Dear ladies and gentlemen, dear guests,
We are pleased to welcome you to our website. This website is designed to share information and materials related to the conceptual approach to dealing with the foreseeable emergency situation where there is a overwhelmingly large number of patients with burn injuries within the territory of the Czech Republic.
Purpose of the website is to provide you with the most comprehensive information possible, and how to organize and provide health care, at all levels, in the event of this foreseeable crisis situation.
This website is based on the document "Concept of Solving an Emergency with a Large Number of Patients with Thermal Injuries", which was created in 2020 in cooperation with the Czech Ministry of Health, representatives of the Czech Society of Burn Medicine, and the Society of Emergency Medicine and Disaster Medicine.
We firmly believe that the website will serve a unique purpose – that is, providing the best possible preparation of the entire health care system for this emergency. We vehemently hope that this crisis will never occur, but at the same time – we believe that with well-managed systematic theoretical preparation, we will be able to facilitate the best possible outcome should it ever transpire.
We welcome your comments, suggestions, and any professional discussion. We are looking forward to collaborating with you.
Sincerely,
Robert Zajíček
Eva Smržová
Bohumil Bakalář
A mass burn casualty incident (hereinafter "MBCI") is a foreseeable crisis situation, where a system of ensuring and providing acute health care must be prepared in advance to resolve it. However, from the point of view of the capacity of the healthcare system and the setting of optimal reaction algorithms, this situation represents a fundamental organizational challenge. That is due to the disparity between the immediate requirements for the provision of health care and its availability; not only in the phase of providing pre-hospital emergency care at the scene, but especially in the phase of the need to provide acute highly-specialized hospital care.
In the normal conditions of emergency medicine, health care for severely burned patients in the Czech Republic has been systematically concentrated in centers of highly specialized care for patients with burns for many years (burn centers, hereinafter "BC").
The current setting of rules for pre-hospital emergency care and early acute hospital care in the Czech Republic ensures the immediate availability of this highly specialized center care for most patients with more severe thermal injuries by primarily routing them to a BC, which is a procedure from which these patients objectively benefit. Other health care personnel providing acute inpatient care (hereinafter referred to as "MF"), including highly specialized trauma care centers (hereinafter "TC"), have therefore been practically without contact with patients with this type of injury for many years, resulting in little or no readiness for their treatment, both at the professional level and at the material and organizational level.
Since the immediate capacity of the 3 national BCs for the admission of acute patients is limited, in the case of an MBCI, only a limited number of patients, ideally only the most severely affected ones, can be directed to these centers. At the same time, it will be necessary in these cases to also provide acute care for other patients with a thermal injury in MF outside the BC, at least for the time necessary to gradually free up and create capacity in the BC.
In this situation, burn centers will need to be provided as quickly as possible with a complete overview and maximum information on all patients with thermal injuries who were primarily transported to other MF so that their secondary transfer to a BC is as rational and smooth as possible.
The aim of this document is to determine the optimal procedure for this emergency situation, which will enable the quality survival of as many patients with thermal injuries as possible ("do the most for the most"). All recommendations contained in this document are intended solely for dealing with MBCI and do not in any way change the applicable rules and professional best practices for the provision of healthcare for patients with other thermal injuries then an MBCI.
Šrobárova 1150/50, 100 34 Prague 10
Jihlavská 340/20, 625 00 Brno
17. listopadu 1790/5, 708 52 Ostrava-Poruba
– a mass burn casualty incident. According to an analysis of MBCI events in the world in recent decades, we assume that it is necessary to ensure the readiness of the national system to care for about 50 severely burned patients. In the event of a major emergency, it will be necessary to activate the mechanisms of international cooperation and involve the surrounding European states in dealing with it according to predefined rules (follow-up to the National Burn Plan of the Czech Republic and the European Burn Plan).
– for the purposes of this document, we refer to an adult patient as such with burns to the extent of 50% or more of the total body surface area (hereinafter referred to as % TBSA). This group of patients is burdened with the statistically highest mortality and benefits the most from the provision of highly specialized health care.
– for the purposes of this document, we refer to a patient as such aged 0–15 years with burns of at least 20% TBSA or with an associated injury, which includes a burn. In the case of MBCI with a larger number of severely burned children, it is necessary to respect the specifics and differences in the approach to securing and routing pediatric patients with this type of injury, which are emphasized in this document.
