uphill from the contaminated area.

Rapid triage
takes place to sort victims into critical, urgent,
delayed, or, if they have deteriorated, expectant
categories.
● Only a minimal amount of treatment is rendered
to provide essential stabilization. The priority is
to commence decontamination. Nonambulatory
victims go through litter decontamination,
● HAZMATs come in the form of explosives, flammable
whereas ambulatory patients and any personnel
and combustible substances, poisons, and
wishing to leave the warm zone go through
radioactive materials. HAZMAT incidents can occur
ambulatory decontamination before entering the
during production, storage, transportation, use, or
cold zone.
disposal.
● Those victims with the most severe
● Nurses and communities are at risk if a chemical is
signs/symptoms of contamination are given
used unsafely or released in harmful amounts into
priority for decontamination. All staff in this area
the environment where individuals live, work, or
must wear the appropriate PPE.
play. Chemical emergencies may result from
3. Cold zone
industrial explosions, transportation or agricultural
● The area that is adjacent (and uphill and
accidents, police actions involving tear gas, or the
upwind) from the warm zone, into which
intentional use of chemicals as agents of war by
decontaminated victims enter. As the victims
terrorists.
enter this area, a more thorough triage is
● The release of a chemical into the environment
performed (including evaluation for secondary
creates a HAZMAT incident that poses unique
injuries), and victims are directed to treatment
challenges for the healthcare system and for those
areas based on the severity and nature of illness
individuals who participate in the response.
or injury. PPE is maintained in this area in case
“Contamination” or the “state of being
the wind changes or victims arrive who have
contaminated” occurs when a person or persons
been improperly decontaminated.The purpose of
inhale, ingest, inject, or absorb harmful substances
this zone is to provide medical care and to
as the result of exposure to chemical or biological
transport victims to higher care facilities.
agents and/or radiological materials
● “Decontamination” is the removal or reduction of
contaminants through the use of water, cleansers, or
neutralizers. Emergency medical services (EMS)
Warm Zone
have specific procedures for triage during HAZMAT
● This is an area that is adjacent to the hospital
events, and in most communities, decontamination
(usually the ED) that has a source of water (in
of victims is done before transport to a hospital.
cold climates it must be a warm water source)
● EMS may transport non-decontaminated victims
for decontamination, and barriers to control
directly to the hospital, however, and it is expected
entrance and exit from the area
that many ambulatory victims will leave the scene
● The triage station is at the entrance to the warm
before being triaged and decontaminated.
zone decontamination area. All ambulance and
● Nurses attempting to act as first responders without
walk-in cases must enter the facility after going
the proper training and equipment and without an
through this triage station. Cases that are clearly
organizational affiliation that provides them with
not contaminated enter the ED, and those that
OSHA protections place themselves at great risk.
require decontamination go through the warm
zone decontamination area before exiting into
the clean zone in the ED (or noncontaminated
area).
Clean Zone
There are three zones that need to be identified. We
● This is the treatment area inside the ED or
have to take note that all distances for each zone are
hospital where newly arriving patients and
estimates and will be incident-dependent based on the
victims are sent after having been triaged and
existing environmental conditions.
decontaminated. This area is considered clean
1. Hot zone
or non-contaminated.
● It is the innermost zone and the area
● Any staff or patients who have entered the
immediately adjacent to the location of the
warm zone must be decontaminated before
incident.
entering the clean zone. Another more thorough
● Minimal triage and medical care activities take
triage is performed in the clean zone area.
place and are limited to airway and hemorrhage
control, administration of antidotes, and
identification of expectant cases (dead or
nonsalvageable).
PPE is the clothing and respiratory gear designed
● All staff are in protective gear in this area.
specifically to protect the healthcare provider while he or
● Victims are located, given basic lifesaving
she is caring for a contaminated patient. To ensure the
measures, and then transported to the warm
greatest possible protection for nurses in the workplace,
zone for decontamination.
hospital, and other healthcare facility, employers are
2. Warm zone
responsible for:
● A distance of at least 300 ft from the outer
perimeter of the hot zone, and upwind and

