investigator’s’ award). The Prize consists
of a cash payment.
A foundation was created for the sole purpose of awarding the Prize
every four years and has separate funds invested to produce income
used for the Prize. A trust fund is owned by the ‘International Burn
Foundation of the United States,’ an organization entirely separate from
Burns (1990) Vol. 16/No. 3
Layton T. R. and Elhauge E. R. (1982) U.S. fire catastrophes of the
20th century. J. Bum Care Rehuid. 3,21.
O’Hickey S. P., Pickering C. A. C., Jones P. E. et al. (1987)
Manchester air disaster. Br. Med. J 294, 1663.
Pietersen C. M. (1989) De ramp met de pijpleiding in de Sovjet
Unie. Alert 9,~.
Pietersen C. M. and Huerta S. C. (1984) Analysis of the LPG Incident
at Sun Juan Lrhuutepec, Mexico City. The Hague: TNO.
Sharpe D. T., Roberts A. H. N., Barclay T. L. et al. (1985) Treatment
of burns casualties after fire at Bradford City football ground.
Br. Med. 1. 291,945.
Schweizer Riick (1989) Annual Disasler Statistics. Sigma 1 (period-
ical publication of the Scheiwzerische Riickversiche rungs-
Gesellschaft).
Paper accepted 30 November 1989.
Correspondenceshould be addressedto: Dr D. P. Mackie, Department
of Anaesthetics, Rode Kruis Ziekenhuis, vondellaan 13, 1942 LE
Beverwijk, The Netherlands.
Information required to apply for the Tanner-Vandeput Prize for 1990:
??Letter of nomination (can be sent by candidate or by someone else)
??Description of work including samples and documentation
0 Current Curriculum Vitae
0 Letters of support from colleagues
Send five copies of this information to:
Dr. John A. Boswick,
International Society for Bum Injuries,
2005 Franklin St. #660,
Denver, Colorado 80205, USA. Tel (303) 839-1694.
Deadline for receipt of applications: July 31, 1990
prize for burn research
the ISBI. The funds do not overlap or mingle in any way with those of
the ISBI.
The only role the ISBI plays in the Tanner-Vandeput Prize is to
coordinate and award the Prize for each Quadrennial Congress. The
International Bum Foundation has a Board of Directors and a Prize
Committee which reviews applications and makes recommendations for
award of each Prize.
The Prize Committee voted to award the first Tanner-Vandeput
Prize, presented at the 7th International Congress held February 1986 in
Melbourne, Australia to Dr Ian Alan Holder of the Shriners Burns Insti-
tute in Cincinnati, Ohio for his work on ‘Infection by Pseudomonas
Aeruginosa.’ He was presented with a cash payment and a gold and
diamond lapel pin signifying his achievement.