– it is necessary to assume that within this type of event there will be different types of injuries of patients, i.e. not only pure thermal injuries. At the same time, it is necessary to assume a varying age structure of injured patients. Both must be taken into account in the proposed algorithms for classification, routing and therapy.
determines the number of patients with a serious thermal injury that can be admitted and adequately treated at a BC.
determines the number of patients with a serious thermal injury, which the BC is able to receive and treat immediately (within 6 hours) after the occurrence of an emergency. Numerical expression of the immediate capacity of burn centers in the Czech Republic, see the table.
defines the total number of patients with a serious thermal injury that the BC should be able to treat and receive within 48-96 hours after the event.
of burn centers in the Czech Republic is estimated at about 40–50 patients with a serious thermal injury.
At the moment of fulfilling the expected capacity of national BCs, it is possible to request the assistance of other EU countries according to the valid and approved rules (connection to the National Burn Plan of the Czech Republic and the European Burn Plan).
| BC Prague | BC Brno | BC Ostrava | |
|---|---|---|---|
| A total of all patients within 6 hours | 10x | 5x | 5x |
| Children up to 6 hours |
4x FHKV Faculty Hospital of Královské Vinohrady 2x MUH Motol University Hospital 2x TH Thomayer Hospital 2x GUH General University Hospital |
3x UH Brno TC Children‘s Hospital, UH Brno |
2x UH Ostrava |
The material is divided into 4 basic chapters describing the individual follow-up steps necessary to ensure the necessary health care in the case of an MBCI, at all its levels (pre-hospital emergency care provided by emergency medical service ambulance groups (hereinafter "EMS"), acute hospital care in the nearest MF / TC, care in a BC):
Proper classification of patients fundamentally affects the fulfillment of the main goal of the entire plan, i.e. ensuring the survival of as many injured patients as possible.
Its principle is to divide all injured patients into groups according to the severity and type of injury, which will make it possible to decide on the implementation of the necessary therapeutic measures and on the optimal primary routing of patients to a MF.
For this reason, it is necessary to create uniform and simple rules applicable to the classification of patients in the various stages of health care.
It is necessary to assume that various types of injuries will occur within this type of event, i.e. not only pure thermal injuries (although this type of event may also occur). At the same time, it is necessary to assume a varying age structure of injured patients.
patients with burns or burns and inhalation trauma (hereinafter referred to as group "B")
patients with burns or burns and inhalation trauma associated with another serious injury (polytrauma, associated injury with burns; hereinafter referred to as group "B + T")
patients with severe injury without burns (polytrauma, associated injury; hereinafter referred to as group "T")
patients with inhalation trauma (hereinafter referred to as group "I")
The classification of patients in the event of an MBCI will gradually take place on 3 levels:
Primary triage on-site performed by EMS ambulance groups; it is necessary to assume that it will be burdened with a significant error rate for objective reasons.
It should permit a decision to already be made on the implementation of the necessary therapeutic measures at the scene and on the primary routing of patients according to the severity of their condition and the type of injury (to the nearest MF, TC, BC).
Secondary triage performed in a TC, or the nearest MF, to which the patient with a thermal injury was primarily transported. It should make it possible to refine the diagnosis and extent of the injury so as to ensure the prioritization of the treatment of patients and determine the optimal order in the group of all patients with a thermal injury from all MF for secondary transport to the BC.
Tertiary triage in the BC performed by a specialist in the field of burn medicine. It enables the determination of the patient‘s definitive diagnosis and prognosis and the determination of a comprehensive treatment plan.
The general principles and rules for the classification of patients during an MBCI are determined by the valid recommended procedures of the Society of Emergency and Disaster Medicine of ČLS JEP (hereinafter referred to as the "SUMMK") Mass disability of health / persons – procedure of solution by the medical rescue service in the field (update 2018) and Classification and identification card for medical classification in case of a mass health disability in the Czech Republic (update 2009). However, these rules need to be modified in some way for use with patients with thermal injuries.
The triage of patients with a mechanical injury ("T") is carried out according to the general rules given by the aforementioned recommended procedures.
For patients with a purely thermal injury ("B"), the determination of the extent of the burned surface area is decisive for the triage, regardless of the depth of the burn.
Estimating the extent of the burned surface area can be performed using the "palmar rule": the patient‘s hand with the fingers together and the thumb extended corresponds to about 1% TBSA.
In the event of patients with extensive burns, it is easier to deduct the non-burned area.
The "Rule of nines" uses the division of the body surface into compartments with an approximate range of 9% to estimate the extent of the burned area.
It is limited by the fact that burns almost never exactly copy the boundaries of individual compartments. It is also necessary to remember that the "Rule of nines" does not apply to children.