ENDRIANO, ENGO| 1
 ● Performing a “hazard assessment” of the
workplace to identify and control physical and
health hazards
● Identifying and providing appropriate PPE for
employees
● Training employees in the use and care of the
PPE
● Maintaining PPE, including replacing worn or
damaged PPE
● Periodically reviewing, updating, and evaluating
the effectiveness of the PPE program
In general, nurses should:
● Properly wear PPE
● Attend training sessions on PPE
● Care for, clean, and maintain PPE
● Inform a supervisor of the need to repair or
replace PPE
Level A
● Provides the highest level of skin, respiratory,
eye, and mucus membrane protection.
Equipment includes a fully encapsulated water-
and vapor-proof suit, boots, gloves, and
hardhat, which contains a self-contained
breathing apparatus (SCBA). The suit should
contain a cooling and communication system.
Level A PPE is required by HAZMAT teams for
use in the field.
Level B
● It is used when the highest level of respiratory
protection is required, but skin and eye
protection will suffice with splash-resistant gear.
The equipment includes SCBA and
splash-resistant clothing, hood, gloves, hardhat,
boots, booties, and two-way communication and
cooling system.
Level C
● It provides the same skin and eye protection as
Level B, but uses an air-purifying respirator
(APR; rather than a SCBA). The APR filters the
air rather than providing oxygen from an outside
source. The APR uses a hood rather than a
mask, which reduces the risk of contamination
around the edges of the mask and avoids the
need for fit testing to ensure a proper fit. Level
C gear is to be used only when the chemical
contaminant is known and the criteria for use of
an APR are met.
Level D
● It provides standard work protection from
splashes; no respiratory and minimal skin
protection are required. The gear includes cover
or standard work clothing, safety glasses,
gloves, and face shield.
The higher the level of PPE, the higher the degree of
protection for the healthcare provider; however, there is
a higher level of burden that is due to weight, bulk, and
the heat factor. Wearing PPE may present various
problems for the nurse depending on the environment,
the level of PPE that is required, and the duration that
the PPE will be worn.
Nurses should be prepared to expect any of the
following conditions while wearing PPE:
● Extreme heat
● Poor ventilation
● Lack of peripheral vision because of the goggles
or head gear
● Inhibited sense of touch because of the gloves
● Heavy weight
● Fatigue
● Difficulty in communications
In the event of deployment of chemical weapons,
emergency care providers will be at serious risk of
exposure, and special respirators may be needed for
additional protection. There are several types of
respirators, each providing a different level of protection.
● Full facepiece APR
● Full facepiece APR retrofit
● Powered APR (PAPR)
● SCBA
● Closed-circuit SCBA
● Reusable elastomeric respirators1
1. Physical removal- Flushing with water or
aqueous solutions. This method is highly
effective and significantly dilutes or reduces the
amount of chemical agent on the skin or mucus
membrane. For absorbent materials: Rub with
flour followed by wet tissues. This is suggested
for emergency situations where water flushing is
not available. M291 resin: Used by the military;
wallet-sized packets with resin-impregnated
pads used for individual decontamination.
2. Chemical methods- Water/soap wash: This is
the most likely method to be used in the
hospital setting. The chemical agent is removed
via mechanical force as well as hydrolysis.
3. Oxidation- Hypochlorite solutions are
considered to be universally effective for
removing organophosphates and mustard
agents.
4. Hydrolysis- Hydrolyzing agents: Alkaline
hypochlorite is effective for hydrolyzing VX and
G agents
● The basic preparation steps in patient
decontamination include the following:
● Get information. Identify the agent (if possible).
● Determine the level of PPE required.
● Mobilize security personnel and trained triage
and decontamination staff.
● Control access to the decontamination site as
well as to the hospital.
● Prepare a decontamination area (warm zone
should be outside the facility).
● Gather decontamination supplies and equipment
● Downwind of clean area, not located near facility
air intake.
● Area for decontamination triage: those with
most severe signs or symptoms are triaged first.
● Receptacles for contaminated clothing,
valuables, and contaminated supplies.
● Source of water (warm in cold climate areas),
soap, and towels.
ENDRIANO, ENGO| 2
● Tape to demarcate dirty and clean sides.
● Screens for privacy or segregation by gender (if
possible).
● Collection system for runoff water.
● Chemical agent monitor supplies (CAM).
● Having the patient perform as much of the
decontamination as possible is preferable to
decrease the amount of cross-contamination.
● Remove all clothing (this will remove 80% to
90% of the contaminants).
● Place all clothing and valuables in a bag. Place
these individual bags in a larger collection
container, taking care to not touch the outside of
the container.
● Wet skin and wash down with soap and water.
Attention needs to be given to hair, face, hands,
and other areas that were exposed and not
covered by clothing. Avoid vigorous scrubbing to
prevent skin breakdown. Wash for 5 to 10
minutes and rinse.
● Decontaminate open wounds by irrigation with
saline or water for an additional 5 to 10 minutes.
● Try to avoid contaminating unexposed skin on
the patient.
● Use surgical drapes if necessary.
● Flush exposed areas with soap and water for 10
to 15 minutes with gentle sponging.
● Irrigate exposed eyes with saline for 10 to 15
minutes, except in alkali exposures, which
require 30 to 60 minutes of irrigation.
● Clean under fingernails with a scrub brush.
● Check for presence of agent using CAM or M-8
paper, and if positive, decontaminate again.
● Relocate to clean area, don dry clothing.
● Ideally, collect runoff water in steel drums if
possible.
● IV setups and solutions can be left in during
decontamination, but should be replaced as
soon as possible with new, clean setups.
● Endotracheal tubes can remain in place during
decontamination, but should be replaced as
soon as possible with new, clean tubes.
● Containment equipment
● Pool or tank
● Tarps
● 6-mil construction plastic
● Fiberglass backboard
● Supports for ambulatory patients
● Sawhorses to support backboards
● Water supply
● Scissors for clothing removal
● Mild detergent (dishwashing liquid)
● 5-gallon buckets
● Sponges and soft brushes
● Towels and blankets/sheets
● Triage tags
● Disposable clothes and shoes for ambulatory
patients
● Large plastic bags for contaminated clothing
with predetermined unique ID tags to go on the
bag and patient’s wrist/neck
● Small plastic bags for patients’ valuables
● Waterproof pens to mark bags
● Clear, zip-front body suits or large
water-repellent blankets to minimize
contamination to transport personnel and
ambulances
● Duct tape (4 in.)
● Direct patient to the decontamination area
(warm zone).
● Separate male and female patients if possible,
and keep children with parents or older siblings,
if possible.
● Instruct patients to wipe feet before entering
the decontamination area—use mat or remove
shoes directly into a plastic bag.
● Instruct patients to remove clothing.
● Place clothing in plastic bag with shoes, label
the bag, and hold it during decontamination.
● Instruct patient to place valuables in a small
plastic bag, label the bag, and hold it during
decontamination.
● Brush or wipe off particulate matter.
● Instruct patient to step into shower, close eyes
and mouth, and raise arms above head.
● Instruct patient to rotate twice, slowly.
● Instruct patient to walk out of shower into
secondary (definitive) decontamination area.
● If possible, keep male and female patients
separate.
● Make sure all clothing is removed, bagged, and
labeled.
● Brush or vacuum any remaining particulate
matter off of skin.
● Decontaminate systematically from the head
down with water.
● Water-wash contaminated area gently under a
stream of water and scrub gently using a soft
brush with soap.
● Use warm, never hot, water.
● Decontaminate exposed wounds and eyes
before intact skin areas; do not introduce
contaminants into wounds.
● Cover wounds with a waterproof dressing.
● Remember the back, under skin folds, axilla,
ears, and genitalia.
● Remove contaminants to the level that they are
no longer a threat to the patient or response
personnel.
● Allow ambulatory patients to decontaminate
themselves.
● Provide instructions in multiple languages to
ensure that patients understand the problem
and follow instructions.
● Administer medicines or ventilation support to
seriously ill patients while undergoing
decontamination.
● Administer invasive procedures in the
contamination reduction zone (on-scene) or
warm zone (hospital setting) only when it is
absolutely necessary.
ENDRIANO, ENGO| 3
● Isolate the patient from the environment by
wrapping in blanket/sheet to prevent the spread
of any remaining contaminants.
● Direct men and women to segregated treatment
areas, if possible.
● Soap, brushes, sponges, and other equipment
used for decontamination should be placed in a
trashcan and not carried into the support zone
(on-scene) or the cold (clean) zone (hospital
setting).
● Apply C-collar immediately if a cervical spine
injury is suspected.
● Place plastic sheet on cart, cover with sheet,
place victim on sheet.
● Remove all clothing and place in plastic bag and
label the bag.
● Place valuables in a small plastic bag and label
properly.
● Brush or wipe off particulate matter.
● Rinse patients gently using handheld sprayer;
begin with face and airway, then open wounds
(cover patient’s mouth and pinch nose when
washing face).
● Ensure axilla, genitalia, and the back are rinsed.
● Use non-rebreather mask or bag-valve-mask to
protect airway
● Wash from head to toe using tepid, not hot,
water and soap 5 minutes when the agent is
nonpersistent and 8 minutes when a persistent
or unknown agent.
● Wash and rinse creases such as ears, eyes,
axilla, groin; rinse for about 1 minute; roll
patient to side if needed.
● Wash around IV site(s) and IV setup. Replace IV
once out of decontamination.
● Thoroughly dry patient and cover with a blanket.
● Soap, brushes, sponges, and other equipment
used for decontamination should be placed in a
trashcan and not carried into the support zone
(on-scene) or the cold (clean) zone (hospital
setting).
● Open wounds should be covered with dressings
after decontamination is complete.
● Transfer patient to clean backboard and exit into
cold zone for rapid assessment, triage, and
assignment to a treatment area.
● Allow children and parents (or other adults
known to them) to remain together.
● Constantly reassure and offer compassion to a
child if the child is separated from his or her
parent(s)—children will be fearful.
● Attempt to reunite children with their parents if
they were separated during the course of the
disaster.
● Take time to inform and reassure older children
of the current situation.
● Prevent children from developing hypothermia.
● Use a water temperature of 100°F.
● Wash/shower for 5 minutes.
● Use great caution—wet infants are slippery.
● A burn center’s capacity is determined by
available burn beds, burn surgeons, burn
nurses, support staff, operating rooms,
equipment, supplies, and related resources; it is
a dynamic number.
● Surge capacity is the ability to handle up to 50%
more than the normal maximum burn patient
census when there is an emergency.
● Burn care is a highly specialized field because of
the need of specific treatment modalities,
supplies and equipment, and specialized
personnel.
● Effective planning for a burn MCI must occur at
multiple levels. Plans should regularly be
rehearsed and updated.
● At the most basic level, families and businesses
should design and practice escape plans and
evacuation drills.
● Community response plans can be complicated,
as they require the integration of many
disciplines such as fire services, public safety,
emergency medical services, public health, and
hospital systems.
● A detailed community hazard vulnerability
analysis should be conducted to determine
potential causes or sites of a burn disaster.
● Oil rigs, railroads, chemical or industrial plants,
and arid forests are all possible sources of major
fires.
● Written transfer agreements between burn
centers and other hospitals/burn centers are a
requirement for a disaster plan; these
agreements should include stipulations about
whether patients will be transferred back to the
referring hospital when it has available beds.
● At the state and national levels, government
agencies are responsible for creating or
delegating disaster planning responsibilities.
● Emergency medical service (EMS) systems,
usually directed by state health departments,
are often responsible for much of the state
planning activities, including communications,
transportation, and drills.
● Burns disasters are specifically included in the
National Disaster Medical System (NDMS).
● Fire is among the most preventable of all
traumatic events and disasters.
● The single most important element of prevention
is education at the individual, community, and
national levels.
● The single most important element of prevention
is education at the individual, community, and
national levels.
● Education and experience are key to successful
patient resuscitation.
● Advanced Burn Life Support (ABLS) is a
standardized 8-hour course designed to teach
ENDRIANO, ENGO| 4
 health care providers to assess and stabilize ● Secondary triage occurs at a hospital or burn
serious burns during the first critical hours center when it has reached capacity and must
following injury. begin transferring patients to other burn
● A BST (Burn Specialty Teams) is led by an centers.
experienced burn surgeon and consists of 15 ● The ABA triage policy is that all burn patients
members (nursing, anesthesiology, respiratory should be transferred to a burn center within 24
therapy, administration, and support personnel). hours of injury.
● If health care resources are overwhelmed by
casualties and transfer possibilities are
● Activation of the disaster plan occurs and a insufficient, resources should be allocated to
structured response is mobilized. where they will do the most good for the most
people.
BURN CLASSIFICATION ● The ABA has developed a triage decision table
of benefit-to-resource ratio based on patient age
FIRST SECON THIRD FOURT
and total burn size.
DEGRE D DEGRE H
E DEGRE E DEGRE
BURNS E BURNS E
BURNS BURNS
● The overall morbidity associated with a burn
injury will be determined by burn depth,
Referre Superfici Partial Full Full
percentage total body surface area (TBSA)
d to as al Thicknes Thicknes Thicknes
involved, patient age, and presence of inhalation
s s s with
injury.
Deep
● Children and older adults have thinner skin and
Tissue
Loss are more likely to sustain a deeper burn injury.
Patients at the age extremes are also less likely
Depth Epidermi Epidermi Epidermi Subderm to tolerate the stress of burn shock.
of s s, some s, all al fat; ● The presence of an inhalation injury severely
Injury dermis dermis may impacts survival in all age groups.
involve ● Extensive burn injuries produce a systemic
fascia, response that pulls fluid from the vascular
muscle, system into the interstitial space. This is
and/or exacerbated in burns greater than 20% TBSA by
bone a significant capillary leak into the
microvasculature and generalized edema.
Appear Redness, Fluid-fill Charred, Charred, Without proper treatment, intravascular fluid
ance intact ed leathery leathery, loss and hypovolemic burn shock result. This is
skin blisters, disfigure why immediate initiation of fluid re- suscitation
pink ment is important.
dermis ● A successful fluid resuscitation will maintain
intravascular volume and organ perfusion until
Moistur Dry Moist Dry Dry capillary membrane integrity is restored
e (approximately 24 to 48 hours post-injury).

Perfusi Normal Quick Markedly Absent

on capillary delayed
refill or
absent Initial burn patient management priorities include:
capillary ● Stop the burning process
refill ● Manage airway, breathing, and circulation
● Begin fluid resuscitation
Sensati Normal Painful, Pressure Pressure ● Keep the patient warm
on pinprick sensatio sensatio ● Evaluate for other life- and limb-threatening
sensatio n only or n only or injuries
n intact no no
sensatio sensatio
n n
1. Stop the burning process
● To prevent further injury and establish safety for
the healthcare provider, the first rescue action
may need to be stopping the burning process.
● Primary triage ideally occurs at the disaster site, ● Smoldering clothing should be removed and
or it can be at the hospital receiving patients chemicals should be brushed away or irrigated
from the scene. as indicated.
● The primary triaging of patients should be ● The use of ice or ice water is contraindicated, it
conducted as the local disaster triage criteria causes vasoconstriction and potentially ischemia
dictate. in the burned skin resulting in deeper injury.

ENDRIANO, ENGO| 5
 ● - If the patient is unconscious and unresponsive,
the cervical spine should be immobilized until
injury is ruled out.
2. Manage airway, breathing, and circulation
● In all emergencies, airway is the initial priority.
● Assess for a patent airway and evaluate
breathing.
● Immediate intubation is indicated in patients
with severe respiratory distress, signs of
inhalation injury, decreased LOC, or other
inability to protect the airway.
● It is critical for victims with inhalation injuries to
be intubated as soon as possible due to the
significant increase in airway edema with fluid
resuscitations.
● Traumatic intubations and multiple attempts 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.
● Endotracheal tubes should be secured with twill
tape in patients with facial burns, as adhesive
does not stick to burned skin.
● Patients who have been in an enclosed burning
building should be suspected of having smoke
inhalation injury and carbon monoxide poisoning
until proven otherwise.
● These patients should be treated with humidified
100% oxygen.
● Smoke inhalation is unlikely in patients injured
outdoors since smoke dissipates quickly in
open-air environments.
● Findings that may be associated with inhalation
injury include hoarseness, wheezing, facial
burns, singed facial hair, and carbon deposits in
the oropharynx or carbonaceous sputum.
● A definitive diagnosis of inhalation injury can be
made with bronchoscopy.
3. Begin fluid resuscitation
● Two large-bore peripheral intravenous (IV)
catheters should be placed to begin fluid
resuscitation, through nonburned tissue if
possible.
● If the catheters must be placed through burned
skin, they should be sutured in place. Again,
adhesive does not stick to burned skin.
● There should be a low threshold for placing an
intraosseous needle in the field when there is
difficulty obtaining access in a several injured
patient.
● Second- or third-degree burns greater than 20%
TBSA and patients with significant smoke
inhalation injury will require fluid resuscitation.
● Peripheral IV catheters can be used, but
placement of a central venous catheter may be
beneficial.
● Blood pressure and heart rate are misleading
indicators of adequate fluid resuscitation due to
physiological factors including progressive
edema to burned extremities, cellular fluid
shifts, vasoconstriction, and pain.
● Urine output is an effective indicator of organ
perfusion; therefore, it is used to evaluate the
effectiveness of fluid resuscitation and to guide
rate titrations as needed.
● An indwelling urine catheter should be placed to
accurately measure urine output; urine output
should be measured at least hourly.
● There are multiple formulas that can be used to
fluid-resuscitate a burn patient.
● The Parkland formula is well established and
commonly used. Before calculation can be done,
it is necessary to determine the patient’s weight
(in kilograms) and correctly estimate the
percentage TBSA burned.
● A good estimation tool for use in the field is the
Rule of Nines. Because of their
disproportionately large heads, children under
30 kg require an adjusted approximation of
percentage TBSA. A child’s entire head
represents 18% of the TBSA, and each lower
extremity represents 14% of the TBSA.
● Warmed Lactated Ringer’s (LR) solution should
be used in burn fluid resuscitation. The Parkland
formula indicates that a volume of 2 to 4
mL/kg/%TBSA burned should be administered
over the first 24 hours from the moment of
injury, with half of the volume being
administered over the first 8 hours and the
second half infused over the next 16 hours.
● Although this is the classic teaching of the
application of the Parkland formula; it is not the
ideal way to resuscitate a burn patient.
● It is best to use the formula to determine the
initial hourly rate and then follow the patient’s
urine output to guide the rest of the fluid
resuscitation. This is a more accurate reflection
of the individual’s true fluid needs.
● The titration should reflect the amount of urine
the patient is producing with a goal of
0.5mL/kg/hr of output in adults and 1mL/kg/hr
in children less than 30kg.
● A good rule of thumb is to decrease the fluid
rate by 10% every hour that the patient has
made their goal for urine output. If at any point
the patient is not meeting their hourly output
goal, increase the fluid rate by 20% and observe
the next hour.
● Ideally, the fluid is titrated down to a
maintenance rate by 24 hours after the injury.
The adult maintenance fluid requirement is
30mL/kg/day plus an estimation of insensible
losses-1mL/kg/% TBSA burned.
● Small children less than 30kg require
maintenance fluids throughout fluid resuscitation
in addition to the calculated Parkland formula
rate.
● A maintenance solution with 5% dextrose is best
to prevent rapid loss of the child’s glycogen
stores.
● Some clinical situations may require a higher
than predicted total volume for fluid
resuscitation. Be aware of the following risk
factors for extra fluid requirements: smoke
inhalation injury, associated trauma, large TBSA
burns (>50%), deep burns, electrical injury,
delayed resuscitation, or alcohol/drug use.
ENDRIANO, ENGO| 6