According to the estimate of the extent of the burned surface area, we classify adult patients with thermal injuries into individual groups according to severity as follows:
extent of the burned area up to ⅓ of the body surface
extent of the burned surface area ⅓-½ of the body surface area
the extent of the burned surface area above ½ of the body surface area
Dle odhadu rozsahu popálené plochy třídíme dětské pacienty s termickým úrazem do jednotlivých skupin dle závažnosti (bez ohledu na jejich věk) takto:
extent of burned area up to 10% of the body surface
extent of the burned surface area 10-20% of the body surface area
the extent of the burned surface area above 20% of the body surface area
In patients with a combination of both types of injuries (mechanical, thermal – "B + T"), the resulting priority of the condition is determined by the trauma that is more severe – the "more severe wins" rule. Example: a patient with a non-life-threatening mechanical injury with a green + priority and a burn at the same time above 50% TBSA has a resulting red priority; a patient with a 30% TBSA burn [priority yellow] and a concomitant mechanical life-threatening mechanical injury [priority red] has a final priority of red).
The expression of suspected inhalation trauma ("I") is based on an assessment of the following indirect signs:
We evaluate the priority of the condition according to the severity of the clinical picture (impaired consciousness, airway obstruction, respiratory insufficiency) and the patient‘s age.
In case of burns to the upper respiratory tract (supraglottic damage), burns of the mucous membranes occur as a direct result of the effect of thermal NOx, most often during an explosion in the face. As a result of the onset of edema, dyspnoea and respiratory failure may develop rapidly. Securing the airways can be difficult due to a swelling of the mucous membranes.
The priority of the condition increases as age decreases – the younger the child, the smaller the transparency of the respiratory tract and the higher risk of respiratory tract obstruction.
In the case of lower respiratory tract burns, the inhaled smoke is toxic. Lower respiratory tract burns are often associated with concomitant CO and hydrogen cyanide intoxication. Lower airway burns significantly increase the lethality of burn patients.
The secondary triage in a MF is intended to enable the patients to have a more precise diagnosis with the determination of the extent and depth of the injury. Its main goal is to determine the priorities in the treatment of patients and to enable the determination of their optimal order for secondary transport to the BC.
To more accurately determine the extent of the burned surface area, we use the Lund Browder diagram (see the Therapy chapter and the Patient Card Annex).
You can orient yourself according to the color and capillary return.
The superficial surface area is pink, the capillary return is within 3 seconds. The formation of bulla is typical.
Only erythema is not counted in the scope.
The deep surface area is white or whitish in color, often with red dots, and may be black, brown or crimson red, i.e. not pink. The capillary return is over 3 seconds.
| Body part in adults | % |
|---|---|
| Head | 7 |
| Neck | 2 |
| Front of the torso | 13 |
| Back of the torso | 13 |
| Both arms | 8 |
| Both forearms | 6 |
| Both hands | 5 |
| External genitals | 1 |
| Buttocks | 5 |
| Both thighs | 19 |
| Both shins | 14 |
| Both feet | 7 |
| Body part in children (in %) | Newborn | 1 year | 5 years | 10 years | 15 years |
|---|---|---|---|---|---|
| Head | 19 | 17 | 13 | 11 | 9 |
| Neck | 2 | 2 | 2 | 2 | 2 |
| Front of the torso | 13 | 13 | 13 | 13 | 13 |
| Back of the torso | 13 | 13 | 13 | 13 | 13 |
| Both arms | 8 | 8 | 8 | 8 | 8 |
| Both forearms | 6 | 6 | 6 | 6 | 6 |
| Both hands | 5 | 5 | 5 | 5 | 5 |
| External genitals | 1 | 1 | 1 | 1 | 1 |
| Buttocks | 5 | 5 | 5 | 5 | 5 |
| Both thighs | 11 | 13 | 16 | 17 | 18 |
| Both shins | 10 | 10 | 11 | 12 | 13 |
| Both feet | 7 | 7 | 7 | 7 | 7 |
Healthcare providers providing pre-hospital emergency care, early acute hospital care and ultimately acute care in a specialized BC gradually participate in the treatment of patients with thermal injuries within an MBCI. This material provides all healthcare professionals with little or no experience in the treatment of major burns with a simplified guide to the basic and uniform treatment of patients with a thermal injury.