Rules of 9 in Adults.
4. Keep the patient warm
● The patient’s entire body should be briefly
exposed to assess for burn size and depth and
any concomitant injuries.
● In skin loss, the body loses its ability to regulate
body temperature.
● After the examination, it is important to keep
the patient warm using rescue blankets or dry
sheets at the scene and warmed IV fluids, warm
blankets, and approved body warmers at the
hospital.
5. Evaluate for other life- or limb-threatening
injuries
● Burn patients are usually awake and alert after
they have been injured.
● If there is an alteration in mental status,
consider the following: associated traumatic
injury, carbon monoxide poisoning, hypoxia,
intoxication, or preexisting medical conditions.
● Burned tissue can swell significantly, so all
constricting clothing and jewelry should be
removed immediately to prevent circulatory
compromise.
● Finger rings should be removed as soon as
possible, with a ring cutter if necessary.
● Hand and finger swelling will make later removal
very difficult.
● Earrings should also be removed as they can
cause pressure necrosis in a swollen ear.
● Peripheral circulations should be monitored
throughout resuscitation using an ultrasonic flow
meter.
● Circumferential full-thickness extremity burns
may compromise distal perfusion and require
escharotomy.
● Digital vessels of each finger, radial, palmar
arch, posterior tibial, and dorsalis pedis pulses
should be checked hourly for progressie
decrease in signal or total loss.
● If necessary, escharotomies should be done
before loss of signal to avoid severe neurologic
damage and tissue necrosis.
When the primary survey is complete, a thorough
head-to-toe evaluation is conducted to assess for other
injuries. The secondary survey should include an
accurate history, the circumstances of the injury and
medical history, and a complete examination to evaluate
for other traumas such as fractures, contusions,
shrapnel, or corneal injury. Following is a patient
pretransport checklist (before secondary triage to
another healthcare facility):
● Primary and secondary surveys are complete.
● All urgent issues are addressed, and the patient
is hemodynamically stable.
● IV fluid resuscitation is initiated.
● Patient is warm and wrapped in sufficient clean,
dry blankets.
● Endotracheal tube, IV catheters, urine catheter,
nasogastric tube are secure and functioning.
● Documentation is complete and with the patient.
Burn Wound Care
1. Keep the wound clean, moist, and covered
2. At the scene of a disaster, or when waiting for
transport to the receiving facility, it is sufficient to
cover the burn wound with a clean, dry sheet. If
the patient is going to be awaiting transport for
more than 24 hours, initial wound care should be
done.
3. The principles of burn care are essentially the
same for thermal, chemical, electrical, and
radiation burns. When the patient arrives at the
receiving facility:
1. The first step in burn wound care is to cleanse
with mild soap and warm water.
2. Remove any debris and loose, dead skin, and
pat dry.
3. A petrolatum-based ointment can be applied to
wounds on the head and neck and be left
uncovered.
4. The ointment will need to be reapplied
throughout the day to keep the wounds moist.
5. Leaving the face uncovered allows better visual
assessment and permits interaction with the
patient.
6. Mafenide acetate can be applied to nose and ear
burns as it is more effective on cartilaginous
tissue.
7. Other burn wounds can be treated with a clear
topical antibacterial ointment such as bacitracin,
followed by a nonadherent mesh dressing and a
gauze wrap to secure into place.
8. Silver sulfadiazine should be avoided until the
burns are evaluated by the burn center; this
cream is thick and opaque, making it difficult to
easily assess the burn wound.
Pain control
● Full-thickness burns tend to be less painful since
the cutaneous nerves have been damaged or
destroyed. Partial-thickness burns, however, are
known to cause variable degrees and types of
pain.
❖ IV narcotics are usually required to
maintain adequate pain control during
wound care.
❖ Continuous infusions may be
appropriate for those patients who are
mechanically ventilated. Oral and
subcutaneous routes should be avoided
ENDRIANO, ENGO| 7
 in burns greater than 20% TBSA
because of decreased reliability of
absorption secondary to burn shock
Walking Wounded
● Patients with first-degree burns or small
nonlife-threatening deep burns can be treated
as outpatients as long as they are able to care
for themselves or have someone to help them.
● This population must be anticipated by the
hospital staff and efficiently managed to avoid
crowding and misdirection of resources.
● There should be a designated care area for the
walking wounded, away from the arrival bays
and high-acuity areas of the emergency
department.
❖ The burns should be assessed, cleaned,
and dressed.
❖ Before patients are sent home, they
must have adequate pain control with
oral medications and be able to meet
their nutrition and hydration needs.
❖ Outpatient supply kits should ideally be
assembled before an event occurs. The
kits should include general wound care
instructions, basic dressing supplies, and
information about warning signs and
follow-up care
Chemical Burn Injury
● Chemical agents fall into three categories:
alkalis, acids, and organic compounds.
● Alkalis and acids may be found in home and
commercial cleaning products, whereas organic
compounds are usually found in petroleum
products.
9. Acid injuries by causing tissue coagulation,
whereas alkalis cause liquefaction necrosis.
10. Alkali burns can be potentially more destructive
to tissues than acids because liquefaction
enables the chemical to continue penetrating
deeper into tissue.
❖ Liquid chemicals should be copiously
irrigated off the skin until pain
symptoms subside; this may take at
least 30 minutes. Neutralizing agents
are not recommended.
❖ Powdered chemicals should be brushed
off before skin irrigation begins.
❖ Chemical burns to the eye require
continuous irrigation with clean water or
normal saline for at least 15 minutes.
❖ When there is no access to running
water, an improvised eyewash station
can be made by spiking a bag of normal
saline with IV tubing, cutting the tubing,
and fitting the connector end of a new
nasal cannula oxygen tubing over the IV
tubing. The saline will flow from the
nasal prongs in two streams, one for
each eye.
❖ In the event of a suspected chemical
injury to a patient, first responders and
clinicians must remember to wear
appropriate personal protective
equipment to prevent secondary
exposure.
Electrical Injury
● Electrical injuries account for approximately 4%
of all burn center admissions and cause around
1,000 deaths per year (ABA, 2016). These
injuries are usually work related.
● Many factors will influence the degree of tissue
damage, including type and voltage of electrical
current, resistance, pathway of transmission in
the body, and duration of contact.
● Deep conductive electrical burns, arc injuries,
surface thermal burns, associated trauma
(musculoskeletal, neurologic, etc.), cardiac
arrhythmias, and compartment syndromes are
all sequelae of electrical injuries.
● Arrhythmias occur with injury to the myocardium
caused by the electric current at the moment of
injury and the resulting ischemia.
● As with all traumatic injuries, management
considerations include:
➢ primary survey and secondary survey, spine
immobilization, proper fluid resuscitation, cardiac
monitoring, maintenance of peripheral
circulation, and ongoing wound care.
● Patients who sustain electrical conduction
injuries are at risk for the development of
compartment syndrome and may require a
fasciotomy to decompress tissue compartments.
● Peripheral circulation should be continuously
monitored.
● Electrical injuries often require more extensive
IV fluid resuscitation than calculated by the
Parkland formula because the visible cutaneous
injury is not reflective of the extent of deep
tissue involvement.
● Dark red pigment in the urine is usually a sign of
myoglobin or muscle breakdown caused by deep
tissue injury. An indicator of adequate fluid
resuscitation is clearance of the pigment from
the patient’s urine
Radiation Injury
● The physical appearance of radiation burns and
thermal burns may be the same. The difference
between these two types of injuries lies not only
in their etiology, but in the time it takes for the
wound to appear.
● Thermal injury is visible almost instantaneously.
Radiation injury can take days to weeks to
appear, depending on the dose and length of
exposure. A visible injury is an indication of a
high localized dose of radiation. Although the
patient’s wound may be indicative of a large
radiation exposure, the patient and the wound
are not radioactive.
● The use of radiation dispersal devices (RDD),
commonly referred to as “dirty bombs,” is
particularly concerning for disaster-planning and
emergency preparedness personnel.
● An RDD is an explosive device designed to
spread radioactive material without a nuclear
explosion. The initial blast from the explosion
can kill or inflict mechanical trauma on those
who are close in proximity to the explosion while
the radioactive material is dispersed.
● The recovery phase of a burn MCI should aim to
return the affected community to its pre-disaster
state.
ENDRIANO, ENGO| 8
 ● Buildings and infrastructure that have been
damaged by the incident should be repaired or
removed if damage is too severe.
● The American Red Cross has traditionally
reached out to those involved in fire-related
disasters by helping them access available
resources to meet their needs.
● Psychological effects on those affected may
persist for years after the event has occurred.
The mental health response is especially
important in a burn MCI because those involved
have lived through a potentially psychologically
damaging event and can experience complicated
emotional reactions.
● Burn patients consume many resources and
have long lengths of stay.
● After the response to the disaster is over, these
patients can remain hospitalized for months. The
average length of stay for a patient with 50%
TBSA burns is 50 days.
● Burn center staff may become exhausted,
operating at or above capacity for this period of
time. It is recommended that staff work regular
8-hour shifts if possible to prevent emotional
and physical fatigue.
● Each phase of the disaster from planning though
recovery needs to be closely examined so that
modifications can be made for future burn MCIs.
● It is especially helpful to make any lessons
learned available to the health care and disaster
planning communities at large through
publications so that others can make use of the
information.
● For example, the William Randolph Hearst Burn
Center’s experience following the World Trade
Center disaster in 2001 was published to share
the information that was learned from that
incident. One issue involved the NDMS nurses
who were deployed for 50 days to assist with
patient care at the hospital. Although the nurses
were experienced in critical care and burn care,
they were unfamiliar with the hospital and how
the computerized charting system worked. The
hospital solved this problem by creating a brief
orientation class for these workers that allowed
them to learn the necessary information and
quickly go back to assisting with patient
management. This is certainly a problem that
other institutions will potentially have if NDMS
workers are deployed to their aid and should be
considered when developing a disaster plan
(Yurt et al., 2005).
Background
Explosions can produce unique patterns of injury
seldom seen outside combat. When they do occur, they
have the potential to inflict multi-system life-threatening
injuries on many persons simultaneously. The injury
patterns following such events are a product of the
composition and amount of the materials involved, the
surrounding environment, delivery method (if a bomb),
the distance between the victim and the blast, and any
intervening protective barriers or environmental hazards.
Because explosions are relatively infrequent,
blast-related injuries can present unique triage,
diagnostic, and management challenges to providers of
emergency care.
➔ High-order explosives produce a defining
supersonic over-pressurization shock wave. Examples of
HE include Trinitrotoluene (TNT), C-4, Semtex,
nitroglycerin, dynamite, and ammonium nitrate fuel oil
(ANFO).
➔ Low-order explosives create a subsonic explosion
and lack HE’s over-pressurization wave. Examples of LE
include pipe bombs, gunpowder, and most pure
petroleum-based bombs such as Molotov cocktails or
aircraft improvised as guided missiles. HE and LE cause
different injury patterns.
Blast injuries are characterized by anatomical
and physiological changes from the direct or reflective
over-pressurization force impacting the body’s surface.
The four basic mechanisms of blast injury are termed as
primary, secondary, tertiary, and quaternary.
11. Primary blast injury is caused by the blast
wave moving through the body. Since only high
order explosives create a blast wave, primary
blast injuries are unique to high order
explosions. The blast wave causes damage to
more extensively to air-filled organs. The
resulting barotrauma can affect the lungs,
auditory organs, the eye, brain, and
gastrointestinal tract.
● Blast ear – tympanic membrane rupture and
middle ear damage
● Blast lung – injury to the lung parenchyma, can
have delayed symptom presentation
● Blast brain – injury to brain parenchyma, even
without direct injury to the head
● Blast eye – rupture of the globe of the eye
● Blast belly – injury causing abdominal
hemorrhage and perforation (immediate and
delayed). It can also cause injury to solid organs
and testicular rupture.
12. The secondary blast injuries are caused by
debris that penetrates or interacts with the body
surface. The debris can be from pieces of the
explosive device itself and its contents, or
material located around the initial blast device at
the time of the explosion. Secondary blast
injuries are more common than primary blast
injuries. Secondary blast injuries are the most
common cause of mortality in victims of an
explosion. Exposed areas of the victims’ body
ENDRIANO, ENGO| 9
 are at high risk for penetration of debris that is
propelled by the explosion. Often areas of
perforation
highest risk for injury are the head, neck, and —globe
extremities. Injuries can include: (eye)
● Fractures rupture
● Amputations concussion
● Lacerations (TBI
● Dislocations without
● Any type of soft tissue injury physical
13. Tertiary blast injuries are caused when the
signs of
person is displaced through the air and impacts
head
on another object by the blast wind, or when a
structure collapses and causes injury to the injury).
person. The resulting injury can be either blunt
trauma due to the impact or penetrating injury if
the victim is propelled and the striking structure Secondary ● Ballistic ● Any body ●
enters the body. Injuries are determined by wounds part may Penetrating
what the victim strikes. The strength of the from debris be ballistic
explosion determines the severity of the injuries and affected. (fragmenta
sustained. High explosive blasts can cause: fragments. tion) or
● Skull fractures Primary blunt
● Fractured bones
fragments: injuries.
● Head injuries
● Any traumatic injury (open or closed injuries, from the ● Eye
chest, abdominal, pelvic injuries, amputations, weapon. penetratio
spinal injuries, and any others) Secondary n (can be
14. Quaternary blast injuries are all injuries that fragments: occult).
are not included in primary, secondary, or from the
tertiary blast injury categories. Quaternary blast environme
injuries can be caused by exposure to resulting nt
fire, fumes, radiation, biological agents, smoke,
dust, toxins, environmental exposure, and the Tertiary ● Results ● Any body ● Fracture
psychological impact of the event. As a result of from part may and
all the debris, wounds can be extremely
individuals be traumatic
contaminated with a wide variety of sources.
● Fire – burn injuries (flash, partial, full-thickness, being affected. amputation
airway) thrown by .
● Fumes/smoke/dust – inhalation injuries and the blast ● Closed
respiratory compromise wind. and open
● Toxins – toxidromes from chemical exposures brain
● Environmental – heat/cold, exposure injuries injury.
● Radiation – minor injury to death, depending on
the type, amount, and exposure time to the
source. Quaternary ● All ● Any body ● Burns
● Biological – variety of illness related to the agent
explosion-r part may (flash,
released
elated be partial, and
injuries, affected. full
illnesses, or ● May thickness).
CATEGORY CHARACTE BODY PART TYPES OF diseases include ● Crush
RISTIC AFFECTED INJURIES not due to exacerbatio injuries.
primary, n of ● Closed
Primary ● Unique ● Gas-filled ● Blast lung secondary, preexisting and open
to structures (pulmonary or tertiary disease. brain
high-order are most barotraum mechanism injury.
explosives, susceptible a). s. ● Asthma,
results —lungs, GI ● Tympanic COPD, or
from the tract, and memberan other
impact of middle ear. e rupture breathing
the and problems
overpressu middle-ear from dust,
rization damage. smoke, or
wave with ● toxic
body Abdominal fumes.
surfaces. hemorrhag ● Angina.
e and

ENDRIANO, ENGO| 10
 significant postconcussive syndrome (PCS)
● symptoms. Retrograde amnesia, compromised
Hyperglyce executive function, headache, confusion,
mia, difficulty concentrating, mood disturbance,
hypertensi changes in sleep patterns, and anxiety are all
on. characteristic of PCS. Survivors will often report
vertigo and memory problems more frequently
than their nonblast-injured counterparts.
Quinary ● Result ● Any body ● Bacterial ● There is also a link between mild TBI and
from part may infection posttraumatic stress disorder (PTSD) in the
additives to be ● Radiation blast-injured patient. The mechanism increasing
the link between TBI and PTSD is thought to be
explosive affected. exposure
damage to the prefrontal cortex, leading to
devices and ● increased susceptibility to emotional responses
hyperinfla Hyperinfla to a traumatic event. PCS symptoms may alter
mmatory mmatory the blast victim’s ability to adjust to the event,
states post state and may increase the likelihood of developing
explosion. PTSD.
Further ● Management of the blast-injured patient with
investigatio TBI is complex. Treatment should be guided by
n into this the Department of Defense’s Clinical Practice
Guideline for the Management of
type is
mTBI/Concussion, the Brain Trauma
required. Foundation’s Guidelines for Field Management of
Combat-Related Head Trauma, and the Brain
Trauma Foundation’s Guidelines for the
Management of Severe TBI.
2. Ear Injury
1. Traumatic Brain Injury ● Tympanic membrane (TM) rupture is the most
● In penetrating brain injury (PBI) to the brain, common PBI reported in survivors. Depending
the blast wave traverses the skull and brain on whether the blast occurs in an open or
parenchyma. The blast wave may result in enclosed space, 2% to 32% of victims will
diffuse axonal injury, intracranial hemorrhage experience a ruptured TM, and of those with
(e.g., epidural, subdural, subarachnoid, and other PBIs, 94% will also have a TM rupture.
intracerebral), cerebral edema, vasospasm, and ● Factors that increase the likelihood of TM
pseudoaneurysm formation. However, the rupture in blast victims include perpendicular
majority of injuries are concussions and are orientation to blast epicenter, explosion within
considered mild TBI. an enclosed space, prior injury or infection of
● The Veteran Affairs/Department of Defense the middle ear, and advanced age.
Classification of TBI Severity for details ● The presence of cerumen may protect the TM or
regarding mild, moderate, and severe TBI. could act as a ramrod and increase the
Criteria MILD MODERAT SEVERE likelihood of injury. Ear plugs and headphones
E may interfere with the blast wave transduction
to the middle ear, thus preventing injury.
Structural Normal Normal or Normal or ● Following a blast, patients with ear injuries may
Imaging abnormal abnormal present with hearing loss, tinnitus, otalgia,
dizziness, and imbalance. The latter signs and
Loss of 0-30 min >30 min >24 hr symptoms may also be indicative of TBI.
conscious and <24 hr ● Because ongoing hearing loss and tinnitus are
ness the second most common causes of disability
claims for veterans, screening measures
Alteration Up to 24 >24 hr >24 hr; following a blast injury are important.
of hrs severity ● Screening for TM rupture in all blast-injured
conscious based on patients is recommended. In the past it had
ness/ other been recommended that otoscopic examination
mental criteria be performed on all blast victims to screen for
state the risk of other PBIs. However, studies have
demonstrated that some patients will present
Posttraum 0-1 day >1 and <7 >7 day with these injuries and not also have TM
atic day rupture. Victims with intact TMs who are
amnesia asymptomatic for other PBIs are unlikely to have
occult injury. Therefore, the use of otoscopic
Glasgow 13-15 9-12 <9 examination as a screening tool for PBIs other
Coma than TM rupture is not recommended.
Scale ● Breeze et al. (2011) have also recommended
● As compared to mild TBI or other mechanisms, hearing assessment/audiometry as early as
blast-related mild TBI may result in more possible following blast injury.