EMS healthcare professional at the scene
A – MF physician providing
intensive care,
B – MF physician providing
surgical care
Physician specializing in BC
The tasks of an EMS healthcare professional intervening at the scene are:
green/yellow/red
Cannulation ONLY yellow/red
yellow/red
green
yellow/red
Analgesia in spontaneously ventilating patients
Analgesia in ventilated patients – can be administered
Sedation (only if necessary and always as a supplement to analgesia)
green
Analgesia
green/yellow/red
Thermal comfort
Treatment of burned surface areas
| Estimated age | 10–20% TBSA yellow | over 20% TBSA red |
|---|---|---|
| 1–3 years | 100 ml/hour | 200 ml/hour |
| 3-5 years (preschool children) | 150 ml/hour | 250 ml/hour |
| 5-9 years (younger school children) | 200 ml/hour | 300 ml/hour |
| 10-15 years (older school children) | 250 ml/hour | 350 ml/hour |
The tasks of the MF physician providing intensive care are to:
evaluation of the adequacy of burn shock resuscitation is based primarily on the restoration of diuresis (target: hourly diuresis 0.5 ml/kg/h in adults and 1 ml/kg/h in children)
Analgesia in spontaneously ventilating patients:
Analgesia in ventilated patients:
Sedation (only if necessary and always only as a supplement to analgesia):
all burns are endangered by heat loss due to loss of thermoregulation in the affected skin, monitor (preferably continuously) their temperature, maintain normothermia
The tasks of the MF physician providing surgical care are:
The treatment of patients with a thermal injury must take place under sterile conditions, preferably in an operating room. Due to the considerable pain when handling body surfaces, deep analgesia or general anesthesia is required during treatment.
The main objectives of the dressing are to prevent the drying and mechanical trauma of the burned area and bacterial colonization of the wound.
Facial treatment:
Indications: deep circular burns of limbs, neck and torso, when there is a risk of developing compartment syndrome (hereinafter "CS")
Periodization:
Execution technique:
The tasks of the BC physician are:
Part of the comprehensive care plan should be a clearly declared surgical procedure including the possible need to use biological covers beyond the scope of normal use. Within the multidisciplinary team, it is possible to decide on the transfer of the patient to palliative care on the basis of transparent medical arguments. Part of the BC physician‘s work is also communication with other MF and burn centers in the Czech Republic, in the case of an emergency also within the scope of the creation of B teams according to EU recommendations and in accordance with the National Burn Plan of the Czech Republic.
The priority of transport and determination of the primary routing of patients with thermal injuries from the place of the event are given by the performed triage, which respects the severity of their condition and at the same time the type of injury (to the nearest MF, TC, BC). A necessary part of the deliberation must always be the evaluation of current transport options and the time factor of reachability of individual MF, as well as the total number of patients and the related filling of BC or TR capacities.
For the secondary transport of patients from an MF to a BC, the most suitable time is within 48–96 hours from the injury; after this time, there may be an increase in infectious complications, which worsen the overall condition of the patient and limit the possibility of transport.
In the event that the number of burn patients exceeds the national capacity of the BC of the CR (i.e. approx. 40–50 severe burn patients), the mechanisms of international cooperation within the European Union will be activated (following the National Burn Plan of the Czech Republic and the European Burn Plan).
Patients with a pure thermal injury (group "B") are primarily routed to the nearest BC according to the severity of the impairment and condition, children have a higher priority in groups with the same severity. We prioritize patients with secured airways – ventilated over spontaneously ventilating patients. After filling the immediate capacity of the BC, other patients with a thermal injury are routed to the TC or to another MF.
Patients with a combination of mechanical and thermal injuries (group "B + T") are, according to the degree of severity of the impairment, the condition, and after considering other factors (filling the capacity of the BC, current transport options, time availability of the BC), primarily routed either to the nearest BC or to the TC in its immediate vicinity (Prague/Brno/Ostrava).
Depending on the degree of severity of the impairment and the condition, patients with inhalation trauma (group "I") are primarily routed to the nearest MF that is able to provide them with adequate care.
In the case of a danger of delay (especially the "B + T" group), pediatric patients are always directed primarily to the nearest TC for children.
| For the primary routing of pediatric patients with a thermal injury (groups "B", "B + T" and "I"): | |
|---|---|
| FHKV Prague
Faculty Hospital of Královské Vinohrady |
BC FHKV TC for children Thomayer Hospital TC for children FN Motol ICU of the Department of Children and Adolescents of GUH (only group "I") |
| UH Brno | BC UH Brno BC for children in the Children‘s Hospital, University Hospital Brno |
| UH Ostrava | BC UH Ostrava |
For the successful course of this phase, it is necessary to provide the BC with a complete overview of the number of patients with thermal injuries who were primarily transported to other MF, the severity of their injuries and their current clinical condition as quickly as possible. This in turn will allow the determination of the optimal order of patients for secondary transport to the BC. The sharing of information about patients from MF takes place in the form of structured information transmitted electronically to the BC on a standard form (Patient Card Annex).