ENDRIANO, ENGO| 11
3. Eye Injury
● ● Though not often reported as a PBI, eye injury
is very common in military conflict.
● PBIs to the eye are a result of the blast wave
being amplified as it is reflected off of the orbital
walls.
● Signs and symptoms of primary blast eye
injuries are a hypotonic eye without globe
rupture and traumatic cataracts. This injury
typically resolves in approximately 10 days.
Damage to the optic nerve, choroid, and retina
may also be present.
● Visual symptoms may also present following
blast-related TBI.
● Screening recommendations for eye injury
include routine ophthalmoscopy following a
blast.
4. Pulmonary Injury
● Primary lung injury is common in those closest
to the epicenter of the blast and is one of the
most common causes of fatality at the blast
scene. As the blast wave moves through
pulmonary tissues, disruption at the
capillary–alveolar junctions occurs and shearing
of the bronchovascular tree results.
● Injury to the lung may include hemorrhage,
pneumothorax, air embolism, alveolovenous
fistula, pulmonary contusion, and
bronchopulmonary fistula. Due to the
mechanisms of implosion and spalling, the
patient is at risk for pulmonary contusion and air
embolus. Barotrauma may result in
pneumothorax.
● The patient’s presenting signs and symptoms
include hypoxemia, respiratory distress, and
hemoptysis following PBI to the thorax.
● Management of the patient with lung injury will
depend on the severity of injury. Respiratory
instability may necessitate the use of intubation
and mechanical ventilation.
● When considering the implementation of positive
pressure ventilation, lung protective strategies,
in addition to permissive hypercapnia, that
should be implemented include low tidal
volumes (5–6 mL/kg) and maintaining lower
oxygen saturations.
● Nontraditional ventilation methods, including
high-frequency ventilation, jet ventilation,
extracorporeal membrane oxygenation, and the
use of nitric oxide, are also options. High peak
airway pressures should be avoided.
● Prophylactic thoracostomy in the setting of
positive pressure ventilation, as well as
thoracostomy to treat pneumothorax and
hemothorax, is recommended. With all patients
with blast lung injury, pain management is a
great concern.
5. Cardiovascular Injury
● Myocardial hemorrhage, cardiac contusion, and
atrial rupture have been reported as primary
injuries.
● Subsequent to the blast, cardiac contusions can
lead to vagal-induced bradycardia or other
arrhythmias. The vagal stimulation may also
result in hypotension. When this occurs,
hemodynamic instability is refractory to fluid
resuscitation. Compensatory mechanisms, such
as vasoconstriction, may be ineffective in these
blast victims.
6. Abdominal Injury
● PBI to the gastrointestinal system is rare,
particularly in the absence of other PBIs.
● Those closest to the epicenter and victims of
underwater blasts or blasts within an enclosed
space are at the greatest risk for abdominal PBI.
● The classic abdominal PBI is mural hematoma of
the bowel.
● Shear force from the blast wave can also cause
hemoperitoneum resulting from mesenteric
vascular injury.
● Intramural edema, hemorrhage, and
microthrombosis in the intestine decreases
tissue perfusion and places the victim at risk of
delayed intestinal perforation.
● Shear injury may also immediately rupture the
bowel wall, most commonly in the colon or
ileocecal region.
● In rare cases, hepatic, splenic, and renal injuries
result from the blast wave. These solid organ
injuries may present as infarction, ischemia,
hemorrhage, or rupture.
● The incidence of abdominal PBI is estimated at
3% of survivors. That being said, secondary and
tertiary mechanisms of injury are much more
likely to occur.
● Presenting symptoms of blast-related
gastrointestinal injury include melena,
abdominal tenderness, nausea, vomiting,
diarrhea, and absent bowel sounds.
● Imaging studies typically used in this patient
population include focused abdominal
sonography for trauma (FAST) and abdominal
computed tomography (CT). FAST may identify
intraperitoneal fluid while CT is most specific for
solid organ injury and intestinal perforation;
contusion and mesenteric injury may be missed
using these methods.
● Patients presenting with peritonitis from
perforation, free fluid on FAST or CT, or
hemodynamic instability should be managed
surgically with exploratory or decompressive
laparotomy and volume resuscitation.
7. Musculoskeletal Injury
● Traumatic amputation can result from primary,
secondary, or tertiary mechanisms.
● As a PBI, the bone fractures from the blast
wave, and the exposure to the sequelae of the
blast wind results in amputation.
● Many blast victims with traumatic amputation
often succumb to other PBIs as the force
required for amputation is great.
● In survivors with traumatic amputation,
providers must be highly alert for other PBIs.
● Follow your hospital’s and regional disaster
system’s plan.
● Expect an “upside-down” triage - the most
severely injured arrive after the less injured,
who by-pass EMS triage and go directly to the
closest hospitals.
ENDRIANO, ENGO| 12
 ● Double the first hour’s casualties for a rough
prediction of the total “first wave” of casualties.
● Obtain and record details about the nature of
the explosion, potential toxic exposures and
environmental hazards, and casualty location
from police, fire, EMS, ICS Commander, regional
EMA, health department, and reliable news
sources.
● If structural collapse occurs, expect increased
severity and delayed arrival of casualties.
● Blast lung presents soon after exposure. It can
be confirmed by finding a “butterfly” pattern on
chest X-ray. Prophylactic chest tubes
(thoracostomy) are recommended prior to
general anesthesia and/or air transport.
● 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.
● Consider the possibility of exposure to inhaled
toxins and poisonings (e.g., CO, CN, MetHgb) in
both industrial and criminal explosions.
● Wounds can be grossly contaminated. Consider
delayed primary closure and assess tetanus
status. Ensure close follow-up of wounds, head
injuries, eye, ear, and stress-related complaints.
● Communications and instructions may need to
be written because of tinnitus and sudden
temporary or permanent deafness.
For your color conding, your level 1 that is color blue,
meaning to say that is for RESUSCITATAION or
immediate resuscitation. So again level 1 that is
resuscitation and the response should be immediate. For
level 2 that is color red for EMERGENCY and the
response should be within 15 mins. And for level 3 that
is color yellow for URGENCY which is within 30 mins
response and for level 4 that is color orange for LESS
URGENCY the response should be within 60 mins. For
your level 5 which is color white that is NON
URGENCY and the response should be within 120 mins.
So let's describe your level 1 it says there it is very very
urgent or emergency and for your color red it says there
it needs immediate attention for the critical life
threatening injury. Transport first is our core competency
here , transport first our injured person before a medical
act. For level 3 which is yellow are serious injuries
needing immediate attention . So in some systems
yellow tags are transported first because they have e a
better chance of recovery, your red sometimes
mamamatay na hit or 50/50 na. Iba iba kasi it color
coding danay orange danay green this is a less serious
or minor injury and van be delayed in transporting. For
your color Black patay na ito ayaw na ig transport and
for color white that is no injury or illness. So when you
see that a patient has a better chance of recovering you
cater to them first compared to those nga 50/50 na.
Let's now go to the management of your mass casualties
per patient. So you have mentioned all about the drills,
the evacuation drills, earthquake drills fire drills. You
have also ,entioned your referral system. mayda kita
gintatawag na two way referral system. For example
your patient is from RHU, an RHU magsusurat ito hin 3
copies hin two way referral form tapos kun igrerefer it
patient ha hospital igcucut ito tapos igbibilin ito ha
referring hospital tapos it nurse mabalik ha RHU dara na
an iya copy han referral amo tutulo ito nga copy. File
han hospital, file niyo, ngan file han patient. Two way
referral system because 2 institutions have contact and
connection with each other. So if you are familiar with
your City and provincial hospital mayda ito instances nga
diri pwede igrefer ha City hospital iton tikang ha
province, hain man hira pwede igrefer? to the provincial
hospital. Mayda kita ginsisiring nga Georgraphical
referral hospital kun ha Cebu for example if tikang hira
ha province naukoy didto hira ha Vicente Sotto pero if
they live in the city didto hira igrerefer ha City hospital.
Dinhi ha aton we have our EVRMC but waray gud kita
hito na geographical referral kay it taga City danay
nakadto ha EVRMC pero if diri na liwat kaya hit EVRMC
igrerefer nat nira ha higher institution maybe in Manila.
So our EMS here is TACRU. For your burn classification
we also have your leveling. You have you rule of nines.
What are Fire Accidents?
Fire accidents can result in catastrophic personal
injury and devastating damage. Victims of fire accidents
can suffer serious harm, including burn injury to their
entire body. Fire accidents can cause death not only
from burns but also from smoke inhalation and toxic
gasses.
A. Electrical accidents or neglect - misuse of wiring
and electrical appliances, leaving a curling iron
on, or an electric blanket, shorting out of small
appliances such as lamps, toasters and even
baby monitors.
B. Smoking – a dropped cigarette or children
playing with matches and lighters, inadequate
ashtray.
C. Kitchen accidents – unattended pots on the
stove or the burner being left on accidentally.
D. Heating equipment – space heaters, gas
heaters, wood stoves, and fireplaces, mainly in
winter months. Portable heaters can be knocked
over or placed too close to flammable materials,
or they are inadequately guarded. All heaters
could overheat if obstructed.
E. Burning refuse/rubbish – accumulating in work
or storage areas.
F. Hazardous goods – materials such as paints,
adhesives or other chemicals.
G. Arson – by mischievous children and adults,
facilitated by ineffectively secured buildings.
H. Specific hazards – machinery in dusty
environments, heated equipment (e.g. soldering
irons), lamps, cutting and welding equipment,
flammable liquids.
ENDRIANO, ENGO| 13
 The BFP is responsible for ensuring public safety
through the prevention or suppression of all destructive
fires on buildings, houses, and other similar structure,
forests, and land transportation vehicles and equipment,
ships/vessels docked at piers, wharves or anchored at
major seaports, petroleum industry installations. It is
also responsible for the enforcement of the Fire Code of
the Philippines (PD 1185) and other related laws,
conduct investigations involving fire incidents and causes
thereof including the filing of appropriate
complaints/cases.

According to its website, the primary functions of the

BFP are:
There are six different types of fire classes and here is a
detailed list covering types of fire included in each class:
● Class A – fires caused by combustible materials
including paper, fabric, wood and other
flammable solids.
● Class B – fires caused by flammable liquids
such as paint, turpentine or petrol among
others.
● Class C – fires caused by flammable gases
including methane, butane or hydrogen among
others.
● Class D – fires caused by combustible metals
including potassium, aluminium or magnesium
among others.
● Class F – fires include those caused by cooking
oils such as a chip-pan fire.
● Electrical Fires – fires involving electrical
equipment but upon removal of the electrical
item, the fire class is changed.
● Prevention and suppression of all destructive
fires;
● Enforcement of the Revised Implementing Rules
and Regulations (RIRR) of the Republic Act No.
9514 otherwise known as the Fire Code of the
Philippines (PD 1185) and other related laws;
● Investigate the causes of fires and if necessary,
file a complaint to the city or provincial
prosecutor relating to the case;
● In events of national emergency, will assist the
military on the orders of the President of the
Philippines;
● And establish at least one fire station with all
personnel and equipment per municipality and
provincial capital.

Four things must be present at the same time in order to

produce fire:
● Enough oxygen to sustain combustion,
● Enough heat to raise the material to its ignition
temperature,
● Some sort of fuel or combustible material, and
● The chemical, exothermic reaction that is fire.
Oxygen, heat, and fuel are frequently referred to as the
"fire triangle." Add in the fourth element, the chemical
reaction, and you actually have a fire "tetrahedron." The
important thing to remember is: take any of these four
things away, and you will not have a fire or the fire will
be extinguished. Essentially, fire extinguishers put out
fire by taking away one or more elements of the fire
triangle/tetrahedron. Fire safety, at its most basic, is
based upon the principle of keeping fuel sources and
ignition sources separate.

✔ Unplug Items You're Not Using.

✔ Use Surge Protectors.
✔ Never Leave Flames Unattended.
✔ Keep Flammable Items Away From Heat.
✔ Don't Smoke In the Home.
✔ Put Out The Fire.
✔ Cut The Clutter.
✔ Remove Lint And Change Filters.

ENDRIANO, ENGO| 14

● Get out as quickly and as safely as possible. The
less time you are exposed to poisonous gasses,
the safer you will be.
● If you are escaping through a closed door, feel
the door, cracks, and doorknob with the back of
your hand before opening the door. If it is cool
and there is no smoke at the bottom or top,
open the door slowly. If you see smoke or fire
beyond the door, close it and use your second
way out. If the door is warm, use your second
way out.
● If you see smoke or fire in your first escape
route, use your second way out. The less time
you are exposed to poisonous gasses or flames,
the safer you will be.
● If you must exit through smoke, crawl low under
the smoke to your exit. Fires produce many
poisonous gasses. Some are heavy and will sink
low to the floor; others will rise carrying soot
towards the ceiling. Crawling with your head at
a level of one to two feet above the ground will
temporarily provide the best air.
● Close doors behind you as you escape to delay
the spread of the fire.
● If smoke, heat, or flames block your exit routes
and you cannot get outside safely, stay in the
room with the door closed. Open the window for
ventilation, and hang a sheet outside the
window so firefighters can find you. Wait by the
window for help. The first thing firefighters will
do when they arrive at a fire is check for trapped
persons. Hanging a sheet out lets them know
where to find you.
● Once you are out, stay out! Firefighters are
trained and equipped to enter burning buildings.
If someone is still inside, direct them to that
person's probable location.
● Get out first, away from toxic smoke and gasses,
then call the fire department from a neighbor's
home or from an outside phone. If a portable
phone is handy during your escape, you may
take it with you, but do not waste precious time
looking for one. Use your neighbor's phone, a
car phone, or nearby payphone to call for help.
● Give first aid where needed. After calling 9-1-1
or your local emergency number, cool and cover
burns, which reduces the chance of further
injury or infection. Seriously injured or burned
victims should be transported to professional
medical help immediately.
● Stay out of fire-damaged homes until local fire
authorities say it is safe to re-enter. Fire may
have caused damage that could injure you or
your family. There may be residual smoke or
gasses that are unsafe to breathe.
● Look for structural damage. Fire authorities may
allow you to re-enter, but may not have
completed a thorough inspection. Look for
damage that will need repair.
● Check that all wiring and utilities are safe. Fire
may cause damage inside walls and to utility
lines not normally visible.
A transportation accident is any accident (or
incident) that occurs during any type of transportation,
including accidents occurring during road transport, rail
transport, marine transport and air transport. It can
refer to:
● a road traffic accident (including vehicle collision,
pedestrian–bicycle collisions,
pedestrian–pedestrian collisions etc.）
● a marine accident (sailing ship accident,
including man overboard)
● railroad accidents (including train wreck)
● an aviation accident and incident
Example:
1. Two people were killed after a car they were
travelling in caught fire after it hit the divider
and overturned in Uttar Pradesh's Ghaziabad.
2. Five members of a family, including two children,
died and six others were injured after their
speeding car crashed into a stationary truck on
the Bulandshahr-Meerut highway in Uttar
Pradesh this morning, officials said.
3. More than 150 people were missing and feared
drowned in northwest Nigeria on Wednesday
after an overloaded boat ferrying passengers to
a market sank in the Niger River, local officials
said.
4. The bodies of four Indians, who were among 22
people killed in the Tara Air plane crash in
Nepal's mountainous Mustang district, were
cremated on Thursday at the sacred
Pashupatinath temple in Kathmandu, Nepal.
Causes:
1. Distracted Driving
Undoubtedly, distracted driving is the number
one cause of car accidents. A distracted driver
does not have their complete attention on the
road, and they may be paying closer attention to
a mobile device, passengers, or even a
cheeseburger. Remember that your only job
ENDRIANO, ENGO| 15
 when you are behind the wheel is to safely get
where you are going. Many distracted drivers
are usually drivers who have been driving a long
time and think they can multitask. Do not let
yourself fall victim to this mindset.
2. Speeding
We have all had drivers blast past us on the
highway, even when going over the speed limit
ourselves. It is not unusual for people to drive
10, 15, or even 20 miles over the posted speed
limit. Keep in mind that the faster you drive, the
slower your reaction time. If you need to
prevent a car accident while driving at 20 miles
over the limit, chances are very high that the
accident won’t be prevented.
3. Drunk Driving
Any person who drinks and gets behind the
wheel is a danger to themselves and others.
When you drink, your senses and cognitive
functions are dulled; getting behind the wheel,
your reaction times are slowed, and your
decision-making capabilities are compromised.
Find a sober party to take you home if you
decide to drink.
4. Reckless Driving
Weaving in and out of traffic. Tailgating and
cutting other drivers off. These are all examples
of reckless driving, and each can cause a severe
accident. If you see anyone driving like this
around you, back off and give them space.
Reckless drivers can be seen speeding as they
weave in and out of traffic, so be careful as you
drive and make your maneuvers. There is
nothing you are going to do to make the driver
more safely. Protect yourself and report the
driver.
5. Inclement Weather
Whether it’s rain or snow, rough weather can
create hazardous conditions for driving. Water
creates slick roadways and can cause cars to slip
and slide without warning. If you are stuck in a
rainstorm, drive extra carefully. Even if you think
your tires are sticking to the road as they
should, the chances are that they aren’t. Do not
risk it. With snow and cold weather, the roads
can ice over and cause car sliding if you have to
slam on the brakes.
6. Running Intersections
Running through red lights and stop signs is
another top cause of car accidents. Red means
stop, and it isn’t a suggestion for you to do with
as you wish. If you see a light turn yellow, slow
down instead of speeding up to try and “catch”
it. Don’t be tempted to run stop signs near your
home as so many people are. Come to a
complete stop. The extra 10 seconds you have
to wait isn’t worth risking your life.
7. Teenagers
Teenage drivers are dangerous because of their
inexperience. A teenager experiencing new
driving situations will not know how to react.
Teenagers are responsible for causing car
accidents every day. If you see a young person
behind the wheel, stay behind them and give
them room. Teenagers can also fall victim to
distracted driving with their phones or friends
being in the car.
8. Night Driving
Many people aren’t aware that nighttime driving
increases the risk of an accident by nearly
double. It can be challenging to see what is
ahead of you or coming at you from the side.
When the sun begins to fall from the sky, your
awareness must be heightened. Night driving
can also lead to drowsiness. Drowsiness can
lead to lane veering either into other lanes or
towards the median, grass area, or curbs.
9. Design Defects
If you are of a certain age, you may remember a
Geo Tracker vehicle. The small SUV made
headlines because of its propensity to tip over
around turns when they weren’t taken with
caution. The Tracker isn’t alone. Many
manufacturers have produced cars and trucks
with design defects that make them vulnerable
to accidents.
10. Unsafe Lane Changes
Have you ever had someone cut you off? The
chances are that you have. When passing
another vehicle, make sure that you have plenty
of room to get in front of them when you decide
to. If you don’t have enough space to pass
safely, don’t. It is that simple. Pay close
attention to either side of your vehicle before
you decide to change lanes. Also, make sure
that you are using your blinker when changing
lanes to let everyone else know about your lane
changes.
11. Wrong-Way Driving
It’s easy to turn the wrong way down a street,
especially when unfamiliar with the area. Be
sure that you pay attention to signs indicating
one-way roads. Before getting onto and off of
highway ramps, know which direction you need
to travel. Wrong-way drivers are especially
dangerous because people are not on the
lookout for them and often react too late.
12. Improper Turns
When you approach an intersection, be sure that
you are in the proper lane for your intended
direction of travel. If you find that you were in
the straight line when you wanted to turn, keep
going straight. You can always go around the
block or turn around in someone’s driveway or a
public parking lot, and either is a safer
alternative than cutting across lanes.
● Road traffic injuries can be prevented.
Governments need to take action to address
road safety in a holistic manner. This requires
involvement from multiple sectors such as
transport, police, health, education, and actions
that address the safety of roads, vehicles, and
road users.
● Effective interventions include designing safer
infrastructure and incorporating road safety
features into land-use and transport planning,
improving the safety features of vehicles,
ENDRIANO, ENGO| 16
 improving post-crash care for victims of road
crashes, setting and enforcing laws relating to
key risks, and raising public awareness.
● Management of Transport Accidents is
dependent on the nature of the injury to the
human body and its severity.
● Physical injuries require management as per
best practice guidelines to promote healing of
the tissues and structures as well as functional
rehabilitation. Headstrikes and trauma to the
neck require focused intervention to minimize
the risk of whiplash or cervicogenic complicating
elements. Rapid deceleration can cause
concussion, internal visceral injury, and damage
to the organs of the abdomen. Traumatic force
can result in symptoms similar to traumatic
encephalopathy.
● All of these elements, big and small, are taken
into consideration when developing a program
of rehabilitation that is designed to manage the
injury, its impact on the life of the person, and
the barriers it presents to recovery.
An armed conflict arises whenever there is
fighting between States or protracted armed violence
between government authorities and organized armed
groups or just between organized armed groups. An
international armed conflict arises when one State uses
armed force against another State or States.
Armed conflicts are governed principally by
international humanitarian law (IHL), which is also
known as the laws of war. IHL is a set of rules – either
codified in treaties or recognized through custom – that
limits the permissible behavior of parties to a conflict.
The primary aims of IHL are to minimize human
suffering and to protect the civilian population and those
former combatants who are no longer directly
participating in hostilities, such as prisoners of war.
EXAMPLE
Examples of recent non-international armed
conflicts include the hostilities that broke out in northern
Mali in early 2012 between armed groups and the Malian
armed forces, and the fighting in Syria between armed
groups and Syrian government forces.
INTERNATIONALIZED INTERNAL ARMED
CONFLICTS:
The expression “internationalized armed
conflicts” is not a legal expression as such and does not
imply a third category of armed conflicts. The expression
rather describes situations of non-international armed
conflicts with a dimension that is said to be
“international”. This dimension can take several forms:
1. One or more third States or an
international/regional organization (the States or
the organization acting through a multinational
force) intervene in support of a state involved in
an armed conflict against an organized armed
group
2. One or more third States or an
international/regional organization (the States or
the organization acting through a multinational
force) intervene in support of an organized
armed group involved in an armed conflict
against a State
3. Other possible combinations between situations
1 and 2.
From a legal point of view, these situations can be
translated into three specific cases:
1. Some remain a non-international armed conflict
2. Others become an international armed conflict
3. Others become “mixed” conflicts.
a. In such conflicts, depending on the
nature of parties to the conflict, IHL of