The safe and effective sharing of documentation electronically between individual MF and BC should be enabled in the near future by the SIMPOC project (Sharing information between burn centers in the Czech Republic) currently under preparation.
The determination of the order of patients for secondary transport to the BC is always determined by the BC physician in cooperation with the MF physicians.
Patient priority for secondary transport is particularly dependent on the scope of injuries and the severity of the clinical state of the patient. Critical age groups are children and geriatric patients where even a smaller burn range can be critical and thus the patient‘s age must be included in the deliberation.
A special group consists of patients with burn monotraumas of the face and with deep burns of the hands, who benefit from specialized care mainly in terms of long-term consequences – in the event of free BC capacity, the location of the impairment should also be taken into account.
For the secondary transport of patients to the BC, the best time is within 48-96 hours of the injury; after this time, there may be an increase in infectious complications, which worsen the overall condition of the patient and limit the possibility of transport.
In the case of pediatric patients, the cooperation of individual workplaces that provide pediatric IC is required. The decision on patient distribution will be based on interdisciplinary cooperation between the BCs, pediatric TCs and pediatric ICUs.
If the capacity of the national BCs is filled, it is possible to request the assistance of other EU countries according to valid and approved rules so that the tertiary transport of patients from the MF or from the BC to a BC certified in the European backbone network is possible (in relation to the National Burn Plan of the Czech Republic and the European Burn Plan).
In the event of an MBCI, the activities of the medical operating center (hereinafter referred to as "MOS") and EMS ambulance groups at the scene take place according to the general principles defined in the recommended procedure of SUMMK ČLS JEP "Mass disability of health/persons – the procedure of dealing with the emergency medical services in the field".
After specifying the information on the extent of the MBCI and the expected number of patients from the event location, the MOS announces the appropriate degree of activation of the trauma plan to the EMS and also passes on this information in the usual way to the MF, including the nearest BC.
As BCs are always part of trauma centers, the transmitted notification must contain clear information that the emergency applies to patients with thermal injuries. This information is continuously updated by the MOS depending on its update from the place of the event.
At the moment of a clear confirmation of an MBCI, it is necessary to verify and confirm the immediate capacity of the BC to receive patients from the event site.
| Contact telephone numbers for the transmission of the notice of the activation of a traumatological plan in the event of an MBCI for individual BCs in the Czech Republic | |
|---|---|
| FHKV Prague | contact point BC FHKV +420 267 163 410 and/or +420 602 322 184 (consulting mobile BC 24/7) |
| UH Brno | contact point TC UH Brno (+420 532 231 010 – Urgent admission Brno University Hospital) |
| UH Ostrava | contact point TC UH Ostrava (+420 597 372 366 – Emergency admission of UH Ostrava) |
After the completion of the intervention from on the part of the EMS (i.e. after the EMS ambulance group hands over the last patient to the MF, TC or BC), it is necessary (through the MOS) to ensure complete information for the BC on the total number of transported patients with a thermal injury and on their routing to individual MFs (electronically along the MOS EMS axis to the contact e-mail – see below, or to the contact telephone number – see below)
In the event of an MBCI, it is necessary to provide burn centers with a complete overview and the maximum necessary information about all patients with thermal injuries who were primarily transported to other MFs. The main goal is to enable the determination of the optimal order of patients for their secondary transport to a BC with a gradual freeing up of capacity. A standard form (Patient Card Annex) is used to share patient information, which is sent electronically from the MF to the contact e-mail address at the PC.
| Contact e-mails for the transmission of information about individual patients in the event of an MBCI for individual PCs in the Czech Republic | |
|---|---|
| FHKV Prague | popaleniny@fnkv.cz |
| UH Brno | popaleniny@fnbrno.cz |
| UH Ostrava | popaleniny@fnostrava.cz |
Telephone consultations between the MF and BC are also possible on these designated telephone numbers (available 24/7 in the case of an MBCI).
| Telephone consultations on designated telephone numbers | |
|---|---|
| FHKV Prague | +420 267 163 392 (ICU) |
| UH Brno | +420 532 233 205 (ICU I) |
| UH Ostrava | +420 597 372 790/791 (ICU) |
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