non-international armed conflicts applies
to the relations between some parties
(e.g. between an armed group and an
intervening outside State), while IHL of
international armed conflicts applies to
other relations, e.g. between to States
intervening militarily in support of two
adverse parties of a NIAC)
The research on causes of armed conflict so far
has not produced a consistent theory acceptable to most
scholars working in the field. However, It is very likely
that there is one consensus: that conflict cannot be
reduced to a single cause, or a single explanation. It is
obvious that there are “very few necessary conditions”
which need to be fulfilled in order for a war to develop,
and “very many sufficient conditions, of which only a few
of these may apply, in any single conflict. War is possible
as soon as weapons are available with which to fight it
and as long as there is a dispute between two or more
parties. What makes war probable, however, is a far
more complicated question." There are different
categories of explanations :
● Genetic and evolutionary/biologist theories
(aggression as a genetic function, maximization
of survival chances) ;
● Behaviorist theories (war as learned behavior) ;
● Cost-benefit theories (maximization of benefit) ;
● Ecological (war for scarce resources) ;
● Social/cultural theories (ethnicity and/or religion
as conflict causes), and cognitive (attitudes)
explanations.
● Early warning is defined as “a process that: (a)
alerts decision makers to the potential outbreak,
escalation and resurgence of violent conflict;
and (b) promotes an understanding among
decision makers of the nature and impacts of
violent conflict.” It involves the regular collection
and analysis of data on conflicts, by
systematically monitoring and reporting conflict
indicators. Early warning systems generate a set
of products, based on quantitative and
qualitative analytical methods. This helps
formulate scenarios and response options that
are communicated to decision-makers. Early
warning systems are linked to response
instruments.
● Early response refers to “any initiative that
occurs as soon as the threat of potential violent
conflict is identified and that aims to manage,
resolve, or prevent that violent conflict,” by
ENDRIANO, ENGO| 17
 using preventive instruments and mechanisms.
Different types of response exist, ranging from
fact-finding, mediation, peace-making dialogue,
negotiations, preventive diplomacy or more
robust mechanisms such as sanctions.
● Early warning can be an effective tool if strongly
linked to responders. However, the link between
early warning and early response has not always
been effective. Strengthening this link to provide
better responses to violent conflicts requires:
○ Promoting stronger interactions between
warners and responders, and exchanges
to discuss strategies for response
○ Timely and quick responses to warning
○ Monitoring the impact of responses to
conflicts to inform decision-making and
strategies
○ A better understanding of the
value-added of EWS among institutions,
the proximity and quality of the
interface between early warning and
response mechanisms
○ Designing evidence-based response
instruments to adequately respond to
warning
○ The design of nuanced response actions
to take into account changes in the
conduct of warfare.
● The mental health consequences of conflict on
children are clear, with elevated rates of
post-traumatic stress, depression, and anxiety in
conflict affected children. These impacts are
recognized as being due to both direct exposure
to traumatic events as well as exposure to
increased levels of daily stressors.
INTERVENTION:
● Armed conflicts may end in many ways,
including through peace agreements entered
into by the warring parties to explicitly regulate
or resolve contentious issues. They may also
end through outright victory, where one party
has been defeated and/or eliminated by the
other.
● The interference by one state in the internal or
external affairs of another state. It could refer to
interference in a state’s freedom to choose its
political, economic, social, or cultural path, or to
interference in the formulation of its foreign
policy. Intervention may take the form of
military action, or it may be undertaken through
the exertion of economic or political pressures.
However, it will be unlawful under international
law if such interference is achieved through the
use of force, be it in the direct form of military
action or in the indirect form of support for
subversive or terrorist armed activities within
another state.
● If third States and/or international organizations
intervene militarily in ongoing non-international
armed conflicts in support of the non-State
armed group party to the conflict, this
internationalizes the conflict.
● IHL demands that parties to a conflict
distinguish between civilians, who are afforded
protection, and combatants, who are legitimate
targets of attack. Civilians may not be
deliberately targeted, although they may still be
killed or injured if this happens as part of a
proportionate attack on a military target. All
parties to the conflict must take measures to
minimize harm to civilians and civilian objects
(such as residential buildings, schools and
hospitals), and must not carry out attacks that
fail to distinguish between civilians and
combatants, or which cause disproportionate
harm to civilians.
1. Parties to conflict should avoid the use of
explosive weapons in populated areas.
2. The UN Security Council should not accept
attacks on children as the “new normal” of
armed conflict.
3. States should ensure that civilians in conflict
zones can access medical care and humanitarian
assistance, and they should enable humanitarian
and health workers to work in safety.
4. States should ensure better protection and
assistance of people forcibly displaced within
their country and uphold their human rights.
5. States should condition their arms exports on
respect for international humanitarian and
human rights law.
Act of war means hostile or warlike action,
whether declared or not, in a time of peace, whether
initiated by a local government, foreign government or
foreign group, civil unrest, insurrection, rebellion or civil
war. It has always been the resort of most humans or
state to resolve a never ending argument or
disagreement with another party. These wars often
results to death and injuries to many civilians including
the prevalence of sexual violence among women,
malnutrition, illness and disability. In order to stop this,
the international community established several
agreements to protect and advocate the rights of many
people. Setting the basic limits of war, these universal
laws of war protect those who are not fighting including
those who are no longer able to.
International Agreements:
● Geneva Convention – refers to several
treaties agreed upon by the international
community regarding the fair treatment of
prisoners of war, civilians in a war-afflicted
country and the treatment of the injured during
wartime. It was emphasized in this agreement
that help should be given to the wounded
without regard to what “side” they had fought
on.
● International Humanitarian Law - a set of
rules that seeks, for humanitarian reasons, to
limit the effects of armed conflict. It protects
persons who are not, or are no longer, directly
or actively participating in hostilities, and
imposes limits on the means and methods of
warfare. It is also known as "the law of war" or
"the law of armed conflict" and does not
stipulate whether the commencement of an
armed conflict was legitimate or not, but rather
ENDRIANO, ENGO| 18
 seeks to regulate the behavior of parties once it ● THREAT (Threat Suppression, Hemorrhage
has started. Control, Rapid Extrication to Safety, Assessment
by Medical Providers, Transport to Definitive
Care)
1. Protect those who are not fighting, such as
civilians, medical personnel or aid workers.
2. Protect those who are no longer able to fight,
like an injured soldier or a prisoner. ● Immediate after-action discussions should be
3. Prohibit targeting civilians. Doing so is a war conducted after an incident to identify what
crime. went well and what needs to be improved
4. Recognize the right of civilians to be protected ● A needs assessment of the overall impact of the
from the dangers of war and receive the help event on the community, victims, survivors, and
they need. Every possible care must be taken to family members is necessary to identify the
avoid harming them or their houses, or needs of the community as a whole and may be
destroying their means of survival, such as critical to the development of local, state,
water sources, crops, livestock, etc. national, and federal emergency funding
5. Mandate that the sick and wounded have a right assistance applications.
to be cared for, regardless of whose side they ● The horror of an act of war or terrorism may a
are on. person their sense of security. The normal
6. Specify that medical workers, medical vehicles reactions to this type of traumatic disaster
and hospitals dedicated to humanitarian work include a wide range of powerful feelings.
cannot be attacked. ● During recovery, it is critical to engage a holistic,
7. Prohibit torture and degrading treatment of trauma-informed approach, which includes
prisoners. diverse faith or spiritual healing practices, to
8. Specify that detainees must receive food and support survivors and surviving family members
water and be allowed to communicate with their in the long term. (It is also important to
loved ones. remember that not all victims are religious or
9. Limit the weapons and tactics that can be used spiritual.) This approach incorporates an
in war, to avoid unnecessary suffering. understanding of the vulnerabilities or triggers of
10. Explicitly forbid rape or other forms of sexual trauma survivors (which traditional service
violence in the context of armed conflict. delivery approaches may exacerbate) in order to
make services and programs more supportive
and avoid re-traumatization.
● Ensure that the emotional and psychological
● Involve the local law enforcement in making needs of the community are met by providing
plans in order to come up with an appropriate mental health support, counseling, screening,
and suitable care plans for the public and treatment.
● Develop and prepare a communication plan ● Ensure that law enforcement; systems-based,
● Assess and prepare the facilities faith-based, and nonprofit victim service
● Establish processes and procedures to ensure providers; first responders; prosecutors; medical
patient and employee safety service providers; mental health providers;
● Train and drill employees medical examiners; funeral directors; and other
● Plan for postevent activities community leaders (based on the nature of the
incident) receive the support and services they
need to address symptoms of
secondary/vicarious trauma.
● Ensure that the potential for increased risk of
● Most acts of war incidents are first managed in
substance, physical, sexual, and emotional
the pre-hospital setting, involving local law
abuse for individuals is addressed.
enforcement and emergency medical services as
the first responders on the scene. A rapid
For your transportation accident mas dako nga
response can promote lifesaving interventions
percentage iton iyo motor vehicle accident compared to
● During the response phase, which occurs in the
your car accident. Usually the survival rate of motor
immediate aftermath of an incident, law
vehicle accident is low it depends upon the impact. Kun
enforcement officials, first responders, victim
motor to motor la the chance of survival is high. Your
service providers, and others coordinate their
transportation accident may be a road traffic accident or
activities to ensure a timely and effective
maybe a Marine accident you have your sea
response. Many of the protocols developed
transportations and you also have your railroad
during the partnerships and planning stage are
accidents. So what are the causes of these accidents you
key to the response phase:
have your overspeeding, drunk driving, so in busses
○ Committee Meeting Protocol
talking to drivers and texting drivers is not allowed. You
○ Incident Command System Protocol
also have to make sure to follow the traffic lights and
○ Communications Protocol
the road signage. You also have your design defects
○ Family Assistance Center Protocol
unsafe lane changes and you also have your wrong way
○ Victim Identification Protocol
driving. For the acts of war causes may be a rebellion or
○ Notification Protocol
just like your NPA or Maute.
○ Volunteer Management Protocol
○ Donation Management Protocol

ENDRIANO, ENGO| 19